Today's Practice Q1 2018 Edition by Meridian Medical Practice Solutions

THE PHYSICIAN’S FINANCIAL HEALTH SERIES: SUCCESSION PLANNING DEMYSTIFIED FINANCIAL ADVISORY SERIES

U.S. NATIONAL EDITION TODAY’S PRACTICE ANNOUNCES NEW ALIGNMENT WITH NFIM:

THE TECHNOLOGY CENTRIC TRANSITION TO

INTEGRATIVE MEDICINE VR

THE NEW REALITY IMPROVING PATIENT OUTCOMES

BIGDATA MEETS HEALTHCARE NECESSITY

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Are you or someone you know or love in pain or have a chronic medical condition? Did you know it takes over 18 years for new technologies to transition into your doctor’s office? It doesn’t have to take that long – Our families and loved ones can’t wait that long. NFIM searches globally for new, safer and better solutions for you and your family. Our goal is to shorten the technology transition cycle from 18 to 2 years by 2027. Come join us as we guide America back to becoming one of the top 5 healthiest countries by 2030.

TECHNOLOGY SPECIAL FEATURE:

INTEGRATIVE MEDICINE

THE FUTURE OF MEDICINE

HOW VIRTUAL REALITY IS

IMPROVING PATIENT OUTCOMES THE INFLUENCE OF TECHNOLOGY ON

TOMORROW’S MEDICAL PRACTICES HUNGRY, HUNGRY HIPAA

DATA PROTECTION: BEST PRACTICES

PRACTICE MANAGEMENT WHY EFFECTIVE PHM REQUIRES A

REAL-TIME CLINICAL PERSPECTIVE A VERY REAL, VERY EXPENSIVE OUTCOME

PHYSICIAN BURNOUT

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ARTICLE DIRECTORY

41 CANCER

SURVIVORSHIP

MARKETING 49 THE EVOLVING ROLE OF

PRACTICE MARKETING

FINANCIAL 55 EFFECTIVE BUSINESS

SUCCESSION PLANNING

LEGAL 59

KEYS TO MEDICARE

AUDIT DEFENSE

65 TIPS FOR CONTESTING

UNEMPLOYMENT BENEFITS

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FEATURED SERIES: THE HEALTHCARE OF TOMORROW

Integrative Medicine:

The Future of Medicine. Peter F. Demitry, MD, MPH | Executive Director, The National Foundation for Integrative Medicine Imagine, for a moment, a different future for medicine in the United States, unlike anything you previously considered. For instance, imagine a new national priority of ‘health’ rather then the current system of focusing on ‘health-care’. Imagine that you could practice medicine as you envisioned back when you were in medical school. You remember, that idealistic desire to help your patients get healthy! Return to that memory for a moment when you expected to be fairly compensated for your training, experience, empathy and ability to get your patients healthy. It’s coming. Are you ready? There are paradigm changes on the horizon. Practitioners who adopt this cutting edge mindset will not only stay relevant, they will thrive in their profession.

Visualize a different economic engine driving medical decisions. After all, money seems to drive everything these days. Consider what the country could do when the percentage of our economy used for healthcare is decreased from 18% of our Gross National Product ($3.2 Trillion) down to a more reasonable 7%. Imagine what we as a nation could do with that extra $1.3 Trillion dollars in cost avoidance per year. Could you start safeguarding your children’s economic future? Envision a time when the annual expenditure would no longer top $10,000 per US citizen, an expenditure yielding the lowest clinical return on investment in the world according to several independent sources.

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Integrative Medicine Consider instead what it would feel like to be part of a medical system soaring from the bottom to the top in global clinical outcomes and efficiencies - out performing France, Australia, Germany, Canada, Sweden, Norway, the UK and Switzerland and all the other industrialized countries that we currently trail despite our over spending. Did you know they routinely use simple, proven, safe technologies for getting excellent clinical outcomes? We should keep our eyes searching as this is instructive for open-minded physicians because the metrics show the global medical enterprise is outperforming us in several areas. Imagine a future when our standards-of-care would never tolerate 128,000 annual deaths in the United States from adverse drug reactions (prescription deaths), which roughly equates to 340-350 deaths per day. As stated in prior articles, our healthcare system is crashing a fully loaded 747 airliner everyday filled with our friends, colleagues, and family members who believe they are getting safe, effective and vetted medical care. Can you imagine the outcry from the nation and its leaders if that ever happened? The equivalent loss of life is happening every year with prescription medications. We have a moral imperative and physicians have taken an ancient oath to significantly mitigate this awful situation using any & all means available. Are we really open and exploring all means available? The aviation industry invested enormous financial and human resources to achieve their brilliant and enviable safety record. Imagine what we could achieve for our patients with similar emphasis. Envision when our medical system’s reliability, and attention to detail intercedes to prevent medical misadventures as effectively as other high regret professions, such as aviation and nuclear power, where systemic errors are ruthlessly identified and crushed out of existence - ensuring that they never repeat. Imagine the relief for 200,000 American families whose loved ones will not have to die a senseless death next year from dangerous procedures when other more safe modalities could have worked first. These are our friends, family and colleagues that will be saved. Imagine when our system will routinely save the

Peter F. Demitry, MD, MPH

“Our healthcare system is crashing a fully loaded 747 airliner everyday filled with our friends, colleagues, and family members who believe they are getting safe, effective and vetted medical care.” 340,000 American lives currently lost as the profession steps up and embraces a culture where every life really does matter, rather then merely ‘saying’ that every life matters. This will and must change as the same carnage year-over-year will cause the system to erode all credibility and implode. It’s starting already. Imagine what it will mean as a profession when our health-care system isn’t the fourth common cause of death in America and admission into a hospital doesn’t require a full time family advocate in attendance as the ‘real’ insurance policy for survival. To attain this brighter future, US medicine will need many more tools in its Doctors’ Bag in addition to its pharmaceutical arsenal. Visualize a dozen new modalities supported by clinical outcomes and evidence that could be rapidly transitioned into your clinical practice. Imagine a profession that embraces rapid safe technology transition paradigms rather than the current 14-23 years (or longer) currently needed despite FDA approval and decades of evidence to change the standard. Imagine criteria for rapid clinical adoption being based on negligible side effects, efficacy, safety and cost profiles which are openly compared with currently accepted therapies of care for your critical review. What would it be like for the insurers to add value when you decide to use these modalities and they supported you? What if the insurance ‘payor’ function left the precision of personalized practice and

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Integrative Medicine

Peter F. Demitry, MD, MPH

art of medicine to those with the doctor-patient relationship and those with the legal physician accountability for each clinical outcome instead of insisting on the one size fits all paradigm that clearly doesn’t work. Listen to what it will sound like when personalized and precision medicine technologies become more than sound-bytes. The patients are learning and starting to ask and will soon be demanding personalized and precision at all levels throughout the health system. Do we think they will not understand that their different genotype and phenotype is irrelevant in the pharmaceutical selection and dosing without consequence? Imagine when insurance payors truly understand that the savings gained through endorsing these new modalities both increase their profits while simultaneously contributing to ‘good’ medicine and better clinical outcomes. Yes, doing ‘well’ financially by doing ‘good’.

Envision being able to see studies with transparent numerators and denominators and where all studies – both with positive and all the negative outcomes - are shared rather than just cherry-picking studies to drive sales.

Envision a future medical R&D culture where integrity is never a study variable and where journal editors promote multiple diverse perspectives which are institutionalized by the funding sources. Cloning of research ideas has a record of great waste. There are so many historical and current day examples. Visualize a vibrantly healthy professional culture of questioning and critically thinking clinicians with multiple perspectives and viewpoints, which is not only tolerated but also welcomed, encouraged and respected. A swarm of engaged questioning practitioners will overcome the silos of a few ‘thought leaders’ purported to solving our challenges. The swarm theory works in many applications. Consider how your practice could mature with transparent medical data presented in a clinically friendly format so you and your patients can make truly informed decisions on how to understand the clinical risks with associated costs.

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Integrative Medicine Marvel where the profession might soar to when integrity dominates and publicly and repeatedly valued and prioritized above all else – never compromised for personal fame or for personal / corporate profit. Imagine what it will feel like to awaken each day excited to start clinic and to witness miracles each day treating your patients and seeing them leave your office visibly better. Imagine what it will feel like to be excited about practicing medicine again! This is possible today. We see and hear this today. Do you see this in your practice?

Peter F. Demitry, MD, MPH nearly 40% of the current health care bill would be saved while simultaneously obtaining better clinical outcomes through the practice of Integrative Medicine. NFIM searches for existing and new technologies and approaches that simply work better than what we are doing today and then work to create the data and training to transition and add it to our clinical arsenals. The tenets in our global search for best in class technologies and protocols include:

About The National Foundation for Integrative Medicine

• We are open to everything – AND vested in nothing

The National Foundation of Integrative Medicine (NFIM) is committed to making this future a reality for all of us. We agree with the Bravewell Collaborative and Institute of Medicine studies where they concluded that

• Health always supersedes health-care

• We look for technology and modalities that work to create a superior safe & clinical outcome

• We do not pick winners or losers – we study and report on everything – you will decide • In God we Trust – Everyone else needs to bring DATA • Follow the Money – (From all the President’s Men) • We play ‘Money Ball for Medicine’ – Follow the Data (Lt Gen Chip Roadman, USAF Surgeon General)

“The tenets in our global search for best in class technologies and protocols include: In God we TrustEveryone else needs to bring DATA.”

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Integrative Medicine

Peter F. Demitry, MD, MPH meet the author:

“NFIM is committed to the collaboration with Today’s Practice as a strategic partner for researching and sharing technologies, honest studies and safe, effective, affordable approaches to health and health-care in America.” The calculus we seek is the full disclosure and transparent discussion addressing optimization of efficacy, safety and costs – we put it out there for all to see, question, debate and learn from. The real mission after all is working with providers to help their patients get back to living the most vibrant life they are capable of living. In this upcoming series of articles, we will start the discussion and debate on alternatives and approaches supported with decades of strong clinical evidence that address all types of pain without adding to the national opiate problem. Imagine a set of tools in your practice that allows you to treat your most difficult clinical pain challenges non-pharmacologically. It already exists, you and your patients just need access.

Peter Demitry, MD, MPH Executive Director National Foundation of Integrative Medicine

Colonel (Dr.) Pete Demitry retired from the US Air Force after over 28 years on active duty and served as the Assistant Air Force (AF) Surgeon General. Dr. Demitry earned his undergraduate degree with Honors from the US Air Force Academy in 1978 and his Medical Degree (MD) in 1986. Col (ret) Demitry graduated from the Air Force’s prestigious Test Pilot School in 1991 and holds the distinction as the only Test Pilot Physician in Air Force history. His test pilot assignments included directing the Advanced Fighter Technology Integration F-16 Joint Test Force, at Edwards AFB, CA — as the only physician to ever hold that position. Dr. Demitry completed medical residency training and research fellowship at Harvard in 1998 and was selected as the Chief Resident in his class. Dr. Demitry is a Diplomat (Board Certified) of the American College of Occupational and Environmental Medicine and a Fellow of the Aerospace Medical Association. Pete is a lifetime member of the Society of Experimental Test Pilots with operational/flight test experience in the F-4, A-10, F-16 and F-15 fighter aircraft. Dr. Demitry has piloted over 37 different types of jet aircraft logging over 2,300 fighter and flight test hours and has been transitioning medical technologies since his AF retirement. In addition to creating the medical vision for Meridian MPS,

Our members and patrons see these miracles every day. Change is coming. It is inevitable and will forever transform your practice one way or the other. There will be those who adopt and move forward to a much better place proving each step along the journey to themselves and their patients, and those that insist the present is adequate or good and will become irrelevant.

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T E CHNOL OGY

How Virtual Reality is

Improving Patient Reality By Ilya Druzhnikov, Co-founder, Exit Reality Think VR is all about gaming? Think again. Virtual reality has applications across the board and now this immersive technology is revolutionizing the healthcare industry. Everyone from psychologists and surgeons to doctors and dentists are exploring ways in which virtual reality can be helpful in facilitating patient care and treatment. Thus far the results have been nothing short of stunning and show promise across multiple applications.

As the technology becomes more affordable and widely accessible, patients all over the world will have increasing access to a broad spectrum of non-invasive, non-narcotic treatment options.

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Virtual Reality

Burn Treatment One area where virtual reality has shown the biggest promise and research-backed success has been in the arena of pain management. And nowhere is that impact quite as profound and heart-warming as when applied to pediatric patients suffering from severe burn injuries. While morphine can typically keep pain under control when patients are lying still in bed, there is no dosage of narcotics that can tame the excruciating pain burn victims experience during daily wound care sessions. Enter virtual reality. Shriners Hospital for Children in Galveston, Texas is one of several hospitals currently using the VR experience SnowWorld to help children in recovery. Created by Dr. Hunter Hoffman of the University of Washington, SnowWorld was designed to distract patients from pain during burn care by immersing them in a snowy landscape where they are tasked with throwing snowballs at snowmen, penguins and woolly mammoths. According to Dr. Hoffman’s research, patients who play SnowWorld during wound treatments report up to 50 percent less pain than similar patients who don’t. Other research suggests that patients engaging in the snow-capped virtual reality actually show changes in the brain that indicate they’re feeling less pain. This is because VR has an analgesic effect, lessening the severity of pain the patient experiences since the parts of the brain that are linked to pain – among them the somatosensory cortex and the insula – are less active when a patient is immersed in virtual reality.

Surgical Procedures Equally astounding, a surgeon out of Mexico City has been using virtual reality and nothing more than a local anesthetic for procedures and surgeries that would normally require powerful (and costly) painkillers and sedatives. With more than 350 successful surgeries under his belt, there’s evidence to suggest the technique

Ilya Druzhnikov is working. Dr. Luis Mosso Vasquez believes that if more doctors opt to use VR technology in lieu of costly drugs, not only will Mexican hospitals save money, but that they will also see fewer patient complications and speedier recovery times.

Phantom Limb Pain Millions of people in the U.S. are currently living with amputations. Of those, a significant number live with or are likely to experience phantom limb pain. The syndrome has proven difficult to treat and drug trials have failed to be effective. Thankfully, researchers have found virtual reality as a promising treatment to help amputees better cope with the pain. Through an immersive VR experience wherein the person’s motions are tracked and used to generate a virtual limb, the patient is not only able to perceive the missing limb, but also to control it by participating in a simple batting practice game. In a study on the effectiveness of this VR approach, a significant number of participants reported reduced pain and one participant even reported regaining some control over a residual limb that has been paralyzed.

Chronic Pain In addition to these acute pain treatment applications, doctors are beginning to experiment with VR as a means to treat chronic pain, a promising first step in addressing America’s much talked about opioid crisis. As reported in a recent Quartz article, patients suffering from chronic pain participating in two small clinical trials, “reported that their pain fell by 60 to 75 percent (compared to the baseline) during their VR session, and by 30 to 50 percent immediately afterwards. The best morphine does is 30 percent.” While most medical research in virtual reality applications for improved patient care has seemingly focused on pain management, the technology shows promise in other areas as well.

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Virtual Reality

Ilya Druzhnikov

Stress and Anxiety Disorders Ever since researchers at Georgia Tech first pioneered the use of virtual reality as an effective therapy for veterans who had undergone previous unsuccessful treatments for post-traumatic stress disorder in 1997, VR has continued to evolve as one of the most effective means to help patients from all walks of life suffering from PTSD. In fact, one in three people who experience a traumatic event – be it a car accident, robbery, natural disaster or battlefield incident - will suffer from PTSD, a condition best treated through exposure therapy. Virtual reality can recreate the situation in which the traumatic event occurred, allowing the patient to “re - e x p e r i e n c e” and process it while in a safe space.

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Virtual Reality In addition to management for stress disorders, psychologists have also explored the application of virtual reality in treating anxiety disorders. The treatment has proved especially effective to help people address fears like acrophobia, arachnophobia and claustrophobia. Given that over 19 million people in the U.S. are plagued by specific phobias, the effectiveness of virtual reality could pave the way for a better alternative to the use of medications.

Stroke Rehabilitation Virtual reality has also shown to advance recovery during physical therapy, as creating a virtual “physical” world can allow patients to practice re-learning functional tasks with increasing degrees of complexity, or make monotonous exercise more interesting. Stroke patients in particular have demonstrated marked improvements in arm and hand movement after four weeks of VR rehab as opposed to cohorts who undertook traditional rehab therapy.

Ilya Druzhnikov

“Virtual reality has also shown to advance recovery during physical therapy, as creating a virtual “physical” world can allow patients to practice re-learning functional tasks with increasing degrees of complexity, or make monotonous exercise more interesting.”

meet the author:

Wheelchair Training For previously ambulatory patients suddenly without the use of their legs, not only are they faced with the hurdles of emotional acceptance, they also have the physical challenges of learning to “drive” a wheelchair to overcome. VR is being explored as a means to help ease that transition. A team of designers at Fjord has come up with a virtual, urban environment that is designed to help first-time wheelchair users safely practice steering and navigating obstacles before having to tackle those new-found challenges in the real world. These applications are just the tip of the iceberg when it comes to ways in which virtual reality can revolutionize the healthcare industry as we know it today. And as the technology becomes more affordable and widely accessible, patients all over the world will have increasing access to a broad spectrum of non-invasive, non-narcotic treatment options.

Ilya Druzhnikov Co-founder Exit Reality

Ilya Druzhnikov is the co-founder of Exit Reality, which develops, deploys and manages VR infrastructure and services for out-of-home distribution to meet the needs of consumers, retail and the VR industry at large. A serial entrepreneur, he has founded two successful companies which led their segments: Panop in web personalization, which has been acquired, and ConnectAndSell in sales acceleration, which is currently in its growth phase. Between stints as a founder, Ilya is an early-stage investor and advisor in numerous startups ranging from genetics and bioinformatics to IoT and foodtech.

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The Influence of Technology on Tomorrow’s Medical Practices Superior Patient Care, Predictive/Preventative Protocols, Stronger Referrals, and 5-Star Physician Rating By Van Mayros

In Medical School, MBA Programs or most advanced Degree Programs, we learned over and over that “people are notoriously reluctant to change.” This includes Physicians. This is about to change. The rate of technological advancements, especially as it relates to medicine and

medical practices, is evolving at an exponential rate. In fact, I would dare suggest that many medical practices will begin to include a ‘Digital Technology Manager’ to monitor and introduce emerging technologies into the practices.

Even for small practices, the age of Big Data Storage and ‘live’ Real-Time Digital Data access is upon us.

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Tomorrow’s Medical Practices

The Quick Ten: For example, here’s just a small ‘Quick Ten’ sampling of such emerging technologies that will impact your practice in the months/years ahead: Artificial Intelligence (AI) digital diagnosis assistance software (such as IBM Watson) Patient Sensor Bracelets tied into the Practice’s patient’s new data analytics network

Van Mayros

The Impact:

Enables information gathering and expertise sharing, which will help Physicians and Physician Teams collaborate and design best-in-class programs that support patient care and program success.

Improves the busy Physician’s ability to more quickly and easily see and analyze once-invisible data and evaluate it based on the leading medical literature, the most current medical information, and evidence-based guidelines for each Patient in real-time with just a few keystrokes. These real-time insights will help as you plan the optimal care for each patient’s specific health needs.

Insurers can proactively manage preventive care for larger numbers of people with the goal of avoiding unnecessary tests and time utilization. Practices will eventually be incentivized to participate by the medical insurance companies, as well as, medical malpractice insurance companies.

Allows Physicians easier access to sift through available clinical trials and ensure that more patients (their patients) are accurately and consistently matched to the right trials.

Each Physician will see more data and deliver more comprehensive insight’s, so they can create a more informed Patient Healthcare Program that keeps patients moving toward their goals of better health.

Personalized Machine Learning Predictive Algorithms connected to National and Global Diagnostic best-in-class Benchmarks DNA Bio Marker Labs digitally linked into your Patient’s Medical Records for early identification of pending disease and preventative treatment therapies, protocols, and programs Integrated Patient Records connected to National RX and other Pharma Databases Patient Health records connected to local Digital/Social Media Healthcare Communities Seniors Remote Patient Robotic Monitoring with Patient Alerts to the Practice Wearable Techno Patches connected to the Patient’s Preventative Health Data Records Bio Physical Activity Bracelets tied into Patient Records Social Media Monitoring of Patient’s Life Events, Posted Symptoms, Health-Related Posts/Tweets, Referral Requests, Complaints, etc.

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Tomorrow’s Medical Practices

Van Mayros

Data to Knowledge (D2K) is no Longer the Objective. Some of you have heard the term Big Data term ‘Data to Knowledge’, or D2K. This means that although data are important, how you and your Practice use data will become more important. We’re moving to a D2K Practice Nirvana of real-time actionable patient knowledge at our finger tips using the patient’s own digital footprint. Simply stated, this means even small (1-2) Doctor Offices will have easy real-time access to a universal D2K platform of over 1.8 Billion people’s digital medical footprints and enormous health-related data facilities databases. This acquisition and analysis of data and its subsequent transformation into actionable insight is a complex workflow which extends beyond data centers, to the edge, and into the cloud in a ‘seamless’ hybrid environment. The key factor driving the adoption of data-intensive computing is the need to rapidly analyze exploding volumes of data at the point of creation and at scale. I’m a Physician - What does this mean? This means having up-to-the hour ‘Medical Intelligence’ on what your patients, and people within your community are talking about, their medical interests, their social medical complaints/concerns, medical purchase intentions, their life events impacting their health, their professional events impacting their health, their company plans, their friends and family linkages, medical predispositions, their medical sentiments, medical patterns, their lifestyles, their purchasing power, their travel likes and patterns, their planned purchase priorities, their viewing patterns, search patterns, their listening patterns, their health issues, etc.

This is Far Beyond the Needs of my Practice? Is it? How can any Physician possibly understand and keep up with all this patient and community data? Why should they? How does this benefit my practice? First and foremost, with respect to the data, you, the extremely busy physician will not have to ‘keep up with

the data’. AI, or Artificial Intelligence along with Real-Time Machine Learning Platforms will control much of this behind the scenes for the Practice as an ‘add-on’ application to their existing patient software system. These real-time AI Machines and Applications Software plug-n-play supplements will become a simple extension of the Practice’s existing medical patient software system helping explain much of the world’s patients and individual digital footprints and how these are impacting their health today and tomorrow. The Physician simply enters the Patient’s name, and the platform will provide all the real-time, or up to the hour digital footprints, predictive analytics, and data profiles of the Patient. These new real-time intelligence platforms are only a part of what’s in your practice’s techno pipeline. Because much of Social Media is ‘Opt-In’, this means your Patients have given permission to social surveillance companies to integrate YOUR patient data into their healthcare records. It’s public domain. For example, is some instances, it would be relevant to know what your patient’s digital footprint looks like and look behind their social curtain. Who they are? Where do they live? Work? Play? Want? Family/Friends linkages? Socioeconomic profiles? Lifestyle Profiles? Demographic Profiles? Companies they have an interest in? Products interested in? Again, in real-time with only the touch of a few keystrokes. Why is this level of patient data important? If a patient’s digital footprint contains several references to extensive upcoming travels, or they’re playing tennis extensively, and their medical records indicate a recent heart-valve issue, it would be imperative for the Physician, their physician, to bring this potential problem to their attention, or take preventative steps to correct the problem now as opposed to ‘down the line’.

The Next Generation of Practice Care Even for small practices, the age of Big Data Storage and ‘live’ Real-Time Digital Data access is upon us. For Medical practices, this basically means your

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T E C H N O LO G Y

Tomorrow’s Medical Practices Practice will become a single source of actionable and relevant patient and consumer information and surveillance at the touch of a button. This new plug and play software extension (Platform) will allow physicians to ‘simply’ and easily match, merge and form a single source of reliable, relevant and actionable patient data with a much higher diagnostic and patient care outcome. A single platform and source of patient ‘truth’ and care. We cannot emphasize enough the importance of understanding and embracing such new technologies as ‘Tricorders’ and ’54 biomarkers’ and integrating these emerging diagnostic and health preventative data into your patient data systems already in place today. Think of it as your own ‘Data to Knowledge’ systems extension. We live in a new data world. Embrace it and adopt it. These technologies are here, and they’ll continue to reshape your Practices!

Van Mayros programming software are driving these new patient insights. All the Physician (Practice) will know is many of the best in class D2K technologies are now available to for their respective practices. For the physician, all he/she will see is a much more extensive view of his/her patients requiring very little to zero technical learning. Monetary impact? Logically, yes, more revenue! These D2K add-ons will not only enhance patient care and perception, but practice branding where patients will become completely dedicated to their physicians because they’ll all easily recognize their doctor(s) honestly care about their health in both the short and long-term. This will create patient loyalty, plenty of referrals and 5-star physician ratings. meet the author:

Conclusion ‘Big Data and Preventative Data Analytics’ will become common lexicons of today’s modern Practices. No longer will be simple patient CRM-Style software be the norm. The systems outlined above are all in place today and ready as plug-in-play existing software additions. Costs? Gone is the need for large expensive data warehouses, complex data hygiene, data auditing, data governance requirements, etc., so expect these plug-in’s to be modestly priced. Privacy? All the systems described above are legally compliant since the data collected are almost always from opt-in open and deep web sources, social sources, search, and the best consumer and business profilers in the world. These new Patient D2K Platforms are the cumulative result of combining the very best technologies in the world under one umbrella and one practice’s current patient care software.

Van Mayros Chairman HM²O, Inc.

One of the nation's leading experts on helping organizations transform disparate data into relevant, useful and timely informational insights. Mayros data to knowledge (D2K) transformations have evolved into the Next Wave of Advanced Predictive Consumer Intent and Interest Analytics, or, 'Cracking the Consumer Intent Code' in Real-Time! Six-time Author (published books) on CRM, Marketing, Customer Acquisition, Marketing Automation, and the origin of global data repositories (The Internet).

Too technical? Behind the technologies, the physician will not see, nor care, that open source search pattern recognition algorithms, social surveillance cognitive pattern recognition, pattern and life event recognition, predictive correlation analytics, artificial intelligence, machine learning, complex event recognition correlation algorithms, and advanced natural language

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Visit adp.com/hellowork and see how we can provide a more human resource for your business.

| Payroll | Good TODAY’S PRA C T I C E: C HA NGI NG T HE BUS I NES SHR OFSolutions M EDI CINE 26 Job

T E C H N O LO G Y

Hungry, Hungry HIPAA...

Data Protection: Best Practices By David Mercy, IT Support LA “First do no harm” is a concise summary of intent, although not the actual wording present in The Hippocratic Oath. Doctors in any medical field have TWO responsibilities in this respect to their patients. First: The physical well-being of the patient. Second: The well-being of their information. Physicians are often more concerned with the treatment of their patients, and rightly so, however, HIPAA regulations and fines should also be taken quite seriously. Violations often happen inadvertently, but they can still place a great burden your practice. A patient will seek a second opinion immediately if their faith in their physician’s medical abilities becomes suspect, but what about the theft of their personal information? Breach of that trust can also lose a patient and incur negative ‘word of mouth’ affecting your practice and your standing in the community. Since the passage of the HITECH Act in 2009, the network of government offices concerned with Health Information Technology has been given the authority to establish programs presiding over a number of areas to improve health care, and the main enforcement arm of this body is HIPAA, which is expanded and given more teeth with which to punish violators every year since. In

July of 2016, The Health and Human Services’ Office for Civil Rights (OCR) greatly stepped up its auditing program. As Government agencies do, once they start levying fines and generating payments, they smell money. Just make sure that lovely green fragrance isn’t coming out of your medical offices. Watch out for this side note: If you are sent an email by the OCR concerning an audit: It should come from ‘OSOCRAudit@hhs.gov’. Check the address carefully – if it has an extra dash and ‘us’ at the end, as in ‘OSOCRAudit@hhs-gov.us’, it is a Phishing scam encouraging you to click a malicious link (do not click). “I’VE GOT INSURANCE” … BUT: ARE YOU COVERED FOR HIPAA FINES? Maybe, maybe not: Read the wording on your Cyber Liability or Data Breach Insurance policy carefully. You may be covered for some HIPAA fines, but not all, and although you may have $1,000,000 in coverage, there is often a ‘sublimit’, like a deductible, which could be $200,000, which monies you may still be responsible for. With many HIPAA fines being in the neighborhood of $50,000, that’s a hit directly on your own pocketbook.

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FI N AN C E

Data Protection CIVIL MONETARY PENALTIES: Covered entity or individual did not know (and by exercising reasonable diligence would not have known) the act was a HIPAA violation. $100 - $50,000 for each violation, up to a maximum of $1.5 million for identical provisions during a calendar year. The HIPAA violation had a reasonable cause and was not due to willful neglect. $1,000 - $50,000 for each violation, up to a maximum of $1.5 million for identical provisions during a calendar year. The HIPAA violation was due to willful neglect but the violation was corrected within the required time period. $10,000 - $50,000 for each violation, up to a maximum of $1.5 million for identical provisions during a calendar year. The HIPAA violation was due to willful neglect but was not corrected. $50,000 or more for each violation, up to a Maximum of $1.5 million for identical provisions during a calendar year. Note that fines have gone well above these limits: Advocate Health System: $5.55 million. CIGNET: $4.3 million. N.Y. Presbyterian Hospital/Columbia University: $4.8 million (N.Y. Presbyterian hit again for $2.2 million 6 years later). Triple-S $3.5 Million. University of Mississippi Medical Center: $2.75 million. Oregon Health & Science University: $2.7 million. Plenty of others have paid the $1.5 million and above.

David Mercy There have been prison sentences and terminations to consider: 6 doctors and 13 employees of UCLA Medical Center were fired for merely looking at Britney Spears medical records when they had no legitimate reason to do so. Better to look at her album covers and not kill your career.

DATA PROTECTION: THE FIVE MOST CRITICAL DO’s and DON’Ts DO encrypt ALL patient information. Data should automatically encrypt when it’s backed up to the cloud, but you need to ensure that all data on your office network is encrypted as well. Faithfully encrypting your data makes some of the following irrelevant. DON’T leave unencrypted data on mobile devices (laptops, iPads, iPhones etc.) Just ONE example: The theft of one of these devices with unencrypted ePHI incurred a $50,000 fine for a Hospice in Idaho. If found to have poor risk analysis and office policies, like a Massachusetts Eye and Ear Infirmary, fines could reach $1,500,000. DO take care with passwords: Make them hard to guess (1234 or 4321 just doesn’t cut it) – make it easy for YOU to remember: ‘My anniversary is May 23’ becomes Mai523 - it’s harder to crack, plus you’ll never forget your anniversary. Don’t write them down, share them or use the same password for everything, because when cyber thugs crack it, they have the keys to your kingdom and the looting begins. DO take notice of ANY email anomalies: If something is off, different than the norm, a red flag needs to go up - a different format for a vendor; if there’s a link or attachment where usually there isn’t one, for example in a PDF file; any message from within your company that is unusual – someone may have spoofed (copied) the email address. THINK TWICE before clicking any links or attachments!

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DO keep all patient data safe, whether on paper or on the network. Nothing left in an unattended area, on a copy machine, fax and particularly at the reception area. You need to protect patient information in every format, no matter where it is. For a complete list, please visit www.itsupportla.com/cyber-security-dos-and-donts/ In all honesty, many medical professionals don’t seem that concerned about HIPAA, but you should be. Once you’ve been stung by a massive fine, you are on the OCR’s radar, which is not a good place to be. Aside from chipping away at the profitability of your practice, neglect of any kind will negatively impact your reputation. It takes no more to be HIPAA compliant than it does to ensure that your network in general is secured against attack. Don’t wait for theft or a Ransomware lockdown of your data to cause you to act. An ounce of prevention is, after all, worth a pound of cure.

meet the author:

IT Support LA is dedicated to protecting privacy; safeguarding the State’s information assets and infrastructure; identifying and mitigating vulnerabilities; detecting, responding and recovering from cyber incidents; and promoting cyber awareness and education. We stand ready to assist and support you in your cyber security risk management efforts. Remember - cyber security is everyone’s responsibility!

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a creative resource divisioniv.com

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One out of five businesses? We disagree.* Together, we’ll bring your company to fruition. And beyond. BRANDING | CAMPAIGN DEVELOPMENT | CAPITAL ACQUISITION PRESENTATIONS | WEB/INTERACTIVE DEVELOPMENT

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POPULATION HEALTH SERIES

Why Effective PHM Requires a Real-Time Clinical Perspective By Pranam Ben, founder and CEO, The Garage Clinical laboratories have been an essential component of safe and effective care delivery since at least the early 20th Century. Yet only in recent years have healthcare providers begun to explore ways to leverage that clinical lab data, along with numerous other types of information, to manage populations of at-risk patients — even prevent potential adverse health events. Effectively managing patient populations is important for clinical integrated networks (CINs) not just because it is in the best interest of patients, but also because it can deliver financial dividends to the organization. As hospital and health system profit margins continue to shrink, driven by greater expenses, CINs and other provider organizations need to explore new methods to deliver care efficiently and reduce costly care interventions. The key is to capture the widest scope of available timely data from multiple sources, especially clinical labs, and then analyzing that information to monitor populations and intervene when a potential negative outcome is identified. When properly deployed, organizations can decrease costly emergency department care and readmissions while improving adherence to providers’ treatment plans. Both of these population health management improvements can drive increased reimbursement under value-based payment models.

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Leveraging Lab Data Lab values are responsible for 60 to 70 percent of all critical clinical decision-making such as admittance, discharge, and medication, according to one highly cited study. Lab results, however, are only recently being fully leveraged with other patient data from the EHR, claims, patient portals, disease registries and other sources to better understand patient behaviors and predict outcomes. This applies to a single patient, but also for populations as well. For example, a provider organization can leverage patient lab data, as well as metadata such as zip code, gender and age group to identify trends among similar patients over the last 10 years. In collaboration with their technology partners, physicians can develop analytic models based on that data to target designated patient populations and the associated reporting requirements of any value-based care program. To be useful for clinical decision making, lab values and other data need to be

updated in real-time, or as timely as possible. Timeliness can be a challenge when CINs depend on laboratory testing ordered by physicians outside their organization, where results can take days to weeks to obtain. Rather, organizations need near-instant access to lab and other data from throughout the care continuum so they can ensure that individual interventions as well as at-risk population trend analysis is accurate and reliable.

Seamlessly Linking Disparate Systems Whether capturing values from a single internal lab or a large, nationally respected lab company, organizations need a centralized virtual location for accessing data and analytics to drive physiciansâ&#x20AC;&#x2122; decisions. That is where population health management technology plays an essential role. CINs that are already fully integrated across a single EHR platform in their hospitals, clinics and rehabilitation centers may have an advantage in that they only need to integrate one such system with a population health management tool. Few CINs, such as those that were created exclusively for accountable care organization (ACO) programs, are all technologically aligned in this way. For instance, ACOs formed from independent physician practices and medical groups, and perhaps a community hospital, may face a major

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integration challenge integrating five or six EHRs with a population health management tool. More advanced, cloud-based population health management platforms, however, can be easily integrated with any EHR system. That means that these tools can easily capture information from across the care continuum and normalize the data so that every provider can easily access and interpret the information regardless of their location or specialty. When vital data is accessible in real-time, physicians can have deeper insight into their patients’ health status and risk level. Providers can then efficiently and confidently move forward with interventions and treatment plans while managing reporting requirements on standard quality instruments such as the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) Quality Payment Program’s (QPP’s) Advanced Alternative Payment Models (APMs) or the Merit-based Incentive Payment System (MIPS).

Making The Data Do The Work Although nearly all patient information is now available electronically, too many physicians and providers need to manually access, capture and combine data from multiple systems, including the lab, to have a holistic, but also granular view of their patient or population risk level and care utilization. Not only do physicians no longer have time for such investigations, this inefficient process adds to costs that ends up impacting revenue under value-based care payment models. Instead, CINs and other integrated healthcare organizations are recognizing the need for a centralized population health management tool to deliver timely clinical insight in a fraction of the time. When combined with crucial lab data and other information from across the care continuum, CINs can reduce care costs to maximize their reimbursement in value-based care payment programs, such as the QPP.

“More advanced, cloud-based population health management platforms, however, can be easily integrated with any EHR system.”

meet the author:

Pranam Ben Founder & CEO The Garage

About The Garage: We’ve had that eureka moment. We’ve brainstormed, refined, built, revised and launched successful technology solutions. Cultivating great ideas – and successful business models – is what we do best. It’s who we are. Our ability to question everything, observe every minute detail, network internally and externally and experiment via rapid prototypes builds a culture of innovation across the company. Our execution discipline purely focuses on delivery of all work products on time and on budget.

https://www.healthitoutcomes.com/doc/why-effective-phm-requires-a-real-time-clinical-perspective-0001

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A Very Real, Very Expensive Outcome.

Physician Burnout By Gregory Sanders, MD Physician burnout is real and prevalent. According to the U.S. News & World Report, 54 percent of doctors in this country meet criteria consistent with burnout. So, what exactly is physician burnout and how can we detect it early? While it is easy to recognize blatant exhaustion, burnout symptoms can also be more indirect. We have all encountered doctors who become cynical towards medicine and the medical system in general, and in my opinion, this is the first early sign that burnout is coming. An overall negative attitude starts during training, where harmless complaining eases the burden of a grueling residency or fellowship program, and seems to bond us together like soldiers. But is it harmless? The first few years beyond training are sheltered from burnout due to financial rewards and a newfound self-rule which has been finally realized after a decade of education. As the years pass, frustration with practicing in a heavily regulated environment starts to sink in. So, what do we do? Well, we tend to revert back to our old coping mechanisms, and vent to partners and colleagues. We gripe

about all sorts of issues ranging from declining reimbursements to clunky electronic health records to hospital politics. It is important to mention that physicians in an academic or hospital-employed model complain about different issues than doctors in private practice. There is substantial overlap but employed physicians tend to be frustrated with hospital administrators and loss of professional autonomy, while physicians in their own practice are challenged by reimbursements, healthcare policy, and addressing their competition. The common theme at the root of dissatisfaction and eventual burnout is that external forces are disrupting physician workflow and impacting success (financial and professional). Doctors have spent decades training under the regime of delayed gratification, so once out in the world they want to practice their way and do not tolerate micromanagement. An ever-increasing workload with less financial reward has not helped the situation.

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Physician Burnout My personal experience is similar to many doctors in this country. I have been in a private practice for 15 years and have seen healthcare change dramatically. My own burnout symptoms have bubbled to the surface at times, offset by rewarding patient encounters and relative job stability in a volatile national employment market. My story does take some unexpected turns. With a background in computer science, I have used software development to solve workflow problems in my medical world. In residency I built a system which managed our complex call scheme. In fellowship I developed a searchable echocardiogram database which is being used for research purposes. Once in private practice I created a software platform to manage rounding at multiple hospitals. Over the years this product grew to include charge capture, secure messaging and discharge management. Ultimately, my little creation has spread to over 20 states in the US, enhancing the workflow of providers of all specialties. Developing this software solution saved me from burnout. It continues to be an outlet to take control of my work environment and institute meaningful change. Instead of relying on out-of-touch commercial products to dictate my workflow, I fixed it myself. Providers know their worlds better than any computer programmer or corporate CEO ever will, and solutions with worthwhile results are not met with the same antagonism as products which merely disrupt while providing little improvement. It is important for physicians to find their voice and take back control of their destiny. I have seen colleagues gravitate towards administrative roles in the hospital or in medical societies, which can produce

Gregory Sanders, MD the same positive effect. Lack of free time is the major obstacle to physician participation. Attending meetings on top of clinical responsibilities and a personal life is simply too much for many doctors. Recently, I have seen an emergence of innovation and startups led by medical professionals. Whether it be devices, software or even DNA analysis, these creative solutions from within our field help to restore our autonomy. Most medical professionals I encounter will proudly state that taking care of patients - the actual practice of medicine - is the most rewarding component of their career. This is the driving force behind our desire to enter medicine in the first place, so this should come as no surprise. Finding ways to avoid burnout by becoming more engaged and taking back some control will enable physicians to enjoy once again taking care of their patients. meet the author:

Greg Sanders, MD Cardiologist and CEO HybridChart

About Hybrid Charts: HybridChart is a mobile-friendly, HIPAA compliant, comprehensive hospital charge capture system that integrates seamlessly with various EHR and helps specialty practices increase their revenue, streamline their discharge process to improve readmission rates, and eliminate the headache of having all of their information in different places. This tool puts charge capture, census management, discharge planning, quality metrics and secure messaging - all in the palm of the hand of the provider at the point of care.

Have You Scheduled Your Practice’s Wellness Visit? While patience care and your pursuit of your mission are your group’s first priority, your Business of Medicine still needs its annual checkup.

The cost of losing an employee can range from tens of thousands of dollars to twice their annual salary. Source: “Employee Retention Now a Big Issue: Why the Tide,” www.linkedin.com, August 16, 2013.

9RECRUIT. 9RETAIN. 9REWARD. H I G H LY Q UA L I F I E D E M P LOY E E S

Your wellness visit will validate:

9 The impact of an unexpected death or disability has been addressed

9 Key employees are retained 9 Aging partners are on track to efficiently exit 9 Routine business tasks are not keeping you from your core business and revenue generation opportunities

Ted Waldron, President 165 Middlesex Turnpike #104 Bedford, MA 01730 781.271.0402 Ted.Waldron@LFG.com

For Financial Professional use only. Lincoln Financial Advisors Corp. and its representatives do not provide legal or tax advice. You may want to consult a legal or tax advisor regarding any legal or tax information as it relates to your personal circumstances. Securities and investment advisory services offered through Lincoln Financial Advisors Corp., a broker/dealer (member SIPC) and registered investment advisor. Insurance offered through Lincoln affiliates and other fine companies. Physician’s Financial Network, LLC is not an affiliate of Lincoln Financial Advisors Corp. CRN-1665229-121616

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Cancer

Survivorship By Manpreet Chadha, MD There are estimated to be 14 million cancer survivors in the United States based on a report by US Centers for Disease Control and Prevention and National Cancer Institute, and more than 32 million cancer survivors worldwide. Unfortunately, many of these cancer survivors experience long-term side effects including physical, psychosocial and emotional. Cancer of breast, prostate, colon and rectum, and melanoma together accounted for more than half of cancer survivors. More than 46% of the cancer survivors are over 70 years of age. At least 50% of survivors experience some late effect of cancer treatment. As the number of cancer survivors continues to grow, it is important to address the unique needs of these survivors. Many survivors face limited access to healthcare specialists, a lack of information about promising new treatments, inadequate or no insurance, difficulty finding employment, and psychosocial struggles.

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Cancer Survivorship An individual is considered a cancer survivor from the time of diagnosis through the balance of his or her remaining life. Coordination of care between primary care providers and specialists is of most importance and focus should be on developing a survivorship care plan which includes educating survivors about their follow-up schedules and communication with other care providers on management. The current article focuses on care of survivors after completion of cancer treatment and typically in clinical remission. General Assessment Cancer survivors should be periodically assessed to determine any necessary intervention and needs at least on an annual basis by either their primary care providers or oncologists. These assessments are directed mainly to determine whether the possible or contributing cause for symptoms like disease status, functional status, medications (including over-the-counter and supplements), comorbidities, review of prior cancer treatments, family history and psychosocial factors. Special detail should be focused on anxiety, depression and distress experienced by cancer survivors. Pertinent issues are addressed in more detail below. Cardiac Toxicity Cardiac toxicity is particularly seen in patients who receive anthracycline based chemotherapy regimen. In addition, breast cancer patients who receive Her-2 directed therapy are at higher risk. Anthracycline induced heart failure can take years or even decades to manifest. Her-2 directed therapies can cause cardiac dysfunction even early on. The risk for cardiovascular problems depends on type of anthracycline use and cumulative dose received. 2D Echo should be done in cancer survivors who have one or more cardiac risk factors within one year after completion of anthracycline therapy and subsequently as guided by clinical course.

Manpreet Chadha, MD Psychosocial side effects Cancer survivors commonly experienced distress which is defined as a multifactorial, unpleasant, emotional experience of a psychological, social, and/or spiritual nature which may interfere with ability to cope effectively with cancer, physical symptoms and treatment. Medical treatment should be initiated early on in patients who require pharmacological and non-pharmacological interventions. Screening for substance abuse should be considered in patients who appear to have drug-dependence and referred to substance abuse specialist done accordingly. Referral to psychiatry should be done early on in care. Growing evidence supports the validity of patient-reported cognitive dysfunction. Neuropsychiatric testing and brain imaging can help provide objective evidence of cognitive dysfunction following cancer treatment. There is limited evidence to guide management of this condition. Depression should be ruled out for cognitive decline. Cognitive Rehabilitation can include occupational therapy, speech therapy and neuropsychology. Use of psychostimulants like methylphenidate or modafinil should be considered under specialist guidance. Fatigue Fatigue is one of the most common complaints and individuals undergoing cancer therapy and can be related to immediate side effect of chemotherapy. Moderate fatigue lasting up to one year can occur in the proportion of cancer survivors and it is common in patients who have received chemotherapy and or radiation. Fatigue can be rated on a scale of 0 to 10 similar to Pain Scale. Contributing factors like comorbidities , alcohol and substance abuse, cardiac dysfunction, endo-

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crine dysfunction, family dysfunction, renal dysfunction, anemia and arthritis should be assessed thoroughly. Medications should be reviewed. Sleep disturbances should be ruled out in contributing to fatigue. Loss of muscle mass has been associated with deconditioning and fatigue in cancer patients. Regular exercise including rebuilding exercise can help attain a better muscle mass and reduce fatigue. Adequate nutritional status should be encouraged. Thyroid function and cortisol stimulation tests should be done in relevant clinical scenario. Pain Pain is a common symptom in cancer patients and survivors. New, acute pain points towards possibility of cancer recurrence. Neuropathy is one of the most common pain symptoms that cancer patients experience and is usually related to prior chemotherapy used specifically with taxanes and platinum based regimens. Non opioids are the most common medications reviewed used for such pain syndrome. Use of gabapentin and pregabalin is commonly done for neuropathic pain. Duloxetine is also used for management of neuropathy pain. Opiods should be reserved for refractory cases with use of lowest appropriate dose and for shortest duration of time. Patient with chronic pain may be well managed by a pain specialist team. Physical therapy for desensitization and cognitive therapy may help patients with post radical neck dissection syndrome. Botulinum injections may be helpful for such patients. Post mastectomy or post thoracotomy syndromes can be managed with use of intercostal nerve

blocks. Use of non-pharmacological measures like physical activity, heat /cold pack, aquatic therapy, ultrasonic stimulation, massage, acupuncture, and yoga have been explored for same. Lymphedema Lymphedema is commonly noted in patients have had lymph node dissection and radiation for various different cancers. Referal to lymphedema specialist if available should be done early on in the course. Compression garments like compression sleeves or stockings should be considered. Progressive resistance training is helpful for reduction in lymphedema. Sleep disorders Lack of sleep and excessive sleepiness are both noted in patients with cancer survivors. Sleep disturbances can be attributed to other comorbidities like alcohol or substance abuse, cardiac dysfunction, respiratory disorder, anemia and iron deficiency, emotional distress or psychiatrist disorder. Hot flashes are the common symptoms of

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Cancer Survivorship sleep disturbance in patients with breast and prostate cancer. Caffeine intake and review of medications including supplements should be done. Coping strategies including relaxation techniques and meditation have been helpful. Patient with chronic symptoms should be referred to sleep specialist for sleep studies.

There is no current evidence to support the use of weight loss supplements and cancer survival. Patient should be screened for vitamin deficiencies based on their cancer treatment and these deficiencies should be corrected interpreted as needed. Vitamin D replacement for adequate bone health is consider it in many cancer survivors.

Healthy Lifestyles Cancer survivors should be encouraged to achieve and maintain healthy weight to improve overall health and quality of life. In some cancers, this has been associated with reduced risk of cancer related death and risk of recurrence. Patient should be encouraged to engage in physical activity regularly and to maintain a healthy body weight throughout life. At least 150 minutes of moderate or 75 minutes of vigorous activity per week should be done spread out over the course of the week. Two to three sessions per week of strength training including major muscle group should be done. Stretching of major muscle groups on a regular basis is helpful as well.

Immunizations Use of inactivated vaccines is considered safe in most cancer survivors. Vaccination schedules can be reviewed at CDC website. Certain cancer vaccine such as live attenuated viruses are contraindicated in actively immunosuppressed individuals specifically in survivors with lymphoma and other malignant neoplasm affecting bone marrow or lymphatic system or history of immune deficiency. Vaccine should ideally be administered approximately two or more weeks before cancer treatment and three or more months after cancer chemotherapy. Inactivated influenza vaccine can be administered during cancer treatment. Live virus vaccines can be administered for two more weeks before cancer treatment or three or more months after chemotherapy is completed. In patients who receive anti-B cell antibody therapy, vaccination should be delayed for at least six months after therapy. Patients with hematopoietic stem cell transplants need special guidance from their transplant physicians on timing and safety of vaccinations.

Nutrition habits should be discussed and reviewed regularly. Calorie intake is helpful in maintaining a healthy BMI. “Prudent diet “has been associated with reduced risk of cancer recurrence.” Limited intake of red or processed meat, and it is recommended to use lean proteins like poultry, fish, legume, low-fat dairy and nuts. Fat sources such as olive or canola oil, avocados, nuts and fatty fishes are encouraged. Fruits, vegetables, whole grains and legumes should be the main source of carbohydrates. Fat should be no more than 20 to 35% of total intake, with saturated fat being less than 10% and trans fat less than 3%. Carbohydrate should be 45 to 65% of dietary intake with high intakes of fruit, vegetables and whole grains. Protein should contribute 10 to 35% of total intake with the goal of 0.8 grams per kilogram.

Manpreet Chadha, MD

Screening for other cancers Routine surveillance for cancer recurrence is typically done per US preventive task force guidelines for all cancer survivors. However second cancers can be noted in cancer survivors at higher rate than in general population because of genetic susceptibility like cancer syndromes, common predisposing factors like smoking, obesity and carcinogen exposures and/or mutagenic effects of cancer treatment (like secondary leukemia).

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Cancer Survivorship

Manpreet Chadha, MD

Lifestyle changes that include smoking cessation, increasing physical activity and weight loss should be encouraged. Patients who have had inherited cancer syndromes should be screened according to guidelines for them. Conclusion Management of survivorship issues involves a multidisciplinary care team with involvement from oncology and treating primary care physician. Involvement of specialists should be considered as guided by clinical condition. Survivorship care plan should be increasingly utilized as a mode to communicate between oncologist and other treating physicians. meet the authors:

Manpreet Chadha, MD Paloverde Cancer Specialists

Dr. Chadha completed her medical school in Delhi, India. She was honored with multiple gold medals during her medical school for academic excellence. She completed her residency in Internal Medicine in Buffalo, New York and Medical Oncology Fellowship at Roswell Park Cancer Institute which is among the oldest National Cancer Institute’s prestigious Comprehensive Cancer Centers in the U.S. Thereafter, she worked as an attending physician at Roswell Park Cancer Institute. She actively participated in phase II and III clinical trials for patients with advanced malignancies. She has worked as an assistant investigator at TGen Clinical Research Services at Virginia G Piper Cancer Center, Scottsdale. During her time at TGen, she was the principal and co investigator in various Phase I, II and III studies involving new therapeutics for patients with advanced cancer. She has more than 40 publications, book chapters and abstracts in national meetings. She joined Paloverde Cancer Specilaists in 2010 and continues to engage in research studies in her current scope of practice at Paloverde Cancer specialists. Dr. Chadha became inspired toward her present path when her grandmother suffered from pancreatic cancer. She is very passionate about caring for her patients and seeking improved ways to deliver quality cancer care. Dr Chadha enjoys travel, painting with oil and acrylic and yoga. She is very fond of sunflowers, “They always keep their face toward the sun (hope).”

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M A RK E T I NG

THE EVOLVING ROLE OF MARKETING By G. Kelly O’Dea Odds are that when today’s physicians completed the long journey through med school, they didn’t expect they would also need the equivalent of an MBA to build a successful practice.

with focus on the fundamental building blocks of marketing that must be addressed first.

The information age, increased competition and Obamacare have spurred major change and challenge in virtually every aspect of physicians’ lives. The simple and uncomplicated days of Marcus Welby MD have faded well into the past.

TP: There has been a tremendous increase in marketing noise. Why do physicians need marketing at all?

Today’s Practice invited G. Kelly O’Dea, noted marketing expert and member of the Meridien Medical Advisory Board, to provide his perspectives and insights into the forces of change and how they affect physicians’ ability to compete successfully. This is the first in a series of interviews across a number of marketing issues. This interview begins

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Most physicians regard marketing as castor oil – you don’t like it but you know you need it. I understand that but would argue that marketing has become vitally necessary for survival, competitiveness and success in today’s market. It can and should become an elixir in driving a successful practice. The problem is that most of marketing activity isn’t doing the job that needs to be done.

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Evolving Role of Marketing TP: How would you diagnose the state of marketing today? Largely disappointing and wasteful. I would point to three main reasons why: Failure to understand what marketing is today. Too often, marketing is regarded as simply an advertising / PR function – “advertise and they will come.” In fact marketing should be about the total approach, founded on strategy and meaningful differentiation, which drives all activities at all points of patient contact. A vital first step is often missed: Doing your homework on both the market and your practice. Most physician practices don’t do sufficient analysis of the market, competition and patient needs to identify how they can successfully fit into the market in a differentiated manner. Not understanding the new power of customer engagement. Patients have become Customers, armed with unprecedented access to information and the power to make choices. They will bypass you if you don’t provide a meaningful reason to be considered. Most of today’s marketing has little meaningful differentiation. Do an experiment I call “The Wall Test.” Put a representative sample of competitive ads in your market on a blank wall. Now stand back and see how much differentiation you can find. Chances are you won’t find much. Now put your ads up against the competition. Chances are you and your brand won’t stand out. This means that there is considerable waste and lack of performance. TP: So, what’s the way forward? For marketing to work, it must be founded first on analysis and then development of a differentiated brand. Only then can you begin to implement

G. Kelly O’Dea consistently across every point of customer contact. Otherwise you risk disappointment and waste. Ask yourself a question: What is my brand and how is it differentiated in a meaningful manner that causes engagement with your prospects? The brand is embodiment of your relationship with the market you serve. It is the cornerstone idea that drives everything you do in marketing yourself or your practice, at every point of contact. If you don’t know your brand and how you’re different, that’s a problem that needs to be corrected. Only then will you see the vital role marketing can play in the success of your practice. Physician, brand thyself! TP: How can you tell if your marketing is working? First of all, change your viewpoint. Make the transition from marketing as castor oil to marketing as an elixir in viewing marketing’s role in your success. Stop looking at marketing as merely an expense. There must be value delivery in the form of improved business and reputation. Excellent brands are built like birds build nests, the desired outcome is known but it builds in stages. Here are some diagnostic questions to ask to see if your brand is building in the right direction: Are customer prospect inquiries increasing? Where are your inquiries coming from? Are your word of mouth referrals increasing? Are new customers increasing? Do you ask for their feedback? Why did they choose you?

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Evolving Role of Marketing

G. Kelly O’Dea

How are you doing with them once they become customers? Do existing customers stay with you? Are you beginning to stand out vs. your competitors?

meet the authors:

G. Kelly Odea Senior Advisor & Marketing Technologist

----------------------------------------------------------The answers to the above questions help you understand whether or not you’re actually engaging with prospects and customers in a way that produces results. In the next interview, we’ll focus on communications planning and execution in today’s new media marketplace. Your comments and questions are welcome.

Described in a Harvard Business School case as a “global marketing pioneer, business builder and change leader,” Kelly is a broadly experienced executive with a consistent growth record across disciplines, major market categories, multiple countries and C-level positions in public and private companies from established to early stage. Senior advisor to clients in such companies as IBM, Microsoft, Shell, Samsung, Boeing, Compaq, Ford, Fujitsu, AT&T, PepsiCo, Kraft and Unilever. Resume includes: President – FCB (Foote, Cone and Belding Worldwide) (NYSE: IPG); Vice Chairman/Global Operations – Bozell Worldwide; President – Worldwide Client Services, Ogilvy & Mather (NASDAQ: WPPGY). At each company, led and restructured the global client mamagement organizaton around the 7S and transnational network models, leading to significant growth in revenue, reputation, operating profit.

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Effective Business

Succession Planning Edward J. Waldron In conjunction with Lincoln Financial Advisors

Business owners invest significant amounts of time and financial resources to make their enterprises successful. Quite often, due to the quick pace of day-to-day operations, planning for succession of ownership is relegated to a low-priority task. But there comes a point in the lifecycle of any business when the owner is no longer able to manage the firm that he or she founded. Because the timing of death or disability is difficult to predict, it’s prudent to have a succession plan in place now to safeguard your family’s financial well being, and to provide your business with leadership during a transition period. One logical solution—and one that most entrepreneurs may want to choose—is to turn the reins over to their children. However, despite its emotional and intuitive appeal, the odds are stacked squarely against a business surviving a transfer down the bloodline. According to the U.S. Small Business Administration, two-thirds of family-run enterprises fail to make the successful transition to a second generation of ownership, and less than 15% survive into the third generation. Making a successful transition even trickier are issues brought on by divorce, blended families, or rivalries among children.

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Succession Planning The best course of action may be either to identify strong candidates within your company who can continue to run the business and provide a source of financial security for your family, or to look at the potential for selling the business to an outside party. Whichever course you eventually decide is right for your business, there are steps you can take now that will ease the transition.

Groom new management. Who is best able to run the business in your absence? Perhaps your children have spent years growing up in the business and have become capable managers in their own right. If not, look to your existing management team, and make your intentions known. Be sure that candidates are capable and interested in taking over.

Edward Waldron, RFC

ESOPs. If you have a large number of employees, another option is an Employee Stock Ownership Plan (ESOP), whereby a bank lends money to the ESOP to purchase your interest in the business, and the employees then buy the shares through regular payroll deductions. Planning for succession can be an unpleasant task, although the outcome can be even more unpleasant if you fail to plan. You’ll have a lot more options if you start to plan when things are going great. What you don’t want is a situation where your family is scrambling to salvage some value from the business after you’re gone.

Determine a value. Work with a valuation specialist to get a fair assessment of what your business might be worth. While valuation analysis may be an art as much as it is a science, you should place a value on your business in the event you decide to sell. There are several valuation methods, including book value, discounted cash flow, or you could hire a professional appraiser. If you decide to transfer the business to your children, a professional appraisal is generally required to withstand IRS scrutiny.

Draft a buy-sell agreement. Depending on the structure of ownership, this document will be a binding agreement detailing the terms of ownership transfer between you and your offspring, you and a non-family successor, or you and your partners. Be sure to specify how the agreement will be funded.

meet the author:

Ted Waldron, RFC Certified Financial Planner

Edward Waldron, RFC is a registered representative and investment advisor representative of Lincoln Financial Advisors Corp., a broker/dealer (member SIPC) and registered investment advisor,165 Middlesex Tunpike, Suite 104 Bedford, MA offering insurance through Lincoln affiliates and other fine companies. This information should not be construed as legal or tax advice. You may want to consult a legal or tax advisor regarding this information as it relates to your personal circumstances. The content of this material was provided to you by Lincoln Financial Advisors Corp. for its representatives and their clients. CRN-1228974-061715

Proceeds from a life insurance policy are frequently used as a way to fund a buy-sell arrangement. Other options include loans from a bank or company earnings that are paid back through an ‘earn-out’ arrangement with your successor, whereby the loan is paid back in regular installments.

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KEYS TO MEDICARE

AUDIT DEFENSE

Understanding and Protecting Your Practice Against Medicare Auditors Stephen D. Bittinger, Esq. Stop. Take a deep breath, and let us take some fear out of every private physician’s worst nightmare – a Medicare audit. First and foremost, you must educate yourself on what is out there, understand how to identify and correct current problems, and proactively work towards audit prevention. If you only take private payers, ask yourself how many of your current private payers include Medicare Advantage Plans, how many of your patients are part of a Federal Employees Plan, and does your practice receive Medicaid or Federal Medicare Supplemental Funds as partial payment from private payers. All of these reimbursements ultimately trace back to Medicare Trust Funds and fall under the authority of Medicare audit contractors review.

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7 Keys to Medicare Defense As most of you know, Recovery Audit Contractors (“RACs”) – error and omissions based auditors – have been ravaging their way down from hospitals to larger private practices. However, many of you may not know that CMS has more recently awarded separate auditing contracts to Zone Program Integrity Contractors (“ZPICs”), which perform fraud and abuse investigation. The Office of the Inspector General’s (“OIG”) Work Plan for Fiscal Year 2015 (“FY2015”) reported that CMS contractors in FY2014: • Recovered over $4.9 billion of Medicare funds; • $3 billion was from investigative contractors (ZPICs); • $834.7 million was from audit contractors (RACs);

Stephen D. Bittinger

7 Keys to Preventing and Defending Medicare Audits 1. Protect your NPI. The vast majority of all payer audits are triggered because the volume or type of services billed under a provider’s NPI are abnormal in comparison to their peers (“outliers”). The two most important lessons on NPI protection: (1) do not lease out your credentials; and (2) avoid incident-to billing like the plague. Yes, you can make supplemental income by “supervising” a couple of your colleagues’ nurses or physician assistants. However, one of the fastest ways to unintentionally get yourself in the hot seat is to be billing five or six days per week in your own practice while a colleague’s practice

• $1.1 billion was from Medicaid contractors. More than just the dollars, the OIG reported that in FY2014: • 4,017 providers and entities were excluded from Medicare participation; • 971 criminal charges were filed against providers and entities; and • 533 civil actions for false claims and unjust enrichment lawsuits were filed in federal court, CMP settlements, and administrative recoveries related to provider self-disclosure protocols. Before you make the knee-jerk decision to sell your practice and change your career, take a few minutes to learn seven key steps to avoiding the nightmare.

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7 Keys to Medicare Defense

Stephen D. Bittinger

mistakenly bills their midlevel services under your NPI fulltime during the same week. Nothing makes a data-miner smile more than finding a physician who appears to be working 200 hours a week based on the codes coming through the pipe. Secondly, the scrutiny of billing midlevel providers’ services “incident-to” a physician has been reaching epidemic proportions. Yes, hospitals and large multispecialty groups have the software protocols and compliance teams to perhaps get away with justifying the risk of billing “incident-to” for another 15% bump on reimbursement, but very few private practices can actually meet the stringent requirements. The best bet is to find another way to increase your margin and stop waiving the red flag in front of the bull.

2. Do Not Play Compliance Officer. Sadly, the days of a physician operating a small practice with a spouse acting as the general administrator have long been swallowed by the ever-increasing complexity of compliance. The private physician already wears many hats (practitioner, business manager, marketer, human resources director, etc.), and wearing the compliance officer hat is simply one too many. An owning physician certainly must comprehend and enforce compliance within the practice, but the amount of time it takes to keep pace with the fluidity of federal, state, and payer regulation makes this an impossible task. Investment in a Certified Medical Compliance Officer (“CMCO”) or Certified Professional Compliance Officer (“CPCO”) (generally “CO”) is essential to setting a physician free to perform at what they do best – practicing medicine and growing a business. A CO should be your right hand that ensures your providers and staff understand all compliance aspects of your practice, are participating regularly in an active compliance plan for the practice, and are ever-vigilant for lapses.

3. Create an Active Compliance Plan. A compliance plan is not the 60-page document you purchased from your healthcare attorney (or printed from the Internet) that has been sitting on a shelf in your break room collecting dust. Time and time again practices have hung themselves by handing over a stale compliance plan to an auditor to prove their efforts at compliance only to discover that the majority of requirements in the plan have not been followed. Auditors will use a stale compliance plan as sufficient “notice” and construe all errors since creation as either intentional misconduct or severe negligence. A compliance plan should identify all current providers and staff in the practice by name, identify their roles, delineate duties, and encompass all services being offered in the practice. Yes, the plan should be updated for every personnel change. Yes, every time the practice drops or adds a service, the plan should change. Every provider and staff member should receive quarterly training, fully comprehend the changes to the compliance plan, and sign a log to document their ongoing participation.

4. Tracking Records Requests and EOB Denials. Besides stopping the misuse of an NPI, tracking records requests and EOB denials from payers is the second best weapon for audit prevention. The basic task of tracking records requests and EOB denials by payer in a spreadsheet by date, volume, service, and value is one of the most predictable forecasters of what is coming. Annually, Medicare starts a charge with the Work Plan, then the Supplemental Plans and private payers follow suit. If your practice is performing a service out of compliance or is an outlier based on the type of service, the requests and denials will begin to trickle in and

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7 Keys to Medicare Defense

Stephen D. Bittinger

slowly increase in frequency and volume once the scent of a problem is hounded out. If your CO, billing staff, and administrators are tracking, they will quickly notice the trends and be able to alert you with hopefully enough time to take corrective action before anything gets out of hand.

normally the best answer. Take the time to do your homework on the company you hire to perform your assessment and make sure that the work product can be actively used and integrated into the daily operations of your practice. Every outside assessment should cause change for the better.

5. Drill for Answers.

7. Proactive Legal Counsel.

Whether your practice detected an issue through tracking or you are wading through the endless shades of gray in payer policies for a new treatment, do not stop drilling for answers until you have solid support. Some of the most tragic demises of successful practices have been due to forging ahead with the provision of services where there has been no prohibitive policy within the Medicare jurisdiction of the practice, only to discover after a brutal audit has started that the services were prohibited or restricted by local coverage determinations in another Medicare jurisdiction. Yes, it is completely unfair and a total lack of due process for the contractors to deny services based on non-binding coverage determinations from other jurisdictions, but the federal government has not stopped them from using this tactic yet. The bottom line is that you must practice medicine defensively and have well-documented ammunition ready if a contractor comes calling.

Finally, every private physician must have legal counsel that is fully competent in the arena of payer policies and audit defense on call if there is even a suspicion that something may be getting out of hand. Yes, your lawyer friend who helped form your corporate entity, buy the real estate, or refers your practice personal injury patients may be able to read the policies and give you a general explanation, but that is almost the equivalent of asking your primary care physician to surgically remove a brain tumor. The federal, state, and private payer appeals and dispute processes are ridiculously overcomplicated and outside of the mainstream legal system. Taking the time to seek out a specialist to be a sounding board could mean the difference between early retirement and the tragic loss of your life work. about the author:

Stephen D. Bittinger Healthcare Audit Defense/Compliance Attorney at NEE | BITTINGER, LLC

6. Outside Assessments. Hiring an outside compliance consultant to perform a biannual or quarterly assessment is invaluable when considering the potential expenses that are eliminated. As with most things in life, you get what you pay for when hiring someone to perform an assessment of your practice. More obviously, there are plenty of experts, gurus, and consultants out there who are willing to tell you whatever you want for a buck. With compliance, the opinion that you like the least is 63

Mr. Bittinger has represented physicians across multiple disciplines, nursing facilities, medical groups, medical facilities, and medical consultants in formation, transaction, human resources, Medicaid appeals, Medicare appeals, RAC audits, MAC audits, ZPIC audits, regulatory issues, HIPAA compliance, and litigation. He has assisted numerous physician groups, medical corporations, and medical product manufacturers with strategic growth plans, successions, and transactions. Additionally, Mr. Bittinger has been able to develop a specialty focus of working independently or collaboratively with healthcare law firms around the country to handle the unique legal needs of integrated physical medicine, multidiscipline, and specialty practice groups with regulatory and strategic defense in RAC, MAC, and ZPIC audits and appeals.

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looking beyond the benefit of the doubt

TIPS FOR CONTESTING

UNEMPLOYMENT BENEFITS By Paul Edwards & Jennie McLaughlin, J.D. What should you do when an employee resigns but later changes their story in an attempt to receive unemployment benefits? We get questions about this quite often. The employee resigns because they are moving, got a new job, want to go back to school, or didn’t think it was a good fit – or maybe they didn’t even give a reason for resignation. When this happens, you should definitely dispute the unemployment eligibility, if for no other reason than to clear up the record as to why the employee stopped working at your practice. When an employee resigns, generally the only way that the employee will be eligible for unemployment is if it was a “constructive discharge.” Meaning, circumstances were so unbearable that the employee had no reasonable choice but to resign. An obvious example of a constructive discharge would be if the employee was subjected to ongoing harassment in the workplace and nothing was being done about it. In a situation of that sort, the employee shouldn’t have to put up with that unlawful behavior, and therefore it’s reasonable to resign and unemployment benefits may be available. Imagine that the employee tells unemployment that she quit because the doctors were disrespectful to her and it was not a comfortable working environment. If you don’t dispute it, and the employee tries going even further and files a discrimination complaint, you can count on the employee’s attorney using the record from the unemployment hearing to show that the practice did not bother to dispute what the employee was claiming.

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Contesting Unemployment Benefits This can certainly make it look like the practice was in the wrong, and that it was a constructive discharge. That fuels the discrimination complaint, and does not put the practice in a good light for the judge or jury.

Your Best Response to Employee Resignation: A Separation Letter and an Exit Interview Form

Knowing that you should fight the unemployment eligibility, how do you go about doing that? At unemployment hearings, the only real issue is the reason for separation from employment. The unemployment office does not make rulings about other matters – although they might point the disgruntled employee in the right direction so that she can pursue another claim, which is another reason to be there to share your side of the story.

Whether you are responding to the unemployment claim by mail or attending a hearing, you want to provide documentation of the employee’s departure. Whenever an employee separates from employment – by termination, layoff, or resignation – the practice should be drafting a separation from employment letter and giving it to the departing employee. This letter should very briefly state the date and reason for the separation. It’s usually worthwhile to write your own confirmation of resignation letter rather than pushing the employee to write one. That way, the practice has control over how the resignation is initially framed in writing.

While at the hearing, or in a written response to the benefits application, don’t get caught up in details of disputing everything the employee says. A lot of he-said she-said back and forth is hard for the unemployment judge to follow, and the judges don’t like to get caught up in that. The more on point and clear the employer is, generally the more success the employer is likely to have. If the employee is holding fast to a story involving the practice doing something wrong, you should simply explain that the employee never brought that to your attention, and that no one is aware of what she is saying being true. If you have policies asking employees to report workplace issues to you, and promising that the employer won’t retaliate in response, you should bring a copy of those policies as well. This way, you can show that if the employee had actual concerns, she could have and should have brought them to your attention. That helps call the employee’s claims into question, and makes it easier for the unemployment office to deny benefits. (Note that all employees should have received a copy of your employee handbook, containing those policies, and signed their acknowledgment upon hire and whenever updates are made. If you haven’t followed these steps, or if your handbook doesn’t contain policies stipulating that employees must report their concerns and can do so safely, please give CEDR a call – we can help.)

Paul Edwards

With this letter, you will want to enclose an exit interview form and a self-addressed stamped envelope, inviting the employee to send feedback to you. This packet of material ensures that you have documentation of the reason for leaving. If the employee doesn’t send back the exit interview form disputing the reason, it can go further toward establishing that what is stated in the letter is correct. about the author:

Paul Edwards CEO/Co-Founder Cedr HR Solutions

Paul Edwards has over 25 years’ experience as a manager and owner. As CEO and Co-Founder of CEDR HR Solutions, Paul is an expert in human resources. His employment litigation avoidance techniques and customized employee handbooks have helped hundreds of medical offices in all 50 states successfully solve employee issues. He is also a featured writer for various medical publications.

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