physiciansnewsincentive payments, but starting in 2015, they will be penalized by way of decreased...

By now you’veheard about the$787 billion AmericanRecovery anReinvestment act of2009 - the stimulus billrecently passed byCongress. The bill isaimed at spurring eco-

nomic growth across multiple industriesby way of government spending.

What’s in it for you?Well if you are a healthcare provider,

you can take advantage of the $51 billionthat has been allocated to the health careindustry, $19 billion of which will beused to incentivize medical practices toadopt and implement Electronic HealthRecords (EHRs).

How does the subsidy work?Starting in 2011, providers deemed

to be “meaningful users” of EHRsystems will be eligible to receive $40,000- $60,000 in incentive payments paid outover five years in the form of increasedMedicare and Medicaid premiums.

For the first year a physician isdeemed to be a meaningful user, he orshe will be eligible for payments of 75%of that year’s Medicare and Medicaidcharges, up to a maximum of $15,000.The maximum payment is increased to$18,000 if the first year is 2011 or 2012.The incentive payments decline for eachsubsequent year within the five-yearperiod; $12,000 will be paid in year two,$8,000 in year three, $4,000 in year four,and $2,000 in year five.

No incentive payments will beavailable after 2015, and no paymentswill be offered to physicians who firstbecome eligible after 2014. This creates adecreasing incentive for late adopters.

What is a “meaningful user”?To qualify as a “meaningful user,”

eligible providers must demonstrate useof a “qualified EHR” in a “meaningfulmanner.” The bill defers to the secretaryof Health and Human Services (HSS) toset specific guidelines for determiningwhat constitutes a “qualified EHR”;however, it does specify that

e-prescribing, electronic exchange ofmedical records, and interoperability ofsystems will be determining criteria.

HSS will be working throughout2009 to set the necessary criteria forcertifying systems, and is expected tohave a final report by January of 2010.Many expect CCHIT (CertificationCommission for Healthcare InformationTechnology) certification to play a majorrole in setting standards of

interoperability. After all, HHS fundedthe creation of CCHIT in 2004 to startcertifying EHRs against a minimum setof requirements for functionality,interoperability and security.

How do I qualify for the maximumpayment?

In order to receive the maximumpayment, physicians must qualify as ameaningful user in 2011. Eligible

PHYSICIANSNEWSDigestPhiladelphia Metro Edition

INSIDE THIS ISSUEFEATURESLori Schutte, the new president of CejkaSearch, discusses results from their annualPhysician Retention Survey including flexiblework options for docs. See page 7.

DEPARTMENTSFinance . . . . . . . . . . . . . . . . . . . . . . . . . . 4Business . . . . . . . . . . . . . . . . . . . . . . . . . 5Law . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13Recruitment . . . . . . . . . . . . . . . . . . . . . . 14

How To Get Your Slice of theStimulus Pie

Continued on page 2

PRST STDUS Postage PaidPermit No. 397Bellmawr, NJ

PhysiciansNews.com April 2009

Continued on page 2

David Jackson

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Iwas one of three Republicans who voted for theso-called moderates’ stimulus bill that virtually tripled the bill’s original funding for theNational Institutes of Health and laid thegroundwork for the shift to electronic medicalrecord keeping. Both carry broad implicationsfor healthcare in Pennsylvania and beyond.

At my initiative, the stimulus bill boosted theamount budgeted for NIH from $3.5 billion to$10 billion. Funneled through NIH’s nationwidenetwork of research institutions, this money willsupport local economies by creating new jobswhile improving public health by translatingresearch discoveries into treatments and cures.

Acting NIH Director Raynard Kington hasstated says that the increased funding will support

priorities in public health including influenza, tuberculosis, malaria, autism, Parkinson’sdisease, diabetes, HIV and cancer. Additionally, funds will be used to support expandedresearch into the Cancer Genome Atlas, stem cell research, and regenerative medicine.

Quick, targeted research grants in the amount of $500,000 will address researchand medical priorities while generating jobs. Investments in renovations, repairs andconstruction, and infrastructure will create even more good jobs through the NIH’s“multiplier effect.”

The stimulus will also expedite the revolution in information technology. The billwill invest $19 billion nationwide in the next five years to bring about the transition frompaper to electronic records that will improve the quality of care and lower medical costs,which last year exceeded $8,000 for every man, woman and child in the countryaccording to estimates of the National Health Statistics Group.

Studies predict a gain of as much as 30 percent in efficiency, mostly throughreducing unnecessary tests and prescriptions, paperwork, and medical mistakes. I willwork to ensure that physicians along with health insurers and patients benefit from these investments.

The Stimulus: Supporting NIH andInformation Technology

US SenatorArlen Specter

PND_PhilaMetroApril09_FINALpress 3/25/09 9:49 AM Page 1

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2 PHYSICIANSNEWS PhysiciansNews.com April 2009

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physicians will receive a first yearbonus of $18,000 (up from $15,000) andwill max out the payment schedule overthe next five years.

The table below illustrates theamount of a subsidy paid each year(columns) based on the year the providerfirst becomes eligible (rows):

No payments will be offered tophysicians who first become eligible after2014.

Practices with multiple physicianswill be eligible to receive incentivepayments for each provider. Rememberthat payments will be based on 75% ofthe correlating year’s Medicare andMedicaid charges. Therefore, in order toqualify for the maximum payment of$18,000 in the first year, each providermust bill Medicare or Medicaid aminimum of $24,000.

Should I purchase an EHR now orwait until 2010?

An obvious concern is whether anEHR implemented in 2009 will meet thestandards set by HHS in 2010. Althougha legitimate concern, waiting until 2010to implement a system may be a mistake.Researching and selecting the right EMRcan be a lengthy process, and manyproviders who wait may find it difficultto have a system in place in time.

Practices would be well-served tobegin the research process now, allowingample time to create a short-list ofsystems, perform demos with severalvendors, check references, meet withvendors in person, negotiate terms, and

complete the implementation andtraining process. To alleviate buyers’concerns, vendors may provide bindingagreements, guaranteeing their systemwill comply with all emerging standards.

Furthermore, buyers’ shouldconsider CCHIT an importantcertification relative to the requirement

for “qualified EHRs.” While there aremany opinions for and against CCHIT,we expect it to play a critical role in theEHR subsidy qualification.

What if I choose not to purchase anEHR?

Unfortunately, for physicians whochoose not to implement an EHR, thestimulus bill is a double-edged sword.Not only will they forego thousands inincentive payments, but starting in 2015,they will be penalized by way ofdecreased Medicare and Medicaidpayments. Physicians who fail to qualifyas meaningful users will face decreases of1% in 2015, 2% in 2016, and 3% in 2017,with a maximum reduction of 5% by2020.

Bottom Line?Although each physician’s individual

situation will dictate whether or not theychoose to implement an EHR, theunique opportunity offered within thestimulus bill should not be overlooked.

David Jackson of Medical SoftwareAdvice (www.softwareadvice.com) can bereached by phone at (415) 449-0535 or byemail at [email protected].

from both institutions performed acomplicated Whipple procedure torestore the young man’s health and thepatient recuperated at Abington.

As Abington has grown from asmall community hospital to a 570-bedinstitution serving a broader region ofsuburban Philadelphia, we’ve developedour services to provide patients with theexpertise they need. Out of thatphilosophy, we determined thatexpanding our surgical program in liverand pancreatic diseases would enableour patients access to the most advancedcare.

We created the Hepatobiliary andPancreatic Surgery program at Abingtonin conjunction with Drexel specialists.The program is led by William Meyers,MD, an Abington physician, professorand chairman of Drexel’s Department ofSurgery, and a national expert on liverand pancreatic surgery. Other specialists in the program include David Reich,

How To Get Your Slice ofthe Stimulus PieContinued from page 1

Collaborative Program atAbington Advances Care forLiver and Pancreatic Patients

When a youngman came toA b i n g t o nMemorial Hospitalwith chronic painand a large mass in the head of thepancreas, he neededcomplex ands o p h i s t i c a t e d treatment like manypatients with

hepatobiliary and pancreatic tumors.But instead of being transferred to adowntown hospital, he received theadvanced care he needed in TheRosenfeld Cancer Center at AbingtonMemorial Hospital.

Having his treatment closer to homewas possible due to an innovative newprogram that teams Abington surgeons,medical oncologists, interventionalradiologists and gastrointestinalspecialists with liver, pancreas and bileduct experts from the Drexel UniversityCollege of Medicine. Together, doctors

The stimulus legislation calls for standards to be developed for the nationwideelectronic exchange and use of patient health information by 2010. Much of themoney will support IT infrastructure along with Medicare and Medicaid incentivesto encourage doctors, hospitals, and other providers to switch to electronic recordkeeping. Special provisions will strengthen Federal laws to protect the privacy andsecurity of patients’ electronic records.

The Congressional Budget Office estimates that 90 percent of doctors and 70percent of hospitals will switch to certified electronic health records within the nextdecade. In turn, that will save the government more than $12 billion throughreduced spending on Medicare, Medicaid and other programs.

I believe the stimulus investments in health information technology andbiomedical research will have a profound impact on the future practice of medicineand I will work to make sure that patients and physicians share in the benefits thislegislation provides.

Arlen Specter is a Republican senator from Pennsylvania.

The Stimulus: SupportingNIH and InformationTechnologyContinued from page 1

Continued on next page

Christopher M.Pezzi, MD


2009 April PhysiciansNews.com PHYSICIANSNEWS 3

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This new program brings a fullspectrum of services to Abingtonpatients facing treatment for tumors,blockages and other conditions of the liver, pancreas or biliary system. Nearlyall procedures—with the exception ofliver transplants—are handled at ourmain campus in eastern MontgomeryCounty, so patients benefit from thecomfort of being close to their familiesand medical providers. A nurse navigatoralso helps by coordinating testing andappointments in what can be verycomplicated care.

At the heart of this new program isa powerful collaborative spirit. Drexelphysicians maintain an office atAbington to see patients; doctors fromboth institutions join in a weeklyvideoconference to review cases and amonthly soft-tissue tumor conference.These joint consultations help us all. I’vebeen practicing for 20 years, but recentlywhen I saw a patient who had a cysticlesion in the body of the pancreas. Idecided to present his case at the nextconference where I could get three orfour more opinions. Something goodalways comes out of such discussion,even when the other physicians agreewith me.

A patient, treated for lung cancer atAbington five years ago, was diagnosedin a follow-up CT scan with a spot on hisliver. We determined that he wouldbenefit from a liver transplant, so theHepatobiliary and Pancreatic Surgeryprogram streamlined the process ofgetting him the needed transplant atDrexel. He is now doing well.

In addition to such successes, theprogram has generated morechemoembolizations of the liver,laparoscopic liver operations,radiofrequency ablation (RFA) for liverlesions, intraoperative ultrasounds inliver and pancreatic procedures, andmajor hepatic resections—including arecent trisegmentectomy that removed75 percent of a patient’s liver.

This collaboration providesAbington patients with the mostcomprehensive care for cancer and otherserious conditions of the liver, pancreasand bile ducts. As this area of surgeryhas evolved rapidly, we are able to offerthe full armamentarium of procedureswithin our growing community. We arealso privileged to have been named aBlue Distinction Center for Complexand Rare Cancers by Blue Cross BlueShield companies which furtherreinforces the hospital’s expertise inoncologic care.

Christopher M. Pezzi, MD is theDirector of Surgical Oncology at Abington Memorial Hospital.

Collaborative ProgramContinued from page 2

Abington and Drexel specialistshave created the Hepatobiliaryand Pancreatic Surgery program, which will providepatients with the most compre-hensive care for cancer andother serious conditions of theliver, pancreas and bile ducts.

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PERSONAL FINANCE

Unless youinvested yourpension and profitsharing plan fundsin certificates ofdeposit, you havemost likely lost anywhere from 30-to-50% of thevalue of youraccounts over thelast six months. We

all hope that the economy and the market eventually improve so we canrecoup some of those losses.

In the meantime, although theupcoming required amendments to mostretirement plan documents will addanother one-time hefty administrationexpense, they also create a perfectopportunity to examine the design ofyour plan(s) to perhaps contribute moreand save on non-physician ownercontributions to help hasten the “reversalof fortune.”

First the bad news. Similar to the“GUST” pension and profit sharing planrestatements that all plans went throughin 2001 through 2003, all plan sponsorswill be required to completely amend andrestate their retirement plan documentsto comply with the final regulationsissued in conjunction with the EconomicGrowth and Tax Relief Reconciliation

Act of 2001 (“EGTRRA”). Updateddocuments must be prepared andexecuted by no later than April 30, 2010.

Among many other provisions,EGTRRA implemented the followingpension related incentives:

• Increased deferral limits for 401(k)plans ($16,500 for 2009)

• New age 50+ “catch-up contribu-tions” ($5,500 for 2009)

• Increased annual additions limit($49,000 for 2009)

• Increased annual compensationlimit ($245,000 for 2009)

• Increased tax deduction limits foremployer contributions

• Permitted rollovers from IRAs toqualified plans

Along with the mandatorydocument amendments, each plansponsor/employer has the

option to file with the InternalRevenue Service for an individualFavorable Determination Letter.Although it is not mandatory, it isstrongly recommended that all restatedplans other than standardized-prototypeplans be submitted to the IRS forapproval. This IRS approval lettersignifies that the IRS approves theprovisions and structure of the plandesign. It is important to have this letterupon an audit of the plan by the IRS andit may also be helpful when transferring

plan assets to a new institution. The newdocument and other forms must besubmitted to the IRS by April 30, 2010 ifa Favorable Determination Letter issought. The IRS does charge a “userfee” to review the plan of either $300 or$1,000, the latter for plans with a “newcomparability” feature.

Now the good news. Themandatory, costly and tedious process ofplan restatements provides a goodopportunity to revisit optional plandesign and administrative provisions.The following opportunities areavailable:

1. Add a 401(k) Feature to anExisting Profit Sharing Plan. You canreduce the employer’s contributions forthe lay staff and increase thecontributions for the professionalstaff/owners if you reach age 50 by theend of the year. If you make a safeharbor election with a mandatory 3%contribution, you can avoid theproblematic and complex anti-discrimination testing.

2. Implement a “New Comparability”Formula for Profit Sharing PlanAllocations. Many times this is the bestway to maximize the allocation ofemployer contributions to the ownersand “favored” individuals. This worksbest when individuals to be favored tendto be older than other participants.

3. Add Roth Provision. This allowsfor the equivalent of 401(k)contributions on an after-tax basis.Certain distributions from Rothaccounts, including accumulatedearnings, are tax free and not subject tothe age 70-1/2 minimum distributionrequirements.

4. Consider Defined Benefit PensionPlan. Defined Benefit Plans for practiceswith no lay staff is the best way to rapidlyaccumulate retirement savings, andliberalized deduction limits makesdefined benefit/defined contributioncombinations more viable.

5. Put Spouse on Payroll. Due toincreased contribution and deductionlimits, it may be worth the 15.3% FICAtax obligation to be able to increase planfunding for the family unit.

Since the plan amendmentprocess has a deadline and the newdesign opportunities may be worthwhile,it is important to start investigating thepossible changes as soon as possible.April 30, 2010 will be here before youknow it and many plan consultants willbe extremely busy late this year and earlynext year.

Jeffrey B. Sansweet, Esq. is ashareholder with the health care law firmof Kalogredis, Sansweet, Dearden andBurke, Ltd. In Wayne, Pennsylvania.

Retirement Plans in the New Decade: Required Amendments and Design Opportunities

Rose Ann received a panicked call from her daughter, Jennie.“What are you doing Mom?” Jennie asked with a voice that oozed concern.“Nothing.” Rose Ann responded calmly.Jennie blurted, “I don’t mean at the moment. What are you doing about the stock

market collapse?”Rose Ann continued, “I know what you are asking. I’m not doing anything, why?”

What she didn’t possess in stature—‘five feet, four and three quarters inches’ Rose Annwould always say—she made up for with determination. Her short, neat gray hair, herturquoise eyes that looked like pools of tropical water and her smile that would light upa room seemed to hide her quiet strength.

“Aren’t you panicked?” Jennie asked, wanting her mom to share her samefeelings… feelings that had been stirred up since her dad’s dementia had gotten so badthat he could no longer be trusted to make decisions. In truth, Jennie wasn’t sure thatMom could handle Dad’s care, let alone all the other decisions that had to be made.After all, Dr. Benjamin “Duke” Harris (named for his “favorite movie star of all time,”John Wayne) lived his life like his namesake… hard charging, independent and hardheaded.

“No, I’m not panicked. Why are you so nervous?” Rose Ann answered. Deepdown, Rose Ann knew that Jennie really didn’t trust her to make decisions. Duke, whoretired almost a decade ago, had always made the majority of the financial decisionsthroughout their entire sixty one years of marriage. Jennie didn’t know that Dukehadn’t been making all the decisions for almost eighteen months… but she refused toacknowledge that Dad’s dementia was that bad.

“My 401(k) account is down forty percent. I’m worried about our future...and I’mworried about you and Dad.” Jennie exclaimed trying to keep her voice from matchingher feelings.

Rose Ann continued, “Jennie, your dad and I are fine. We made some decisionsover a year ago that created additional reliable income for us. We have enough incomefor our lifestyle and health issues coming in every month for as long as we live…and we

have created a legacy for you and the grandkids… and we’ll be leaving a legacy to acouple of organizations that we care about deeply… the hospital and our alma mater.”

“Your college?” Jennie interrupted somewhat rhetorically, having heard the storiesof their courtship during college and having seen their lifelong connection with theschool and their former classmates.

“Yes. We went to a special presentation sponsored by the college a few years backnow and heard from a unique specialist. He said that your wealth is first about securingyour lifestyle; then about your legacy to family and charity. He called it legacyplanning… living your legacy. I just remember that the concept of reliable lifetimeincome equal to your lifestyle was really attractive to me… and then you don’t have toworry about the ups and downs of the stock market. Dad said that he had heard aboutsome of these options, but never did anything about it. He had a demanding career, asyou know, and tried to take care of our finances by himself. You know your dad;because he was so competent at his profession, he thought he was equally competent atmanaging our finances. Well, he wasn’t. You can’t master two professions at the sametime… no one can. Well, anyway, it was all new to me… and it seemed very attractiveconsidering our needs… lifetime income equal to our lifestyle. ” Rose Ann continued.“The specialist that spoke said that wealth planning must begin with lifestyle planning;then legacy. Well that resonated with me. Then he asked if we had a lifestyle plan… notone of those you-are-going-to-earn-8%-each-and-every-year-for-the-rest-of-your-life projections you get from brokers, but a reliable lifestyle plan. Well, your father said wehad everything taken care of. However, I knew that we didn’t… because he wouldn’ttake the presenter up on a free second opinion. Why wouldn’t he get a second opinion…at no cost? So I said to him, ‘Duke, in the medical profession, if someone comes to seeyou and you show them that there are more options available to them then they wereaware of… and they won’t get a second opinion from you… what do you always say?’Duke answered without having to think, ‘They’re stubborn and scared… and stupid! Ican’t help them unless they are open-minded. If they don’t want to know… let themkeep their head in the sand.’ So I asked him straight up, ‘Duke, where’s your head? Inthe sand? Let’s at least explore the options.’”

Rose Ann is not typical. She is not afraid to listen to something new and makechanges. She has long since learned to watch successful people and do the things that

Jeffrey B.Sansweet,

Esquire

Recession Proof Estate PlanningBy Scott Keffer

Continued on page 15



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In the last thirtyyears, no area ofhospital practicehas received moreattention than qual-ity improvement programs (QIPs).Just inventoryingthe different typesof programs triedand abandonedduring this time

frame would be a daunting task.Government at all levels, business associ-ations, and health-care practitionersthemselves have advocated for programsjust to see them go away and be replacedwith another. Sadly, as reported by theInstitute of Medicine, medical errorsremain a major concern, and the area ofquality improvement continues to be aserious national problem.

Moreover, a study published in theJournal of the American MedicalAssociation in June 2005 reported whatmany of us already suspected. Despitebillions of dollars spent, organizedquality improvement programs showlittle real and lasting impact. Even moredepressing is a recent Joint Commissionon Accreditation of HealthcareOrganizations report that, despiteincreased attention, wrong site surgeriescontinue to increase.

Why is this the case? Why doeshealth care, unlike, say, automobileassembly, resist structured processimprovement? I do not pretend to havethe definitive answer, but my experienceshave certainly provided some clues.

The first, and perhaps the mostimportant, factor in my view is thefailure of organized medicine to evaluateand adopt a particular methodology andpromote its use. Such practices asevidence-based medicine and clinicalpathways have many adherents and are inwide use, but neither of these appears toprovide the total answer to quality andprocess improvement, particularly in thecomplex environment of the hospital.

Regardless of whether an optimal

The Physician’s Role in Quality Improvementmethodology currently exists, the bestclue to the failure of QIPs is the lack ofphysician leadership. With no majorphysician group leading the way, QIPshave been left to administrators, businesscoalitions, insurers, and regulators. Noneof these groups has the clinicalknowledge to either develop theseprograms or actually implement thechanges needed to improve the deliveryof care. We must recognize the obviousfact that physicians, nurses, and otherclinicians are the ones who actually takecare of patients, and they are the oneswho will either adopt or ignore a QIP.

It is a central tenet of changemanagement that for people to actuallysupport making changes, they must bedeeply involved in the conceptualizationand design of the change. Moreover,

without physician and nursing leadershipof the process, administrators andbureaucrats are simply unable toimplement significant change on thehospital unit. In addition, administrativeturnover and legislative changes causemany of these programs to be changed ordropped just as some positive results areoccurring. Indeed, the Institute ofMedicine has suggested that it requiresseventeen years for major changes to thepatient-care process to be adopted andactually become common practice. Noparticular QIP has yet been in place forany time period of this length, not evenclose.

Administrative turnover is a majorissue when the hospital executive or thechief medical officer is the champion ofthe program. Frequently, just as aprogram is showing a useful result, one

of these key leaders leaves the institution.The issue of changing legislativemandates is also a common problem withboth state and federal programs beingintroduced on a regular basis withoutfunding streams attached and with littlephysician leadership in theirdevelopment.

Clearly, it is the responsibility oforganized medicine and individualphysicians to take charge of these efforts,or we will likely continue to lurch fromprogram to program and not achieve theresults we desire. This “flavor of themonth” approach simply has not worked.

In the absence of medical leadership,QIPs have little chance of succeeding.Led by physicians who are truechampions of quality improvement,programs are more likely to take root inthe institutional setting. This seems soclear to me that I constantly wonder whythere is not more organized physicianleadership in this matter.

The role of Pay for Performance andGain-Sharing in Quality Improvement

There is another aspect to qualityand process improvement programs thatis proving to be very controversial: thatof employing financial incentives tomotivate physicians to participate.Hospital executives are always lookingfor ways to partner with their medical-staff members, but aligning the desire toimprove care or reduce costs with moneyincentives has an unsatisfactory history.One only needs to remember when manyhealth-maintenance organizationsprovided bonuses to physicians forreducing specialty referrals or numbersof expensive diagnostic tests, to see howthe public, as well as legislative bodies,feel about this.

Although discussion regarding payfor performance and gain sharing iswidespread, physicians are advised to becautious in participating in theseprograms. Patients must not feel thattheir care providers are conflicted inmaking judgments regarding their healthcare needs, but rather must feel thatphysicians are willing and able to do

what is best for them. Moreover, there issomething troubling about letting thepublic think that physicians will only dowhat’s right when they are paid to do so.

We all agree that delivery of thehighest-quality health-care services is ourgoal. Long lists of programs have beenattempted with little lasting effect and agreat deal of wasted effort and money. Itis the responsibility of organizedmedicine and individual physicians totake charge of this aspect of health careand provide the leadership needed todetermine the correct path to take. Eventhough there is a great deal of emphasison providing financial incentives tophysicians to participate in theseprograms, physicians need to be cautiousabout doing anything that may causepatients to question their motives. Thephysician-patient relationship, under firefor many years, needs to be foremost inthe minds of caregivers.

It is also worth noting the so-calledHawthorne effect. Simply put, this effectis a management concept first noted inthe early 1900s. Management researchersin a manufacturing plant saw that anyattention paid to workers caused allparticipants to more carefully performtheir activities, and the process almostautomatically became more efficient.Conversely, when attention was takenaway from the process, performance fellback to previous levels.

The Hawthorne effect has beenevident in health care for many years.Quality improvement programs alwayscause some improvement when theyfocus on a particular area.Unfortunately, the same reversion toprevious levels of performance takesplace in health care as well. For us tomake any lasting improvement, we mustbe unwavering in our commitment. Todate, this has not happened except inisolated institutions where true physicianchampions exist. We need more of them!

Samuel H. Steinberg, Ph.D., FACHEis the Senior Strategist at HealthStrategies & Solutions, Inc.

Samuel H.Steinberg,Ph.D., FACHE

Even though there is a great deal ofemphasis on providing financialincentives to physicians to partici-pate in these programs, physiciansneed to be cautious about doinganything that may cause patients toquestion their motives.

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For all too many Americans, a good night’s sleep is but a dream. However, evidence from a study by gastroenterologists and sleep specialists at omas Jeerson University Hospital could ultimately and safely put an end to those restless nights. e study has demonstrated that gastroesophageal reux disease (GERD) may be responsible for sleep diculties. Furthermore, while sleeping pills may help some patients sleep better, prescribing them for patients with GERD may have signicant consequences with respect to esophageal health.

e study is a collaborative eort between the Jeerson Digestive Disease Institute’s Gastrointestinal Research Center and the Jeerson Sleep Disorders Center. e research team includes Anthony J. DiMarino Jr., MD, Professor of Medicine at Jeerson Medical College (JMC) of omas Jeerson University and Director of Jeerson’s Division of Gastroenterology and Hepatology; Karl Doghramji, MD, Professor of Psychiatry and Human Behavior at JMC and Director of the Jeerson Sleep Disorders Center; and Sidney Cohen, MD, Professor of Medicine at JMC and Director of Research in Jeerson’s Division of Gastroenterology and Hepatology. ey and other researchers at JMC have been studying a group of subjects who have a history of sleeping diculty but no medical problems that might cause such diculty and no known history of GERD.

Common denominatorAcid reux and insomnia are typically considered separate problems for most adults. Some 50 percent of American adults report having trouble sleeping at least once or twice a month. Fi!y percent of the adult population has reux at least once a month, about 20 percent once a week and about 10 percent

every day. It turns out that the common denominator among a signicant number of people who have trouble sleeping is not restless legs or anxiety, but rather gastrointestinal problems. When the lower esophageal sphincter doesn’t close properly, stomach acid can leak back into the esophagus, causing GERD and, as a result, heartburn.

“Together, esophageal reux and sleep diculties can be a recipe for trouble,” says Dr. DiMarino. “If the sphincter is open or not working, a reex during sleep causes arousal, and the patient wakes up into a lighter sleep, changing the brain wave pattern. e person needs to swallow but must wake up to do so. e acid returns to the stomach, and the alkaline saliva raises the pH. en, the person falls back to sleep.” e individual who experiences cycles of partially waking up, or tossing and turning, generally feels tired the next morning. “We’ve found – and this has been corroborated in similar studies – that reux disease with esophageal acid exposure may account for impaired sleep in 25 to 35 percent of patients who have trouble sleeping,” Dr. DiMarino adds.

Dr. Doghramji, noting that GERD is sometimes overlooked by physicians as a source of sleep problems, oers some advice: “If an individual is getting adequate amounts of sleep but doesn’t feel refreshed during the day, consider the possibility of GERD. It’s not an innocuous problem.”

Those at riskAccording to Dr. Cohen, those at risk are overweight individuals – particularly middle-aged men who have had reux for a long time, eat fatty foods and tend to eat late at night. A high percentage of these individuals don’t experience classic heartburn all day but have problems at night. “Relying on

heartburn symptoms alone when looking for reux and interrupted sleep will mean missing a high percentage of these patients,” he says.

Before treating a patient with sleep medications, physicians must think twice about potential reux problems. e Jeerson study found that patients who take a sleeping pill don’t wake up as much and had acid reux in their esophagus for a longer period of time. Sleeping pills actually blunt the protective mechanism in the esophagus, putting the patient at risk for possibly dangerous complications such as esophagitis, Barrett’s esophagus and even esophageal cancer, which is the second fastest rising cancer in the country. “Continuing undiagnosed reux could be one of the factors behind the increasing number of adenocarcinomas of the esophagus,” adds Dr. DiMarino.

For information about treatment for GERD, or to make an appointment with a Jefferson digestive disease specialist, call 1-800-JEFF-NOW or 215-955-8900. For an appointment at the Jefferson Sleep Disorders Center, call 1-800-JEFF-NOW or 215-955-6175.

CONTEMPORARYGASTROENTEROLOGYApril 2009

Retired Pathologist Heading Off GERD

When now-retired Sewell, NJ pathologist John Pickering, MD, 65, was in his 20s, he would constantly wake up with a burning sensation in his chest. In the morning, he often had the taste of vomit in his mouth. Eating heavy meals or drinking alcohol late at night made the symptoms worse. As he got a little older, he realized it was becoming a serious problem and that he actually had gastroesophageal re!ux disease (GERD). He began taking various antacid drugs.

Dr. Pickering’s wife, Diane, was – and still is – working in the Division of Gastroenterology and Hepatology at Jefferson Medical College. She had suggested that he see Dr. DiMarino for treatment of his intestinal polyps. When Dr. DiMarino found lesions in the esophagus, he increased Dr. Pickering’s antacid medications. “His long-term prognosis is excellent,” says Dr. DiMarino, noting that Dr. Pickering’s case is typical of many individuals with GERD. Still, he estimates that at least one-fourth of all people with sleep problems don’t know that they have GERD, which causes them to brie!y awaken to swallow the re!uxed acid.

“Surprisingly,” notes Dr. Doghramji, “physicians who treat sleep problems may not have considered GERD as a possible cause. It’s an under-recognized problem.”

Thomas Jefferson University Hospitals www.JeffersonHospital.org/gastroRedefining Healthcare 1-800-JEFF-NOW

JG 09-2993

Jeerson Collaboration Focuses on Connection between Reux and Sleep Problems

Karl Doghramji, MD, Anthony J. DiMarino Jr., MD, and Sidney Cohen, MD


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MEDICINE & BUSINESS

The ability to balance time inclinical practice withpersonal interests andc o m m i t m e n t s is becoming an increas-ingly important factorof physician job satisfaction. It isapparent that thistrend will continue toshape the future of

medical practice for many years to come.Medical groups will need to understandthe realities of today’s workforce and findthe best way to maximize the contribu-tions of every physician – at every stage ofhis or her medical career.

According to the newly released 2008Physician Retention Survey from CejkaSearch and the American Medical GroupAssociation, 48% of medical groupsresponding agreed that options for part-time practice encourage physicians to stayin practice while meeting personal or family needs. The challenge will be how toaddress staffing models so as to retainthese physicians and ensure a satisfyingand rewarding career, while also meetingincreasing patient demands for healthcare.

Medical groups who keep an eyetoward the future will recognize that theycan sharpen their competitive edge in find-ing and keeping physicians by instituting flexible work schedules thatallow work/life balance consistent withthese physicians’ respective career stages.Formalized mentoring and retention programs and job satisfaction surveys thatfacilitate communication and feedbackwill also support this approach. The endresult is a workplace environment thatallows for both professional growth andpersonal satisfaction.

Greater numbers of physicians arereceptive to part-time employment

Over the course of the last decade,there have been significant generationaland gender shifts among physicians. As the predominantly male Baby Boomergeneration approaches retirement, ayounger, more diverse generation ofphysicians, who are just as likely to befemale as male, are entering the workforce.

Consider these statistics:- According to the American Medical

Association, nearly half (46%) of all physicians are over the age of 50.

- The emerging generation ofphysicians who are 39 years of age andyounger represent 28 percent of the physician workforce and are nearly equalin numbers of men and women with 55 percent male and 45 percent female.

- The Association of AmericanMedical Colleges reports that today’smedical school enrollment is 50/50 maleand female. And, even as the U.S.

population grew 15 percent from 1996through 2008, the number of doctors graduated each year remained essentiallyflat, at approximately 16,167 physiciansannually.

- Between 2005 and 2007, the percent-age of all physicians practicing part-timeincreased by 46% overall from 13% (5%men and 8% women) to 19% (7% men and12% women) as reported in the 2007Physician Retention Survey from theAMGA and Cejka Search.

Flexible work options keep physiciansin practice

According to the 2008 RetentionSurvey, among all male physicians wholeave a practice, it is those physicians who are age 55 or older who are most likely to leave the practice (30%). Amongall females, those under the age of 39 aremore likely to leave (46%) than their malecounterparts.

When these turnover trends are combined with current physician demo-graphic trends in today’s economic environment – it appears that there is aneven greater opportunity to keep physicians in practice by offering flexiblehours, particularly to pre-retirement andearly-career female physicians.

Nearly two-thirds (62%) of respon-dents to the survey said they believe thatphysicians are delaying retirement due tothe economy and almost half (49%) findthat part-time options are enabling physi-cians to delay retirement. As a result, med-ical groups appear to be adjusting theirstaffing models to meet these physicians’needs. Respondents indicated a generalwillingness to modify work schedules ofpre-retirement physicians to encourage

Medical Groups Keep an Eye to the Future: Flexible Work Options Create a Competitive Advantage

them to stay longer. Seventy-three percentof respondents offer their pre-retirementphysicians reduced hours, 56% allow forno call responsibility and 20% allow forspecialization with certain patient groups.Alternative approaches include extendedvacation periods of up to several monthsat a time and flexibility to modify jobdescriptions, as appropriate.

Today’s younger physicians – femaleand male – are also increasingly seekingflexible work arrangements. With moreequivalent numbers of women entering theworkforce, female physicians are moreinclined to expect work-life balance concessions from employers, especiallypart-time schedules. Among those femalephysicians who practice less than full-time,the vast majority (70%) cite family respon-sibilities including pregnancy, followed bythose who are pursing unrelated profes-sional or personal interests (22%). Eventhe younger male physicians are more likely than their predecessors to preferlighter schedules. Male physicians offer agreater variety of reasons for pursing part-time employment. Approximately31% are engaging in unrelated professional or personal pursuits, 20% arepreparing for retirement, and another 20%cite administrative or leadership duties astheir reason for seeking part-time employment.

Part-time trends sharpen the focus onretention

Organizations will need to constantlyexplore innovative ways to position theirindividual practices to focus on marketrealities. Physician turnover cannot becompletely eliminated, but medical groupscan help minimize the impact of turnover

with positive efforts by leaders to appreci-ate the needs and expectations of theirphysicians.

With the expected departure of a significant number of retiring physiciansand the certainty that today’s generation ofphysicians are focused on being content inboth their work and personal life, medical groups should continue to expandand focus on developing their recruitmentand retention programs.

Year to year, respondents have reinforced the effectiveness of mentoringas both a recruitment and retention strategy. A majority of member groups(65%) assign a mentor to newly recruitedphysicians citing that these programs helpyounger physicians adapt to the rigors of ademanding profession while maintaining afulfilling personal life. Of these, nearlyhalf (48%) offer written guidelines for theirmentors.

Assigning a mentor increases reten-tion and facilitates early identification ofnew physician issues and problem-solving.Job satisfaction surveys and exit interviews are another method for gaininga more complete understanding of theneeds of today’s physicians. Among themember groups polled, two-thirds (66%)conduct regular satisfaction surveys oftheir physicians. The information gath-ered is used for a variety of purposes,among them being to monitor trend infor-mation (67%), create action plans (58%)and communicate to departments (52%).

One respondent cited: “We have agood handle on physician issues based onour medical director and physician evaluation program. When a resignation

Lori Schutte





MEDICINE & BUSINESSAnswering the EmergingQuestions in Patient Experience

Patient experi-ence” expertsare popping up inhospitals and clinicsthroughout thecountry, the lateststaff hired to givemore appeal to doctors and theirmedical care. Butare such invest-ments really neces-

sary? After all, patients mainly seek solidmedical care, and doctors and nurses aregenerally nice people. In my role as aconsultant I have worked with experts inthe emerging field of patient experiencewho must carefully weigh this issue everyday. Here’s what they have to say aboutfour key questions.

Question 1: Why has patientexperience work become so important?

“Financial vitality has taken centerstage, and there is nothing more criticalto the bottom line than attracting andkeeping patients loyal to one’s hospital,”says Sheila Delaney Moroney, Managerof Customer Service and the Patient

Experience at Hennepin County MedicalCenter in Minneapolis, Minn., “It’sclinical care first, of course, but a closesecond is the patient’s perception aboutwhat some might call the ‘fluffy’ stuff—communication, care coordination,respectful and courteous staff andmeasures of comfort.”

Hospitals are discovering however,that although clinical excellence isnecessary, it’s not everything. As of July2007, participation in Medicare’sHospital Consumer Assessment ofHealthcare Providers and Systems(HCAHPS) survey and reporting ofresults became tied to Medicarepayments for hospitals. These surveysassist hospitals by providing feedback onservices—which will in turn benefitpatients because the hospitals can thenaddress issues to improve patientsatisfaction. Because hospitals’HCAHPS scores can be viewed online athttp://www.hospitalcompare.hhs.gov,future customers are just a click awayfrom establishing a picture in their mindfor how quality of an experience they’relikely have with any given provider.

Furthermore, because of thesophisticated nature of medical service,hospital and clinic “consumers” aren’tlikely to be able to assess the quality ofexperience. Oftentimes, all they can goby is their impression of service – andhow it compares to the best or worstbedside manners they might see ontelevision hospital dramas.

Doctors and nurses believe thathospitalized patients want a cleanenvironment, absolutely no mistakes andtimely tests and treatments. But whenasked, patients say they are looking forsomething else. They want empathy fortheir illness and situation, and they wantto know what’s going on with their care,what’s been discovered and what isplanned.

Dr. M. Bridget Duffy, ChiefExperience officer for the ClevelandClinics in Ohio notes, “It’s the rarepatient that can judge the clinical andtechnical quality of the care they receive,but everyone knows how they weretreated. Emotional aspects of care drivequality for patients.”

Question 2: What are some thingshospitals are doing to improve the patientexperience?

Many experiments are underwaywith few proven strategies. Still, ourexperts find that there are a handful ofkey ingredients that almost always makea difference in this work.

Effective Leadership. Peggy Kurusz,Director, Research & Development forSt. Louis, Mo.-based Ascension Healthsays, “personable, visible top leadersstrongly connected to the community-at-large,” as a necessary precondition forexperience-related success. Indeed,compassionate hospital leaders who areactive in the community are the startingplace for expectations of goodexperiences with prospective patients.

Engaged Employees. Sheila Moroneyfrom Hennepin County Medical Centernotes, “caregivers are not always aware ofhow significant of an impact the nuancesof their words and subtle actions have onpatients’ and families’ perceptions of thehospital experience. Something as simpleas sitting down when talking with apatient can have a positive impact.”Employee engagement is oftenmentioned as key to a positive patientexperience. When employees are treatedwith dignity and respect, they are morelikely to treat their patient similarly. Thisstrategy is far more than a ‘be nice’directive. Staff training that includesphysicians can make utterly concrete thenecessary skills to produce a positivepatient experience.

Change in Traditional HospitalCulture. This is perhaps the mostamorphous quality, yet all of the expertsreached out to agree that a cultural shift

is necessary to improve patients’experiences. Ascension Health refers tocultural change as “holistic, reverentcare.” Hennepin County Medical Centerdescribes the change as “relationshipbased care,” and the Cleveland Cliniccalls it “healing solutions.” Children’sHospitals across the country wereperhaps the first to recognize the impactof hospital culture on the child and thefamily experience during hospitalization.Family dynamics, school needs andcommunication are integrated into theirmedical care.

Rounding Programs. Roundingprograms are clinical processes thatassure staff members check with patientsat least every hour, asking if they needanything, offering to move things withinreach and checking on pain status andcomfort. On many units, the entire staff– from housekeeping to the hospitalCEO – take turns at checking in withpatients. Special training prepares staffto ask appropriate questions and offerreassurance and empathy. Hourlyrounding that proactively addressespatient needs is considered a “bestpractice” strategy to improve thepatient’s hospital experience and thehospital’s HCAHPS scores.

Measurement. Peggy Kurusz ofAscension Health reports that theirhospitals use the “Net Promoter Score”to measure and compare the impact ofprograms. Establishing a measurementof current baseline patient satisfactionwith their experience is a commonstarting point. New to health care, theNet Promoter Score asks one question:How likely are you to recommend a givencare provider to your family and friends?People respond using a 10-point scale.Responders are classified as “Promoters”(scores of 9 or 10), “Passives” (scores of7 or 8) or “Detractors” (all others). Asimple calculation (the percentage ofPromoters minus the percentage ofDetractors) yields a single number, theNet Promoter Score.

Question 3: What barriers have youexperienced in this work?

Ironically, many of the barriers tosuccess are the mirror image of enablersto success, such as disengaged leadershipand lack of measurement. Others aremore unique and specific to this work.Overall, providers seem to think thesecret is simple: generate greaterinvolvement of patients and optimizeemployee experiences.

As it relates to the former category,medical personnel, especially physiciansand nurses who have a great deal ofpatient contact, are in a powerfulposition to influence patient and familyperceptions. If they do not feel proudand committed to their hospital, theycannot promote an optimal patientexperience. Peggy Kurusz of AscensionHealth tells us that, “criticism fromemployees, such as remarks about badhospital food or late lab draws diminishesthe patient’s sense of comfort andsecurity.” Disruptive behavior on the

Alison Johnson,RN, MBA

“


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Q:What new procedures do you offer for hip replacement?A: The anterior hip replacement procedure is probably the most

exciting new approach. It is performed while the patient is lying

on his/her side, and the joint is accessed from the front with a

small incision (less than half the length of a traditional incision),

without the need to cut muscles or tendons.

Q:What are the benefits of the anterior hip approach?A: Besides eliminating muscle trauma from cutting the muscle from

the bone, this approach allows patients to leave the hospital faster

(in two to three days) with no precautions. They return to their

normal activities, including driving, in as few as two weeks. In

addition, due to the nature of the procedure, the patient doesn’t

have to worry about the stability of the replacement. The ideal

patient for this procedure is active and maintains a healthy weight,

regardless of age.

Q: Do you perform hip replacement procedures differentlyin young patients?

A: On some occasions, yes. There’s a procedure called surface

replacement, during which, instead of drilling into the femur to

secure the prosthesis, the femur head is ground down and simply

capped with a prosthetic ball that is then placed back into the

socket. This procedure is fairly new in the United States and offers

young patients a clear advantage: if necessary they can still have

a regular hip replacement later in life because the femur has not

been disrupted.

Q:What recent options do you offer for knee replacements?A: We offer surgical procedures that require smaller incisions so there

is less scarring and minimal disruption to muscle, tendons and soft

tissue. This minimally invasive approach can be used for partial or

total knee replacements. And again, there is a quicker recovery time.

Q:What do physicians need to know about Abington’s jointreplacement program?

A: We are not just committed to, but passionate about embracing new

procedures and technology. We are leaders in mini-incision surgery,

and perform a high volume of all types of joint surgeries. We are

using computer-assisted technology. Most important, we focus on

the patient. Our goal is to help our patients be as active as they

want to be, within reason.

For more information, call the Human Motion Institute’sprogram coordinator at (215) 481-BONE (2663), or thehospital’s Physician Referral Service at (215) 481-MEDI.

You may also e-mail our program coordinatorat [email protected].

THE POWER TO HEAL

Andrew M. Star, M.D.,Chief, Orthopaedic SurgeryDivision and Director, JointReplacement Surgery

Abington’s Human Motion Institute offersnew joint replacement options specifically

geared toward younger or more active adults.While traditional joint replacements continue to provide positive results for many adults, Abingtonhas responded to the joint replacement needs of active baby boomers—and even younger patients—

who want to maintain their quality of life and resume an active lifestyle.


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As an attorney and consultant tothousands of physicians across thecountry, we are constantly astounding bythe attitudes of physicians regarding thesale of their medical practice. Most oftentoday, we hear the complaint that doctors do not feel their can sell theirpractice for any significant value. Theygenerally do not feel the practice is“worth anything,” especially if they donot have younger partners to buy themout.

Even in medical practices that arelarger, and have a significant number ofyounger physicians, most doctorsmaintain the same complaint. While theymay typically have a right to couple ofmonths of payments from accountreceivable (AR) after they retire, this is apittance compared to the value they havebrought to the practice over the years. Wewould agree with them in this assessment-- a few months of AR certainly does notcompensate a physicians for 20+ years ofbuilding a practice and its reputation.

So what can you do about it?Unfortunately, the most common advicephysicians seem to get from theiradvisors is some version of “grin andbear it.” We all know, advisors say, thereis no white knight that is going to comein and buy your practice for a seven

figure sum, especially if you may beretiring that year or in the near future. Infact, we’ve seen very few physicians whohave built a solid plan for a lucrative buy-out based on their existing advisors’ help.

In this article, we hope to do acouple of things. The first is to give youhope that there are ways to in essence“sell” your practice for millions ofdollars, if you plan and prepare forretirement. Second, is to give you acouple of brief, quick ideas of how sucha sale could occur.

Let’s look at a couple of key issuesthat may allow you to sell the practice formillions when you retire. Remember thatthese techniques and others may workbest for group practices and solopractices as well.

1. You Must Plan and Plan Early“Common sense” advice -- that

neither an outside party like amanagement company nor insiders suchas younger doctors will suddenly cut youa seven figure check as you are about toretire -- is absolutely correct. If your buy-out plan is to just simply and go aboutyour practice as a physician and seepatients -- with no forethought business-wise about how you will sell your practice

when you retire -- you will get virtuallynothing for your practice. On the otherhand, if at the outset of your practice, 10,20, or even 30 years before you retire, youbegin funding a buy-out vehicle for yourpractice upon retirement, and you do thisproperly, you are almost assured ofgetting a multi-million dollar check uponretirement.

While we will see a couple ofalternative techniques below, the keypoint is simple —buyouts of medicalpractice need to be planned, they need tobe funded over time, and they need thecommitment of the physician many yearsprior to the “sale.” In this way, the bestthing you can do to insure that you willreceive millions upon your retirement foryour practice, is to focus on this issuetoday, and implement a plan as soon aspracticable.

2. Use A Non-Traditional RetirementPlan to Fund the Buyout

Traditional retirement plans arelikely the only ones you have heard of –qualified plans such as pensions, profit-sharing plans, 401(k)s, 403(b)s, and, forthese purposes, SEP-IRAs and Keoghs.What are non-traditional plans? Theseare less well-known to physicians andmay be called non-qualified deferredcompensation plans or split-dollar plans.

We have addressed these specific plans inpast articles.

As an example here, let’s considernon-qualified deferred compensationplans. These plans are relativelyunknown to physicians even though mostFortune 1000 companies make them

available to their executives. While manyof these plans in public companiesinvolve company stock or stock options(which, of course, do not work in amedical practice environment), many usestructures that a physician certainlycould easily employ in a practice.

Because they are not “qualified,”these plans can be offered only to a fewemployees – such as the physicians, oronly partner physicians. Mostimportantly for this discussion, there aremany ways this type of plan can create alarge buy-out fund for retiringphysicians, including:

A. Require each physician to put acertain dollar amount or income % intothe plan. The plan’s funds then growover a period of years and, as each olderphysician retires, they have a right to acertain % of the plan assets. Of course,this would be in addition to theirqualified plan (i.e., pension) as well.

B. There could be vestingrequirements built into the plan, so ifphysicians leave the practice theymay/may not lose their benefits in theplan, allowing remaining doctors tobenefit from their share.

C. While the alternatives arenumerous, just by implementing a planusing A. and B., a medical practice could

create a multi-million dollar buy-outfund over a 5 to 10 year period.

3. Use a Captive Insurance Companyto Fund the Buyout

Captive Insurance Companies(CICs) for medical practices are typicallyimplemented for their risk management,tax, and asset protection benefits. Asdescribed in other articles, certain smallCICs can enjoy beneficial tax treatment(made even better by a 2004 law signedby President Bush), allowing thephysician owners an opportunity to buildtax-favored wealth, as opposed to givingprofits up to insurance companies. Inaddition to these benefits, the CIC can bean ideal source of buy-out funds forretiring physicians.

In many cases, a CIC will havesignificant reserves left to invest andbuild each year it is in existence. Over 10-20 years, the CIC could accumulate verylarge amounts. If a buy-out formula islayered into the stock agreements of theCIC, this can be another source of buy-out funds for doctors when theyretirement from the practice as well.

ConclusionThese are just two of a number of

techniques physicians can employ to“sell” their practice lucratively when theyretire. As above, the key is planning.There are no outside buyers of practiceswilling to pay you millions for yourpractice anymore. If you want such abuy-out, you must plan for it yourself.

David Mandell is an attorney,lecturer, and author of five books forphysicians. Jason O’Dell is a financialconsultant, lecturer and author of twobooks for physicians. They are bothprincipals of the financial consulting firmO’Dell Jarvis Mandell LLC(www.ojmgroup.com) and can be reachedat 800.554.7233.

How to Sell Your Medical Practice forMillions: Create an Internal Buy-Out Fund

Buyouts of medical practice need to be planned, they need to be fundedover time, and they need the commitment of the physician many years priorto the sale.

David B. MandellJason M. O'DellChristopher M. PezziJeffrey B. SansweetLori SchutteSamuel H. Steinberg

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occurs it is not a surprise, as we would have been engaged earlier and trying to man-age the physicians’ expectations and needs.”

Member groups have greater pressure to meet the demands of patient care The increase of part-time practice arrangements is changing the makeup of the

physician staff and placing greater pressure on medical groups to meet the demands ofpatient care needs and growth initiatives. In order to attract and retain physicians in thischanging environment, medical groups need to be flexible with physicians about theirschedules and call requirements.

There is no “one-size-fits-all” formula for the success of a model that includesphysicians practicing part time. Although dependent upon business needs, one way isto use non-physician providers to enhance efficiency and augment organizational capacity of healthcare services.

Medical groups appear to be increasing their reliance on advanced practitionerssuch as physician assistants and nurse practitioners in their practice models. Nine outof ten medical groups reported use of advanced practitioners to help attract and retainprimary care physicians and are either actively expanding their number of advancedpractitioners (46%) or maintaining current levels (50%) to help extend and leverage theirphysician staff.

Rethinking staffing models offers potential for increased staff and patient satisfaction Forward-thinking medical groups can view this challenge as an opportunity to

develop effective workplace environment strategies that foster professional growth andpersonal satisfaction. Those who follow best practices will be rewarded with a competitive advantage: a loyal physician workforce.

Whether male or female, in early career or approaching retirement, physicians have changing needs and expectations about how to balance time in clinicalpractice with personal interests and commitments. The need to have work/life balanceis growing in importance. The fact remains that this is an opportunity for medicalgroups to rethink staffing models in order to retain experienced physicians approachingretirement and explore new ways to attract and retain younger generations ofphysicians.

Medical groups today are paying more attention to physician recruitment andretention efforts throughout the physician’s career cycle, including those times whenoptions for part-time practice make sense and create continuity for delivery ofhealthcare. As evidenced from the Cejka Search and AMGA 2008 Physician RetentionSurvey, leading medical groups are committed to creatively and effectively developingpractices and programs to address the challenges of physician retention – while ensuring a satisfying and rewarding career for physicians.

Lori Schutte is the President of Cejka Search.

PERSONAL FINANCEEconomic Crunch Affecting 401(k) Plans:What Employers can do to help their401(k) Participants

Neil H.Alexander,

JD, CFP®

Rachel M.Hawili,

AIFA®

Historically, it’s been a challenge toget employees to embrace their401(k) plan. Employees frequently don’tjoin their 401(k) plan, contribute too little to reach their ultimate retirementgoal, or select inappropriate investmentsfor their particular situation.

Now, there’s a growing concern that401(k) participants may overreact to therecent market downturn in ways that willhave a negative long-term effect on theirretirement savings. Some examplesinclude reducing or stopping theircontributions to their 401(k) plan,becoming too conservative with theirinvestment choices, or taking hardshipwithdrawals or loans from their account.

Over the last twenty years,contributing to a 401(k) plan has provento be a smart way to save for retirement.It allows the average employee to havemoney automatically deducted on a pre-tax basis from their paycheck before theyget a chance to spend it.

The trouble starts when planparticipants become overly concernedabout the market and reduce, or stop, theamount they contribute to their 401(k)plan. Doing this not only results in lessmoney at retirement, it preventsparticipants from taking advantage of avaluable investment strategy called“dollar cost averaging”.

Dollar cost averaging involvesinvesting the same amount everypaycheck, regardless of how the marketis performing. Over time, this will result

in more shares purchased at a loweraverage price because participantspurchase fewer shares in an up marketand more shares in a down market. Byreducing or stopping the amountcontributed to their 401(k) plan,participants not only miss theopportunity to buy additionaldiscounted shares, they lose the ability tosave for retirement on a pre-tax basis, asignificant advantage in any market.

During market downturns,participants are also prone to seek shelterin more conservative investments, such asmoney market or stable value funds.These, too, are not in their best interestbecause they sell their originalinvestment after the market has dropped,locking in the loss, and then are typicallyslow to get back into the market,preferring to see the market recoverbefore they reinvest. In short, they’reselling low and buying high.

Simply stated, the best advice formost participants is to stay the course.Since 1980, 19.5% of the average bullmarket’s gains were earned in the first 10days of the recovery from a marketdownturn. Because nobody is able toaccurately predict when a recovery hasactually started, participants should notonly stay invested, they should continueto invest additional money every payperiod to take advantage of the lowerprices.

The weakening economy has alsocaused a jump in the number ofemployees requesting hardshipwithdrawals and loans from their 401(k)accounts. The consequences of taking ahardship withdrawal can be severe,

including having to pay both ordinaryincome tax and a 10% penalty on thedistribution if a participant is youngerthan 59?. Additionally, most plansprevent employees from makingcontributions for 6 months after taking ahardship withdrawal.

Loans can be tricky too. If aparticipant loses their job during therepayment term, the loan becomes dueimmediately. If the loan isn’t repaid, notonly will that money not be available atretirement, but the participant will have

to pay a 10% penalty and ordinaryincome tax on the unpaid balance. Also,loans incur double taxation because theloan is repaid with after-tax money andthen the money is taxed again when it’swithdrawn in retirement.

It is also important to note thattaking a hardship withdrawal or a loanduring a market downturn also involvesselling at, or near, an investment’s lowpoint. When the market eventuallyrecovers, these assets are not in the planto enjoy the benefit of the recovery.

How can employers help? It’scritical that plan sponsors provide their401(k) participants with the necessaryinformation to make informed decisions

about their retirement account. Someexamples include:

• Communicating the different waysinvestors panic during market downturnsso that plan participants are less likely tooverreact – remember, the average bearmarket only lasts 129 days;

• Ensuring plan participants areproperly allocated so market downturnshave less of an effect on individualaccount balances;

• Explaining the dangers of pre-retirement distributions, such as hardshipwithdrawals and loans;

• Adding Target Date Funds to401(k) plans to allow plan participants toturn over control of their account to aprofessional money manager who willinvest their retirement assets based ontheir expected retirement date; and

• Providing employees with access toa financial advisor to answer questionsabout their specific situation.

It’s the duty of retirement plansponsors to ensure their employees don’toverreact to the recent market volatility.By providing targeted employeeeducation, plan sponsors allowemployees to place recent economicdevelopments in their proper historicalcontext. Remember, this too shall pass.

Neil H. Alexander is the Director ofHT Corporate Services, the retirementplan consulting division of Hefren-Tillotson, Inc., an investment advisoryfirm headquartered in DowntownPittsburgh. Rachel M. Hawili is aRetirement Plan Coordinator with HTCorporate Services. Reach them at 412-258-1069 or [email protected].

Because nobody is able to accuratelypredict when a recovery has actuallystarted, participants should not onlystay invested, they should continueto invest additional money every payperiod to take advantage of thelower prices.

Medical Groups Keep an Eye to the FutureContinued from page 4


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part of physicians can be especiallydamaging, destabilizing patient care andcompromising communication.Physician’s compassion for their coworkers and their patients can have anequally positive effect. Hospitals, itseems, consequently use a “carrot andstick” approach, adopting andimplementing policies to disciplinedisruptive behavior from physicians andothers, and rewarding and recognizingthose that exhibit compassionatebehavior.

When it comes to increasing patientinvolvement, the experts surveyed

Emerging Questionsperspective can be invaluable when

they are ready to engage. Imagine asurgical patient assisting with the designof the pre-operative process or a recentlyhospital admitee advising on optimalcommunication and educationapproaches. The inclusion of patients ondesign teams and the formation of aPatient and Family Council may notoccur to all providers, but can provideinvaluable perspective to hospital orphysician practice plans.

Interestingly enough, patients rankhospitals poorly on letting them knowwhat is wrong with them and what to

expect from testing and treatment. Thepatient’s care plan may be developed in avacuum, without their input orknowledge. The mantra “nothing aboutme without me,” born out of the patientsafety movement, can be adopted toimprove the patient experience.Hospitals are wise to instill practicestandards that include a daily review ofthe plan of care with each patient.

Question 4: What’s the best first stepa hospital or physician practice can take toimprove patient experience?

The panel of experts seemed to agreethat the most critical first action was toensure that the organization’s highestlevel of leadership was engaged. Thefocus is two-fold. First, engage yourboard of trustees and your CEO and

physician community to make this a topstrategic priority for the enterprise.Second, leaders must hear from andunderstand the concerns of the peoplewho come to their hospital or clinic forcare. As Cleveland Clinic’s Dr. Duffystresses, “this is vital.”

The patient experience experts alsorecommend planning for a “year ofawareness” about the patient experience.Develop a presentation about patientexperience work and take it to every staffmeeting and encounter with the Boardand senior leadership. Include it innewsletters and orientations. Postinformation on bulletin boards and inelevators. Make sure that everyone in theorganization, including patients, knowsthat you care about providing animproved experience in your hospital orclinic.

Beyond that, it becomes importantto determine your focus and selectmeaningful measures, as this work can beeasily set aside or swayed by anecdotewithout measurement. Involve patientstoo, inviting them to attend a staffmeeting and recount their experiences, orperhaps asking them to join a redesignteam or form a Patient Advisory Councilto bring recommendations to yourorganization.

And finally, the most compellingreason for physicians to engage in thiswork is to render medical care moreeffective and humane. Physicians areideal promoters and leaders for a betterpatient experience. The rewards can beimmediate for patients, hospital andclinic staff and for physicians themselves.

Alison Johnson, RN, MBA is thedirector of clinical consulting atMinneapolis-based Halleland HealthConsulting and can be reached [email protected].

Seminar: Is it Time for YOUR Practice to Jump onthe Bandwagon?Margolis & Company P.C., a regional CPA and business-consulting firm,will facilitate an EHR/Stimulus Incentives panel discussion on Tuesday,May 12th at their offices in Bala Cynwyd, PA. Physicians News is a proudsponsor of this important seminar, which will cover the key questions that areon the minds of physicians.

Beginning in 2011, the Medicare and Medicaid programs will implementincentive payments to physicians who have adopted electronic health records(“EHRs”). Conversely, there will be penalties for physicians who do not adoptelectronic records.

The incentive program announced by CMS indicates a serious attempt topromote the adoption of EHRs. Health experts say that EHR's will improvequality and reduce costs. While physician organizations such as academicfaculty practice plans and large freestanding multi-specialty clinics haveimplemented EHR's, most small and medium-sized practices have taken await-and-see attitude.

The current incentive program from Medicare and Medicaid will largelyunderwrite the out-of-pocket costs of EHR's. It provides up to $18,000 perphysician if implementation occurs in the years 2011 or 2012 plus $12,000 thesecond year, $8,000 for the third year, $4,000 in fourth year and $2,000 for thefifth year of use. On the other hand, practices that do not adopt electronicrecords will eventually see their Medicare reimbursement fall to 97% of thestandard fee schedule.

In addition to providing more detail on the incentives and penalties, theEHR seminar at Margolis & Co. will explain how electronic health records canbe used to improve coordination of care through information sharing acrossthe provider spectrum.

Panelists will talk about new efficiency and quality initiatives that arelikely to be tied to the use of electronic records. They will review importantoperational details such as the conversion from paper charts to electronicrecords, the efficiency and productivity gained from EHR's and ways tostreamline tasks such as prescription renewals, capturing and reporting testresults, and meeting quality reporting requirements of Medicare and otherpayors.

Representatives from major vendors like NextGen, Sage and McKesson'sPractice Partner will be hand to explain the advantages and disadvantages ofelectronic health records and to provide an overview of some of the mostcommon EHR systems. Attendees will also be given an opportunity to asktheir own questions.

The seminar is on Tuesday, May 12 at Margolis & Co., 401 E. CityAvenue, Suite 600 in Bala Cynwyd, PA. Breakfast at 8:30AM; paneldiscussion begins at 9AM. Please call (610) 784-0155 for more information.You can register for this free event via e-mail to Lisa Tierney [email protected].

Continued from page 8



MEDICINE & THE LAWFederal Stimulus Law Raises the Bar for HealthInformation Privacy and Security

The federal stim-ulus bill enact-ed on February 17,2009, the "AmericanRecovery andReinvestment Actof 2009" (ARRA),contains many newcompliance chal-lenges for physi-cians and other

health care entities and their vendors. Inaddition to creating a new federalbureaucracy for a new national electron-ic health records (EHR) infrastructure toset EHR standards and administer EHRstimulus money, and establishing newMedicare and Medicaid reimbursementmethods to incent EHR adoption,ARRA contains many new health information privacy and security requirements.

This article summarizes the mostsignificant privacy and securityrequirements of Title XIII of ARRA,the "Health Information Technology forEconomic and Clinical Health Act"(HITECH). Under HITECH, healthcare providers and companies currentlyregulated as HIPAA covered entities willbe subject to new privacy and securityobligations, and entities which are notcurrently regulated under HIPAA,including vendors to health careproviders, will be directly regulated underthese new privacy and securityobligations and will be subject topenalties for non-compliance.

New Federal Breach NotificationRequirements

Prior to HITECH, health careproviders had no statutory or regulatoryobligations under HIPAA to notifypatients of breaches of protected healthinformation (PHI) unless required to doso by applicable state breach notificationlaws. HITECH not only creates a newfederal breach notification obligationapplicable to health care providers butalso creates new breach noticeobligations applicable to certain entitiesnot currently regulated by HIPAA.

Breach notice requirements: HIPAACovered Entities and Business Associates

No later than 60 days afterdiscovering a breach of unsecuredprotected health information, a healthcare provider covered by HIPAA will berequired to notify each affected patientthat their information has been, or isreasonably believed to have been,accessed, acquired, or disclosed. UnderHITECH, a breach occurs when there isan unauthorized acquisition, access, useor disclosure which compromises thesecurity or privacy of PHI. HITECHdefines "unsecured protected healthinformation" (unsecured PHI) asprotected health information that is not

secured through the use of technology ormethods to be specified in guidanceissued by the HHS Secretary; HITECHdirects the HHS Secretary to issueguidance specifying which technologiesand methods render PHI unusable,unreadable or indecipherable tounauthorized individuals.

HITECH permits breach notices tobe made by written or electronic mail, orby a posting on the covered entity's website or in a media outlet if there isinsufficient contact information for 10 ormore individuals. If 500 or moreindividuals' information is involved,media notice must be provided and thecovered entity must also immediatelynotify the Secretary of Health andHuman Services (HHS). HITECHspecifies that the content of breachnotices must include a description ofwhat happened, the dates of both thebreach and the discovery of the breach, adescription of the information involvedin the breach, the steps that individualsshould take to protect themselves frompotential harm from the breach and a

description of what the covered entity isdoing to investigate, mitigate losses andprotect against further breaches.

HITECH also establishes a statutorybreach notification requirement directlyapplicable to HIPAA business associates.Under HITECH, a HIPAA businessassociates is obligated to notify thecovered entity of a breach of unsecuredPHI. The notice from the businessassociate to the covered entity must beprovided no later than 60 days from thediscovery of the breach and must includethe identification of each individualimpacted by the breach.

Breach Notice Requirements:Vendors of "Personal Health Records"

Outside of the HIPAA context,vendors of personal health records

(PHRs) are obligated under HITECH toprovide certain notifications in the eventof a breach of security. As distinct froman EHR containing PHI created andmaintained by a HIPAA coveredprovider or health plan, a PHR istypically initiated and maintained by anindividual, often through the services ofa PHR vendor, such as a sponsor of aninternet-based PHR platform.HITECH's new definitions key tounderstanding these new PHRrequirements include "personal healthrecord", "breach of security", "PHRidentifiable health information", and"unsecured PHR identifiable healthinformation."

Under HITECH, a "personal healthrecord" is defined as an electronic recordof PHR identifiable health informationabout an individual that can be drawnfrom multiple sources and that ismanaged, shared and controlled by orprimarily for the individual. "PHRidentifiable health information" meansindividually identifiable healthinformation that is provided by or on

behalf of the individual and thatidentifies the individual or that there is areasonable basis to believe that theinformation can be used to identify theindividual. "Unsecured PHR identifiablehealth information" means PHRidentifiable information that is notprotected through the use of technologyor methods as specified in guidance to beissued by the Secretary of HHS (throughthe same guidance process applicable tounsecured PHI, discussed above)."Breach of security" means, with respectto unsecured PHR identifiable healthinformation in a PHR, acquisition ofsuch information without theauthorization of the individual.

Following the discovery by a PHRvendor of a breach of security of

unsecured PHR identifiable healthinformation, the PHR vendor mustnotify each individual impacted andmust also notify the Federal TradeCommission (FTC). The samerequirements for timing, method andcontent of breach notices applicable inthe HIPAA context to unsecured PHI,discussed above, apply to breac

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