Dr. David Edward Marcinko MBA MEd CMP™

More JAMA [Hypocritical] Censorship on Big-Pharma Funding

Posted on April 7, 2009 by Dr. David Edward Marcinko MBA MEd CMP™

Janus-Like Opposing Views Becoming Contentious

[By Staff Reporters]

According to Tracy Staton, the Journal of the American Medical Association may be fighting to keep long-running internal arguments over conflicts-of-interest with big pharma a secret. But, in public, it’s advocating strict limits on industry funding for medical associations.

JAMA Proposals

A set of proposals published recently in JAMA, calls for associations such as the American Society of Clinical Oncologists, to refuse general budget support from drug and device companies. Currently, many specialty physicians’ groups are partly funded by industry. Companies also sponsor conferences, physician fellowships and buy ads in the societies’ journals. The proposed guidelines would allow associations to continue to accept industry advertising and to allow industry-sponsored booths at conferences.

Distinction

The key distinction, the article’s lead author said, is that ads and booths are clearly presenting a company’s point of view. “You can read the ads, skip the ads, but there’s nothing hidden,” David J. Rothman, a professor at the College of Physicians and Surgeons at Columbia University, told the Wall Street Journal. “What I don’t like is when I can’t tell if what I’m hearing is science, or marketing in the guise of science.”

Opposing Viewpoints

But others disagree. For example, the American College of Cardiology’s chief allegedly told the paper that industry funding has “zero impact on the content of any program here.” And PhRMA said that the guidelines could limit the information doctors receive. “It’s important to realize that [doctors] have their own sense of integrity,” a PhRMA spokeswoman.

Assessment

ME-P publisher, Dr. David Edward Marcinko, on the other hand, believes that Columbia University’s torturous verbal parsing is

“merely a distinction with little substantive difference.”

Link:http://online.wsj.com/article/SB123854648226076095.html

Conclusion

And so, your thoughts and comments on this Medical Executive-Post are appreciated? Do you agree with the current – but aging medical establishment – or the emerging generation of young and idealistic medical students and physicians who increasingly abhor the big-pharma practices? Is this another example of tawdry JAMA censorship? Is the AMA running away from its moral ethos of professional integrity?

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Filed under: "Doctors Only", Breaking News, Drugs and Pharma, Ethics, Health Law & Policy, Op-Editorials | Tagged: AMA, American College Cardiology, American Society of Clinical Oncologists, big-pharma, College of Physicians and Surgeons, Columbia University, David J. Rothman, david marcinko, drug companies, hope hetico, JAMA, Journal American Medical Association, pharmaceutical companies, PhRMA, WSJ | 5 Comments »

Doctors Preventing Medical Identity Theft

Posted on April 7, 2009 by Dr. David Edward Marcinko MBA MEd CMP™

More on the “Red Flag” Rules

[Staff Reporters]

According to MedicalNews, Inc and Lynne Jeter, the Medicare “Red-Flag” rules are set to take affect on May 1, 2009.

Three Categories

And, according to David Williams, CPA, FHFMA, a healthcare partner for HORNE in Jackson, Mississippi, the Red Flag guidelines for hospitals, clinics and medical practices can be broken down into three categories.

1. Red Flags that definitely apply to healthcare:

Documents provided for identification appear altered or forged.
Photographs or a physical description on file are not consistent with the appearance of the patient.
Other inconsistent information identifies the patient.
Inconsistent signatures are on file.
Patient forms or applications appear forged, altered, or destroyed and re-assembled.

2. Red Flags that may apply to healthcare:

Statements sent to the patient – or guarantor – that is returned as un-deliverable despite ongoing transactions on active records.

3. Red Flags that most likely do not apply to healthcare:

A fraud alert is included with a consumer report.
A consumer reporting agency provides notice of a credit freeze in response to a request for a consumer report, a notice of address discrepancy, and/or unusual credit activity.
Financial institutions and creditors use challenge questions that the person opening the covered account cannot answer with readily available information.
A request is made for new, additional or replacement cards or the addition of authorized users on the account shortly after a change of address request.
A new revolving credit account is used in a manner commonly associated with known patterns of fraud patterns.
The use of a covered account is inconsistent with established patterns of activity on the account.
There is unexplained usage of a covered account that has been inactive for a reasonably lengthy period of time.

Assessment

Link: http://www.medicalnewsinc.com/news.php?viewStory=222

Conclusion

Your thoughts and comments on this ME-P are appreciated. Feel free to review our top-left column, and top-right sidebar materials, links, URLs and related websites, too. Then, subscribe to the ME-P. It is fast, free and secure.

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Filed under: Career Development, Healthcare Finance, iMBA, Inc., Practice Management, Risk Management, Sponsors | Tagged: clinics, CMS, David Williams, HIPAA, HORNE, hospitals, identity theft, medical practices, medicare, medicare red flags, Patriot Act, red flags, Sarbanes-Oxley | 8 Comments »

Impact of Performance Fees on Mutual Funds and Physician Portfolios

Posted on April 6, 2009 by Dr. David Edward Marcinko MBA MEd CMP™

More Complex than Realized by Some Doctors

[By Dr. David Edward Marcinko; FACFAS, MBA, CMP™]

[By Professor Hope Rachel Hetico; RN, MHA, CMP™]

Physician-investors may find themselves paying advisory fees, brokerage commissions, and other sales charges and expenses. All of these layers of expense can reduce or eliminate the advantage of professional management, if not monitored carefully. Also, fees can have a major impact on investment results. As a percentage of the portfolio, they normally range from low of 15–30 basis points (or .15% to .30%, a basis point is one one-hundredth of one percent) to a high of 300–400 basis points or even higher.

Charges are Universal

All portfolio managers, mutual funds, and investment advisors charge fees in one form or another. Ultimately, they must justify their fees by creating value added, or they would not be in business. Value added includes tangibles, such as greater investment return, as well as intangibles, such as assurance that the investment plan is successfully implemented and monitored, investor convenience, and professional service.

Comparisons Required

Always compare investment performance of funds or managed accounts after fees are deducted; only then can adequate comparisons be made. Also, compare fees within asset classes. Management fees and expenses of investing in bonds or bond funds are much different than the fees of investing in, for example, small companies or emerging market stocks. Whereas 100–200 basis points of fees may be appropriate for an equity portfolio or fund, similar charges may offset the advantages of a managed bond portfolio. With managed bond portfolios, real bond returns have limited long-term potential, because returns are ultimately based on interest rates. For example, if a 3% real (i.e., after inflation) return is expected, 200 basis points in fees may produce a negative after-tax result: 3% real return minus 2% fees minus 10% taxes equals a negative 9% total return.

Sales Charges

Mutual funds (and some private portfolio managers) charge sales charges to sell or “distribute” the product. Investors who buy funds through the advice of brokers or “commission based” financial planners will pay a sales load. The many combinations of sales charges fall into three basic categories: front-end, deferred (or back-end), and continuous.

Front-End Fees

Front-end fees are a direct assessment against the initial investment and are limited to a maximum of 8.5%. They usually are stated either as a percentage of the investment or as a percentage of the investment, net of sales charges. For example, a 6% charge on a $10,000 investment is really a $600 charge to invest $9,400 or a real charge of 6.4%. Many low-load funds charge in the range of 1% to 3%. Rather than pay brokers or other purveyors, these fund companies or sponsors use the charges to offset selling or distribution costs. Although rare, some funds charge a load against reinvested dividends.

Deferred Charges

Deferred charges (or back-end loads, or redemption fees) come in many forms. Often, the longer the investor stays with the fund the smaller the charge is upon fund redemption. A typical sliding scale used for deferred charges may be 5-4-3-2-1, where redemption in year 1 is charged 5%, and redemption in year 5 is charged 1%; after year 5, there are no sales charges. Sometimes deferred charges are combined with front-end charges.

Redemption Fees

Certain quoted redemption fees may not apply after a period, such as one year. Funds often use such fees to discourage the trading of funds. Frequently, these charges are paid to the fund itself rather than to the fund management company; or broker. Long-term physician investors actually benefit from this fee structure; short-term shareholders who redeem shares bear the additional liquidation costs to satisfy redemption requests.

Continuous Charges

Continuous sales charges, known as 12b-1 fees for the SEC rule governing such charges, represent ongoing charges to pay distribution costs, including those of brokers who sell and maintain accounts, in which case they are known as “trail commissions.” The fund company may be reimbursed for distribution costs as well. In the prospectus, funds quote 12b-1 charges in the form of a maximum charge. This does not mean that the full charge is incurred, however. For example, a fund with a .75% 12b-1 approved plan may actually incur much lower expenses than .75%. Compared to front-end charges, a .75% per year sales charge of this type could be more costly to investment performance, given enough time.

Sales Loads

Portfolio managers can charge sales loads as well, usually in the form of a traditional WRAP fee arrangement (the investor pays a broker an all-inclusive fee that covers portfolio manager fees and transactions costs). No-load funds can be purchased through brokers or discount brokerage firms. The broker charges a commission for such purchases or sales.

Management Advisory Fees

Private account managers and mutual funds charge a fee for managing the portfolio. These fees typically range between 25 and 150 basis points. Bond funds tend to charge in the range of 25 to 100 basis points, and equity funds charge 75 to 150 basis points. Fees charged by private account managers usually are higher because of the direct attention given to a single doctor client. These managers do not pass along additional administrative costs, however, because they pay them out of the management fee. These management fees come in many forms. Tiered fees can charge smaller accounts a higher fee than larger accounts. Mutual funds often charge “group fees”: a fund family may tier its fee structure to encompass all funds offered by the fund family or by a group of similar funds (such as all international equity funds). Performance fees, although subject to SEC regulations, may be charged as well. A performance fee may be charged if the manager exceeds a certain return or outperforms a particular index or benchmark portfolio.

Administrative Expenses and Expense Ratios

Most private managers are compensated with higher management fees, as mentioned above. Therefore, many private accounts usually do not incur separate administrative expenses. Some management firms charge custodial fees or similar account maintenance fees. Mutual funds incur a number of administrative expenses, including shareholder servicing, prospectuses, reporting, legal and auditing costs, and registration and custodial costs. Mutual funds report these expenses and management fees as an expense ratio—the ratio of expenses to the average net assets of the fund. Expense ratios also include distribution costs or 12b-1 charges.

Brokerage Commissions

Almost all buyers and sellers of securities incur brokerage commissions. Private “wealth managers” usually provide commission schedules to prospective physician-investors or current clients. Some private managers charge higher management fees and a discounted commission schedule, while others charge lower fees and higher commissions. These combinations of management and commission fees make comparison of prospective managers’ cost structures a difficult task. Most portfolio managers obtain research from brokerage firms, which can affect the commission relationship between broker and manager. Reduced commission schedules exchanged for information are known as “soft dollar costs.” Mutual funds may negotiate similar reduced commission schedules. In this regard, more-competitive brokerage firms can charge lower fees to investors. Commissions are not part of the expense ratio, because they are a part of the security cost basis. Firms with higher portfolio turnover are more likely to have higher commission costs than those with low turnover. Asset class impacts such costs as well. For example, small-cap stocks may be more expensive than large-cap stocks, or foreign bonds may be more expensive than domestic bonds.

Total Cost Approach

To arrive at a relevant comparison of fees among funds and managers, and to see what the total effect of fees on investment performance is, analyze the various charges on a net present value basis. Begin with a given investment amount (e.g., $10,000) and factor in fees over time to arrive at the present value of those fees. Present the comparisons in an easy-to-use table.

Sources of Fee Information

Consult the mutual fund prospectus for fee information. The prospectus has a fund expenses section that summarizes sales charges, expense ratios, and management fees; it does not cover commissions, however. Expense ratios usually are reported for the past 10 years. Commission or brokerage fees are more difficult to find. The statement of additional information and often the annual report disclose the annual amounts paid for commissions. When the total commission paid is divided by average asset values a sense of commission costs can be determined. Private wealth managers disclose fee structures in the ADV I filed with the SEC. Managers must disclose these fees to potential and current clients by providing either ADV Part II or equivalent form to the investor.

Reporting Services

Reporting services, such as Morningstar and Lipper, provide similar information from their own research of mutual funds. These services can be extremely beneficial, because fee information is summarized and often accounted for in the reports’ investment return calculations. This helps the investor and planner make good comparisons of funds. Information services that cover private managers provide information, primarily about management fees.

Assessment

To the extent that online trading, deep discount brokerages, lack of SEC and FINRA oversight, and the recent financial, insurance and banking meltdown has affected the above, it is left up to your discretion and personal situation. Generally, all fess are, and should be, negotiable.

Disclaimer: Both contributors are former licensed insurance agents and financial advisors.

Conclusion

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***

Filed under: "Advisors Only", "Doctors Only", Ethics, Experts Invited, Financial Planning, Glossary Terms, Investing, Portfolio Management, Recommended Books, Research & Development | Tagged: 12b-1 fees, administrative fees, ADV I, ADV II, advisory fees, AIG, assets under management, back end fees, banking, banks, basis points, brokerage commissions, certified financial planner, certified medical planner, CFPs, CMPs, continuous charges, cost structures, CPAs, david marcinko, deferred sales charges, discount brokers, expense ratios, FAs, fee-only expenses, financial advisors, FINRA, front end fees, full services brokers, group fees, hard dollars, hope hetico, insurance, investing sales charges, investing sales expenses, investment returns, Lipper, loads, manaeg money AUMs, management advisory fees, MBAs, Morningstar, no loads, PhDs, Portfolio Management, redemption fees, RIA, sales loads, SEC, soft dollars, WRAP accounts | 8 Comments »

Direct Reimbursement [DR] and RiskManagers.Us

Posted on April 6, 2009 by Dr. David Edward Marcinko MBA MEd CMP™

Transparent Dental Benefits versus Confusion

[By Darrell K. Pruitt; DDS]

“If you are not a part of the solution, there is good money to be made prolonging the problem.”

Company slogan- www.riskmanagers.us

Meet Mr. William Rusteberg

Today, I met William Rusteberg on the PennWell forum when he replied to the thread, “Why the long NPI, BCBS-TX?” which I copied below, along with my response which includes a plug for Direct Reimbursement [DR].

http://community.pennwelldentalgroup.com/forum/topics/why-the-long-npi-bcbstx?page=1&commentId=2013420%3AComment%3A26976&x=1#2013420Comment26976

Mr. Rusteberg represents a company called RiskManagers.Us, whose specialty involves the benefits market, yet it is not exactly an insurance company – just like there is no such thing as true dental insurance. RiskManagers.us is a firm that works directly with businesses to identify and develop cost-effective benefits packages – emphasizing transparency and fairness. Now that is refreshing, friends!

Defining RiskManagers.Us

Here is how RiskManagers.us describes itself:

“We do not work for an insurance company, we work for you. As an independent brokerage, and consulting firm we can represent any licensed insurance company in Texas, Colorado, Mississippi, Louisiana, Alabama, Illinois & Florida.”

If one visits the Web site’s “Reference Library,” here are some of the topics offered:

· Self Funding – Need a second opinion?

· Texas leads in transparency issues

· Can’t get claim information? HB 2015 May Solve Your Problem

· Medical Stop Loss Through a Captive

· PPO Discounts – Games People Play

· PPO Networks – Shell Game

· Can Hospitals waive Deductibles in Texas?

“What is a NPI number?”

Mr. Rusteberg’s initial question on the PennWell forum simply asked, “What is a NPI number?” Following my explanation, he wrote:

“It seems that many of those in your profession would do well in accepting cash only, or directly working with employer groups who sponsor dental/medical plans on a direct pay basis. We have had good success in doing this for our clients – we have one employer in San Antonio who pays medical care providers directly and quickly – providers like it and the plan pays a fair and reasonable rate, not relying on a PPO network to “re-price” claims. We have done the same on dental plans, eliminating the insurance company, PPO network and paying dental care providers submitted charges directly and quickly. We see little or no trend increases on dental charges using this method. In my view, insurance companies interfere in patient – provider relationships in a financially detrimental way.”

Thanks for your reply.

My Response:

I like you, William;

What you describe sounds like my all-time, personal favorite dental benefits plan. It is called Direct Reimbursement {DR}, and it not only gives the employer the unlimited capability to design a plan which reflects the level of commitment desired by the company, but most importantly, it naturally preserves quality of care by allowing employees unlimited freedom of choice in dentists. And that’s as good as the market gets.

http://www.directreimbursement.com/

In addition, since there are no NPI requirements for DR, employees are also permitted see dentists who decline NPI numbers for ethical reasons. That increases employees’ choice by 50% over BCBS-TX clients, according to recent information provided by the Healthcare IT Transition Group.

http://www.npidentify.com/stats.htm#states

Little Management Needed

Just like the benefits plans you mention, with DR, very little money is spent on management because such policies are so simple and transparent that there is no room for profit-enhancing (wasteful) confusion used by unethical companies like BCBSTX, Aetna, Cigna, UnitedHealth, Delta Dental, United Concordia, and so many other members of the National Association of Dental Plans (NADP).

Assessment

Without transparency and the invisible hand of freedom-of-choice, free-market competition for healthcare dollars disappears as fast as executive bonuses rise. We’ll see where it goes from here. It would sure be swell if a Direct Reimbursement representative takes interest in the conversation; anyone home?

Conclusion

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Filed under: "Doctors Only", Breaking News, Career Development, Ethics, Health Economics, Health Insurance, Managed Care, Op-Editorials, Practice Management | Tagged: ADA, Aetna, BCBS-TX, Cigna, concierge medicine, Darrell Pruitt, david marcinko, delta dental, dental benefits, dental insurance, dentists, direct reimbursement, discount dentistry, doctors, Heal;thcare IT Transition Group, HIPAA, HMO, IPA, managed dental care, MCO, NADP, National Association of Dental Plans, NPI Number, PennWell forum, PPO, private pay healthcare, RiskManagers.Us, self insurance, United Concordia, UnitedHealth, William Rusteberg, www.RiskManagers.Us | 12 Comments »

Hospital Non-Profit Care and Community Benefits

Posted on April 6, 2009 by Dr. David Edward Marcinko MBA MEd CMP™

The IRS Sounds-Off

Staff Reporters

According to the Internal Revenue Service [IRS], a survey of nearly 500 not-for-profit hospitals in 2006 revealed that 9 percent total revenues were dedicated to community benefit. The just finalized 2006 report warned that attempts to set a percentage threshold for determining compliance may have a

“disproportionate impact on hospitals, depending upon their size, where they are located their community benefit mix, and other hospital and community demographics.”

Link: http://greisguide.com/?p=1059

Definition

The current “community benefit” standard was established by the IRS in 1969 in Revenue Ruling 69-545. The standard sets out factors to be considered in measuring community benefit, including: (i) a board made up of a broad base of community members; (ii) an open medical staff; (iii) participation in Medicare and Medicaid; (iv) application of surplus funds toward improving facilities, equipment, patient care, medical training, research, and education; and (v) a full-time emergency room open to all regardless of ability to pay (the emergency room standard applies differently to tax-exempt Long Term and Acute Care Hospitals [LTACH] that do not maintain a full array of emergency department services). Under the current community benefit standard, individual hospitals are given flexibility to determine what services will-best serve their communities.

www.HealthDictionarySeries.com

Assessment

Some pundits suggest that if Congress doesn’t establish new charity care requirements, the IRS should revert to its community benefit standard last in force in 1969.

Interim Report: http://greisguide.com/wp-content/uploads/2009/02/eo_interim_hospital_report_072007.pdf

Conclusion

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Filed under: Glossary Terms, Health Economics, Health Insurance, Health Law & Policy, Healthcare Finance, Quality Initiatives | Tagged: community benefit, congress, IRS, LTACH, Medicaid, medicare, non-profit hospitals, not-for-profit hospitals, Revenue Ruling 69-545, www.healthdictionaryseries.com | 8 Comments »

Defining Current Dental Terminology [CDT®] Codes

Posted on April 5, 2009 by Dr. David Edward Marcinko MBA MEd CMP™

What they Are – How they Work

By Staff Reporters

OMAP Unique Procedure Codes*

The HHS [Health and Human Services] Office of Medical Assistance Program’s [OMAP] unique procedure codes were originally listed in the appropriate service guides. The maintenance of these codes was the responsibility of OMAP. These procedure codes were reviewed as needed and deleted either when a program no longer exists or when other Healthcare Common Procedure Coding System [HCPCS] codes are created which fully describe the service. Most of the unique codes were created to meet the needs of specialized services or programs. OMAP’s unique procedure codes were all five character configurations with the following alpha/numeric combinations: four numeric/one alpha (e.g., 7300Y); three numeric, two alpha (e.g., 206EP); two alpha/three numeric (e.g., BA311); or three alpha/two numeric (e.g., VIS01).

Current Dental Terminology (CDT procedure codes)

The American Dental Association’s (ADA) Code on Dental Procedures and Nomenclature is contained in the CDT-3 user guide. The maintenance of these codes is the responsibility of the Council on Dental Benefit Programs with consultation from: Blue Cross and Blue Shield Association, the Health Insurance Association of America, the Health Care Financing Association, National Electronic Information Corporation, and the American Dental Association recognized dental specialty organizations. The ADA updates the user guide approximately every five years. CDT codes are five-character, alpha-numeric configurations (e.g., D2110). Contact the American Dental Association to obtain a current copy of the CDT-3 Users Manual.

* Note: Due to HIPAA (Health Insurance Portability and Accountability Act) requirements, Medicare Local codes and OMAP Unique codes were replaced with national standard procedure codes.

www.HealthcareFinancials.com

Assessment

For more terminology information, please refer to the Dictionary of Health Economics and Finance.

www.HealthDictionarySeries.com

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Filed under: "Doctors Only", Book Reviews, Career Development, Glossary Terms, Health Insurance, iMBA, Inc., Practice Management, Recommended Books | Tagged: ADA, American Dental Association, American Dental Association's Code on Dental Procedures and Nomenclature, Blue Cross and Blue Shield Association, CDT, CMS, current dental terminology codes, HCPCS, Health Care Financing Association, Health Insurance Association of America, Healthcare Common Procedure Coding System, HHS, HIPAA, National Electronic Information Corporation, OMAP | 6 Comments »

Inspect our 2-Volume Hospital Print Guide [for Free]

Posted on April 5, 2009 by Dr. David Edward Marcinko MBA MEd CMP™

ADVETISEMENT

Evaluate “Healthcare Organizations” [Financial Management Strategies] AND Order Now!

By Dr. David Edward Marcinko; MBA

By Professor Hope Rachel Hetico; RN, MHA

[Editor and Managing Editor]

As healthcare continues to evolve, leaders and executives have the formidable and immediate challenge of creating both short-term and long-term financial strategies. Given that today’s knowledge-base is different from that of even six-months ago, and the need is for solutions to tomorrow’s economic problems, success seems always just beyond your grasp!

Why Subscribe?

But fortunately, you can be ready; Healthcare Organizations: [Financial Management Strategies] is your blueprint for success. To ensure your organization’s competitive edge and perhaps even its survival, you must quickly gain the financial management tools and techniques necessary to lead in the 21st century. What you learn and implement using this Guide enables you to respond proactively to the rapidly changing healthcare environment. Your subscription to Healthcare Organizations: [Financial Management Strategies] not only helps you lead, it brings together healthcare executives and visionary thought leaders to help you develop essential models and successful financial management strategies, going forward.

www.HealthcareFinancials.com

Subscription Support

Specialty Technical Publishers is pleased to provide customer information and support services for Healthcare Organizations: [Financial Management Strategies] by phone, fax, or e-mail. Customer information services hours are between 7 am and 5 pm Pacific Standard Time; or http://www.stpub.com/pubs/custinfo.htm
Testimonials

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Operating Room Supervisor

Hospital Administrator

Baltimore, Maryland

Assessment

For today … for tomorrow … for all healthcare organizations … for you! Remember, the Guide is available on a 30-day, risk-free trial. You may contact http://www.STPub.com at (604) 983-3434, fax (604) 983-3445, or e-mail at custinfo@stpub.com to place an order, or ask questions regarding pricing and/or availability. All shipments arrive within 5 to 10 days. Prepayment is required for all international shipments and a courier charge will be added to the subscription price. After hours, we suggest you review the STP website FAQs section for answer to your inquiry: www.stpub.com/pubs/custinfo.htm

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Opinion Poll on eMRs

Posted on April 4, 2009 by Dr. David Edward Marcinko MBA MEd CMP™

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Defining Current Procedural Terminology [CPT®] Codes

Posted on April 4, 2009 by Dr. David Edward Marcinko MBA MEd CMP™

What they are – How they work

By Staff Reporters

The American Medical Association’s Physicians’ Current Procedural Terminology® is contained in the CPT user guide. The maintenance of these codes is the responsibility of the American Medical Association with consultation from the AMA CPT Editorial Panel, Advisory Committee, and the AMA CPT Health Care Professionals Advisory Committee. Procedure codes in the CPT user guide are reviewed and revised annually. The Health Care Financing Administration’s – now CMS – Common Procedure Coding System [HCPCS] lists three levels:

Level I National Codes

CPT codes are five-character, all numeric configurations (e.g., 99215). Contact the American Medical Association to obtain a current copy of the CPT® Users Manual.

Level II National Codes

The HCPCS Level II National codes are contained in the HCPCS user’s guide and are published in the Federal Register. The maintenance of these codes is the responsibility of the Health Care Financing Administration [CMS]. Procedure codes in the HCPCS user guide are reviewed and revised annually. HCPCS codes are five characters with one alpha and four numeric configurations (e.g., A0042). Contact any publishing company that provides medical coding reference books to obtain a current copy of the current HCPCS User Manual.

Level III Medicare Local Codes*

Historically, local Medicare carriers developed local procedure codes which were published in the local Medicare Newsletters. The maintenance of these codes was the responsibility of the local Medicare carrier. Medicare local procedure codes were all five-character configurations with the following alpha/numeric configuration: one alpha, (W, X, Y or Z) with four numeric configurations (e.g., Y5523); and two alphas, (W, X, Y or Z) same character with three numeric identifiers (e.g., XX001). Contact your local Medicare carriers to obtain their Medicare Newsletters.

* Note: Due to HIPAA (Health Insurance Portability and Accountability Act) requirements, Medicare Local codes and the Office of Medicare Assistance Program Unique [OMAPU] codes were replaced with national standard procedure codes.

Assessment

For more terminology information, please refer to the Dictionary of Health Economics and Finance.

Conclusion

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Evaluate our 2-Volume Institutional Print Guide

Posted on April 4, 2009 by Dr. David Edward Marcinko MBA MEd CMP™

Healthcare Organizations [Financial Management Strategies]

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Assessment

Rest assured, Healthcare Organizations: [Financial Management Strategies] will become an important peer-reviewed vehicle for the advancement of working knowledge and the dissemination of research information and best practices in our field. In the years ahead, we trust these principles will enhance utility and add value to your subscription. Most importantly, we hope to increase your return on investment [ROI] by some small increment.

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Conclusion

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Blindsiding Delta Dental

Posted on April 3, 2009 by Dr. David Edward Marcinko MBA MEd CMP™

Delta Dental Sends More Easy Prey My Way

By Darrell K. Pruitt; DDS

When it comes to blindsiding witless PR departments, what good is Schadenfreude if it can’t be shared for the entertainment of my large collection of quirky, unshaven sports fans – a special class of readers who would stick around to watch the sequelae of an ignited paper bag on a front porch … even if from a safe distance.

Devoted and Abandoned Employees

The rumor is, watching PR professionals silently vanish from the Internet is becoming a popular spectator sport – especially when it’s the more expensive hacks for sleazy discount dental companies like Delta Dental. I intend to show you that when someone writes really nasty things about their most devoted employees – employees who publicly donate their name and reputation to Internet branding for the interests of Delta Dental – Delta Dental will still not come to their defense (No wagering, please). The devoted and abandoned, whose objectives in life are to take hits for some team, make easy prey.

Thinking of Ari Adler

Remember Ari Adler? He heads Delta’s Corporate and Public Affairs division, and was quoted in DrBicuspid Assistant Editor Rabia Mughal’s article, “Dentists or patients: Who should get the insurance check?”

http://www.drbicuspid.com/index.aspx?d=1&sec=sup&sub=pmt&pag=dis&ItemID=301436&wf=34

It was on DrBicuspid that Adler broke the news to the nation that Delta Dental now guarantees the fillings done by their preferred providers. When confronted by a special bastard to explain Delta’s unprecedented sales pitch, Adler immediately sat his butt down and shut up. (See “I will hurt you Delta Dental”)

http://community.pennwelldentalgroup.com/forum/topics/i-will-hurt-you-delta-dental

Lost in Web Space

That was two months ago, and Adler still hasn’t uttered another peep on behalf of Delta Dental. Now doesn’t that make the air in the land of the free just a little more pleasant? And yesterday, Rabia Mughal posted another article illustrating managed care dentistry’s level of ethics titled “Study: Insurers’ market power lowers dentists’ income.”

http://www.drbicuspid.com/index.aspx?sec=sup&sub=pmt&pag=dis&ItemID=301668&wf=34

Mughal describes the findings of a study titled “The effects of insurance carrier market power on dentists and patients” that appeared in the January edition of the JADA. Here is the abstract of the study:

http://jada.ada.org/cgi/content/abstract/140/1/90

The effects of insurance carrier market power on dentists and patients

By L. Jackson Brown; DDS, PhD

By Albert H. Guay; DMD

By Donald R. House; PhD

Background

Market power among dental insurance carriers is a carrier’s ability to reimburse dentists at rates below what would exist in more competitive areas. Competition among carriers for dentists’ participation in their networks protects dentists from highly discounted fees. The authors examined the extent to which dental insurance carriers facing less competition increase fee discounts.

Methods

The authors selected a sample of dentists from listings of general practitioners. They identified 219 metropolitan areas and contacted 11,542 dentists in those areas by mail, telephone or both. A total of 8,017 dentists completed surveys (a response rate of 69.46 percent). The authors’ key focus was the possible relationship between carrier market power and the size of the fee discount. The authors compared discounts across metropolitan areas with their differing levels of insurance coverage and carrier market shares.

Results

Carrier market power was directly related to the sizes of fee discounts. The larger discounts were found where there was significant dental insurance coverage and few carriers providing this coverage. Dentists’ net incomes were significantly less in areas with larger fee discounts.

Conclusions and Practice Implications

Dental insurance carrier market power leads to increased fee discounts. These higher discounts reduce dentists’ earnings. Although the larger discounts may result in lower overall patient costs, this patient benefit is temporary. Ultimately, the number of practicing dentists in these communities will decrease as dentists seek improved practicing conditions elsewhere. This reduction will lead to overall fee increases until the earning potential of dentists is restored.

Abbreviations: IPAs: Independent practice associations. • PPO: Preferred provider organization. • UCR: Usual, customary and reasonable.

####################

As one can imagine, Delta Dental, the largest dental discount service in America, did not like what both the ADA study and Mughal had to say about discount dentistry brokers. This time though, instead of sending Ari Adler into the wide open spaces once more, Delta sacrificed a new, unsuspecting traditional-type of PR executive whose feelings have never been hurt. Her name is Janis Oshensky, and she is the vice president of professional relations for Delta Dental Plans Association.

Enter Again Ms. Janis Oshensky

Ms. Oshensky confidently said that it is her opinion that the study is flawed. Here is what Ms. Oshensky told Mughal:

“The study speculates that dentists will leave markets dominated by a few large carriers, which would lead to higher fees for uninsured patients and reduced access to care. In fact, the miniscule effect of concentration on the fees paid to dentists — as they are reported in the study — is unlikely to trigger a mass exodus of dentists from concentrated areas.”

Ms. Oshensky further states – on dentists’ behalf – that we actually realize that discounts do not necessarily mean less pay, and that network participation increases dental visits (for the same pay). Now that woman deserves a company wristwatch!

Devoted to Delta

To show you how devoted Oshensky is to Delta Dental, her act almost fooled me into believing that she believes the NPI number makes sense. That’s no joke. Look at what she posted on the Delta Dental Website celebrating Delta’s success, and you will see what I mean:

“Thanks to all of the dentists and health professionals who have applied for NPIs and who have notified us of their new identifiers. While we’re not ready to completely replace the current identifiers with NPIs, we’re making great progress and will work to keep dentists and their office staff informed about our NPI readiness.”

http://www.deltadentalnj.com/npi/PrepareToAccept.shtml

Now that’s talent. I would imagine that she probably charges more than Adler ever will. Her name is all over the Internet on behalf of Delta Dental, and she sounds even more enthusiastic about the NPI number than Patrick Cannady of the ADA Department of Dental Informatics did a couple of years ago when his department was still telling ADA members to quickly volunteer for the ten digit identifier. You know, come to think of it, Delta Dental’s Website closely resembles the ADA’s. How do you think that happened?

Re-Enter Rabia Mughal

My hat goes off to author Rabia Mughal. How he can successfully lure another Delta Dental slow-mover into the open following the ambush of Ari Adler is pure genius in a mis-match of wits.

Assessment

So here we go again, sports fans. Come on out, Janis Oshensky, I can make you famous. Please bring everything you know about the NPI number with you as well because I have a few questions to ask … or not. Schadenfreude macht Freude.

Conclusion

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Physician’s Acquiring Real-Estate

Posted on April 3, 2009 by Dr. David Edward Marcinko MBA MEd CMP™

Innovative Funding in Difficult Times

[Staff Reporters]

Real estate can be acquired by physician-investors, even in these difficult times, in many different ways. For example, through direct purchase, participation in a real estate partnership vehicle with other investors [such as general partnerships, limited partnerships, various corporate entities, and, in most states, limited liability companies (LLCs), and investments in real estate securities such as Real Estate Investment Trusts (REITs).

Section 1031

Real estate also can be acquired through tax-deferred exchanges under Section 1031 of the IRS Code, in which a client “trades” one investment property for another, deferring the taxes due on the sale of the exchanged property. This allows the doctor to reinvest “pre-tax” dollars in another real estate investment, potentially benefiting from appreciation on the larger investment. The physician may also exchange one larger property into two or several smaller properties and pay tax consequences on each one as those properties are sold as cash is needed.

Tax and Risk Management

The way a physician takes ownership of real estate will affect the tax treatment of income and profit. For example, having an LLC-owned investment property will provide him/her with the same protection from individual liability as a corporation, while allowing him/her to have much more favorable tax treatment. Real estate can be bought directly by purchasing it in the following manners:

1. Paying cash,

2. Paying a cash down payment and acquiring a loan,

3. Paying cash to the seller who is financing, or

4. Financing the purchase by using either new real estate financing, seller financing, or credit borrowing when a lender is willing to loan solely on the strength of, and the financial statement of, the borrower, or a combination of these.

Trading and Secured Loans

Real estate also can be acquired by trading other valuable assets, sometimes in combination with financing. A client can obtain interests in real estate by making loans on real estate assets that are secured by a deed of trust or a mortgage. Another method is to invest as a participating lender. In such an instance the borrower needs to agree to provide equity kickers or participation in cash flow whereby the lender (doctor) can benefit directly from the real estate performance.

Equity Participation Plans

With an equity participation, the physician-investor can profit or gain from the sale of the property, sometimes in a preferential manner (i.e., the money the doctor loaned is returned, with interest, and a predetermined percentage or portion of the gain is given to the owner/borrower before distribution of the sales proceeds). Similarly, the doctor can participate in annual cash flow, giving a fixed or a fluctuating amount depending on the performance of the investment. As a lender, many of the benefits of ownership of real estate are not available to the MD, but the doctor should have a security interest in the property and no direct responsibility for operation of the real estate investment. Also, if possible, the borrower should provide additional guarantees of performance. The borrower could do this by providing additional security, such as the deeds of trust on the borrower’s house, other real-estate, and the acquired property; bank letters of credit; or guarantees of performance from people other than the party to whom the money is originally loaned.

Assessment

If a physician-investor is considering acquiring or lending on real estate, s/he should check with his professional advisors, including accountants and attorneys, before proceeding. The doctor’s attorney should review any contracts or agreements before the client signs anything. The physician also will need a due diligence review to ascertain both the relative values of the real estate on which money is being loaned and the borrower’s track record and background.

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The Gay Doctor Dilemma

Posted on April 3, 2009 by Dr. David Edward Marcinko MBA MEd CMP™

Understanding Domestic Partnership Problems

[By Staff Reporters]

Legal Strangers

In spite of many changes to state laws and with a few exceptions, for all intents and purposes, unmarried physician couples are still considered strangers to one another. The unmarried partner has no right to make health care decisions, no right to Social Security survivor benefits, and no inheritance rights without proper documentation. An unmarried partner generally has no standing to seek damages for the “wrongful death” of a spouse, nor any standing for any other contractual rights.

Tax Treatment

Unmarried couples do not get the same tax treatment—such as the ability to file a joint tax return—as do married couples. While this may not necessarily mean higher taxes for married couples, it can make deductions difficult to determine for unmarried couples. Nor can an unmarried couple use the spousal Individual Retirement Account deductions for a nonworking spouse. An unmarried couple may not use a family partnership for tax purposes.

Non-Tax Benefits

Unmarried partners do not have the benefits that spouses have when a relationship ends or one partner dies. Domestic partners may not receive alimony or child support, except in special cases. A partner may not receive pension rights, and generally will not receive employer benefits, except in certain companies and municipalities. One partner who is forced to quit practice when the other partner is transferred may not receive unemployment benefits, while a spouse can. Unmarried partners may not qualify to get residency status for a non-citizen partner to avoid deportation.

Estates and Gift Problems

Estate tax law allows married couples an unlimited deduction for estate and gift tax purposes. Unmarried couples do not get this benefit, and may be taxed on what would otherwise be a tax-free transfer. If one partner dies intestate (without a will) the couple’s joint property would not necessarily go to the survivor. A married couple can give away $26,000 per recipient each year without gift tax consequences, but an unmarried individual with a high income is limited to $13,000, per recipient per year, even when living with a partner.

Personal Benefits

Domestic partners may be kept from visiting a partner in a prison or in the hospital or any other place restricted to “immediate family” members. Without specific legal permission, such as a durable power of attorney, the blood relatives of the partner who is ill can keep the domestic partner from seeing his or her mate. Except in a few municipalities and companies, domestic partners may not be eligible for bereavement leave when one partner dies.

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Is JAMA Censoring Physician Dissent?

Posted on April 2, 2009 by Dr. David Edward Marcinko MBA MEd CMP™

Allegedly Stoops to “Name-Calling”

By Dr. David Edward Marcinko; MBA, CMP™

According to the Wall Street Journal Health Blog, Jonathan Leo, a professor of neuro-anatomy from a small university in Tennessee, critiqued a study published in the Journal of the America Medical Association [JAMA], and pointed out an association between the study’s author and a pharmaceutical company. He posted his thoughts on the website of the British Medical Journal [BMJ].

JAMA Responds

According to the report, a none-too-happy Leo then received calls from JAMA’s executive deputy editor, one Mr. Phil Fontanarosa. And surprisingly, Editor-in-Chief Dr. Catherine DeAngelis, MD got involved by asking Leo’s superiors to retract his post from the BMJ’s site. Sound familiar ME-P readers? According to Keven Pho MD, the WSJ called Dr. DeAngelis for comment, and this is how the interview allegedly went:

“This guy is a nobody and a nothing.”

She said of Leo.

“He is trying to make a name for himself. Please call me about something important.”

She added that Leo

“Should be spending time with his students instead of doing this.”

When asked if she called his superiors and what she said to them, DeAngelis supposedly said,

“It is none of your business.”

Environmental Scanning

One can only wonder if the AMA has adopted the strategy of former CDC Director Julie Gerberding, of Atlanta, GA. Local gossip suggests that one initiative under her noxious leadership was her so-called policy on “environment-scanning” or, monitoring the news-media, internet space, blogs, wikis and other venues to identify “emerging threats to the agencies” reputation.” WOWSA!

Link: https://healthcarefinancials.wordpress.com/2009/02/05/goodbye-julie-gerberding-md/

An Alternative Theory

My alternative opinion is the AMA might be taking censorship lessons from Blue Cross and Blue Shield of New Mexico [BCBSNM], and its’ public-relations representative and former reporter, Ross Blackstone of the Health Care Service Corporation [Blue Cross and Blue Shield of Illinois, New Mexico, Oklahoma and Texas].

Monitoring the ME-P?

Or, perhaps they are reading [Think: monitoring] this Medical Executive-Post itself? They may even be teaming up with Becky Kenny [media relations specialist with Blue Cross and Blue Shield of New Mexico] who goaded [threatened?] the trade magazine ModernHealthcare. As ME-P readers know, ModernHealthcare is an advertiser-driven media outlet that removed a perfectly acceptable post of diverging eHR opinion from its blogsite?

Industry Shame

Such acquiescence is both a sign of shameful health insurance industry [BCBSNM] heavy-handedness, and poor journalistic ethos from ModernHealthcare’s leadership. The BCBSNM public relations hacks, and media representatives, also appear as clueless shills who are no-doubt glad they are employed in these troubling economic times.

In other words, do they do what they are told? Jump Rover! Fetch Fido; etc! Or; are they more like the innocent child who spills grape juice on a white carpet? Let’s simply forgive them for their brainless duplicity. Yet, MH capitulated; how unfortunate!

Link: https://healthcarefinancials.wordpress.com/2009/03/04/don%e2%80%99t-rush-ehrs/

Doctors Censoring Patients [The Retro-Evolution]

By the way:

“What’s up with all this censoring?

The Internet has been publically available to the masses since 1995, and I was using electronic bulletin boards [eBBs] years before then. The next thing you know, doctors will start trying to censor the opinion of their patients, much like customers rate restaurants.

Ops! My bad! This has already occurred. Sorry!

The ironic thing here is that patients don’t know about quality care. But, they do know if they’ve been kept too long in the waiting room; or, if the doctor’s office staff was surly; or, if the doctor had a miserable bedside manner. So, the doctors are really being rated on their personality; not their medical acumen. I pity the fools. These medical guys, and healthcare guru gals, just don’t seem to realize that “perception is reality.” But, they sure feign outrage at poor patient reviews.

Link: https://healthcarefinancials.wordpress.com/2009/03/02/doctors-censoring-patients/

Assessment

From my perspective, this is another public-relations disaster for JAMA, and especially Dr. DeAngelis, who must have known she was on the record with a national newspaper. After all, she is the editor of JAMA. Maybe not however, as we have previously opined that professional experts are not necessarily professional journalists.

Link: https://healthcarefinancials.wordpress.com/2009/03/09/healthcare-experts-versus-health-journalists

Of Cover-Ups and Crimes

“But, one must still wonder aloud; is this cover-up becoming worse than the proverbial crime?”

Resorting to personal attacks is somewhat unbecoming of the editor-in-chief of a prestigious medical journal, and reflects poorly on JAMA; don’t you think? Then again, JAMA and the AMA itself, is not as prestigious as it once was; is it?

In fact, when I asked ME-P managing-editor and Professor of Health Administration, Hope Rachel Hetico; RN, MHA, CMP™ to opine on admitted third-party limited information; she graciously replied with the utmost gentleness:

“With less than 25% of the nation’s MDs in the AMA; JAMA is probably still somewhat prestigious to those who don’t know any better; but many of us do know better. The older generation just needs some-time to catch up to modernity, and transparency – or resign. The top-down and command-control model of leadership is long gone – please be patient with them.”

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Link: www.MedicalBusinessAdvisors.com

Conclusion

And so, your thoughts and comments on this Medical Executive-Post are appreciated. Should Catherine DeAngelis MD resign over this incident? Please criticize or defend her actions. Is healthcare industry censorship on the rise – or is the industry just following-the-money? What do you think of ModernHealthcare or BCBSNM?

Is personal integrity – or scrutiny – the reason Joseph Biederman MD [Harvard’s controversial chief of pediatric psychopharmacology] ended his ties to the pharmaceutical industry recently for diagnosing bipolar disorder in children [as well as for the nature of big-pharma’s support behind his research]? Please opine.

Industry Indignation Index: 63

Disclaimer: I am not a member of the AMA. But, for a decade I was on the editorial staff of both a leading national medical, and surgical journal, back-in-the-day. I am currently the Editor-in-Chief of Healthcare Organizations [Financial Management Strategies] a 1,200 page, quarterly premium print-journal, available on a subscription basis.

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Physician Advisors: www.CertifiedMedicalPlanner.com

Link: http://feeds.feedburner.com/HealthcareFinancialsthePostForcxos

Filed under: Breaking News, Career Development, Drugs and Pharma, Ethics, iMBA, Inc., Industry Indignation Index, Media Mentions and PR, Op-Editorials, Professional Liability, Quality Initiatives | Tagged: AMA, american medical association, BCBSNM, becky kenny, Blue Cross and Blue Shield of Illinois New Mexico Oklahoma and Texas, Blue Cross and Blue Shield of New Mexico, BMJ, British Medical Journal, Catherine DeAngelis, CDC, censors, censorship, david marcinko, EHRs, Harvard, Health Care Service Corporation, hope hetico, JAMA, Jonathan Leo, Joseph Biederman, journal of the american medical association, Julie Gerberding, kevin pho, medical censorhsip, Modern Healthcare, ModernHealthcare, pediatric psychopharmacology, Phil Fontanarosa, Ross Blackstone, wall street journal health blog | 18 Comments »

Say it Ain’t So Kathy Sebelius

Posted on April 2, 2009 by Dr. David Edward Marcinko MBA MEd CMP™

More HHS Nominee Tax Problems

[By Staff Reporters]

Although it’s sounding more and more like comedian Bill Murray’s movie “Ground Hog Day”, according to Tracy Staton, Health and Human Services department secretary-nominee Kathleen Sebelius, became the second appointee for the agency to admit underpaying her taxes.

Unintentional Problems

Sebelilus fixed three years’ worth of returns due to “unintentional” problems, and paid almost $8,000 in back taxes and interest. The snafu may not be serious enough to jeopardize her nomination, however. Senate Finance Chair Max Baucus issued a statement saying the errors were “minor” and accidental, and that he supported her confirmation (The committee’s ranking Republican Charles Grassley is reserving judgment until after her confirmation hearing).

A Daschle “Do-Over”

We all know that Senator Tom Daschle’s nomination to head up HHS hit the wall after a tax review found he owed some $140,000 in back taxes and interest. Is this a similar KS do-over; aka “mulligan”?

Industry Indignation Index: 45

Assessment

More importantly, are these so-called healthcare demagogues and gurus aware that “perception is reality”; especially in the healthcare space where integrity and trust matters most? Or, as ME-P Publisher Dr. David Edward Marcinko wondered aloud,

“Do politicians and/or those of us in healthcare really believe we are above it all?

Link: http://blogs.wsj.com/health/2009/04/01/sebelius-runs-into-tax-problems-but-daschles-were-bigger

Conclusion

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OUR OTHER PRINT BOOKS AND RELATED INFORMATION SOURCES:

LEXICONS: http://www.springerpub.com/Search/marcinko
PHYSICIANS: www.MedicalBusinessAdvisors.com
PRACTICES: www.BusinessofMedicalPractice.com
HOSPITALS: http://www.crcpress.com/product/isbn/9781466558731
CLINICS: http://www.crcpress.com/product/isbn/9781439879900
ADVISORS: www.CertifiedMedicalPlanner.org
BLOG: www.MedicalExecutivePost.com

Filed under: Accounting, Ethics, Health Law & Policy, Industry Indignation Index, Risk Management, Taxation | Tagged: back taxes, Charles Grassley, HHS, Kathleen Sebelius, Max Baucus, tax, Thomas Daschle, underpayment taxes | 8 Comments »

Medical News of Arkansas Interviews Dr. Marcinko

Posted on April 1, 2009 by Dr. David Edward Marcinko MBA MEd CMP™

Current Status of Hospitals and the Economy [Op-Ed]

[By Steve Brawner]

What: An exclusive telephonic and email interview.

Who: Dr. David Edward Marcinko; FACFAS, MBA [Editor, administrator and health economist]

Topic: The recession and economy, hospital operations, and the Obama administration.

Where: The telephone and internet virtual ME-P ether.

Why: To forecast informed opinions and pontifications on the healthcare industrial complex.

Among the dilemmas in healthcare, we seek answers to queries like:

• When will the recession end, and how will it affect hospitals and physicians?
• What operations and organizational policies can hospitals pursue to survive?
• How will the Obama stimulus affect hospitals and healthcare organizations?

Now, in as much as this controversy affects patients, administrators, politicians, Wall Street, nurse-executives and physicians alike, we went right to the source for up-to-date information regarding this current topic.

Assessment

Get ready for this controversial [unedited] interview and Q-A session, with Dr. David Edward Marcinko; Publisher-in-Chief, of this ME-P.

Arkansas Medical News Interviews Dr. Marcinko

Read it Here: interview-dr-marcinko1

Sponsored Link: www.MedicalBusinessAdvisors.com

Conclusion

OUR OTHER PRINT BOOKS AND RELATED INFORMATION SOURCES:

PRACTICES: www.BusinessofMedicalPractice.com
HOSPITALS: http://www.crcpress.com/product/isbn/9781466558731
CLINICS: http://www.crcpress.com/product/isbn/9781439879900
ADVISORS: www.CertifiedMedicalPlanner.org
FINANCE: Financial Planning for Physicians and Advisors
INSURANCE: Risk Management and Insurance Strategies for Physicians and Advisors
Dictionary of Health Economics and Finance
Dictionary of Health Information Technology and Security
Dictionary of Health Insurance and Managed Care

[HOSPITAL OPERATIONS, ORGANIZATIONAL BEHAVIOR AND FINANCIAL MANAGEMENT COMPANION TEXTBOOK SET]

***

Filed under: "Advisors Only", "Ask-an-Advisor", "Doctors Only", Breaking News, Interviews, Point-Counter Point, Sponsors | Tagged: david marcinko, DO, doctors, DPM, economy, healthcare industrial complex, Healthcare Organizations, healthcare stakeholders, hospitals, MD, Medical News of Arkansas, obama, patients, recession, steve brawner, Wall Street | 5 Comments »

Events-Planner: April 2009

Posted on April 1, 2009 by Dr. David Edward Marcinko MBA MEd CMP™

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Events-Planner: APRIL 2009

Staff Writers

“Keeping track of important health economics and financial industry meetings, conferences and summits”

Welcome to this issue of the Medical Executive-Post and our Events-Planner. It contains the latest information on conferences, news, and relevant resources in healthcare finance, economics, research and development, business management, pharmaceutical pricing, and physician/entity reimbursement! Watch for a new Events-Planner each month.

First, a little about us! The Executive-Post is still a newcomer. But today, we have almost 15,000 visitors and readers each month from all over the country, in addition to our growing subscriber base. We have been a successful collaborative effort, thanks to your contributions. As a result, we are adding new resources daily. And, we hope the website continues to provide the best place to go for journals, books, conferences, educational resources, tools, and other things you need to establish the value your healthcare consulting and financial advisory intervention. And so, enjoy the Executive-Post and our monthly Events-Planner with our compliments.

A Look Ahead this Month

April 1: Print Edition Healthcare Journalism: If you would like to “step-up-your-game” and be considered as a peer-reviewed contributor to the third print edition of: The Business of Medical Practice [Advanced Profit Maximizing Techniques for Savvy Doctors]; contact Ann at: MarcinkoAdvisors@msn.com. There are several chapter topics still available. Now, the important dates:

April 1-3: Adv. Modeling Methods for Health Economic Evaluation, York, UK.

April 4-8: HIMSS Annual Conference, Chicago, IL.

April 6: Premier Forum on Medication Therapy Management and Patient Compliance Programs. CBI; Las Vegas, NV

April 7: FINRA Small Conference Series, New York, NY.

April 14: World health Care Congress; Washington, DC.

April 15-16: Tiburon CEO Summit, Ritz Carlton, New York, NY.

April 15-18: Academy of Managed Care Pharmacy’s 21st Annual Meeting and Showcase, Orlando, FL.

April 16-18: TIPAAA Annual Conference, Marriott River Center, San Antonio, TX.

April 20-24: Health Economics of Pharmaceuticals and Other Medical Interventions. Nice (Cannes) France.

April 21-22: Market Access Strategies for Personalized Medicines and Companion Diagnostics, Brussels, Belgium.

April 21-23: Introduction to Applied Health Economics: Methods for analysis of healthcare utilization and expenditure, University of York.
April 23-25: AIP Conference on Philanthropy, Rosemont, Ill.

April 25-29: Society for Pain Practice Management Meeting, Phoenix, AZ.

April 26-29: Wound Healing Society Symposium, Dallas, TX.

Apr 27-28: 8th Annual Forum on Patient Compliance, Adherence and Persistency, Philadelphia, PA.

April 27-29: Workshop on Health Technology Assessment From Theory to Evidence to Policy, Toronto, CANADA.

April 28-May 1: Pharma Pricing and Market Access Outlook Europe, 2009, London.

April 29-May 2: American Geriatric Society Meeting, Chicago, IL.

Please send in your meetings and dates for listing in the next issue of our Events-Planner.

MarcinkoAdvisors@msn.com

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Filed under: "Advisors Only", "Doctors Only", Breaking News, Career Development, Marketing & Advertising, Sponsors | Tagged: david marcinko, Events-Planner, FINRA, geriatric, Health Economics, health meetings, HIMSS, Managed Care, pharmacy, Tiburon, wounds | Leave a comment »

About Bond Uni-Trusts

Posted on March 31, 2009 by Dr. David Edward Marcinko MBA MEd CMP™

What they Are – How they Work

By Staff Reporters

Bond uni-trusts are a type of closed-end investment company. Their funds issue a fixed number of shares, and the value of the shares is determined by the market for them.

Obtaining unit trust bonds

A physician-investor wishing to buy into a closed-end fund must buy shares from an owner of the shares of that fund. The same holds true for selling shares. The market price may or may not be related to the net asset value of the fund. If the market for the shares is higher than the net asset value, then the shares are said to be trading at a premium. If the market for the shares is lower, they are said to be trading at a discount.

Appropriate uses

Unit trusts are generally sold in units of $1,000. As funds are received into the trust, reflecting payment of principal and interest, they are distributed to the shareholders. Because the portfolio is fixed and therefore does not incur the higher expenses normally associated with research and trading, the unit trust’s expenses are relatively low. For these reasons, unit trusts are appropriate for physician-investors who need a steady and periodic income. The doctor-investor who needs to withdraw capital may do so by selling shares back to the unit trust at their current net asset value. Again, depending on where interest rates are, the medical professional may or may not suffer a capital loss.

Assessment

For more terminology information, please refer to the Dictionary of Health Economics and Finance.

www.HealthDictionarySeries.com

Conclusion

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Healthcare Organizations: www.HealthcareFinancials.com

Health Administration Terms: www.HealthDictionarySeries.com

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Filed under: Book Reviews, Financial Planning, Glossary Terms, Investing, Portfolio Management, Sponsors | Leave a comment »

On Drug Reps as Future Dinosaurs

Posted on March 31, 2009 by Dr. David Edward Marcinko MBA MEd CMP™

More Doctors Closing Office Doors to Drug Salesmen

[By Staff Reporters]

According to Kevin B. O’Reilly, of the AMNews on 3/23/09, drug reps may soon become dinosaurs-of-sorts. And, the relationship between doctors and drug reps is cloudy, darkening and may never be the same again.

Changing Relationships

Pharmaceutical companies, battered by sluggish drug pipelines, the looming loss of blockbuster patented drugs, an economy in recession and scrutiny of their relationships with physicians; are re-examining the value of sending drug reps into doctors’ offices. Detailers are struggling to grab a shrinking slice of physicians’ valuable time, and attention, while adjusting to new drug industry rules banning freebies such as pens and notepads.

Declining Reputations

While most physicians still have positive views of detailers and drug-makers, those sentiments are cooling. And, the next-generation of medical students and future physicians may be another driver of this wave. About one in four physician’s works in a practice that refuses to see drug reps. Of doctors who do see reps, about 40% will meet with detailers only with scheduled appointments. The by-appointment-only figure jumped 23% during the last six months of 2008, according to a survey of more than 227,000 medical practices representing 640,000 physicians that was released in February.

***

Assessment

What is your practice policy on this issue? Are drug reps being replaced by webcasts, podcasts, IMs, text-messages, cell phone advertisements, direct-to-doctor [D2D] communications and/or some other new-wave social media or rich e-format?

Channel Surfing the ME-P

Have you visited our other topic channels? Established to facilitate idea exchange and link our community together, the value of these topics is dependent upon your input. Please take a minute to visit. And, to prevent that annoying spam, we ask that you register. It is fast, free and secure.

Conclusion

OUR OTHER PRINT BOOKS AND RELATED INFORMATION SOURCES:

PRACTICES: www.BusinessofMedicalPractice.com
HOSPITALS: http://www.crcpress.com/product/isbn/9781466558731
CLINICS: http://www.crcpress.com/product/isbn/9781439879900
ADVISORS: www.CertifiedMedicalPlanner.org
FINANCE: Financial Planning for Physicians and Advisors
INSURANCE: Risk Management and Insurance Strategies for Physicians and Advisors
Dictionary of Health Economics and Finance
Dictionary of Health Information Technology and Security
Dictionary of Health Insurance and Managed Care

Filed under: "Doctors Only", Drugs and Pharma, Ethics, Managed Care, Practice Management | Tagged: Big Pharma and Drugs, big-pharma, D2C, D2D, detailers, drug makers, drug reps, generic, IMs, patent, pharmaceuticals, text messages, webcasts | 13 Comments »

Usual and Customary UnitedHealthcare?

Posted on March 30, 2009 by Dr. David Edward Marcinko MBA MEd CMP™

More on “Sleazy” Healthcare Stakeholders

[By Darrell K. Pruitt; DDS]

If the leaders of the American Dental Association have the power and stoic determination to casually sweep aside trouble-making members who might tarnish their image, one would think that they could certainly avoid associating with sleazy healthcare stakeholders; such as UnitedHealthcare.

The Insurance Giants

Have you ever suspected that insurance giants like UnitedHealthcare, WellPoint, Aetna and Cigna (and other members of the National Association of Dental Plans) lie to patients when the say a dentist’s fees are above “usual, customary and reasonable” levels? You could be correct. NY Attorney General Andrew Cuomo says UnitedHealthcare, WellPoint, Aetna and Cigna lie to physicians’ patients – understating New York state physician’s fees up to 28 percent. Why would the crooks treat dentists’ patients any differently?

Employing Tapeworms to Control Fat

Cuomo caught UHC and others cheating their customers with smoke, mirrors and Ingenix – its wholly-owned data mining and consulting subsidiary. Who would have guessed that UHC would tweak Ingenix to manipulate claims data to favor UHC and other insurance companies who subscribe to their services? These are the same parasites who want to run the nation’s Pay-For-Performance (P4P) mandate – a cornerstone of President Bush’s healthcare reform ideas. They want to tweak professional reputations for healthcare reform and the common good.

And of Ingenix

Ingenix is a full-service consulting business for insurers, backed with the credibility of 14 years of accumulated health claims it is privy to. The “friend in the business” not only cooks the data to produce profit-enhancing Usual, Customary and Reasonable (UCR) fee schedules, Ingenix is also active in “pay-for-performance program assessment, strategy, planning, design, implementation, evaluation and improvement.”

http://www.ingenixconsulting.com/about_history.html

So if you like the way UnitedHealthcare dental consultants treat you now, just wait until they are given authority to determine your worth to society using Ingenix leveraging tools.

P-4-P

I first read about pay-for-performance [P4P] in dentistry in February 2006 in an email from Patrick Cannady who is an employee in the ADA Department of Dental Informatics. He told me that nation-wide quality control in dentistry is an important benefit of having a HIPAA-compliant, paperless dental practice – and that the Department of Dental Informatics is very excited about the opportunity to help prepare US dentists for the future. A month or so later, I learned that the NPI number the ADA still pushes on membership is the crucial legal link to government-approved P4P data-mills like Ingenix – a wholly-owned UnitedHealthcare profit center. Do you think it is odd that the NPI is “voluntary,” yet irreversible?

AMA’s Award

In January, the AMA was awarded $350 million in a lawsuit against UnitedHealthcare and Ingenix on behalf of physicians, and they plan to sue other major insurance companies as well. So what has the ADA done to discourage UnitedHealthcare’s and other NADP members’ atrocious behavior that undeniably harms dental patients? You won’t believe it when I tell you. Here’s more: In a recent Associated Press interview, Sen. Jay Rockefeller, chairman of the Senate Commerce, Science and Transportation Committee, said UnitedHealthcare is nothing but a company of cheats. He says, “They’re lowballing deliberately. They deliberately cut the numbers so the consumer has to pay more of the cost.”

http://www.google.com/hostednews/ap/article/ALeqM5gL4XFckx9sah3eFEMuHYD3V2WGhQD97763800

So if Cannady’s department is all for P4P and other benefits from interoperable digital records, the question on most ADA members’ minds should be: What does the ADA think of UnitedHealthcare?

ADA News Online

Two weeks ago the ADA News Online posted an advertisement that looks like an article (with no byline) for the spring meeting of the American Association of Dental Consultants (AADC) on May 7-9 in Scottsdale, Arizona.

http://www.ada.org/prof/resources/pubs/adanews/adanewsarticle.asp?articleid=3493

Since it is so well known that UnitedHealthcare is the major funding sponsor of the AADC, the word in the neighborhood says AADC, like Ingenix, is another UnitedHealthcare profit center awaiting the wrecking-ball.

Link: http://www.google.com/hostednews/ap/article/ALeqM5gL4XFckx9sah3eFEMuHYD3V2WGhQD97763800

Assessment

Last year’s annual meeting of the dental consultants – who deny dental claims to protect the ethics in dentistry – featured ADA Senior Vice-President Dr. John Luther as a guest speaker. Dr. Luther is Cannady’s boss. He oversees the Department of Dental Informatics. Yep. The ADA is tight with UnitedHealthcare. One can tell a person’s character by the company he or she keeps.

Conclusion

OUR OTHER PRINT BOOKS AND RELATED INFORMATION SOURCES:

DICTIONARIES: http://www.springerpub.com/Search/marcinko
PHYSICIANS: www.MedicalBusinessAdvisors.com
PRACTICES: www.BusinessofMedicalPractice.com
HOSPITALS: http://www.crcpress.com/product/isbn/9781466558731
CLINICS: http://www.crcpress.com/product/isbn/9781439879900
ADVISORS: www.CertifiedMedicalPlanner.org
BLOG: www.MedicalExecutivePost.com
FINANCE:Financial Planning for Physicians and Advisors
INSURANCE:Risk Management and Insurance Strategies for Physicians and Advisors

Filed under: Breaking News, Career Development, Ethics, Health Insurance, Health Law & Policy, Managed Care, Op-Editorials | Tagged: AADC, ADA, Aetna and Cigna, AMA, American Association of Dental Consultants, Department of Dental Informatics, Ingenix, Jay Rockefeller, John Luther, National Association of Dental Plans, NPA, NY Attorney General Andrew Cuomo, P4P, Patrick Cannady, Science and Transportation Committee, Senate Commerce, UCR, UHC, UnitedHealthcare, WellPoint | 3 Comments »

How Doctors Pay for Wealth Management Services

Posted on March 30, 2009 by Dr. David Edward Marcinko MBA MEd CMP™

Many Methods Possible and Often Confusing

[By Dr. David Edward Marcinko; FACFAS, MBA, CMP™]

What is of the utmost importance to a physician-investor is: (1) to have a plan, (2) a means of implementation and monitoring investments, and (3) a process to review goals and objectives in the future. Some or all of these steps may require the supervision of a financial planner or fiduciary investment advisor. “Professional” advisors who assist doctors and investors with the development of an investment plan also may become involved with implementation, monitoring, and performance reporting. Other “advisors” work only with plan development, referring implementation and supervision to others.

Basic Methods

There are three basic methods of payment for professional investment management: by commission, fee only, or a combination of the two. The method of payment used depends on the type of service provided and on who provides it.

1. Commissions

Some advisors who assist investors with investment planning, implementation, monitoring, and reporting do not charge a direct fee. They provide planning services for no charge if investors buy and sell the investments that they recommend. Investment brokers who are licensed to buy and sell securities may use the resources of a brokerage firm to assist investors with planning.

Commission-based advisors generally will recommend load mutual funds, thereby receiving either front-end or trail commissions. Trail commissions are paid over time or as a fee based on a percentage of the account value, similar to a 12b-1 fee. Brokers may provide or recommend professional money managers affiliated through their brokerage firm. The broker is paid directly or indirectly by some form of referral fee, or through a trading commission arrangement with the money management firm.

2. Only Fees

Fee-only professionals provide planning and supervisory services for a fee. The fee may be a flat periodic fee, an hourly fee, or a percentage-of-assets fee. Investment planning often is paid for by a flat or hourly fee. Supervisory services (encompassing implementation), monitoring, and reporting, often are paid by the hour or as a percentage-of-asset fee. Percentage-of-asset fees usually are tiered based on the size of the account.

3. Combination Fees and Commissions

Many investment professionals use a combination of commission and fee planning. They may charge a nominal fee for planning and discounted commissions for other services. Another combination is the fee offset, in which a flat or similar fee is charged and then is reduced by commissions, referral fees, and similar charges earned by the planner or advisor.

Registration

Investment advisors registered with the SEC may provide fee-only services. Registration does not guarantee the investor is using a competent investment advisor or money manager as it is required for those advisors giving investment advice.

Certifications and Designations

Many professionals become certified by a peer or professional group to provide fee-only services. They must pass exams and otherwise demonstrate some level of competence to obtain and maintain certification marks. Certified Financial Planners (CFPs®), ChFCs Chartered Financial Consultants [insurance industry], personal financial specialists (PFSs, who also must be CPAs), and more than 100 others can advise investors. Within these designations, there are so called “specialists” in areas of investment planning (on a more sophisticated level), implementation, and supervisory services. Except for CPAs and Certified Medical Planners™; none of these “advisors” are truly fiduciaries.

www.CertifiedMedicalPlanner.com

Supervisory Service

Supervisory services can be basic or sophisticated. In the simplest form, an advisor monitors the implementation process and periodically reviews the investment plan to assure that it is being followed. These advisors delegate or let the investor delegate the selection and supervision of actual investments to other brokers, investment managers, etc. Other advisors take a more direct role in the selection and supervision of brokers, investment managers, and mutual funds. At a more sophisticated level, an advisor prepares periodic reports, uses software to monitor and review portfolio structures, and implements strategies and tactical asset allocation decisions.

Assessment

To the extent that online trading, deep discount brokerages, lack of SEC and FINRA oversight, and the recent financial, insurance and banking meltdown has affected the above, investing – with or without an advisor – is left up to the physician. Generally, all fess are, and should be, negotiable. When it comes to the financial services product sales industry; always remember that most of these folks are salesmen; so always remember “caveat emptor” or “buyer beware.”

Disclaimer: The author is a former licensed insurance agent, Certified Financial Planner® and founding principal of the Certified Medical Planner™ online educational program, in health economics and medical management, for financial advisors and healthcare consultants.

Conclusion

OUR OTHER PRINT BOOKS AND RELATED INFORMATION SOURCES:

DICTIONARIES: http://www.springerpub.com/Search/marcinko
PHYSICIANS: www.MedicalBusinessAdvisors.com
PRACTICES: www.BusinessofMedicalPractice.com
HOSPITALS: http://www.crcpress.com/product/isbn/9781466558731
CLINICS: http://www.crcpress.com/product/isbn/9781439879900
ADVISORS: www.CertifiedMedicalPlanner.org
BLOG: www.MedicalExecutivePost.com
FINANCE: Financial Planning for Physicians and Advisors
INSURANCE: Risk Management and Insurance Strategies for Physicians and Advisors

Filed under: "Doctors Only", Alerts Sign-Up, Funding Basics, Investing, Op-Editorials, Portfolio Management, Sponsors | Tagged: 12b-1, certified financial planner, certified medical planner, CFP, ChFC, CMP, commissions, CPA, fee only, financial advisors, financial planners, FINRA, PFS, registered investment advisor, registration, RIA, SEC, Series 63, Series 65, Series 7, stock broker, wealth manager | 3 Comments »

Understanding Managed Bond Funds

Posted on March 29, 2009 by Dr. David Edward Marcinko MBA MEd CMP™

Considerations for the Physician-Investor

By Staff Reporters

Proper diversification among types of bonds is an important investment objective. The maturity schedule and the number of issuers are often very important, along with the issuers’ creditworthiness.

Individual Constraints

The constraints on purchases of individual bond issues often put the physician-investor at a disadvantage. Minimum amounts of investments are imposed by the marketplace or the issuer. Many doctor-investors find it impractical to meet these requirements and also obtain proper diversification (the amount of portfolio funds committed to debt-based securities simply is not large enough to obtain diversification and at the same time meet the other limitations). Accordingly, many investors find mutual funds devoted to debt-based securities most effective in achieving diversification.

A Large Marketplace

The mutual fund marketplace has many types of bond funds, and diversification can be obtained quite easily. The investor with a relatively reduced amount to invest in debt-based securities should consider using mutual funds.

Assessment

For more terminology information, please refer to the Dictionary of Health Economics and Finance.

www.HealthDictionarySeries.com

Conclusion

And so, your thoughts and comments on this Medical Executive-Post are appreciated?

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Medical Risk Management: http://www.jbpub.com/catalog/9780763733421

Healthcare Organizations: www.HealthcareFinancials.com

Health Administration Terms: www.HealthDictionarySeries.com

Physician Advisors: www.CertifiedMedicalPlanner.com

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Filed under: Financial Planning, Investing, Portfolio Management | Tagged: bond funds, bond insuror's, bond rating, bonds, credit, credit rating, credit rating agency, creditworthiness, debt securities, debts, junk bonds, municipal bonds, mutual bond funds, Mutual Funds, revenue bonds, treasury bonds | 3 Comments »

Exercising Healthcare Employee Options

Posted on March 29, 2009 by Dr. David Edward Marcinko MBA MEd CMP™

Vital Information for Medical Professionals and Heathcare Workers

[By Staff Reporters]

To a large degree the decision to exercise a stock option will depend on whether the medical professional, hospital or other healthcare services employee is going to hold the stock following the exercise or is going to sell the stock immediately.

A Bifurcated Decision Point

1. If the employee intends to sell the stock, then he or she should try to time the exercise so that the stock is at its highest value.

2. If the employee is going to hold the acquired stock for future investment, then he or she should exercise the option as late as possible under the terms of the option agreement; the employee thus enjoys all upside potential without any investment and has nothing at risk.

Exceptions

There are two exceptions to the general rule:

1. First, if the rate of dividends is sufficient to cover the financing cost, or is at least equal to other investment returns, then exercise of the options makes sense.

2. Second, if the option is an Incentive Stock Option [ISO], the potential application of the alternative minimum tax (AMT) rules may force the employee to stagger the exercise.

Assessment

For more terminology information, please refer to the Dictionary of Health Economics and Finance.

Conclusion

And so, your thoughts and comments on this Medical Executive-Post are appreciated?

Link: http://feeds.feedburner.com/HealthcareFinancialsthePostForcxos

Our Other Print Books and Related Information Sources:

Practice Management: http://www.springerpub.com/prod.aspx?prod_id=23759

Physician Financial Planning: http://www.jbpub.com/catalog/0763745790

Medical Risk Management: http://www.jbpub.com/catalog/9780763733421

Link: http://feeds.feedburner.com/HealthcareFinancialsthePostForcxos

Filed under: Alternative Investments, Investing, Portfolio Management | Tagged: alternate minimum tax, AMT, dividends, exercising options, incentive stock options, ISOs, options, stock options, under water options | 1 Comment »

ME-P is Sponsored by the Certified Medical Planner™ Program

Posted on March 28, 2009 by Dr. David Edward Marcinko MBA MEd CMP™

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By Ann Miller; RN, MHA

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Reflections on a Tent Hospital

Posted on March 28, 2009 by Dr. David Edward Marcinko MBA MEd CMP™

Thoughts on Pop-Up Healthcare Facilities

By Dr. David Edward Marcinko; FACFAS, MBA, CMP™

Publisher-in-Chief

According to the Philadelphia Inquirer, February 10, 2009, it took Mark Ross about 22 minutes to inflate the hospital for the first time. Yesterday, he did it in 14 minutes. In the event of a large-scale emergency – a direct hit by a hurricane for example, or a plane in the Delaware River [Think Hudson River, NY] – Ross and other volunteers can have the mobile hospital running anywhere in Southeastern Pennsylvania within two to four hours of the first alert.

The Valley Forge Experiment

The day before, on February 9, in Valley Forge PA, dozens of current and potential volunteers got to see three tan and white tents – and reams of equipment – for the first time. The $1 million cost was paid by state and federal governments. With a portable generator, 50 cots, 130 ventilators, 26 wireless cardiac monitors and 27 patient carts loaded with tongue depressors, eye shields and IV sets, the rapid-response team is intended to fill the 72- hour gap before federal emergency help arrives after a disaster.

Back-in-the-Day

Now, despite this Valley Forge innovation, mobile, semi-permanent and pop-up healthcare facilities are not a new machination in civilian life or non-warfare times. In fact, please allow me to tell you of my canvass tent-hospital experience, back in the late seventies.

My Tent Hospital

At the time, I was completing my training program as a senior attending resident [SAR], and surgical fellow. The “hospital” where I moonlighted was located in a sleepy town about 40 miles North of Atlanta, Ga. Driving there in my lime-green, oil-burning 1969 Chevrolet Impala with balding tires [retreads] was always novel experience.

As I recall history, the tent-hospital began as a private medical clinic in a three bedroom converted brick ranch-house that was the style in the late 1950s’-60s. It was the private practice of a solo practitioner-internist for his rural patients who lived on farms too far from the big city – or for patient’s who mistrusted the medical establishment. There were many. It grew quickly, from the days before Medicare/Medicaid reimbursements, to modernity.

Think Cirque du Soleil

Expanding to a larger facility, with sparse economic resources, necessitated innovative thinking at the time. The hospital itself was a very large circular tent [bulls-eye configuration], built on semi-permanent concrete foundation with trampoline-like floor. The tent was shaped like a disc or sphere. In the center was an operating room for the visiting general surgeon. The next concentric layer was comprised of four rooms. The admissions, records department and triage room; a dirty-room with toilet; a clean room with bed and shower; and a kitchen with doctor/nurse station and lounge. The next third outer concentric layer consisted of about twelve patient “rooms”. The patients entered each room from the inner second layer, while the doctors and nurses opened a door-slot on the outer third layer for the introduction of food, information, gowns and equipment, visitor chit-chat and medications, etc. Each room was muck like a dungeon, jail or cell [Recall the Seinfeld episode where Kramer housed visiting Asians in his cabinet drawer or shelf]. The docs and nurses continually circulated the third outer “floor” layer, ministering to their respective patients. By the way; no staff nurse ever complained of tired feet, leg soreness or calf cramps because of the springy trampoline-like floor.

Not a TV MASH Unit

This “hospital” was not like a military MASH unit, at all. It was definitely civilian in nature, purpose and construct:

Think: Army CASH unit; not MASH unit.

CASH = Combat Army Surgical Hospital [semi-permanent].

MASH = Mobile Army Surgical Hospital [ambulatory]

My Experiences

During my summer working there, I managed a small part-time, two-room medical clinic with a singular nurse. We treated all sort of minor injuries and ills, cuts, scrapes; boils and blisters; aches and sprains; dog bites, bee stings and allergies, and simple closed extremity fractures, infections, etc. I even operated on a half-dozen patients under local anesthesia with conscious sedation. For the holidays, I received presents from several nurses and patients who remembered me from the previous summer.

New Facility

My “tent hospital” was in operation for almost two decades before the founding physician retired. The site was replaced by a publically funded, much larger and permanent “modern” facility, as the surrounding suburbs grew. The new Woodstock Hospital is now a short-term facility, with 21 beds, but is not yet rated by any hospital service agency because of statistically low volume requirements. It is a District Authority owned hospital facility.

Source: Centers for Medicare and Medicaid Services for the years 2005-2007.

Assessment

Now, here’s the thing. My tent-hospitals’ claim-to-fame was that it, at the time of closure, was the only hospital in the State of Georgia to have never had a hospital acquired [nosocomial] or post-operative infection? To my knowledge, the feat has not been duplicated in this state. Of course, the new facility was not so fortunate. Increased medical acuity, treatment services and a different-mobile patient population was cited as the likely culprit.

Conclusion

And so, your thoughts and comments on this Medical Executive-Post are appreciated. Quality initiatives are good. And, health 2.0 information technology is the future of medicine. But, sometimes, prologue is past.

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Filed under: Career Development, Military Medicine, Op-Editorials, Quality Initiatives | Tagged: CASH, CMS, hospitals, MASH, Woodstock Hospital | 2 Comments »

Future of Health Publishing and Business Journalism

Posted on March 27, 2009 by Dr. David Edward Marcinko MBA MEd CMP™

Good Content and “Fly” Beats the Competition

By Dr. David Edward Marcinko; MBA, CMP™

[Publisher-in-Chief]

Last month, Steve Brawner [Steve Brawner Communications, a free-lance journalist for the Medical Business News, Inc., and the publisher of Medical News of Arkansas] contacted me to talk about hospitals, healthcare economics and the current financial dilemma in medical care. The interview will appear, as a special report, in April

But, after discussing answers to his top ten questions, we at the Institute of Medical Business Advisors, Inc www.MedicalBusinessAdvisors.com posited another interesting query. It was not on any particular subject area of our expertise, but aimed at us as electronic-publishers, reporters and health journalists.

The Future of Journalism

In other words, the question was:

“What do we think is the future business model for health journalism?”

Now, we’ve been mulling this thought over some time now, and our opinion goes something like this:

“We don’t – the old media is collapsing.”

And, while I don’t pity the likes of Chicago billionaire Sam Zell [the so-called “grave-dancer” for his penchant to buy distressed companies on the cheap and revitalize them for profit] – poor Sam – he was a very successful real-estate entrepreneur and the Chairman of Equity Group Investments. He thought this knowledge or luck was transferrable to the publishing industry, it wasn’t.

But, I do feel for distressed print newspapers like the Seattle Post Intelligencer, Chicago Tribune and especially the Baltimore Sun; as a native Balti-moron. I have both a favorite uncle, and older cousin, whose entire careers were spent in the print and ink business, there.

Link: https://healthcarefinancials.wordpress.com/2009/03/09/healthcare-experts-versus-health-journalists/

New Media “Fly”

How has this happened? Well, Google destroyed the advertising model for most media, and blogs and social networks have democratized the commentary / opinion playing field to some greater / lesser extent. Think: Mark Zuckerberg [Facebook] of Harvard, whose parents are both physicians – incidentally Mark’s got “fly” – Zell does not. We got the electrons at the ME-P, but little cash.

The Problem

The problem is that not many “new” media outlets, like the Medical Executive-Post, can afford to take on the interesting part of publishing; which is paying real investigative journalists. Think: The Huffington Post. Something I would love to be able to do; as there’s lots of muck to be raked in health economics, finance, administration, health IT; as well as medically focused financial planning, Wall Street and related personal investing activities for doctors – an integrated oeuvre of topics to say the least.

www.HealthDictionarySeries.com

Our Own Investigative Reporter

About the closest we have to a true investigative reporter is Darrel K. Pruitt; DDS. And, although he is no Bob Woodward or Carl Bernstein; he does occasionally do a good job. Think: William Mark Felt as FBI agent “deep-throat”.

Of course, as regular readers of the ME-P are aware, Darrell broke the dental profession’s [allegedly dufus] conspiracy with CCHIT [allegedly faux], and regularly reports on the folly of eHRs, eDRs, NPIs and eMRs. Think: citizen doctor journalist.

Link: https://healthcarefinancials.wordpress.com/2009/03/02/cchit-is-prejudiced-and-lacks-diversity-%e2%80%93-an-indictment/

Link: https://healthcarefinancials.wordpress.com/2009/03/02/avi-baumstein-and-hipaa-compliancy/

Link: https://healthcarefinancials.wordpress.com/2009/03/04/don%e2%80%99t-rush-ehrs/

Assessment

But, when the ME-P gets financially solid enough to hire others, and put them into the mix of expertise, commentary and free-labor entrepreneur punditry we now have on the site; then there’ll be no need for the current newspapers [at least insofar as our covered topic channels are concerned]. Until then; we don’t know what the answer is, but it, like the economy, doesn’t look good for the print media space.

Link: http://www.shirky.com/weblog/2009/03/newspapers-and-thinking-the-unthinkable

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As Editor-in-Chief of the premium subscription, two volume, 1,200 pages, institutional print-guide Healthcare Organizations [Financial Management Strategies], we prefer engaged readers who demand compelling content; old or new media.

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According to the conventional wisdom expressed above, this printed guide should be a relic of the past, from an era before instant messaging and high-speed connectivity. But, our experience shows just the opposite. Applied healthcare economics and financial management literature has grown exponentially in the past decade and the plethora of internet information makes updates that sort through the clutter and provide strategic analysis all the more valuable.

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Conclusion

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Filed under: Book Reviews, Health Economics, Health Insurance, Healthcare Finance, iMBA, Inc., Managed Care, Media Mentions and PR, Practice Management, Recommended Books, Research & Development | Tagged: Baltimore Sun, Bob Woodward, Carl Bernstein, Chicgo Tribune, Darrell Pruitt, eDRs, EHRs, EMRs, Facebook, health journalist, Healthcare Organizations, hospitals, iMBA, Inc., journalism, Mark Zuckerberg, Medical Business News Inc, medical clinics, Medical News of Arkansas, NPI, Sam Zell, Seattle Post Intelligencier, William Mark Felt | 1 Comment »

Obama on the SGR Physician Payment Formula

Posted on March 27, 2009 by Dr. David Edward Marcinko MBA MEd CMP™

Solo Doctors and and Small Group Practices May Benefit

By Staff Reporters

According to Diana Manos of Healthcare Finance News, on March 23, 2009, small medical group practices and solo and/or independent physicians may benefit most from the recently proposed Obama healthcare budget. In it, President Obama asked Congress for $76.8 billion for the Department of Health and Human Services [DHHS] for fiscal year 2010. Some funding would come from changes to the way healthcare is provided, with a new emphasis on pay-for-performance [P4P] for Medicare providers.

The AMA’s Response

It was reported that, Joseph M. Heyman, MD, chairman of the American Medical Association’s Board of Trustees, said the AMA is pleased with the administration’s proposed new baseline – or projected spending over a period of time – or Medicare physician payment updates.

“Unlike previous budget forecasts, the administration’s new budget baseline recognizes that Congress needs to and will act to avert the serious access crisis that looms as physicians face drastic payment cuts in the coming decade due to the failed Medicare physician payment formula,” he is reported to have said. Furthermore,

“The AMA strongly supports the use of a realistic baseline as a foundation for Congress to move forward with a permanent solution to the flawed SGR physician payment formula, and urges the committee and Congress to ensure that a new Medicare physician payment baseline is adopted in the 2010 Fiscal Year (FY) Budget Resolution.”

Assessment

Under the president’s budget request, Medicare Advantage would be revamped; physicians and hospitals could expect to be paid for performance [P4P] under Medicare; pharmaceutical companies would face steeper competition from generic drug companies and the government would clamp down on inadvertent and fraudulent overpayments under Medicare. The budget also calls for “comprehensive, but fiscally responsible reforms” to the physician payment formula [Sustainable Growth Rate], moving toward rewarding doctors for efficient quality care.

Link: http://www.healthcarefinancenews.com/news/small-physician-practices-can-expect-real-changes-healthcare-under-obama-budget

Conclusion

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Filed under: Health Economics, Health Insurance, Healthcare Finance | Tagged: AMA, DHHS, HITECH, Joseph M. Heyman, MA, Medicare Advantage, Obama Healthcare, P4P, Pay-for-Performance, SGR, sustainable growth rate | 59 Comments »

BCBS-TX Dental Insurance is Rude to Everyone

Posted on March 27, 2009 by Dr. David Edward Marcinko MBA MEd CMP™

Why the Long NPI – BCBSTX?

[By Darrell Pruitt; DDS]

More than a year ago, Dr. Robert Ahlstrom, an ADA [American Dental Association] and NHII (National Healthcare Information Infrastructure) task force member, told attendees to the ADA’s 3rd International Evidence-Based Dentistry Conference that the NPI number is

“Critical to the future of dentistry.”

But, to this day, he refuses to reveal why. Even though I have learned that he is a very shy man on the Internet; on that Sunday in May in ADA Headquarters, he confidently added,

“It is only voluntary unless you want to get paid.”

His case-closed proclamation shut down discussion cold in a Soviet manner. Did I mention that this occurred at an “Evidence-Based Dentistry” conference? Soviet East Germany was also called the German Democratic Republic.

NPI Harmful to Dentists and Patients

There is nothing evidence-based or otherwise about the NPI number – that benefits anyone but healthcare stakeholders. In fact, the number actually harms both dentists and patients. Like Ahlstrom, the irreversible NPI number is simply un-American. However, the NPI means profit for sleazy dental insurance companies like BCBS of Texas – especially when dentists’ reimbursements for work done long ago are delayed by NPI-NPPES screw-ups. Some physicians’ payments have been delayed for a year or more because of NPPES crosswalk difficulties. Who needs that?

Veteran’s Example Scenario

A new patient called my office this week wanting an appointment to start a crown. We don’t normally block off two and one-half hours for a patient on the first visit, but the Veteran told my office manager that before he was recently discharged, they did a root canal, post build-up and temporary on a tooth that still needs a crown. I like to think other dentists would also risk big holes in their schedules for Veterans. We owe them at least that much.

BCBSTX Dental Insurance

When he showed up with his BCBSTX dental insurance information, my office manager had to tell him that even though his boss was promised by the BCBSTX sales representative that the dental benefits package he bought for his employees was good anywhere, it cannot be used in my office because I do not have an NPI number. I am licensed to practice dentistry in the state of Texas, but that is not enough for BCBSTX. Capricious qualifications are certainly their choice if they prefer to do business that way in Texas, but why does BCBSTX leave it to my office manager to inform their clients about their deception? If a client who pays premiums to BCBSTX likes a dentist who does not have an NPI number, those premiums are pure profit for BCBSTX. It is easy to understand that the more obstacles BCBSTX can put between their clients and obligations to cover their dental bills, the bigger are the bonuses for executives. What’s more, BCBSTX’s leaders’ lousy work ethic permeates the entire dental insurance industry. Compared to BCBSTX executives, AIG executives who kept bonus money should be honored as national heroes.

BCBSTX Rude to Everyone

As the Veteran who almost became my patient works to fit him-self back into society, perhaps the next opportunity he has to break away from work for a few hours, he will be lucky enough to come across a dentist who has an NPI number. If things go well, BCBSTX will not have wasted a Veteran’s time twice – and wrecked a dentist’s schedule – for what? BCBSTX has nothing against Veterans in particular, they are rude to everyone. Since nobody from the company can be held personally accountable, tyranny is as natural as Ponzi schemes.

Attention Texas Employers:

I wish deceptive business practices which insurance companies use to cheat their clients were against the law in Texas. Attention Texas employers; as a dentist who has witnessed harm from BCBSTX, I warn you not to waste money on their dental plan. BCBSTX’s sales reps cannot be trusted to tell the truth and will aggravate your employees as well as neighborhood dentists.

Assessment

If BCBSTX gets away with this dishonesty, what other senseless, but profit-enhancing hoops will they demand next year? How many more dentists and patients can an Attorney General allow them to cheat before speaking up? Come out and fight for your honor, BCBSTX … or not. I bring more than your best attorney can handle and I am waiting.

Conclusion

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Filed under: "Doctors Only", Career Development, Health Insurance, Information Technology, Military Medicine, Quality Initiatives, Risk Management | Tagged: ADA, BCBSTX, Blue Cross, Blue Shield, dental benefits, dental insurane, evidence based dentristy, evidence based medicine, Health Insurance, insurance fringe benefits, National Healthcare Information Infrastructure, NPI Number, NPPES, Robert Ahlstrom, Veterans | 22 Comments »

I Shake my Fist at Pfizer, Inc.

Posted on March 26, 2009 by Dr. David Edward Marcinko MBA MEd CMP™

And, Laugh out Loud over D2D Marketing

By Dr. David Edward Marcinko; FACFAS, MBA, CMP™

[Publisher-in-Chief]

We all know how intrusive direct-to-consumer [D2C] marketing by the pharmaceutical industry has become. Especially for those male “enhancement” type drugs that seem to be a ubiquitous feature on TV, the print media and internet, etc.

No, I’m not talking about sildenafil citrate or minoxidil; although I do recall seeing them on TV for the last decade, or so; maybe more. The target audience for both keeps getting younger and younger; or am I getting older and older? Still, allow me to assure all ME-P readers that the problems they reportedly treat are not my own.

Gotcha!

For this post however, I am talking about antibiotics.

Pfizer Seriously

Seriously, we are all aware that D2C marketing, and patients, goad doctors into “action” during an office visit [i.e., prescribe], when perhaps they ought not to. A follow-up office visit is often able to be scheduled, too.

Think: the antibiotic drug resistance epidemic.

Therefore, I was so righteously upset recently that I had to go out for a premature hour-long run, as I have been doing almost daily for thirty years, just to cool off.

Why?

It’s because I received the email copied verbatim, below.

Doctor [my name was not used, but my personal email address was correct],

For decades, azithromycin has been proven clinically effective to fight infections in your patients. With Zmax, azithromycin is reformulated to provide the same powerful efficacy against infection in a single, well-tolerated, liquid dose.

Zmax — the novel one-dose formulation of azithromycin
Zmax is indicated for community-acquired pneumonia (CAP) in pediatric patients and adults and acute bacterial sinusitis (ABS) in adults. Zmax uses extended-release microspheres to deliver one well-tolerated, front-loaded dose.

Zmax is not to be confused with Zithromax®, Z-Pak®, or Tri-Pak®

By delivering 100% compliance with just one dose, Zmax is the only formulation of azithromycin that avoids the complexities of multiple-day dosing for your patients.3-5

Prescribe Zmax and save with the “Never Pay More Than $20” coupon
Prescribe Zmax as your antibiotic-of-choice for your patients with CAP and ABS.
Zmax guarantees that your patients never pay more than $20 with the cost-saving Zmax coupon. For more information, please visit www.ZmaxInfo.com or www.PfizerPro.com/Zmax

Sincerely,
Raymond W. Urbanski; MD, PhD
Vice President
Clinical Development and Medical Affairs
Established Products Business Unit
Pfizer, Inc.

Now, I have prescribed Zithromax® in the past, and will probably do so again in the future. I have lectured for several big-pharma companies throughout the years, and have written a textbook on bone and soft tissue extremity infections, and their diagnosis and treatment. I have served, and still serve, as a medical expert witness in malpractice cases involving infectious diseases, etc. But, I do not, repeat, do not need to be reminded by personal email about this anti-microbial, or any other drug. Being spammed in the office is one thing; but please not at home. I “reply-cancelled” the email; I think. Will let you know, down-line.

Of Podcasts and Webcasts

Recently, I was asked to make several new-wave podcast and modern webcast presentations for physician distribution by third-party vendors of the pharmaceutical industry. From what I could gather, this sort of “product information” distribution has not been eagerly embraced by the profession to-date, and so they are searching for industry recognized “names” to do their bidding. And so, as an educator, I acquiesced regarding same. But, I do pine for the attractive female pharma-rep visits back-in-the-day; replete with food for “lunch and learn” office presentations [mea culpa].

Think: Sermo, if you want a medical opinion.

Assessment

Poor Dr. Urbanski, by the looks of his sur-name, I bet he’s Polish like me. I also bet that he gets more than a few emails, cards, faxes and letters like this post.

So, here’s where you need to imagine me shaking my fist at Pfizer, Inc.

I also laugh mockingly, as well.

Click to play :

PS: Ray, call me; let’s do lunch.

Conclusion

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Filed under: "Doctors Only", Breaking News, Career Development, Drugs and Pharma, Ethics, Glossary Terms, Marketing & Advertising | Tagged: azithromycin, D2C, D2D, direct-2-doctor, doctor-2-doctor, Pfizer, Raymond W. Urbanski | 7 Comments »

Our Valued ME-P Sponsors and Vendors

Posted on March 26, 2009 by Dr. David Edward Marcinko MBA MEd CMP™

Dear ME-P Advocates and Colleagues

Many thanks for reaching out to us.

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Filed under: Experts Invited, iMBA, Inc., Marketing & Advertising, Sponsors | Tagged: advertising, CFAs, CFPs, CMPs, CPA, dentists, doctors, FAs, financial advisors, Health Insurance, healthcare economics, Healthcare Finance, Healthcare Organizations, hospitals, lawyers, marketing, MBAs, ME-P, medical executive post, osteopaths, PhDs, podiatrists, Sponsors, vendors | Leave a comment »

HMO Physician Office Visit Co-Payment Creep

Posted on March 26, 2009 by Dr. David Edward Marcinko MBA MEd CMP™

Patients Showing Doctors the Money [1999–2008]

By Staff Reporters

Copayment	2008	1999
$5	6%	23%
$10	16%	60%
$15	29%	12%
$20	30%	1%
Other	19%	3%

Source: Kaiser/HRETHRET Survey of Employer-Sponsored Health Benefits

www.kff.org

Assessment

Considering the “down and dirty” interest rate “rule of 72”, a twice doubling of copayments from $5 to $20, and a Hewlett-Packard 12-C hand-held financial calculator; allow us to suggest an annual copayment rise of 15% percent for the decade.

Conclusion

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FINANCE: Financial Planning for Physicians and Advisors
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Dictionary of Health Economics and Finance
Dictionary of Health Information Technology and Security
Dictionary of Health Insurance and Managed Care

***

Filed under: Career Development, Health Insurance, Managed Care, Practice Management | Tagged: copay, copayments, Employer Sponsored Health Benefits, fringe benefits, Hewlett-Packard 12-C, high deductible health plan, HSA, insurance deductibles, interest rates, Kaiser, rule of 72 | 1 Comment »

Asset Allocation Methods for Physician-Investors

Posted on March 25, 2009 by Dr. David Edward Marcinko MBA MEd CMP™

What’s Old … is New Again?

By Dr. David Edward Marcinko; MBA, CMP™

Publisher-in-Chief

Asset allocation policies, incorporating the risk/return fundamental equation, have traditionally been classified under the following approaches: Principal Stability and Income, Income, Income-Oriented, Balanced, Growth, and Aggressive Growth.

Traditional Concepts

In all forms of traditional asset allocation and diversification policy approaches, the physician-investor is presumed to diversify within the chosen asset class in order to reduce the potential for specific or unsystematic risk.

Principal stability and income approach

Objective: Income, liquidity, and stability of principal.

Investment: Shorter-term fixed income securities with a large concentration in money market exposure to enhance liquidity and price stability. Accounts tend to maintain cash equivalent reserve balance of 30–50% of the portfolio.

Income approach

Objective: Maximum income.

Investment: 100% fixed income exposure.

Income portfolios arise from the traditional notion that an investor should spend only income and reinvest capital gains. Sometimes this is a legal requirement, as in a trust that has an income beneficiary distinct from the principal beneficiary.

Income-oriented approach

Objective: Income and some capital growth.

Investment: Accounts tend to maintain 15–35% in equity investments; balance of investment in fixed income.

Income and growth approach

Objective: Capital growth and income using a balanced approach to limit volatility.

Investment: Accounts tend to maintain 45–65% equity exposure; balance of investment in fixed income.

Income and growth portfolio policies generally refer to both the fixed income and equity portions of the portfolios. Because of the income bias, the overall stock portion of the portfolio will usually have a dividend yield greater than the market yield. This method allows the portfolio manager to invest in some no- or low-dividend yielding issues.

Growth approach

Objective: Capital growth with income as a secondary objective.

Investment: Accounts tend to maintain between 65%–85% equity exposure; balance of investment in fixed income, usually cash reserves.

Aggressive growth approach

Objective: Long-term capital growth.

Investment: Accounts maintain 100% equity exposure. Exposure to variety of equity types normal (small capitalization, international, emerging markets, etc).

Assessment Of course, the above is much more accurate during stable economic times, than it is today; don’t you think? Are newer concepts required today … or is past … prologue.

Link: https://healthcarefinancials.wordpress.com/2008/10/25/new-wave-thoughts-on-investing/

Conclusion

And so, your thoughts and comments on this Medical Executive-Post are appreciated.

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Medicare and Medicaid Health IT Network Proposal

Posted on March 25, 2009 by Dr. David Edward Marcinko MBA MEd CMP™

Governmental Initiative for the Elderly and Poor

By Staff Reporters

According to Nancy Ferris of Government Health IT, on Mar 18, 2009, a rapid learning health information data network could close some gaps in medical knowledge and cut costs for Medicare and Medicaid recipients.

A Congressional Letter

In a letter to Congress, a group of health policy experts urged creation of a network to share information on Medicare and Medicaid patients in order to improve treatment received. In particular, Lynn Etheredge, one signatory of the letter, wants information to be shared on “dual eligible’s”. This term is defined as low income, elderly patients who receive money for medical care from both Medicare [Federal] and Medicaid [State] sources.

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According to Etheredge, there are 7 million such dually-eligible patients in the US, which represents 40 percent of Medicaid spending, and 25 percent of Medicare spending. Etheredge and the others suggest that a network backed by government policy would hasten treatments for everyone.

Assessment

Others who signed the letter include Kenneth Kizer, who created the health-records system for the Department of Veteran Affairs; Commonwealth Fund President Karen Davis; National Quality Forum [NQF] President and CEO Janet Corrigan and National Committee for Quality Assurance [NCQA] President Margaret O’Kane.

Link: http://govhealthit.com/articles/2009/03/18/network-for-data-on-medicaid-medicare-patients.aspx

Conclusion

And so, your thoughts and comments on this Medical Executive-Post are appreciated. One conclusion of this letter was that“[Researchers] spend way too much time simply acquiring data.” Do you agree, why or why not? Please opine. Will networked eHRs, eMRs and eDRs really save money and time; or cost money and time? Can they be inter-operable and connected on a nationally networked basis that is cost-effective, secure and available to all providers? What about CCHIT, and other vendors?

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Medical Real Estate Investments

Posted on March 25, 2009 by Dr. David Edward Marcinko MBA MEd CMP™

Physician’s Need to Understand Compensation Methods

[By Staff Reporters]

Property Managers

Medical property managers are compensated for their services on an hourly or fee basis. In addition, they may be reimbursed for expenses related to the maintenance of the property, such as materials, and they may also pay for expenses incurred by subcontractors.

Fees

Fees usually are based on a percentage of gross collected rents, but are negotiable. Property managers of larger medical complexes may receive higher fees than managers of small complexes because of the details involved in managing larger properties. Fees also are affected by the total pro-forma income stream. In general, the better a manager enhances the property’s performance, the more the manager is paid.

Barter

Some owners pay fees and provide rent-free units for resident medical managers to handle on-site leasing; or for offices for managers to take care of buildings warranting on-site property management. Bartered phantom income may be reportable to the IRS.

Real Estate Brokers

Each state has specific requirements regarding the sales and leasing of medical, commercial and other real estate. Every state, however, has the clear and mandatory requirement that no commission or fee can be paid to anyone who is not licensed in that state as a real estate broker, an associate broker, or sales agent if the person represents or works on behalf of another. All fees and commissions must be paid to the company employing the broker, associate broker, or sales agent. Violation of these laws can have serious consequences to both the principal and the real estate broker.

Hybrid Compensation

A medical real estate broker is usually compensated by either a negotiated fee or a negotiated commission; or hybrid of both methods. Neither fees for work or commissions earned are set or standardized in any way. The amount earned or the amount paid is the result of an agreement. The agreement or contract must be in writing, under the Statute of Frauds, just as all real estate offers and contracts must be in writing sales or on leases of more than one year.

Commissions

If a broker is working on commission, h/she is paid only when she is successful and the sales transaction closes and title is passed to the buyer. Sales commission is established either in a Listing Agreement or a Buyers Brokerage Agreement. No fee is due if the sale does not occur. Rates of commission vary widely by city, region, and state. The amount of commission usually is a percentage of the sales price or a set amount. The percentage of commission is dependent on competition; effort required; to some degree, the size of the transaction; and market activity. For example, the sale of a large regional shopping center might be a 3% commission whereas the sale of a small retail building under $1 million might warrant a 7% commission.

Lease Execution Warrants Payment

Leasing commissions are based on gross rental income over the term of the lease, are due when the lease is executed by both landlord and tenant, and can be paid at one of the following times:

On execution of the lease.
Partly on lease execution and partly on occupancy; or
On occupancy, depending on the landlord’s written agreement with the broker.

Leasing commissions usually are a negotiated percentage of gross rents, with the percentage varying dependent on type of lease. For example, the percentage rate of commission might be more on a net lease, in which the tenant pays all expenses, than if the same lease were structured on a gross or fully serviced basis; or in which the landlord provides services within the rents due. Commission on ground leases might range up to 10% and office space might range from 4% to 6%.

Example:

Term: 5 years (60 months)

Monthly rental rate: $1,000 per month

Gross rental income under the lease: $1,000 x 60 = $60,000

Commission calculation (using a 6% rate): $60,000 x 6% = $3,600

The fees paid under sales and leases are usually split between the colleague brokers working on the transaction and are shared between the listing agent and the selling or leasing agent under a co-brokerage agreement between the brokers. This too is a negotiated percentage. It is common for commissions to be split on a 50/50 basis, but it is not the rule. How the commission is divided between brokers depends on the transaction. The commission is often shared evenly between cooperating brokers, but the split ultimately is the seller and listing agent’s decision.

Hard-to-Move Properties

On extremely difficult medical real estate properties [as is seen in many parts of the country today], incentive splits may be offered. Incentive splits offer the selling or leasing agent a greater share of the commission if he or she is successful. Under commission agreements between a seller and a broker, or a buyer and a broker, in which the broker is representing a buyer, nothing is earned until the transaction is complete and the broker has added value, unless spelled out to the contrary in the agreement or the broker is working on a fee basis. On a typical sale, commissions are paid through escrow at closing. Leasing commissions are usually, but not always, paid upon lease execution.

Other forms of payment for property managers and real estate brokers

It has become increasingly common for medical property managers and real estate brokers, particularly when representing a buyer or a tenant, to work on a contractual basis. In these instances, the parties are paid on an hourly or set-fee basis, regardless of whether the transaction is completed. In some cases, a principal may decide he wants only some of the services offered, such as a lease review, and those are also paid on a negotiated basis for the service provided.

Assessment

Combinations of fixed fees and commission incentives also are common, but in most all cases there is not a set amount or standard fee charged by all brokers.

Conclusion

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About Sharkey, Howes & Javer

Posted on March 24, 2009 by Dr. David Edward Marcinko MBA MEd CMP™

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We were established in Denver, Colorado in 1990, when Eileen M. Sharkey, CFP®, formed the firm of Sharkey, Howes & Javer, a partnership with Lawrence E. Howes, MBA, CFP® and Joel B. Javer, CLU, CFP®. Since then, our team of professional planners and support staff has grown to serve over 1000 clients.

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Larry Howes, MBA, AIF®, CFP® is a founder and principal of Sharkey, Howes & Javer, Inc., a firm that provides financial planning and portfolio management to individuals and businesses. He received his MBA from Regis University and Bachelor of Science degree in Management from Metropolitan State College in Denver and was admitted to the Registry of Financial Planning Practitioners in 1986. He received his CFP® designation in 1987. Larry was awarded an AIF®, Accredited Investment Fiduciary, in 2004 from the University of Pittsburgh. He is also a Certified Medical Planner™ (Hon).

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Mr. Howes is an adjunct professor of financial planning at Metropolitan State College – Denver.

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Using Home Mortgage Brokers

Posted on March 24, 2009 by Dr. David Edward Marcinko MBA MEd CMP™

Advantages and Disadvantages

By Staff Reporters

A physician or other medical professional may consider using the services of a home mortgage broker when s/he does not want to spend much personal time searching for the best loan. Other reasons include poor credit history, low credit ratings level; or similar. Of course, this will cost the doctor-client money, but the expense may be worth it; or not.

Duties and Responsibilities

A mortgage broker’s main responsibility is to represent a physician-borrower to different lenders and to take the borrower through the process of acquiring a loan. These brokers are usually aware of the best lending institutions and where to get the best deals.

Disadvantages

However, using a broker has three disadvantages. First, a fee will be charged. Second, some lenders will not work with some brokers. Third, some lenders will add extra fees to their loans to pay the broker’s commission.

Assessment

During the current financial crisis, the use of this intermediary may be a necessity in some cases.

Conclusion

And so, your thoughts and comments on this Medical Executive-Post are appreciated. What has been your experience using the services of a mortgage broker; if any?

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Independent Medical Practitioner as Solo Primary Care Surrogate

Posted on March 24, 2009 by Dr. David Edward Marcinko MBA MEd CMP™

Doctors Facing a Bleak Future Business and Financial Planning Model

By Dr. David Edward Marcinko; MBA, CMP™

[Publisher-in-Chief]

According to Physicians News, on March 19, 2009, the demand for family physicians is growing. Proposals for health system reform focus on increasing the number of primary care physicians in America. Yet, despite these trends, the number of future physicians who chose family medicine dipped this year, according to the 2009 National Resident Matching Program. What gives?

NRMP

The National Resident Matching Program [NRMP] recently announced that a total of 2,329 graduating medical students matched to family medicine training programs. This is a decrease in total student matches from 2008, when 2,404 family medicine residency positions were filled.

Primary Care Demand Explodes

Meanwhile, demand for primary care physicians continues to skyrocket. For example, in its most recent recruitment survey, Merritt Hawkins, a national physician recruiting company, reported primary care physician search assignments had more than doubled from 341 in 2003 to 848 last year.

The Decline of Solo Medical Practitioners

Regular readers and subscribers to this Medical Executive- Post are aware of the declining number of solo medical practitioners; we have been sounding the alarm here, in our books, journal, speaking engagements and elsewhere for years now.

In fact, the statistic that we often cite is that more than 40% of the nation’s physicians are employed doctors; not employers as in the past. This business model shift has occurred over the past decade or so, and has accelerated of late. The decline in solo and independent doctors has occurred elsewhere as well, but much more slowly [i.e., dentistry, podiatry and osteopathy] as these specialties have been somewhat isolated from the traditional allopathic mainstream.

Going forward, this solitary model seems to be a good thing, and a fortunate result of the un-intended consequence of previously keeping these folks out of the healthcare mainstream.

The Decline of Independent Medical Practitioners

Now, in the March 2009 issue of Healthcare Finance News, we learn that the number of hospital owned physician practices has been climbing over the last four years, according to the Medical Group Management Association [MGMA]. Think: PHOs back-in-the-day.

And, while this trend only marginally affects patients and patient care, it is quite disruptive to physicians, their families, personal wealth accumulation, retirement and estate planning endeavors.

For example, according to Professor Hope Rachel Hetico, RN, MHA, CMP™ of our firm www.MedicalBusinessAdvisors.com

“The professional good-will valuation component of a medical practice is being decimated. Today, some practices are being bought and sold for tangible asset value, only.

Assessment

Therefore, allow me to identify this emerging trend which suggests independent medical practice as reflective of solo primary medical care. In other words, as independence goes the way of the “dodo-bird”, so goes primary care practitioners precisely at a time when the later is needed more than the former.

Why? Employed doctors stay that way by making money for their employer and hospital-bosses. Specialists make more money than primary care doctors. So, if you want to stay an employed doctor; which specialty would you pursue?

Answer: The NRMP class this year spoke out loud and clear. Any specialty but primary care!

Channel Surfing the ME-P

Conclusion

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ADVISORS: www.CertifiedMedicalPlanner.org
FINANCE: Financial Planning for Physicians and Advisors
INSURANCE: Risk Management and Insurance Strategies for Physicians and Advisors
Dictionary of Health Economics and Finance
Dictionary of Health Information Technology and Security
Dictionary of Health Insurance and Managed Care

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Medical Practice Financial Statement Valuation Adjustments

Posted on March 23, 2009 by Dr. David Edward Marcinko MBA MEd CMP™

Why Benchmarks are Out – and Scrutiny is In

By Dr. David Edward Marcinko; MBA, CMP™

Publisher-in-Chief

CEO: www.MedicalBusinessAdvisors.com

As discussed elsewhere on this ME-P, the medical practice appraiser’s primary goal is to determine the value of the business based on its expected earnings or cash flow. To accomplish this, the medical practice appraiser looks to the company’s historical financial statements to see how it has been reporting its earnings. Because of differences in accounting practices across organizations, the appraiser must analyze how the medical practice’s financial statements differ from those of other practices and how those differences might have an effect on the practice’s value. This is particularly true when the appraiser is comparing the performance of the medical practice company being valued with those of so-called industry benchmarks. In all instances, it is important that the appraiser compare numbers that have been accounted for in the same way. Below is a discussion of the most common adjustments.

Nonrecurring or Extraordinary Items

Nonrecurring or extraordinary items of income or expense reported by the practice will be eliminated from the profit and loss statement. These include the following:

• Insurance settlements (income or expense) or life insurance proceeds on the death of the key physician-partner.

• Large payments in settlement of lawsuits (either as income or as expense).

• The gain or loss on the sale of certain assets or portions of the practice which are not likely to be repeated.

• Expenses related to the start-up or discontinuance of a new or old segment of the practice.

• Moving and related expenses.

• Expenses relating to fire or flood damage not covered by insurance.

• Adjustments to prior years’ financial statements when the practice discontinued an employee benefit (such as eliminating the company’s pension or profit-sharing plan).

• Adjustments for income and/or expenses related to non-operating assets, such as a portfolio of marketable securities not used in the practice or medical real estate held for investment purposes.

Valuation Calculations

The appraiser needs to gather the following facts regarding the financial statements of the practice and may need to make adjustments to account for these differences. The information will give the appraiser an understanding of the company’s normalized earnings and will be used to make valuation calculations.

• How does a specialty practice [such as physiatry’s DME] value its inventory—LIFO or FIFO? In certain specialties, inventory is accounted for on the LIFO or “last-in, first-out” basis. When prices are rising, profits are reduced because the DME items being sold are presumably bought most recently at higher prices. The “old” or lower-cost inventory is held in reserve while the higher-cost inventory is sold off. This situation may reverse in times of recession and low or no inflation. At that point, profits will be distorted by the low-cost items. Recognizing these facts, practice owners have more commonly used FIFO or “first-in, first-out,” inventory accounting to value their inventory.

• What kind of reserves has the practice been taking for doubtful accounts receivable? Some doctors will not – or very slowly – write off bad debts or take reserves for them, and thus the income is improperly overstated. The appraiser will look at the actual bad debt expenses relative to the doubtful accounts receivable booked to determine if the practice’s adjustments are reasonable.

• How does the practice depreciate its hard assets? A variety of approved methods are used to depreciate assets over their useful lives. It is important for the appraiser to recognize the impact these methods have on corporate earnings. Some assets can be depreciated over a short time frame, which will mean higher annual write-offs; others, such as real estate, must be depreciated over a much longer period and thus will have a smaller impact on annual expenses.

Asset-Related Issues

The appraiser must address asset-related issues, such as:

• Has the practice’s assets been valued recently? If not, will current appraisals be required?

• Are any non-operating assets carried on the books of the practice? These assets may have to be valued separately and added to the operating value of the business.

Assessment

In our experience valuating medical practices, adjustments made for excess compensation and perquisites paid to the physician-owner and other family members, are the most common items of contention between buyer and seller.

For example, above average physician income usually equates to lower medical practice transferrable enterprise value; and vice versa.

Link: https://healthcarefinancials.wordpress.com/2007/11/30/90

Channel Surfing the ME-P

Conclusion

OUR OTHER PRINT BOOKS AND RELATED INFORMATION SOURCES:

PRACTICES: www.BusinessofMedicalPractice.com
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CLINICS: http://www.crcpress.com/product/isbn/9781439879900
ADVISORS: www.CertifiedMedicalPlanner.org
FINANCE: Financial Planning for Physicians and Advisors
INSURANCE: Risk Management and Insurance Strategies for Physicians and Advisors
Dictionary of Health Economics and Finance
Dictionary of Health Information Technology and Security
Dictionary of Health Insurance and Managed Care

Product Details

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Reflections on Evidence Based Dentistry

Posted on March 23, 2009 by Dr. David Edward Marcinko MBA MEd CMP™

My Search for Truth – 2009

[By Darrell Kellus Pruitt; DDS]

Do the leaders of the American Dental Association [ADA] encourage critical thinking by membership? Or; do they fear my opinion of what appears to be destructive and self-serving institutional bias in my ADA that favors businesses peripheral to the care of dental patients, and at patients’ expense? I think it is clear that there are a few good ol’ boys imbedded in the fat ADA who prefer to hide behind a comfortable, but obsolete command-and-control ADA business model. The mighty ostrich stuck its head in the sand. Then along came a noisy, gasoline-powered weed-whacker. Never saw it coming.

Evidence-Based Dentistry Champion Conference

On May 29-30, the First Annual “Evidence-Based Dentistry (EBD) Champion Conference” will be convened in ADA Headquarters in Chicago. Just like last year, the meeting with a brand-new name is sponsored by Procter & Gamble and The Journal of Evidence-Based Dental Practice with Dr. Michael G. Newman as its Editor and Chief. Even though this effort is enthusiastically supported by large corporations with products to sell, like P&G, managed care insurance companies such as Delta Dental, and electronic health records vendors such as Allscripts, the power of the reclusive stakeholders is further amplified by bureaucrats inside and outside the ADA – siphoning off my professional organization’s credibility. That is my opinion based on actual contact with a few characters in this group.

Evidence-Based Dentistry: 3rd International Conference

I attended the meeting last year when it was called “Evidence-Based Dentistry: 3rd International Conference” – I assume that in the last year, it lost its “international” status, and now caters only to “EBD Champions” (cheerleaders). Last year, they were also looking for Champions for their EBD ideas, but the bias was better concealed. I reported on the meeting in an article called “Evidence-Based Dentistry – My search for truth.”

http://community.pennwelldentalgroup.com/forum/topics/evidencebased-dentistry-my

Shortly into the meeting on May 4, 2008, I could tell by a show of hands from attendees that as a dentist who actually puts his hands in patients’ mouths as a regular part of his job; I was virtually alone in the auditorium. This was confirmed by the volume of “Boo” directed at me later that day. The Champions who had been selected months before the conference had already met that week and they were pumped. One could smell the zeal for EBD – whatever it means.

Journal of Evidence-Based Dental Practice

In his introduction to last year’s conference, Dr. Michael G. Newman, Editor in Chief of the Journal of Evidence-Based Dental Practice, told attendees that P&G is providing all the information about EBD to all the dental schools in the nation. I will be honest with you. Being booed last year for addressing what I think is the inferior quality of managed care dentistry during the final discussion period may have affected my attitude about EBD. In addition, being subsequently blocked from responding to a hurt and angry managed care discount dentistry broker by an ADA employee named Dr. Ron Zentz also disappointed me in my ADA. Dr. Zentz told me “This is not the place for this” as he stood between me and the microphone. Later I could not get Zentz to concede the indisputable fact that quality is proportional to reward. When I pressed him for an answer to the managed care question, he stoically repeated exactly what the insurance representative said: “Whether the dentistry is managed care or not, it makes no difference in the quality of care.” Here is something cute: The event was an “Evidence-Based” conference on the second floor of the Headquarters of the ADA, and Dr. Zentz is employed in the ADA’s “unbiased” science department. Get it? Now that’s funny!

Trouble-Makers Don’t Get Invited Back

My bad behavior last year may have something to do with why I was not invited to attend this year, even though I worked hard on the prerequisite essays which I will share with you later. Nevertheless, I have to warn that ADA-approved propaganda from P&G doesn’t strengthen this dentist’s confidence that our leaders are protecting the future of dentistry, friends. Take a look at what healthcare parasites have quietly done over the last decade or so to physicians’ practices with the blessing of the AMA, and counter to the interests of patients. Those same parasites were in ADA Headquarters on May 4, 2008. Our house at 211 East Chicago Avenue reeked.

EDB Vagueness

Like the HIPAA Rule on which Newman’s favorite interpretation of EBD leans hard, the beauty of EBD is in its vagueness. Both HIPAA and EBD can mean damn well anything one needs them to mean, and stakeholders with lots of influence have their fingerprints and drool all over the plans. For example, Dr. Robert Ahlstrom, a stakeholder and one of the speakers at last year’s conference uses HIPAA to support EBD and vice-versa according to closed-circuit, cause-I-said-so science that he evidently makes up as he goes. It is difficult for me to imagine that Ahlstrom’s eleven reasons that HIPAA benefit dentistry – which he presented as testimony for HHS Secretary Michael Leavitt over a year ago – were approved by a committee. I think Ahlstrom made up his reasons while waiting in the hall for the NCVHS meeting to begin. If the reasons were indeed approved by an ADA committee, I extend my sympathy. It must be difficult for challenged people like that to safely find their way home from work every day.

(See “HIPAA and Dentistry – About Ahlstrom’s Controversial HIPAA Testimony”)

https://healthcarefinancials.wordpress.com/2009/01/08/hipaa-and-dentistry/

Where is the Evidence?

A few hours before Dr. Ahlstrom, an ADA NHII (National Health Information Infrastructure) Task Force member, took the podium, Dr. Newman pleaded with dentists to always ask, “Where is the evidence?” I know Dr. Ahlstrom heard Dr. Newman’s words because Ahlstrom was sitting on the first row, next to ADA Senior VP Dr. John Luther, who is in charge of the ADA Department of Dental Informatics – a major beneficiary of EBD and HIPAA.

***

Buzzwords

I have come to the conclusion that EBD is a buzzword for a scheme supported by avaricious stakeholders who seek to regulate dentistry using healthcare IT. I assume it will be left to Dr. Robert Ahlstrom to present the plan to the next administration in his special, fanciful way. It is clear to me that the ADA is using Ahlstrom to lead American dentists down a computerized, cook-book path initially promoted several years ago at ADA Headquarters by none other than Newt Gingrich. The path ends with the NPI, NPPES and Ingenix-style Pay-for-Performance instead of free-market competition and consumers’ desires. Like Ahlstrom, EBD is little more than a tool.

Living with Rejection

I learned a couple of days ago that my application for this year’s conference was rejected. A PDF letter signed by Dr. Michael Newman, Editor and Chief of the Journal of Evidence-Based Dental Practice stated that the competition for seats was intense this year, and that I just didn’t have what the selection committee was looking for in a “champion” – even though one can see by their essay questions that the EBD stakeholders desire dentists who can draw audiences.

My Responses

Below are my responses to this year’s questions that I posted on September 23, even before I hooked up with PennWell, and the ME-P. I’m even more widely read now.

Q: Are you involved in the treatment of populations with limited access to care?

Counseling people who have big problems and little money is part of the job. Almost every day I help patients make hard decisions that affect their appearance as well as health. Compromises are always difficult, especially when it involves children. I do my best to provide my patients with the information they need concerning their specific problems in a personal manner. In that respect, I am no different than almost all other dentists I know.

Q: Given the opportunity, how do you plan to disseminate the information and knowledge of EBD?

For dentistry-related news, I am arguably the most popular commentator on the Internet. If I am convinced that EBD is in patients’ best interest, I can promote the concept to a wider audience than anyone else in dentistry and it will not cost a thing. I can use any number of websites in addition to a private network of colleagues that has been in place for almost three years.

If I leave the conference suspecting that stakeholders ambushed EBD to manipulate dentist-patient relationships for selfish reasons, I will work even more effectively to undermine it. Fair is fair.

Q: Are there any specific examples that demonstrate your ability to be a good disseminator?

Apart from having an increasingly popular column about healthcare matters on this ME-P https://healthcarefinancials.wordpress.com/?s=darrell+pruitt+dds ), I am always seeking new and innovative ways to attract attention to dentistry. I am very good at what I do.

Here is a simple demonstration of my talent: Googlesearch “Darrell Pruitt DDS.” You will discover that I’ve got what they call “googlejuice.” I create interesting content. People you need to reach read me.

The question is; does the ADA have the confidence to subject EBD to my critique? On the other hand, does the ADA have the courage not to?

Since I will not be allowed to keep colleagues in my neighborhood as informed in real-time and in detail as they should be, I invite one or more “EBD Champions” to describe what they learned following the Conference in May right here on this ME-P and PennWell forums. And as always, I invite Dr. Robert Ahlstrom to discuss what he plans to do with my dental practice.

Assessment

Tomorrow, as part of “Transparency and the ADA – a dissecting experiment,” I intend to post another question on the EBD link following my weekly report. I will ask if Dr. Robert H. Ahlstrom will be addressing the audience before having my name put on a short-call list to replace late-cancellations. Depending on the answer, I may go camping instead.

Channel Surfing the ME-P

Conclusion

OUR OTHER PRINT BOOKS AND RELATED INFORMATION SOURCES:

PRACTICES: www.BusinessofMedicalPractice.com
HOSPITALS: http://www.crcpress.com/product/isbn/9781466558731
CLINICS: http://www.crcpress.com/product/isbn/9781439879900
ADVISORS: www.CertifiedMedicalPlanner.org
FINANCE: Financial Planning for Physicians and Advisors
INSURANCE: Risk Management and Insurance Strategies for Physicians and Advisors
Dictionary of Health Economics and Finance
Dictionary of Health Information Technology and Security
Dictionary of Health Insurance and Managed Care

Filed under: "Doctors Only", Career Development, Ethics, Op-Editorials, Quality Initiatives, Research & Development | Tagged: ADA, Allscripts, American Dental Association, delta dental, Dr. John Luther, Dr. Michael G. Newman, Dr. Robert Ahlstrom, Dr. Ron Zentz, EBD, eDRs, evidence based dentistry, Evidence-Based Dentistry: 3rd International Conference, HIPAA, Ingenix, National Health Information Infrastructure, Newt Gingrich, NHII, NPI, NPPES, P&G, P4P, Pay-for-Performance, PennWell, Procter & Gamble, The Journal of Evidence-Based Dental Practice | 7 Comments »

About Healthcare Employee Cash-Balance Plans

Posted on March 23, 2009 by Dr. David Edward Marcinko MBA MEd CMP™

What they Are – How they Work

By Staff Reporters

Motivated by cost savings, an increasing number of hospitals, healthcare systems and large healthcare organizations are converting their traditional legacy defined benefit pension plans to cash balance plans. While the trend seems sudden, it is not surprising. Healthcare related companies are reaping substantial savings from cash balance plans. And for the most part, younger doctors and other employees are enthusiastic about the plans.

However, older employees (age 50 or above) realize that in switching from a traditional defined benefit [legacy] plan to a cash balance plan, their retirement benefits decreased, initiating an onslaught of overwhelmingly negative publicity. Indeed, several years ago, Congress rushed to pass legislation requiring employers to provide benefits computations to affected employees.

Overview

Even though many defined-benefit plans are under/over-funded, they are calculated on an actuarial basis and are quite costly to maintain. And because plan costs can vary from one year to the next, budgeting is difficult.

However, if a healthcare company terminates a pension plan, replacing it with a defined contribution plan such as a profit sharing plan, all employees must be 100% vested, any surplus is subject to income tax, and a portion of the surplus is subject to an additional excise tax even if all of it is transferred to a succession plan. A cash balance plan is a pension plan, so the change is viewed as an amendment to the pension plan. This is true even though in many respects the cash balance plan operates like a defined contribution plan.

The Cash Balance Plan

A cash balance plan works in the following manner: The sum accrued in a hospital’s employee’s defined benefit plan is converted to a lump sum cash value; the employer agrees to make specified contributions to the employee’s account based on compensation; and the account earns a specified rate of interest, say 5%. The employee receives regular statements showing the current cash value of his or her account. [The amount is listed as a lump sum amount even though it is usually paid as an annuity].

If the hospital or other employer already has a defined benefit pension plan and converts it to a cash balance plan, there is no tax on the surplus. The reason, as noted above, is that a cash balance plan is treated as a pension plan. Thus, the employer merely amended its pension plan and can use the existing surplus to provide the required contributions, which are usually less than the actuarial costs of maintaining a traditional pension plan. And, in the former bull market this recent decade, many employers did not have to make contributions at all. Today, of course, the opposite may be true.

Example

Let’s say the average earnings on an investment is 15%, and the rate of interest payable to the plan is 5%. In recent years, many funds have earned 15% or more if they invested in an index fund. It was thought that, if continued, it would be quite some time before some employers are required to make any contributions out of their own funds. Not so today, however.

Clearly, the savings can be substantial, and the costs of maintaining the plan are easily budgeted for. These advantages convinced some public utilities, telephone companies, financial, hospitals and healthcare institutions to convert their plans to cash balance plans.

Impact on Employees

The cash balance plan is actually a hybrid plan—a cross between a traditional defined benefit pension plan and a defined contribution plan. But one of the key differences between the cash balance plan and a defined benefit plan is the manner in which the benefits are calculated. In a traditional defined benefit plan, an employee’s retirement benefit grows slowly in the early years and more rapidly as he or she approaches retirement. By contrast, a cash balance plan increases growth in the early years and decreases growth in later years of employment.

Youngsters

Younger healthcare employees usually liked the change; before the recent financial meltdown. Their accounts were portable; they grew quickly; and could be rolled over into an IRA or into a new employer’s plan. And, their account balances were listed as lump sums, so they know precisely how much they’ve accumulated. Today unfortunately, they have mostly been decimated.

Oldsters

Older healthcare employees initially liked the concept because the values of their pensions (on an actuarial basis) were converted to dollar amounts so they could see how much had accrued in their accounts without having to calculate an anticipated pension award. But, after further review, it was evident that upon retirement the cash bonus plans would yield smaller pensions than the defined benefit plans. Opinions differ today?

Health Workers in the Middle

When a hospital or similar entity converts from a defined benefit plan to a cash balance plan, employees their late 40s may see their pensions reduced by 25% or more while older employees see reductions of up to 50%. If the formula for calculating benefits under the defined benefit plan is 2% times years of service, and high-five compensation, then each year of service increases an employee’s pension. More importantly each time high-five compensation increases, the amount is accrued back to the employee’s original date of employment. So, as a hospital employee gets older, the high five-has tremendous impact. An employee who is age 60 can actually accrue most of his or her pension in the last five years of employment.

www.HealthDictionarySeries.com

No “Mo”

Cash balance plans don’t have that type of momentum [“Mo”]. The company contributes a certain amount based upon compensation and a specified interest rate. Usually, the interest rate is based on the 30-year treasury rate (approximately 2.5%).

Closing the Gap

Some employers are offering a grandfathered benefit designed to reverse the penalty for older workers. For example, employees within 10 years of retirement (usually age 65) will receive the greater of the cash balance plan or the pension under the original plan. This reduces the cost savings for the company.

Some employers increase the contribution percentage for employees based on age (i.e., 7% of compensation is contributed for employees aged 40—rather than the standard 5%—and 9% of compensation for those aged 50).

Assessment

Finally, some hospital employees are offered special “sweetners” in the form of additional lump sum credits when converting from an existing plan to a cash plan. The best benefit provides that all existing employees will receive the greater of the old plan or the new plan upon retirement. Only a small number of employers typically adopt this approach.

Conclusion

And so, your thoughts and comments on this Medical Executive-Post are appreciated. Nurses, hospital workers and hospitalists – please opine and subscribe to the ME-P here – it’s fast free and secure:

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Consultants and Hospital Employment Statistics

Posted on March 22, 2009 by Dr. David Edward Marcinko MBA MEd CMP™

Economic Conditions Better than Other Major Industries

By Staff Reporters

According to Richard Pizzi, on March 9th, Healthcare Finance Newsweek reported that employment at US hospitals climbed 0.14 percent in February to a seasonally adjusted 4,719,300 people.

Bureau of Labor Statistics

Responding to just issued BLS data, the number employed was 6,800 more than in January and 131,800 more than in February 2008. Without seasonal adjustments, which remove the effects of fluctuations due to seasonal events, hospitals employed 4,703,700 people in February 2009, 2,200 more than in January and 130,100 more than a year ago.

Impact on Healthcare Consultants

This was good news for financial advisors, insurance agents and accountants; medical management consultants and health economists; HIT suppliers and related DME vendors, etc.

Assessment

The news was not so good in other areas of the American economy, however, as the national unemployment rate rose from 7.6 percent to 8.1 percent. The US economy shed an additional 651,000 jobs in February 2009. But, according to Rachel Pentin-Maki; RN, MHA of www.MedicalBusinessAdvisors.com

“Employment continues to be strong in almost all aspects of the healthcare industrial complex. This includes professionals, technicians, nurses and para-professionals, as well. However, in the long-term, we believe that medicine will not attract the best and brightest young minds in the future. The economic, political and competitive demographics are just not favorable.”

Conclusion

And so, your thoughts and comments on this Medical Executive-Post are appreciated. Is healthcare really a recession proof industry? What about those bright young minds; where will they go for professional careers, instead?

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Apply to our Financial Advisor Consultant Listing Service

Posted on March 22, 2009 by Dr. David Edward Marcinko MBA MEd CMP™

We’re collecting information on financial advisors, financial planners, accountants, attorneys and/or related folks in the Health 2.0 space who have a particular affinity or expertise advising doctors, nurses, medical professionals, and related others. And, we have been for some time, now.

New Channel Development for Medically Focused Financial Advisors and Management Consultants*

Beta-in-Progress

By Ann Miller; RN, MHA

[Executive Director]

A New Approach

Unfortunately, this usually means that some really interesting and smart folks, who purchase our books, dictionaries, print-journal, blog or email us; may get lost in the confusion. The result is that too many great medically focused consultants that we’d love to hear about are getting lost in the shuffle. And so, we’re trying something else instead.

Tell us about your Practice

Tell us about your financial advisory practice, and you may end up being mentioned in dispatches, or featured on a separate channel that we are developing. Selection and inclusion criteria include but are not limited to the following credentials:

Undergraduate or Graduate degree
Industry acknowledged certification or designation
Clean CRD record
Clean criminal record
Insurance agents need not apply
Stock brokers need not apply
Fiduciaries are encouraged
RIAs and independent advisors are encouraged
Published authors or educators are encouraged
Mission statement on physician niche focus required.

Assessment

So, if you want our readers to pay attention to your financial advisory practice or firm, this will get it into a systematic review process starring our crack staff. Otherwise you may face the peril of lost notoriety to other non-specific niches; or referral sources.

Publisher’s Note: The inclusion or rejection decision is final; but not set in stone and our terms and conditions may change without notice; the beta project may also be cancelled at any time. We reserve the right to reject anyone, at any time, for any reason or no reason at all. This is a beta project-in-development. The advisors listed are not affiliated or endorsed by iMBA Inc., in any way. This is an advertisement opportunity only.

*NOTE: There is a $120 annual fee for this listing service. It is waived for subscribers of our two volume companion print journal, upon request. www.HealthcareFinancials.com

List Link: https://healthcarefinancials.wordpress.com/schedule-a-consultation/financial-advisor-listings/list-of-advisor-consultants/?preview=true&preview_id=8633&preview_nonce=a3203ab9f9

Conclusion

And so, your thoughts and comments on this Medical Executive-Post are appreciated. What do you think about this idea to develop a new promotional channel for truly physician focused financial advisors?

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Filed under: "Advisors Only", Breaking News, Career Development, CMP Program, Ethics, Financial Advisor Listings, iMBA, Inc., Marketing & Advertising, Sponsors | Tagged: CFA, CFP, CPA, Financial Advisor Listings, financial advisors, financial consultants, financial planners, MBA, PhD, wealth managers | 1 Comment »

Advetising in “Worth” and “Bloomberg” Magazines

Posted on March 21, 2009 by Dr. David Edward Marcinko MBA MEd CMP™

Advertisers – Give Me a Break!

By Dr. David Edward Marcinko; MBA, CMP™

Did you know that financial advisor Judith Zabalaoui, age 71, considered a pioneer of the fee-only business-model of financial services sales, pleaded guilty to using a Ponzi scheme to embezzle more than $3 million from her New Orleans area clients between 1993 and 2007? Yep, it’s true, but this is not really noteworthy to many pundits considering the current financial meltdown on Wall Street. But, do you know … the rest of the story?

Resource Management Inc.

Most of Zabalaoui’s clients came from Resource Management Inc. in Metairie, La., which she founded in 1974, according to the Times Picayune. Apparently, she became a Certified Financial Planner® in 1979, but the certification expired in 1999.

Link: http://www.nola.com/business/t-p/index.ssf?/base/money-1/1233728420253000.xml&coll=1

Assessment

So, here’s the rub. According to reports, Resource Management Inc. was the only firm in the country where each of the principals were allegedly “selected” by Worth [1996 to present], Money [1987] and/or both magazines as one of the top financial consultants in the country. The company also made Bloomberg Wealth Manager’s list of top wealth managers in 2004.

Industry Indignation Index: 55

Now, with all due respect and humility, I have been asked several times by Worth and Bloomberg to “promote yourself” in their “advertiser-driven” publications as a top financial consultant; but never Money magazine. I have always refused their selection charges for same of $12-18,000.

Full disclosure: I am the Founder of www.CertifiedMedicalPlanner.com and a reformed insurance agent, registered investment advisor and Certified Financial Planner™.

Conclusion

And so, your thoughts and comments on this Medical Executive-Post are appreciated. Was Judith Zabalaoui a fiduciary and what about these magazine “best-of” awards? Are they worthwhile monikers or worthless sales advertisements? What about all the so-called financial certifications, designations and charters; meaningful or meaningless? What is your opinion?

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Filed under: Career Development, Ethics, Financial Planning, Industry Indignation Index, Marketing & Advertising, Media Mentions and PR, Op-Editorials, Quality Initiatives | Tagged: Bloomberg, certified financial planner, certified medical planner, david marcinko, insurance, insurance agent, Money magazine, RIA, Worth | 2 Comments »

Integrating Financial and Medical Practice Succession Planning

Posted on March 20, 2009 by Dr. David Edward Marcinko MBA MEd CMP™

Some Steps to Consider

By Dr. David Edward Marcinko; MBA, CMP™

[Publisher-in-Chief]

Medical practice succession planning is a dynamic process requiring current physician ownership and management to plan for the future and implement the resulting plan. Many doctors approach succession planning initially through retirement planning. Once they understand the issues and realities of the tax laws, they are much more amenable to working out a viable succession plan. At the Institute of Medical Business Advisors Inc, we find that some physician-clients have not clearly articulated their goals, but have many pieces of the plan that need to be organized and analyzed to meet their objectives; including both personal and financial issues.

Link: www.MedicalBusinessAdvisors.com

A Step Wise Process

The steps necessary for successful succession planning are as follows:

Gathering and analyzing data and personal information
Contacting the doctor’s other advisors
Valuing the practice according to USPAP and IRS guidelines
Indentifying the right qualified physician purchaser
Projecting estate and transfer taxes
Presenting liquidity needs
Gathering additional corporate information
Identifying dispositive and financial goals
Analyzing the needs and desires of non-key employees

An Integrated Approach

Succession planning can help address financial and nonfinancial issues in a timely manner. Proper planning can also help the doctor accomplish goals with effective, appropriate strategies that satisfy family needs as well as tax issues. Here is a triad approach:

1. First: Address financial and nonfinancial issues in a timely manner

As with other estate planning engagements, there is no due date for succession planning. The owner of a medical practice is busy growing and managing the office. S/he is often not focused on the desirable outcomes in an orderly practice succession. For example, if family members are involved in the practice, there is a good chance that personal issues will need to be addressed. These nonfinancial issues can be just as important as financial concerns when building a comprehensive, workable succession plan.

2. Next: Focus on taxes

Taxes are important because the medical practice probably represents the largest concentration of wealth in the doctor’s estate. When planning for estates with large amounts of wealth, doctors frequently ignore personal issues. It’s important not to make the critical error of maximizing tax savings but destroying the practice through a poor succession plan.

3. Finally: Identify and reach goals

When the physician-owner has addressed succession planning issues in a timely manner, s/he has the opportunity to develop the most effective objectives to accomplish goals. Given enough time, the doctor can even modify goals to reflect changes in the economic environments, as well changes in his or her personal life.

Assessment

Medical practices exhibit particular strengths and weaknesses not typically found in publicly owned companies or non-professional family businesses. For example, many times the doctor doesn’t realize the type and amount of planning that needs to be done to transfer the business to a new doctor for maximum value. That is why doctors often need the advice of professionals to define goals and formulate medical practice succession strategies.

Conclusion

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Avoiding an IRS Appraisal Audit

Posted on March 20, 2009 by Dr. David Edward Marcinko MBA MEd CMP™

Valued Friends and Colleagues

By Linda Trugman; CPA, CVA

We hope this e-mail post finds you well. We have attached our most recent newsletter “Valuation Trends” for your perusal and hope you find something of interest in it; especially “20 Ways to Avoid an IRS Appraisal Audit.”

Link: trugman-valuation

Assessment

As a reminder, our updated website at www.trugmanvaluation.com includes a resource center which provides additional information that might be useful to you including sample reports, various conference presentations and podcasts.

Conclusion

We are available to assist you, and your clients, with your valuation and litigation support needs and look forward to hearing from you. And so, your thoughts and comments on this Medical Executive-Post are appreciated.

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Challenging Standard & Poor’s 500 Index

Posted on March 20, 2009 by Dr. David Edward Marcinko MBA MEd CMP™

Dr. Jeremy Siegel Opines

[By Staff Reporters]

According to Financial Advisor News – an electronic trade magazine on March 17 2009 – Standard & Poor’s underestimate the earnings of its S&P 500 Index. So says, Jeremy Siegel PhD, a finance professor at the University of Pennsylvania’s Wharton School of Business and author of Stocks for the Long Run.

The Dilemma

The problem started when the Wall Street Journal ran an op-ed piece by Siegel that argued Standard & Poor’s uses a “bizarre” methodology for calculating the earnings and P/E ratio for the S&P 500. In it, Siegel explained that the earnings of S&P 500 companies are currently treated equally, but should instead be weighted in proportion to their market capitalization. Market capitalization weighting, he noted, is used to measure the S&P 500 returns. Such a system gives larger weight to the earnings of a company such as Exxon-Mobil, and lower weight to an S&P 500 member such as Jones Apparel.

Siegel’s Example

For example, “a 10% rise in Exxon-Mobil’s price would boost the S&P 500 by 4.64 index points, while the same fall in Jones Apparel would have no impact since the change is far less than the one-hundredth of one point to which the index is routinely rounded,” Siegel wrote.

Outcome

As a result of the above, if capitalization weightings were applied to 2008, the earnings of S&P 500 companies would have been $71.10 per share instead of $39.73 per share.

S&P’s Support

In response, an S&P official said Siegel’s argument “fails the test of both logic and index mathematics.”

Conclusion

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Understanding Money Market Account Risks

Posted on March 19, 2009 by Dr. David Edward Marcinko MBA MEd CMP™

Terms and Definitions for Physician Investors

By Staff Writers

The recent banking industry debacle has prompted several of our cost-conscience doctor-clients to rethink money market account risks and related products. We trust this brief review is helpful to all concerned.

Money Market Deposit Accounts

First, the term “money market account” must be defined.

Link: http://www.HealthDictionarySeries.org

There are two types of money market accounts [MMAs] that most people refer to when using this term. The first is a money market deposit account (MMDA). This is an account at a bank designed to compete with money market mutual funds (MMMF). MMDAs usually pay less interest than money market mutual funds and in return offer federal insurance on balances, now up to $250,000 with convenience through check writing and access through ATMs [reverts back to $100,000 after December 31, 2009]. MMDAs under this amount do not have any risk of failure because they are insured by the US government.

Money Market Mutual Funds

Money market mutual funds are mutual funds that invest in short-term instruments with maturities of less than one year, and usually offer check writing on the account. They are not federally insured, but are considered safe in stable economic times. Net Asset Value [NAV] is one dollar; USD. Nevertheless, a few have “broken-the-buck” with NAV at some increment below $1.00 USD.

Evaluation Methods

The first way to evaluate the MMMF risk is to look at the average length of maturities in the portfolio. The shorter the maturity – the safer the MMMF. The second way is to look at the type of security owned by the fund. Government securities are generally less risky than corporate securities. Interested investors can also contact a rating service that evaluates the securities in a MMMF’s portfolio.

And now – a few related words about “so-called” high-yielding CDs.

High Yielding Brokered Bank CDs

First, the physician-investor should determine if the CD is issued by a federally insured institution. If the answer is yes, the investor knows that a portion of his money is safe if the institution fails. If the answer is no, the doctor should obtain the institution’s ratings from the appropriate rating agencies and analyze the institution’s financials. Second, the physician-investor should investigate the volatility of the CD’s return.

Assessment

When interest rates fluctuate, the price of MMAs and CDs fluctuate much like bonds. Therefore, short-term securities are less risky than long-term securities; all things being equal.

Conclusion

And so, your thoughts and comments on this Medical Executive-Post are appreciated. Are you looking at these terms and conditions more closely during this national economic crisis? Please opine and advise.

Filed under: Financial Planning, Insurance Matters, Risk Management | Tagged: ATM, banks, CD, certificate of deposit, FDIC, MMDA, MMMF, money market deposit acount, money market mutual funds, NAV, net aset value | Leave a comment »

This Time the Hospital Financial Crisis is Different

Posted on March 19, 2009 by Dr. David Edward Marcinko MBA MEd CMP™

Oh Really … No so Fast!

Submitted by J. Wayne Firebaugh, Jr; CPA, CFP®, CMP™

Dr. Malcolm T. MacEachern, Director of Hospital Activities for the American College of Surgeons, presciently observed that:

… Our hospitals are now involved in the worst financial crisis they have ever experienced. It is absolutely necessary to all of us to put our heads together and try to find some solution. If we are to have effective results we must have concerted and coordinated immediate action. … Repeated adjustments of expenses to income have been made. Never before has there been such a careful analysis of hospital accounting and study of financial policies. It is entirely possible for us to inaugurate improvements in business methods which will lead to greater ways and means of financing hospitals in the future … It is true that all hospitals have already trimmed their sales to better meet the financial conditions of their respective communities. This has been chiefly through economies of administration. There has been more or less universal reduction in personnel and salaries; many economies have been affected. Everything possible has been done to reduce expenditures but this has not been sufficient to bring about immediate relief in the majority of instances. The continuance of the present economic conditions will force hospitals generally to further action. The time has come when this problem must be given even greater thought, both from its community and from its national aspect…

Source: Steinberg, C. Overview of the US Healthcare System; American Hospital Association 2003.

Many hospital CXOs, healthcare administrators and physician executives would agree that Dr. MacEachern accurately describes today’s healthcare funding environment. However, they might be startled to learn that Dr. MacEachern made these observations in 1932! There is the old truism that there is nothing new under the sun.

American Hospital Association Statistics

Healthcare statistics suggested that the financial crisis is much the same today as it was for hospitals during the Great Depression. The American Hospital Association’s (AHA) reported gloomy statistics for hospitals include:

In 2001, 29% of hospitals had negative total margins.
Approximately $101.3 billion of uncompensated care was provided between 1997 and 2001 with an average annual increase of 16% during that time period.
Emergency departments in 62% of all hospitals report operating at, or over, capacity.
Technology costs are soaring as traditional technologies such as X-Ray machines, for $175,000, are being replaced by contemporary technologies such as CAT Scanners at $1 million that are in turn being replaced by CT Functional Imaging with PET Scans costing $2.3 million. Even such a “simple” instrument as a scalpel that costs $20, is being replaced by equipment for electrocautery costing $12,000, that is then being replaced by harmonic scalpels costing $30,000.
Between 2000 and 2002, 33% of hospitals reported increases in liability premiums of more than 100%.
The average age of hospital plants has increased 21% from 7.9 years to 9.6 years in just one decade.
In the four years ending 2002, hospital bond downgrades have outpaced hospital bond upgrades by almost 5 to 1.

Editor’s Assessment

As editor’s of the premium subscription, two volume, 1,200 pages, institutional print-guide Healthcare Organizations [Financial Management Strategies], we prefer engaged readers and contributors like Mr. Firebaugh, who demand and create compelling content like the above. Please review these links for same.

www.HealthcareFinancials.com

Info: http://www.stpub.com/pubs/ho.htm

TOC: http://www.stpub.com/pdfs/toc_ho.pdf

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Filed under: Career Development, Health Economics, Health Insurance, Healthcare Finance, Managed Care, Marketing & Advertising, Media Mentions and PR, Recommended Books | Tagged: AHA, American College Surgeons, American Hospital Association, CAT, CT, david marcinko, financial crisis, hope hetico, hospitals, medical crisis management, MRI, PET, Wayne Firebaugh | 4 Comments »

Understanding Life Insurance Sales Compensation

Posted on March 18, 2009 by Dr. David Edward Marcinko MBA MEd CMP™

How Agents and Brokers are Paid for Selling Policies

By Dr. David Edward Marcinko; MBA, CMP™

By Hope Rachel Hetico; RN, MHA, CMP™

[ME-P Publisher-in-Chief and Managing Editor]

The recent AIG, and related insurance debacles, have prompted several of our cost-conscience doctor clients to rethink insurance agent sales commissions and related perks. We trust this brief review is helpful to all concerned.

Life insurance company agents

Life insurance agents are appointed by the insurer with the authorization to solicit and deliver contracts of insurance. The agent’s power under life insurance is more limited than that of a property and casualty agent because an agent cannot bind a life insurance carrier to an individual risk, as opposed to a property and casualty agent who can bind his or her insurance company.

Agent Commissions

Agents are compensated primarily on a commission basis from the insurance company they represent. Compensation is higher for the first year a policy is in force. Thereafter, the agent may receive compensation for renewal—a percentage of the annual premiums—and much smaller compensation during subsequent years. If the agent achieves a certain level of production, the agent may receive additional bonuses or other types of compensation. Think: Million Dollar Round Table; or Million Dollar Club Producer.

Commission Rates

Commissions for agents typically run 50% to 55% on cash value products and 40% on term products. Agents’ commissions generally are lower than brokers because they are housed by the insurer, and therefore most of the agents’ expenses are reimbursed or paid by the insurance company.

The Fringe Benefits

The agent also receives fringe benefits from the company, such as health insurance, life insurance, disability insurance, a retirement plan, or a cafeteria-type plan. Usually, agents must maintain a specified level of first-year commissions in order to continue employment with the company.

Life Insurance Brokers

A broker represents the client directly and can show illustrations from many different companies because theoretically there is no allegiance to any one particular company.

Dual Agent-Managers

Some brokers who may act both as general agents and agency managers (individuals who oversee an office of insurance representatives) usually earn commissions as stated above and overrides on first-year premiums to as much as 40%. There is a separate scale on renewals from the sales staff. These overrides are in addition to basic commissions earned either through the broker selling a product on his or her own or as manager of the office. In addition, brokers may earn subsidies for their office and production bonuses.

Assessment

One advantage that life insurance agents have is that some direct writing companies employ only agents to represent them and sell their products. A broker may not have access to sell certain lines of companies that an agent does.

Disclaimer: Both contributors are former licensed insurance agents and financial advisors.

Conclusion

OUR OTHER PRINT BOOKS AND RELATED INFORMATION SOURCES:

PRACTICES: www.BusinessofMedicalPractice.com
HOSPITALS: http://www.crcpress.com/product/isbn/9781466558731
CLINICS: http://www.crcpress.com/product/isbn/9781439879900
ADVISORS: www.CertifiedMedicalPlanner.org
FINANCE: Financial Planning for Physicians and Advisors
INSURANCE: Risk Management and Insurance Strategies for Physicians and Advisors
Dictionary of Health Economics and Finance
Dictionary of Health Information Technology and Security
Dictionary of Health Insurance and Managed Care

Filed under: Ethics, iMBA, Inc., Insurance Matters, Retirement and Benefits | 9 Comments »

Consulting for the ME-P

Posted on March 18, 2009 by Dr. David Edward Marcinko MBA MEd CMP™

Talk to Us

By Ann Miller; RN, MHA

[Executive Director]

We would like to better understand who is visiting the Medical Executive-Post, and what you like, or do not like, about our blog site, print journal and/or communications forum. Most of all, we wish to know who is just visiting versus who is posting, commenting and subscribing; and why?

Assessment

Your responses are confidential, and will only be used for internal use to improve the website blog. We will not sell your information to anyone, ever!

Conclusion

And so, your thoughts and comments on this Medical Executive-Post are appreciated. Please send in your considered responses to me at: MarcinkoAdvisors.@msn.com

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Filed under: "Advisors Only", "Doctors Only", Experts Invited, Media Mentions and PR | Tagged: david marcinko, Financial Planning, Health Economics, healthcare consultants, Healthcare Finance, healthcare financials, hope hetico, medical executive post, medical management | Leave a comment »

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