PM JAN 2009 12/30/08 1:44 PM Page 1

PRST STD US Postage Paid Permit No. 397 Bellmawr, NJ

PHILADELPHIA METRO EDITION Vol. XXII, No. 4 January, 2009 $3.50 PhysiciansNews.com Bundled Payment Reform

By Christopher Guadagnino, Ph.D. and hospitals, and focusing on select model represents the natural evolution of orthopedic and cardiovascular inpatient pay-for-performance, in that it integrates services. In the private sector, the Robert evidence-informed clinical science with entral to the nation’s health care Wood Johnson Foundation has granted aligned incentives that address the frag- reform agenda is the principle of $6.4 million to pilot a bundled payment mentation of care delivery under the cur- Cvalue-based reform – restructur- model known as Prometheus Payment, rent, siloed fee-for-service reimbursement ing provider payment incentives to con- which will focus initially on five proce- model, according to Alice Gosfield, J.D., trol volume growth and to optimize effi- dural diagnoses – hip/knee replacement, first chairman of the board of Prometheus ciency, quality and access. Four value- coronary artery bypass graft (CABG) Payment Inc., and principal of Alice G. based payment methodologies are cur- surgery, cardiac catheterization, bariatric Gosfield and Associates P.C. in Philadel- rently receiving considerable attention from the Centers for Medicare & Medic- aid Services (CMS) and the Medicare The approach features evidence-based guidelines, Payment Advisory Commission (Med- PAC), and may shape physician reim- benchmarked performance incentives and a degree of bursement in the near future: bundled risk-sharing among a constellation of providers. payments, gainsharing, the use of the medical home to coordinate care, and Alice Gosfield, J.D. pay-for-performance arrangements. surgery, and hernias; and five chronic ill- phia. This month, bundled payment pilots nesses – congestive heart failure, chronic “Pay-for-performance models offer concerns can be addressed satisfactorily. are being launched around the country. obstructive pulmonary disorder, asthma, small drips of money on top of an exist- The American Medical Association The concept features a single payment coronary artery disease, and hyperten- ing payment system that doesn’t give us (AMA) notes that the concept is already made for an array of health care services sion. Two pilot sites are launching the the quality we want. It is not sustainable used by Medicare to pay inpatient ser- by multiple providers to care for a patient model this month – in Illinois and Min- as a business model, and is transitional, at vices and some global surgical services, diagnosed with a specific condition neapolis – while Aetna and Independence best,” Gosfield argues. Gainsharing is that it could provide incentives for reduc- across a defined episode of care. Such a Blue Cross are evaluating the Prometheus more about cost containment than quality ing the costs of patient care and, if the “global case rate reimbursement” Payment model for possible piloting with and has a short shelf life: a one-year bundle includes both hospital and physi- includes services provided by a hospital, the Crozer Keystone Health System in waiver structure and an eventual uncom- cian services, it could permit physicians physicians, laboratories, imaging centers, southeastern Pa. pensable moment when waste is reduced to share in any savings produced by pharmacies and outpatient care. The These payment pilots are designed to and no more savings can be squeezed out changes in patient management. The approach features evidence-based guide- stimulate greater collaboration among of the arrangement, she says. The medical AMA is concerned, however, that the lines, benchmarked performance incen- hospitals, physicians and other health home model may be dying on the vine as concept is not yet well-developed for use tives and a degree of risk-sharing among care providers, who will share the finan- payment might never be sufficient for the among multiple independent providers, that constellation of providers. cial incentive to reduce potentially avoid- infrastructure physicians need to produce while key unanswered questions remain CMS is launching an Acute Care able complications and share in cost sav- the promised quality improvements, Gos- regarding the contents of the bundle, how Episode (ACE) demonstration featuring ings. The bundled case rate reimburse- field maintains. to allocate the bundled payment amounts, global payments within Medicare fee-for- ment model also accommodates bench- The bundled payment approach may Continued on page 4 service, to be shared among physicians marked performance incentives. The be attractive to some physicians, if certain

Peter Lund, M.D. Promoting the Tenets of INSIDE Medical Professionalism FEATURES Federal Audits ...... p.6 members of the medical society, were concerned that in our advocacy related to doctors and patients, we didn’t Employment Contracts ...... p.11 Peter Lund, M.D., is immedi- have some kind of compass that would allow us to know Insurance Arbitrage...... p.12 ate past president of the the direction of our advocacy. We decided to fall back to Pennsylvania Medical Soci- basics, which is medical professionalism, including tenets ety (PMS) and founder of the like honesty, integrity, the adherence to the code of med- Institute for Good Medicine – ical ethics, the pursuit of medical excellence, the concept DEPARTMENTS a program within the PMS to of mentoring our younger colleagues, a self-regulatory Medicine & Law ...... p.6 promote and exemplify the aspect of our profession – making sure it is behaving in tenets of medical profession- the interest of the public, and our social contract to make Medicine & Business...... p.11 alism. sure that medicine is delivered in the best possible fashion and is servicing the entire community that we practice in. Personal Finance ...... p.12 PND: What are the activities and goals of the Institute The Institute of Good Medicine was launched at the Physician Recruitment....p.13 of Good Medicine? beginning of my presidency, which was in October 2007. PL: It became apparent years ago that I, and many of the Continued on page 8 PM JAN 2009 12/30/08 1:44 PM Page 2

NEWS BRIEFS

Keystone Health Plan East sub- proposal before the request would by group to recommend action in three mitted a rate filing with the Pennsyl- deemed as approved, the Business areas: reducing wasteful spending, vania Department of Insurance seek- Journal added. (Philadelphia Business changing how doctors and hospitals are ing to increase the base rates of its Journal, December 12, 2008) paid, and reducing administrative HMO group product, for employers *** costs, reported the Wall Street Journal. groups with less than 100 enrolled The trade group for health insur- In 2006, health spending in the U.S. employees, by an average of 10.55 ers offered its own universal-cover- reached $2.1 trillion, consuming 16 percent. age proposal that calls for Congress percent of the nation’s gross domestic Health According to the filing, the pro- to slow the growth of health care product, according to economists at the posed increase will affect 145,046 con- costs by 30 percent in five years, federal Centers for Medicare and Med- tracts and produce additional premium envisioning a total savings of more icaid Services. The group reiterated its Insurance income for Keystone of about $80 per than $500 billion. position that insurers would be contract per month, or $140.1 million The money could be used to fund required to offer individual policies to annually, reported the Business Jour- coverage of the uninsured and to cut people with pre-existing illnesses – as nal. The requested effective date of the costs for those with insurance, said long as all Americans were required to change is April 1, while the Insurance officials from America’s Health Insur- have health insurance, the Journal Department has until Feb. 26 to take ance Plans, which called on Congress added. (Wall Street Journal, December formal administrative action on the to establish a public-private advisory 4, 2008)

A Philadelphia judge said no to giving parted with Albert Einstein Healthcare effort led by southeastern Pennsylvania city parkland for an expansion of Fox Network earlier this year, is now splitting hospitals, with funding of $3 million Chase Cancer Center, saying that every with Frankford Health Care System Inc. through 2011. square foot of 69-acre Burholme Park had Frankford, which operates Frankford Hos- The funding will be provided to the Health to be protected. pital, Frankford Hospital-Torresdale and Care Improvement Foundation, a nonprofit Judge John W. Herron of Philadelphia Frankford Hospital-Bucks County, will health and safety organization that oversees Orphans Court ruled, in a contentious three- remain “closely affiliated” with Jefferson, but the partnership’s projects, while matching year-old case, that Fox Chase’s bid for a long- not as a member of the system, reported the funds are expected to be raised from the hos- term lease of 19.5 acres could not be allowed Inquirer. The two systems said they could pital community next year, reported the Busi- Health to happen, denying the petition to lease 19.4 “best serve their respective communities as ness Journal. Launched in 2006 with three- acres of Burholme Park to Fox Chase, report- independent organizations which maintain year financial support of $1.25 million from ed the Inquirer. Wrote Herron, “This rule of substantial business and clinical ties,” while IBC, the partnership initially focused on the law does not recognize any exception based the realignment needs regulatory approval and prevention of hospital-acquired infections, and Networks on the valid needs of Fox Chase to expand or is unlikely to take effect before the end of the is working on several projects, including pre- the city’s salutary goal of protecting an year, the Inquirer added. (Philadelphia venting pressure ulcers and continuing to raise increasing tax revenue obtained through the Inquirer, November 21, 2008) awareness about antibiotic-resistant staph hospital’s expansion,” the Inquirer added. *** infections through a new campaign called (Philadelphia Inquirer, December 9, 2008) Independence Blue Cross said it will “Students Fight MRSA,” the Business Jour- *** extend its support for the Partnership for nal added. (Philadelphia Business Journal, Jefferson Health System Inc., which Patient Care, a quality and patient safety December 16, 2008)

The director of Gov. Ed Rendell’s Office of public schools, reported the New York Times. n’t approved or using actors as physicians with- Health Care Reform is stepping down. Most of the $2.5 billion in financial assistance out saying so, while the guidelines say celebrity Rendell said that Rosemarie Greco will leave available to medical students comes in the form endorsers shouldn’t say they use a drug unless her post on Dec. 31, but will continue to advise of non-subsidized loans, while few top schools they actually do, reported the Wall Street Journal. the governor from his Philadelphia office, report- have the resources to discount tuition for students The Pharmaceutical Research and Manufacturers ed the Associated Press. Greco has served with from lower-income families, the Times noted. of America, the industry trade group that issued Rendell since 2003 and helped craft policies The steep costs may discourage low-income stu- the standards, said the aim was to address the aimed at cutting health care costs and improving dents from going to medical school, and sway concerns of doctors, Congress and other critics access to care. Her deputy, Ann Torregrossa, will graduates toward higher-earning specialties like while continuing to keep patients informed about Health take Greco’s place, the Associated Press added. radiology and away from lower-paying ones like valuable treatments, the Journal noted. Critics (Associated Press, December 23, 2008) primary care, the Times added. (New York Times, said the changes announced don’t go as far as *** December 19, 2008) those advocated by a panel on drug safety for the Almost one-quarter of U.S. medical stu- *** Institute of Medicine, including that companies Policy dents now graduate from medical school with Prescription drug makers updated their wait two years before advertising a prescription $200,000 or more in debt, an expense that lim- voluntary standards for direct-to-consumer drug directly to consumers so that its effects can its entry to the profession, according to a study advertising to make the ads more informative, be better understood, while critics also said that published in the New England Journal of but the measures stop short of changes sought television ads should include the phone number Medicine. by government and industry critics. at the FDA for patients to call to report a side The median cost of attending a year of med- The companies said they will halt advertising effect. Under the voluntary standards, only print ical school, including all fees, is now $62,243 at that includes promoting prescription drugs for ads would include the number, the Journal private schools and $44,390 for state residents at uses that the Food and Drug Administration has- added. (Wall Street Journal, December 11, 2008)


7Ê" -Ê" PENN MEDICINE WELCOMES…

-
/9Ê -1,
Ê
7 Michael F. Stiefel, MD, PhD Department of Neurosurgery

Dr. Stiefel joins the department of Neurosurgery as an assistant professor of neurosurgery, Director of the Comprehensive Cerebrovascular and Hi«ÀiÃi˜Ìˆ˜}ÊF ÞÈVˆ>˜ÃÊ>˜`ÊFÀœviÃȜ˜>ÃÊ Endovascular Neurosurgery Program and Associate Director of Neurovascular Critical Care. Dr. Stiefel received his medical degree from the Medical College ˆ˜Ê7Ê7ëiVÌÃʜvÊ:ˆÃ>LˆˆÌÞÊ?˜ÃÕÀ>˜ViÊ of Virginia. He completed his internship in general surgery and his residency in neurosurgery at the Hospital of the University of Pennsylvania. Following 9>ˆ“ÃÊ>˜`Ê9>Ãià his residency, Dr. Stiefel completed a fellowship in Endovascular Neurosurgery at the Barrow Neurological Institute. ™ Dr. Stiefel’s clinical interests include cerebrovascular and endovascular neurosurgery and interventional neuroradiology. He specializes in microsurgical and endovascular treatment of cerebral aneurysms, £x£xÊÊÊÊÊÊÊC>ÀŽiÌÊ IÌÀiiÌ]Ê# IՈÌiÊ££ääÊÊÊÊÊÊÊÊ arteriovenous malformations (AVMs), arteriovenous fistulas (AVFs) and carotid and intracranial F ˆ>`i« ˆ>]F7Ê£™£äÓ stenoses, as well as skull base surgery and stenting and bypass procedure. His many research interests include the role of inflammation in cerebral vasospasm and stroke. Ji°ÊÓ£x°ÇÎx°{ÓÓÓ JœÊÀiiÊnnn°È™™°{ÓÓÓ ÜÜÜ°ÃiÌâiÀi}>°Vœ“ 800.789.PENN pennhealth.com

Page 2 PHYSICIAN'S NEWS DIGEST (PM) January, 2009 http://www.PhysiciansNews.com PM JAN 2009 12/30/08 1:44 PM Page 3

NEWS BRIEFS

Pennsylvania received an overall received a grade of D and a national 11 percent of adults in Pa. are uninsured grade of C+ and tied for 8th in the ranking of 38th. The primary factors compared with averages of 11.7 and 17.2 nation for its support of emergency behind the low grade revolve around percent nationwide. Pa. also fared well in patients in a national report card on high malpractice payments. the category of public health and injury state of emergency medicine released The state’s grade of C- and ranking of prevention with a grade of B- and a Story by the American College of Emer- 23rd in access to emergency care was national ranking of 17th. However, nega- gency Physicians (ACEP). due specifically to the state’s need for tive indicators such as the state’s infant The report card comes at a time when primary care and mental health mortality rate, high smoking and binge Of The the national picture looks bleak: job and providers, high hospital occupancy rates, drinking rates, lack of mandatory motor- insurance losses, a rapidly growing and low Medicaid reimbursement rates cycle helmet law, and a lower than aver- senior population and a recent survey for office visits. Medicaid reimbursement age score on child safety seat/seat belt Month forecasting critical shortages of primary for office visits are only 54.5 percent of legislation prevented the state from care doctors all point to escalating emer- the national average, despite a 38.1 per- receiving a higher grade and ranking. gency patient populations. The low point cent increase between 2004 and 2007. (Pennsylvania Chapter of the Ameri- of Pa.’s report card was in the category On a positive note, slightly more than can College of Emergency Physicians, of medical liability environment where it seven percent of children and fewer than December 5, 2008)

Ambulatory surgical centers in Pennsyl- tem Association of Pennsylvania said the was based on voluntary responses from more vania continue to grow in terms of numbers report shows how the proliferation of ambula- than 1,600 hospitals nationwide, reported the and profits, according to the latest report tory surgery centers continues to increase the Star-Ledger. The study, the first to look issued by the Pennsylvania Health Care pressure on acute care hospitals at the same nationwide at how hospitals report events that Cost Containment Council (PHC4). time that the national economic downturn cause patients physical or psychological harm, Between June 2007 and May 2008, 17 new threatens to further weaken hospitals, the was published in the journal Quality and Safe- ambulatory surgical centers opened in Penn- Business Journal added. (Philadelphia Busi- ty in Health Care. The survey, which was sent sylvania, bringing the statewide total to 245, ness Journal, November 25, 2008) to hospital risk managers, found that just 32 Hospitals while the total margin recorded by the outpa- *** percent of all hospitals nationwide have estab- tient centers increased 3.9 points to 24.7 per- Almost every hospital now collects data lished “supportive environments” that allow cent in fiscal 2007 from 20.85 percent in fiscal on patients injured or killed by medical anonymous reporting, while only 13 percent 2006, reported the Business Journal. While mistakes, but only one in five share that have broad staff involvement in reporting & Medical not as brisk as the prior 12-month period when information, even with key managers who unintended injuries to patients, with nursing 28 new facilities opened, the recent growth in could work toward making improvements, staff bearing the brunt of such responsibility. It new ambulatory surgical centers still reflects a national survey found. found great reluctance on the part of doctors to the ongoing outpatient surgery trend, the Such practices prevent hospitals from cre- get involved in reporting, citing factors such as Schools PHC4 said, adding that the centers outnumber ating systems that would protect staff workers concerns about liability, professional embar- the state’s acute care hospitals 245 to 170 and who report mistakes and may foster an envi- rassment and the time allotment required, the continue to perform remarkably well, the Busi- ronment that keeps such critical information Star-Ledger added. (Star-Ledger, December 9, ness Journal noted. The Hospital & Healthsys- under wraps, according to the survey, which 2008)

The Hospital & Healthsystem Associa- state House in Nov. suggesting the funds could reported the Associated Press. (Associated tion of Pennsylvania (HAP) and the Penn- be diverted to pay for non-health care projects Press, December 11, 2008) sylvania Medical Society (PMS) sued the and to help fill a projected $500 million gap in *** state to obtain hundreds of millions in next year’s budget, the Business Journal Sen. Charles Grassley – ranking Repub- unspent dollars they say should be devoted added. (Philadelphia Business Journal, lican on the Senate Finance Committee – is to the MCARE Fund. December 11, 2008) weighing proposing legislation in early In its petition filed at Commonwealth *** 2009 that would hold nonprofit hospitals Court, HAP said the state has violated state law Former Senate Majority Leader Tom more accountable for the billions of dollars and the Pa. Constitution by failing to transfer Daschle will pull double duty in the Obama in annual tax exemptions they enjoy. dedicated cigarette tax funds to the MCARE administration, where he will serve as the The legislation would require nonprofit Regulation Fund to pay for MCARE abatement, which Health and Human Services secretary and hospitals to spend a minimum amount on covers all or part of physicians’ state-mandated also oversee a new White House Office of charity care, and set curbs on executive com- malpractice insurance coverage, reported the Health Reform. pensation and conflicts of interest, reported the Business Journal. The PMS filed its own peti- Jeanne Lambrew, who helped Daschle Wall Street Journal. Under the new legisla- & Law tion with the Commonwealth Court seeking to write a book about health care reform, will tion, penalties would be imposed on nonprofit preserve funds in a dedicated health care serve as deputy director of the new White hospitals that fail to meet the new require- provider retention account earmarked for the House health policy office. Lambrew worked ments, while penalties could escalate from eventual phasing-out of the MCARE Fund, on health care reform issues at the White taxes and fines to stripping a hospital of its which has a projected $1.8 billion unfunded House during the Clinton administration and federal-tax exemption if it continues to misbe- liability. The PMS said the action was filed in currently serves as a senior fellow at the Center have, the Journal added. (Wall Street Journal, response to remarks made on the floor of the for American Progress, a liberal think tank, December 18, 2008) Establish Your Practice Consolidated Billing Services In a Premier Facility Professional Medical Billing On-site Management High Visibility • Serving Private Practice and Hospital-based Physicians since Easy Access 24 Hour Security 1986. Allendale Answering Service, Inc. • Separate, dedicated FOLLOW-UP STAFF performs all Live Operators - 24/7/365 post-billing collection activity at NO EXTRA CHARGE. Generous Parking / Offices 300 - 5000 square ft • Use our full-service billing agency or do a combination of in-house data entry with CBS serving as your “back office.” For Additional Information, Contact • Fully electronic with all major carriers including automated Donna Strano, Manager - 610-265-2242 reconciliation (payments). HIPAA compliant. Call us today for a free billing analysis indicating what your practice should be collecting! www.cbsbill.com [email protected] 610-734-0610

http://www.PhysiciansNews.com January, 2009 PHYSICIAN'S NEWS DIGEST (PM) Page 3 PM JAN 2009 12/30/08 1:44 PM Page 4

Testing Bundled Payment Models

Continued from page 1 flexibility to hospitals and physicians by and CMS intends to take an active role lines or expert opinion, while also factor- bundling all related inpatient services with ACE demo sites to market the ing in cost modifiers for: how to risk-adjust those payment into an episode of care by paying a sin- demonstration. CMS will share up to 50 • Regional variations in practice patterns amounts, and whether the payment gle, global payment that can be used as percent of any Medicare savings in the (intended as a buffer to avoid punitive approach might lead to cherry-picking the health care groups deem most appro- form of payments to offset patients’ pricing for providers in some regions, at patients and inappropriate care rationing. priate. CMS says it is initially focusing Medicare cost-sharing obligations, in the least at the outset when the model is CMS’s ACE Demonstration on nine orthopedic and 28 cardiovascular form of a payment not to exceed their piloted). Beginning this month, CMS is launch- inpatient surgical procedures because annual Part B Premium amount. • Patient severity and comorbidity. ing a three-year Acute Care Episode profit margins and volume have histori- The ACE demo will test whether • An additional 10 percent margin over demonstration with up to 15 physician- cally been high, the services are easy to aligning payment incentives between the base severity-adjusted ECR (as anoth- hospital organizations (PHOs) located in specify, and quality metrics are available hospitals and physicians leads to er financial buffer against too lean a pay- Texas, Oklahoma, Colorado and New for them. CMS is limiting participation to improved care coordination, and CMS ment at the outset, in recognition of the Mexico to test the use of global payments artificially depressed fee schedules that for defined episodes of care as an alterna- are reflected in historical claims data tive approach to fee-for-service payment. Beginning this month, CMS is launching a three-year upon which ECRs are based). An episode of care is defined as Medicare • An allowance for 50 percent of poten- Part A and Part B services provided dur- Acute Care Episode demonstration with up to 15 tially avoidable complications, e.g., ing an inpatient stay for hip/knee replace- physician-hospital organizations (PHOs). infections and routine complications spe- ment surgery and/or CABG surgery, cific to surgical treatment and medical while the time window for an episode of care incurred in hospitals. care during the first year of the demon- providers that meet evidence-based profi- expects the arrangement to result in • An incentive payment for achieving cer- stration will be the traditional window ciency volume thresholds for procedures. greater program efficiency and higher tain benchmark levels of performance (to covered by current Medicare hospital The ACE demo builds upon earlier quality of care and outcomes for be phased in as potentially avoidable rules, e.g., all pre-admission hospital test- global payment demonstrations – one for Medicare beneficiaries. Sites have the complication rates decrease). ing services, post-discharge services, and heart bypass surgery and one for cataract option to reward individual clinicians, Simply reducing the number of avoid- emergency room services. After year one surgery, both in 1996 – that CMS says teams of clinicians, or other hospital staff able complications could potentially of the demo, CMS and demonstration achieved cost efficiencies through who succeed with measurable clinical bring tremendous savings to the health sites may consider including some post- streamlined processes leading to fewer quality improvement. An independent care delivery system. According to acute care services in the episode of care. re-operations, lower readmissions, and evaluation will be conducted to evaluate Prometheus analysis, some 30 percent of All inpatient facility (hospital) and shorter lengths of stay. The ACE demo the feasibility and cost effectiveness of fee-for-service payments for acute professional (physician) services ren- expands the concept to a broader set of the bundled payment methodology. myocardial infarctions and 60 percent of dered to the demonstration’s patients inpatient orthopedic and cardiovascular Prometheus Model payment for diabetes care goes toward from the date of admission through the procedures with the potential to expand A central premise of episode-based potentially avoidable complications, date of discharge at the demonstration to post-acute care services (e.g., cardiac payment models is that a bundled pay- while ECRs would incent providers to facility are included in the bundled pay- and orthopedic rehabilitation) after the ment rate should cover the cost of coordinate and improve their care by ment. CMS notes that the project is first year, says CMS. Unlike previous resources for treating a patient for a par- holding them accountable for the “techni- specifically designed to align financial bundling demonstrations, CMS notes, ticular condition over time, while poten- cal risk” of patient outcomes that are the incentives across providers and provide patients will share in Medicare savings tially reining in the rapid rise in unneces- result of suboptimal care, says Gosfield. sary volume and cost of health care, The AMA is closely examining improving quality by reducing avoidable Medicare payment reform proposals, complications, and avoiding putting including bundled payment models, and providers at risk by providing insufficient will reserve the opportunity to compare funds to cover the cost of services ren- and contrast physician payment reform dered. Those goals are ambitious, and the proposals until its Council on Medical Prometheus payment model seeks to Service, an influential advisory commit- accomplish them by paying hospitals, tee to the AMA, has completed its study Published By physicians and ancillary health care and allowed the nation’s medical soci- PHYSICIAN’S NEWS MEDIA, LLC providers a single, evidence-informed eties an opportunity to provide their 117 Forrest Ave. Narberth, PA 19072 case rate (ECR) – a clinically-derived and views, according to AMA spokesman 610-668-1040 risk-cushioned bundled payment aimed at Robert Mills. The Council is developing FAX: 610-668-9177 promoting coordination among providers recommendations to the AMA’s House of http://www.PhysiciansNews.com involved in a given patient’s care episode Delegates, regarding how alternative E-mail: [email protected] to deliver improved outcomes for the Medicare payment methodologies should patient, with an explicit profit margin be structured in order to best serve Brad Broker, Editor & Publisher built in. patients and physicians, and in a report Managing Editor Developed by a nonprofit corporation, last November indicated that bundled Christopher Guadagnino, Ph.D. Prometheus Payment, Inc., ECR payment payments need to address a number of amounts are based on the resources issues, including: Office Manager Sandra Scavuzzo required to provide care as recommended • How the package subject to bundled in widely-accepted clinical guidelines, payment should be defined (e.g., physi- Staff Artist while the model also allows for a portion cian-only services; all services related to Miriam Greenwald of the payment to be withheld and re-dis- a single care episode). tributed based on provider performance • Whether there should be a single pay- on measures of clinical process, out- ment or separate payments for different CONTRIBUTING EDITORS comes of care, and patient experience components of the package. David H. Glusman, CPA Dennis Hursh, Esq. with care received, according to Gosfield. • Which entity or entities should receive Margolis & Company, PC Hursh & Hursh PC To generate ECRs, Prometheus Pay- the bundled payments and how much Alice Anne Andress William H. Maruca, Esq. ment convened working groups consist- flexibility they should have in allocating Parente Randolph Fox, Rothschild, O’Brien & Frankel, LLP ing of medical professionals, health care them among different stakeholders researchers and data modeling experts (specifically, how to ensure physicians Deborah Robinson, Esq. Jeffrey B. Sansweet, Esq. Houston Harbaugh Kalogredis, Sansweet, Dearden & Burke Ltd. who examined prevalence of diagnoses, retain control over their portion of bun- costs, treatment variation, coordination, dled payment). Mark F. Seltzer, Esq. Edward F. Shay, Esq. Mark F. Seltzer, PC Post & Schell, PC reimbursement and other issues, and ulti- • How to determine the appropriate pay- mately selected five procedural diagnoses ment amount for the package and/or its John W. Jones, Jr., Esq. Karl A. Thallner, Jr., Esq. and five chronic illnesses for which to components. Pepper Hamilton LLP Reed Smith LLP model ECRs. The workgroups developed • Whether and how to risk-adjust pay- the scope of each ECR by examining ment for such things as severity of illness Physician’s News Digest (ISSN 1079-6312) is published monthly, 12 times a year. Andrew Peltzman, work-ups required to diagnose the condi- and differences in patients’ socioeconom- Founder. None of the content of this publication may be reproduced, resold, republished or copied with- tion, services covered by the ECR, and ic status. out written permission from the publisher. Physician’s News Digest does not assume any responsibility evidence-informed criteria for successful • How to pay for an episode of care, if the for damages resulting from omissions or errors. The opinions expressed herein are those of the authors and do not necessarily represent those of the publisher. PND reserves the right to edit any material sub- completion of care, Gosfield notes. most resource-intensive tests and proce- mitted for publication. Articles appearing in PND are for general information only and should not be con- An ECR defines the boundaries of dures occur early in an episode (for sidered legal or business advice or used as such. “typical” care and establishes a base pay- example, should payment be front-loaded ment, designed to cover all health care Circulation–17,000–Subscriptions: $35/year Continued on page 5 Copyright© 2009 by Physician’s News Media, LLC services recommended by clinical guide-

Page 4 PHYSICIAN'S NEWS DIGEST (PM) January, 2009 http://www.PhysiciansNews.com PM JAN 2009 12/30/08 1:44 PM Page 5

Testing Bundled Payment Models

Continued from page 4 Over time, Prometheus expects that whether to participate in the model, and providers will only receive their regularly providers will establish their own internal how to configure themselves. Physician contracted fee schedules. or paid in equal installments). cost-accounting processes and will be groups may join with hospitals, therapy There is still a substantial volume of • Whether to provide additional payments able to negotiate ECRs based on a full providers, imaging facilities or any other appropriate and necessary health care ser- for teaching hospitals and hospitals car- understanding of what it actually costs entity with which they think would be vices which are not being delivered, and ing for the uninsured, as well as for out- them to deliver the care – including clini- worthwhile to collaborate to achieve bet- national studies estimate that Americans lier cases. cian time. In the end, knowledge of what ter results for patients. There is no obliga- are getting only 55 percent of the services • How to ensure that physicians and/or it costs to treat a patient for a condition is tion that these aggregations of providers that evidence says they should be receiv- hospitals do not avoid treating difficult at the core of a well-grounded negotiation accept money together, but they can if ing. Where data demonstrates underuse in patients. for a case rate. they want to. Providers are entirely free comparison with guideline-based care • How to ensure that quality of care does While clinical practice guidelines are to determine their own organizational under the Prometheus model, additional not suffer. often ambiguous and not all have a solid relationships and referral relationships. dollars will be available to good • How to ensure that bundled payment evidence base, Prometheus will focus on To further motivate explicit clinical col- providers. Physicians who manage care covering both hospital and physicians’ those that are widely accepted and uncon- services does not run afoul of federal troversial, providing a transparent basis antitrust laws and laws applying to tax- to determine whether the salient process- Physician groups may join with hospitals, therapy providers, exempt hospitals, and federal laws pre- es have been deployed for the patient’s imaging facilities or any other entity with which they think would cluding physician self-referral, kickbacks, care, while minimizing the risk that and hospital payments to physicians for providers will skimp on care to enhance be worthwhile to collaborate to achieve better results for patients. reducing or limiting patient services. financial margins. Good clinical practice Bundled payment issues that matter to guidelines based on consensus are also the hospital community include the fol- eligible for inclusion as a basis for pay- laboration, if two providers seek to be well are able to keep the difference lowing, according to Paula Bussard, ment, even though their evidence base paid for the same portion of the ECR and between the actual cost of delivering care senior vice president of policy and regu- may not have been subjected to random- cannot agree between them as to who was and the case rate. While physicians who latory services of the Hospital & Health- ized controlled clinical trials or rigorous managing which portion of the care, nei- over-utilize resources may experience system Association of Pennsylvania: assessment. Either is preferable to the ther will be paid under the ECR, and they reductions in revenues, changing their • Payments can’t be one-sided, e.g., dic- inferior alternative of using historical will both be paid under their existing practice to reflect clinical practice guide- tated by payors without provider input. claims data that reflect current utilization contracts. While physicians still choose line-based care should be able to lower • All parties must agree on the measures patterns, which have no basis in evidence to whom they wish to refer patients, they their expenses and thereby increase their to be used. of what constitutes good care, and will have the incentive to pay closer margins. Applying guidelines to drive • The model must not be “one-size-fits- include significant distortions currently attention to collaboration with their refer- payment for participating providers all,” and must be adaptable to all configu- present in care delivery. ral network colleagues. should reduce overuse and misuse of rations of hospitals and their relationship The model avoids saddling providers Hospitals will have an incentive to health care services, but it remains to physicians. with the risk that they may have a sicker create closer collaborative bonds with unknown whether this resulting correc- • It must minimize unintended conse- patient panel than average, or that physicians without having to own their tion will result in a net decrease in health quences, such as channeling sicker and patients’ conditions or disease mix can be practices and, while in theory they should care expenditures. Reducing avoidable more complex patients to hospital emer- more unfavorable (in terms of resource lose some admissions as care quality complications could, on the other hand, gency rooms for care. use) per patient than the average, by improves, they would be seeing different potentially trim billions of dollars from “Who should be at risk for a hospital attempting to construct payment rates that case mixes. those expenditures. readmission if a patient can’t get an reflect the quantity and range of services Although the ECR is a fixed rate, the Prometheus believes that no new legal appointment with a physician?” asks Bus- recommended by guidelines relevant to model discourages providers from skimp- structures are necessary to make the sard. “As the stakeholders develop these the patient’s condition, and adjusting ing on care because it takes into account model work, and that relatively simple models, they need to address the possibil- them to account for normal clinical varia- necessary resources to treat more com- contract amendments establishing a ities of these issues,” she adds. tion and relative severity of illness. plex patients, risk-adjusts for co-morbidi- carve-out for the negotiated ECRs and Offering promise for a successful bun- The model accounts for facilities and ties, and uses a performance contingency protecting providers from medical man- dled payment model are a growing base providers who treat more vulnerable pop- fund (10 percent for physicians and 20 agement programs (e.g., profiling, utiliza- of measurable, coordinated knowledge of ulations by offering higher severity- percent for hospitals and other providers) tion review, prior authorizations) for the best clinical practices, and actual care adjusted rates for managing relatively that is payable only if the provider reach- rest of their business are all that is neces- es a minimum threshold of performance. sary. Certain groups of providers may Providers who consistently fall below choose to formally configure themselves Prometheus expects that providers will establish their own that threshold will lose the right to be into a network but there is no obligation internal cost-accounting processes and will be able to negotiate paid under this model. Services associat- for that to happen, as the model empha- ed with symptoms extraneous to the ECR sizes clinical collaboration without finan- ECRs based on a full understanding of what it would be excluded from the ECR and cial integration. Prometheus believes the actually costs them to deliver the care. paid for separately. Non-participating model can work for solo physicians, providers continue to be paid under cur- group practices, standalone hospitals, or rent payment methods, while the cost and integrated delivery systems. Since no one cost experience, notes Bussard. “Given sicker populations or those with more quality of care they deliver is included in is paid for referrals in the model the right systems for coordinating them, risk factors, while all rates are adjusted to 30 percent of the provider’s performance (providers are paid for the work that they we now have the opportunity to align the account for facilities that have a specific scores. Prometheus believes providers do in accordance with the rate that they clinical and financial aspects of health mission (e.g., teaching or disproportion- actually stand to make significant profit Continued on page 15 care delivery,” she says. ate share). To avoid the potential for margins while non-participating The Prometheus model attempts to cherry-picking patients, once a provider address key physician and hospital con- decides to participate in the model, all cerns, as Gosfield explains, and as patients with the condition in the ECRs Prometheus Payment explicates on its paid for by a participating health plan website: will be paid in this way. ECRs also have At the outset, neither health plans nor fail-safe “breakers” that insulate the providers have credible data regarding provider in the event a patient turns into a the actual costs associated with deliver- catastrophic case. “Full Service” Medical Billing ing specified clinical care as articulated While physician-hospital organization in a clinical practice guideline. Patients disputes arose in the past because the who are truly complex will not be includ- hospital drove the negotiations and held • Rates 4.5% to 7.5% • No Added Charges ed under Prometheus until enough is physicians’ money for disbursement – known about how to create ECRs for often without explicit bases to parse out very clinically complicated patients. In money to individuals – allocation of • Monthly Analysis • No Volume Too Low order to test the new bundled payment ECRs is assigned in advance, while 30 process, a starting point has been defined percent of a provider’s performance as an approximation to price a guideline scores turn on the behavior of other • HIPAA Compliant • No Binding Contract equitably: historical claims data, cush- providers treating the patient, rewarding ioned to correct for artificially depressed those who collaborate in the patient’s fee schedules. ECRs will have to be best interest. Under the model, no one recalibrated regularly (at least once a holds a provider’s money unless the CALL (215) 564 – 5745 year) to account for introduction of new provider chooses that approach. Est. clinical evidence and new technology. Providers themselves decide on 1990 (866) 473 – 5248

http://www.PhysiciansNews.com January, 2009 PHYSICIAN'S NEWS DIGEST (PM) Page 5 PM JAN 2009 12/30/08 1:44 PM Page 6

MEDICINE & THE LAW Protect Yourself from Federal and State Audits

carried out by commercial programs). Audit and Investigation Protocols State and Local Initiatives Upon receipt of a subpoena or other There are also a number of state and demand for records, search warrant, or local initiatives that have been developed notice of facility inspection or audit, your and are being implemented. Providers organization should have adopted proto- need to be aware of these projects and cols that will guide management through Miriam Greenwald 2008

© how they operate at state and local levels the audit process. These protocols should and understand that they may be indepen- include the following: dent of federal activities. • Engage counsel as early in the process as In light of the heightened risk of possible. receiving a subpoena, record demand, • Determine which government agency search warrant and/or facility inspection and office you are dealing with, and at or audit notice by several government what level of government. agencies at one time (and at several levels • Ensure that all requests and demands are of government, including federal, state streamlined so that your organization does and local), it is imperative that providers not become subject to more than one audit take certain compliance measures on a for the same issues and have to pay for the prospective basis, as well as follow certain same review more than once. adopted protocols when threatened with • If your organization receives more than By John W. Jones, Esq. FY2006 with an additional $50 million in an audit or investigation. one request, coordinate the requests with each of 2007 and 2008, and $75 million in Prospective Compliance Steps those agencies and have counsel interface 2009 and annually thereafter to carry out Measures to take on a prospective basis them to narrow the issues, limit the scope With the passage of the Deficit Reduc- the operations of MIP. The MIP will be would include: of the audits and attempt to streamline tion Act of 2005 (DRA), government conducting audits and supporting states’ • Developing and implementing an effec- through one agency. scrutiny of providers and provider audits program integrity efforts. The DRA tive compliance plan. • Have counsel work with the agency to have increased and organizations are find- directs the Secretary of HHS to enter into • Reviewing for effectiveness existing coordinate facility inspections and ing themselves in uncharted waters – fac- contracts with eligible entities, known as plans and procedures and developing pro- responses to document requests and sub- ing subpoenas, record demands, audit Medicaid Integrity Contractors (MICs), to tocols and practices to improve compli- poenas. requests and even search warrants from carry out the MIP’s activities, including: federal, state and local officials. The • Review of actions of individuals or enti- prospective measures taken by a provider ties furnishing items or services for which Measures taken by a provider need to include not only the need to include not only the adoption, a Medicaid payment may be made. adoption, implementation and continued review of an effective implementation and continued review of • Audit of claims for payment for items or compliance plan but also internal protocols that provide the an effective compliance plan but also the services furnished or for administrative organization’s management with guidance when threatened development and implementation of inter- services rendered. nal protocols that provide the organiza- • Identification of overpayments to indi- with an audit or investigation. tion’s management with guidance when viduals or entities receiving federal funds. threatened with an audit or investigation. • Education of service providers, managed ance and address risk areas. • Establish reasonable parameters and Federal Initiatives care entities, beneficiaries and other indi- • Engaging in internal reviews and audits timetables for any inspection, audit, docu- The Department of Health and Human viduals with respect to payment integrity of claims and medical records. ment production and employee interviews. Services was directed, under the Deficit and quality of care. • Evaluating whether self-disclosure and • Work with the agency, through counsel, Reduction Act of 2005 (DRA) to establish The MICs will focus on these issues voluntary repayment is appropriate. and take measures to keep the audit or a Medicaid Integrity Program (MIP). The and, in the event that potential fraud is • Establishing protocols and procedures investigation from becoming adversarial. MIP was designed to provide the Centers detected, the MICs will refer the case to that will guide an organization when • Properly communicate with management for Medicare and Medicaid Services the the Office of Inspector General. These ini- threatened with a subpoena, records and employees about an audit or investi- resources necessary to combat Medicaid tiatives will be in addition to, and separate demand, search warrant or notice of facili- gation. fraud, waste and abuse. Accordingly, from, Medicare audit initiatives and ty inspection or audit. • Take actions to ensure that any audit or Congress appropriated $5 million for enforcement activities (as well as audits investigation does not interfere with care delivery or patient relations. • Adequately protect, through privilege, communications between the organiza- tion, consultants and counsel. TRANS SERVICE INSURANCE AGENCY • Preserve records and cease routine and non-routine document destruction. 100 COMMUNITY COURT • Determine whether entrance and exit PITTSBURGH, PA 15205 interviews of employees is appropriate 1-800-260-0025 and select trusted employees for these interviews. • Monitor the audit process and have trust- ed employees supervise and assist with the audit process. Specializing in • Secure a copy of the audit results. Dis- cuss with counsel defenses to the audit results if unfavorable, drafting of position paper and, if appropriate, filing timely MEDICAL appeals. • Throughout the audit process, take steps to limit your organization’s financial MALPRACTICE exposure, including with respect to any overpayment (through conducting your own internal investigation), as well as costs associated with complying with the INSURANCE audit or investigation.

John W. Jones, Esq. is a partner in the Health Care Services Group at Pepper Hamilton LLP in Philadelphia, Pennsyl- Contact Greg Rodgers at 1-800-260-0025 vania.

Page 6 PHYSICIAN'S NEWS DIGEST (PM) January, 2009 http://www.PhysiciansNews.com Scott Becomes Chief of Thoracic Surgery

FOX CHASE CANCER CENTER

Fox Chase Expands Options for GI Surgery, Endoscopy Services and High-Risk Patients

Oleh Haluszka, M.D., director of gastrointestinal endoscopy at Fox Chase Cancer Center, is excited about the unique resources he and his colleagues can now offer to patients referred for GI malignancies, precancerous conditions or even some benign problems. For example, new additions to the Fox Chase treatment team include an expert in single-port-access laparoscopy for benign and malignant conditions of the gastrointestinal tract. Scarless Surgery Andrew A. Gumbs, M.D., joined the Fox Chase department of surgery in December in the new position of director of minimally invasive hepato-pancreato-biliary (HPB) surgery. He is the first American surgeon to complete a fellowship in minimally invasive HPB surgery at the Institut Mutualiste Montsouris in Paris, France. “Andrew is one of a handful of surgeons in the United States to offer major hepatic resections and Whipple procedures that are totally laparoscopic,” Haluszka pointed out. “He also will continue his pioneering work in scarless surgery—not only for GI cancers but also for benign conditions.” Gumbs’ single-incision laparoscopy uses a trans-umbilical approach. It is ideally suited for diagnosis, staging and surgical treatment for benign tumors and other conditions such as gallstones, and even splenectomy for benign and malignant conditions. “Fox Chase is one of only a few institutions in the world that has made a major commitment to performing less invasive surgical Oleh Haluszka, M.D., and Andrew Gumbs, M.D. (right), who procedures for cancer whenever they can assure optimal tumor specializes in complex laparoscopic management of liver, removal,” Haluszka added. pancreatic and gastric tumors Therapeutic Endoscopy Stephen J. Heller, M.D., a board-certified gastroenterologist and therapeutic endoscopist, has joined Haluszka in the Fox Chase Comprehensive GI Services: department of medicine as an attending gastroenterologist. His addition facilitates offering new therapies for endoscopic ablation of Fox Chase Cancer Center provides comprehensive care for GI precancerous conditions and palliative treatments of gastrointestinal patients. In addition to routine GI and liver consultative services, malignancies. Fox Chase GI specialists develop clinical and research programs For example, Heller will use therapeutic endoscopy to provide aimed at advancing general GI care. preventive treatment for patients with Advanced therapeutic GI intervention precancerous conditions and early cancers— • ERCP for benign and malignant conditions; with for example, in patients with premalignant pancreatoscopy and cholangioscopy as necessary lesions of the esophagus, large polyps of the • Endoscopic ultrasound with needle access for diagnosis and colon and rectum, and early tumors of the therapy stomach. In cases of more advanced disease, • Endoscopic mucosal resection he uses biliary and enteral stenting to offer • Full range of ablative technologies for Barrett’s esophagus, patients a better quality of life. including radiofrequency ablation and cryotherapy “Steve will continue our tradition of • Panenteroscopy of the gastrointestinal tract via the latest prompt, expert evaluation and treatment of technologies for deep enteroscopy patients requiring tertiary endoscopic • Endoscopic treatment of all forms of intestinal strictures services,” Haluszka emphasized. including palliative stenting High-Risk Interventions Easy access to GI/liver research protocols Michael John Hall, M.D., M.S., has joined Fox Chase Cancer • Cancer prevention and early diagnosis Center’s medical oncology staff as an attending physician. He primar- • Cancer treatment modalities (Phase I, II and III trials) ily treats patients with cancers of the pancreas, small-bowel, and colon, • Treatment of viral hepatitis B and C in the naïve patients as but he also offers resources for healthy people at high risk of GI cancer. well as patients who fail therapy As a member of the Fox Chase Gastrointestinal Tumor Risk Assessment Comprehensive GI Cancer Risk Assessment Program Program, Hall takes part in the comprehen- for moderate- to high-risk patients and their families with sive cancer risk assessment of every patient significant cancer history referred to the program. This includes pedigree analysis, risk counseling, and when appropriate, clinical genetic testing. “These high-risk patients then go back to the referring physicians practice for continuing follow-up,” Haluszka said. To refer a patient, call 215-728-2570 | www.fccc.edu PM JAN 2009 12/30/08 1:44 PM Page 8

Promoting Medical Professionalism

Continued from page 1 practice any longer but he took hospice stand that physicians are doing their part with us. With Drug Free Pennsylvania patients out fly-fishing, because he loves to help improve the health of our com- we’ve recently done a program to try to It involves utilizing the staff at the med- fly-fishing. It was an example, not only munity and fulfilling one of the tenets of help parents understand the misuse of ical society and doctors throughout the of fulfilling his need to do something for medical professionalism. prescription drugs by their children and state to promote what they feel are the somebody else, but of fulfilling the need PND: What were significant findings to try to protect their children from pre- best aspects of professionalism. For to give care to people in their last days of the Institute’s patient poll? scription drugs that may be laying on example, we have hosted skill nights at on this earth. PL: We polled patients in Pennsylvania their shelf. We have a broadcast going virtually every medical school in the We’re also going around to medical and we found out that patients didn’t out to about 60 radio stations across the state, talking to first- and second-year staffs across the state to give lectures at have a complete understanding of health state promoting better protection for medical students about the importance of grand rounds, having them understand care issues, and their health care literacy these children. With the American Lung medical professionalism, and also how our advocacy interacts and works was not as astute as we thought it should Association, it was the Get a Shot pro- demonstrating some surgical skills. The with issues of professionalism and also be. And so we were able to use those gram – a promotion to try to keep Penn- interaction was wonderful in the sense making a pitch to doctors across the state polls as an avenue to help re-educate sylvanians healthier by using flu shots that the students got a chance to speak to that we need to become experts on health Pennsylvanians on specific issues that we early. There isn’t a supply issue this year, doctors who are out there practicing, care reform. It’s going to happen, and thought were important. For instance, and everybody should be able to get their understand what it’s like to be a practic- doctors need to be educated on what is we’ve known that there are a lot of myths shots. We formed another project based ing physician and also learn more of a out there, and what it will mean to about going to doctors for cancer care. on what we learned from the polls: the physical skill that is necessary in medi- patients and doctors across the country. We were able to work with the American use and abuse of energy drinks, and to try cine. PND: What did the Institute learn in Cancer Society to promote a Get a Check to help kids understand that energy Another issue is that doctors are out there polls it recently conducted of PMS program this past year that went out to drinks can be destructive and even fatal if trying to do good works for the commu- members? 60 radio stations and news media across used improperly. Believe it or not, that nity but never asking anything in return. PL: We polled doctors on what their vol- the state to build up an awareness that got a lot of national attention. We have That’s part of being a good professional: unteerism activities were and we found patients need to be checked for skin can- lots of information on our website seeing a need in the community and that doctors actually commit a lot of their cer, prostate cancer, breast cancer, lung www.myfamilywellness.org, and also on going forward and trying to solve it. We time each week to volunteer activities cancer and colon cancer. the Pennsylvania Medical Society web- wanted to celebrate that, so we surveyed within medicine. The average actively Another thing was the smoking ban. site, in which we can promote the appro- and evaluated volunteer activities across practicing physician in Pennsylvania When that was being promoted we were priate use of these energy drinks. the state and found many physicians commits at least three hours a week to able to use patient poll information to We were working with organ donation were involved in free clinics, and one- volunteer activities in medicine. The leverage our legislators to move forward organizations this past year. We’re also on-one works with patients. That idea retired physician commits about 5 hours on a smoking ban, which we estimate looking at the American Red Cross. An was celebrated through a volunteerism a week. That is reasonably hard data that will save 2,000 Pennsylvanians a year. obvious health issue that we’re very con- brochure mailing and also through our physicians are out there volunteering Our poll data on smoking showed that cerned about is obesity and diabetes and website. Other physicians realized what their time. We sometimes get beat up over 75 percent of Pennsylvanians want we’re trying to coordinate with the activities were available and tried to mir- that we’re not doing enough about it. to be in a smoke-free restaurant, and American Diabetes Association to see if ror some of those in other areas of the Yet, at the same time, physicians day-in there was only a minor percentage that we can promote healthier lifestyles and state. It became an exchange of volunteer and day-out give their time and don’t wanted to have smoking. I think it gave diet. Unfortunately, Pennsylvania is one information. For example, there’s a even know they’re doing it. That finding us significant social justification to move of the heavier states in the country and retired ob/gyn in the state who doesn’t was instrumental in helping us under- the smoking ban forward, outside of the that’s basically a result of diet and exer- known medical benefits. cise. We need to try to improve that in When it came to the upcoming election, the state. we found out that 64 percent of Pennsyl- PND: What additional physician men- vanians considered health care as either toring projects do you have planned? their first or second reason why they PL: The next step in terms of mentoring were deciding who to vote for, despite is helping students who are now coming the economy. That’s important informa- out of medical school and going into resi- tion for us as we move forward to advo- dencies, and also those residents who are cate for our patients, and it gives us a in Pennsylvania and want to go into prac- significant leverage as we try to move tice. We would like to figure out how to the health care reform agenda forward. mentor them into a successful practice in In reference to questions about cancer, Pennsylvania. The best people to find out patients had some fear about going and what they need are the people who are getting checked. There were myths that currently trying to do that process. Senior they had – that somehow it was going to medical students want to know how to hurt, or that they didn’t want to find out find out about good residencies. What we the news. This was an important issue for would probably do is work with residen- us to understand: the apprehensions that cy directors to help answer some of the patients have when they try to find out questions that the students might have. about getting checked for cancer and For the transition from residency into pri- cancer prevention. That was important vate practice, we’re probably going to for us to try to hone our message to get use some of our existing infrastructure at 02/4%#4 02%6%.4 $%&%.$ people to change their behavior on that the medical society. We have a for-profit issue. consulting firm in the society called Patients indicated that they had a fairly PMSCO and we’ll probably be asking BdgZi]Vc&-!%%%]ZVai]XVgZegd[Zhh^dcVah^ci]Z clear awareness of diabetes risk factors, them to help us answer some of the con- Cdgi]ZVhiYZeZcYdcbZY^XVabVaegVXi^XZ^chjgVcXZ in terms of age, gender, forms of dia- tractual issues to make sure that, when [gdbEgdBjijVa

&%&6gX]HigZZi!7dhidc!BVhhVX]jhZiih%'&&%q&#-%%#''*#+&+-qlll#egdbjijVa\gdje#Xdb promote and they fall directly in synergy who want to practice in Pennsylvania.

Page 8 PHYSICIAN'S NEWS DIGEST (PM) January, 2009 http://www.PhysiciansNews.com PM JAN 2009 12/30/08 1:44 PM Page 9

Neurosciences Institute

Abington’s Stroke Center recently won the American Stroke Association’s Gold Performance Achievement Award. The neurosciencesspecialists at Abington provide around-the-clock care for acute strokes, ruptured or unruptured intracranial aneurysms and serious brain hemorrhaging.

Q: Why should patients choose Abington for preventive Q: Is the clot-busting medication rTPA available at your facility? or emergent care? A: Yes. The clot-busting medication known as “recombinant tissue A: With specialists on-call 24/7, patients have the benefit of immediate plasminogen activator” or rTPA may be given intravenously to diagnostic cerebral angiography followed directly by treatments that patients who come to the emergency room within three hours of include intra-arterial thrombolytic therapy, embolization, coiling the onset of stroke symptoms. When appropriate, we also offer and minimally invasive clot removal. Our skilled interventionalists intra-arterial administration of rTPA within three to eight hours and surgeons offer the complete array of procedures, from surgical of stroke symptoms with or without mechanical thrombolysis. to medical, with a full continuum of backup procedures, should the patient require alternative options. Q: In what other ways is Abington distinctive in neurosciences? A: Abington’s Stroke Center was the first in the state to receive Q:What new interventional treatments does Abington offer the JCAHO Gold Seal of Approval for its clinical excellence patients who present with critical brain events? in responding to stroke emergencies in 2004. In 2008, A: Abington specialists perform the coiling procedure on ruptured Abington received the distinguished Gold achievement award or unruptured aneurysms, with or without the placement of from the American Stroke Association for adherence to the intracervical or intracranial stents. Our neuro-interventionalists national Get With The GuidelinesSM program, supporting use the Merci® clot retrieval device to remove the clot once it is stroke prevention, management and treatment. The Stroke embolized. Using catheter-based procedures, they are able to Center works to constantly improve patient outcomes through a perform the complete spectrum of minimally invasive procedures, collaborative, multidisciplinary team of specialists. The Center also thus avoiding craniotomies in many cases. has a dedicated Stroke Committee that meets regularly to review progress and set new goals. The Stroke Center has three dedicated Q:What is the scope of endovascular treatments offered teams: Interdisciplinary Stroke Team, Interventional Stroke Team to patients? and the Stroke Committee, which meet regularly to review progress A: Our specialists provide diagnostic cerebral angiography as a helpful and set new goals. tool for accurate detection; endovascular coil embolization; carotid artery surgery and/or stenting to prevent future strokes; intracranial stent placement; balloon test occlusion; pre-operative tumor For more information about Abington’s Comprehensive embolization for cancer patients; and treatment for epistaxis. Stroke Center, visit amh.org/stroke or call Debi Murphy at (215) 481-3627.

CLINICIANS ON STAFF: Robert A. Koenigsberg, D.O., Interventional Neuroradiologist; Nancy Gogal, RN, Nurse Manager, Cardiac Catheterization Lab; Debi Murphy, CRNP, Stroke Program Coordinator; B. Franklin Diamond, M.D., Medical Director, Stroke Center; Qaisar A. Shah, M.D., Neuro-Interventional Neurologist; Lee J. Harris, M.D., Chief, Neurology Division; Steven J. Barrer, Chief, Neurosurgery and Jennifer Frabizzio, MD, Neuro-Radiology POWER TO HEAL

ABINGTON’S STROKE CENTER RECENTLY WON THE AMERICAN STROKE ASSOCIATION’S GOLD PERFORMANCE ACHIEVEMENT AWARD. PM JAN200912/30/081:44Page10

© Copyright 2008 Magee Rehabilitation Hospital MAGEE RehabilitationHospital. Believe. Thisistheword weliveat of recovery andreturnhasbeenwritten. who nevertire untilthebestpossiblestory skills andpassionofourpeople.People ability. Patientspushedbytheexceptional course toreclaim physicalstrength and stroke, andthenshiftsagainonadefiant fortheworsethroughturn anaccidentor ahead. Chapterscreated whenlifetakesa BELIEVE thatbetterchaptersliejust MageeRehab.org PM JAN 2009 12/30/08 1:44 PM Page 11

MEDICINE & BUSINESS Negotiating Your First Employment Contract

hammered out, it’s time to focus on termina- the claim is brought. Under a claims-made tion provisions. A physician may believe that policy, the claim has to be made while the he or she has signed a two-year contract, but policy is in force. If an action occurred in the if termination provisions would enable the year the claims-made policy was in force but employer to terminate the contract upon 90 the claim is not brought until the subsequent days written notice without cause, then the year, the physician, absent the purchase of a

Miriam Greenwald 2008 term is 90 days. Most employers want a “tail policy,” would be uninsured.

© “without cause” provision in the employment The question then is who is responsible for contract to protect themselves from potential- the tail-policy premium. From the employee’s ly embarrassing situations. Misbehavior by perspective, the employer is reaping the bene- employed physicians may give rise to a cause fit of the lower premium by having a claims- for termination. However, because of the cir- made policy and hence, the employer should cumstances surrounding the termination, the be responsible for the tail. However, many employer may prefer to terminate the physi- employers believe that the physician should cian quietly and forego the public embarrass- always be responsible for the tail. A compro- ment associated with the bad behavior. On mise may be that if the physician is terminat- the other hand, employees often feel threat- ed for cause or quits, she or he is responsible ened if the employer can terminate the con- for the tail but if the employer dismisses with- tract upon a certain period of notice without out cause, then the employer would be cause and are justified in arguing that for the responsible for the tail. first term of the contract, the employer can Gaining Equity. This article would be only terminate the contract for cause. This incomplete if there were not at least a periph- By Michael G. Wiethorn, Esq. tion at the time that the employer endeavors gives the physician some security, especially eral discussion of acquiring equity in the prac- to enforce it. As a general rule, the employer if moving a great distance to accept the new tice that you join. Discuss this before you sign must have a protectible interest and the position. the first contract. Having a letter of intent is Considering accepting that first position covenant must be reasonable in its geograph- Some termination provisions are very sub- advisable so that you have a written expecta- with a new employer? You’ve probably ic scope and duration. If you are employed by jective, such as the loss of license, privileges tion as to when and under what conditions already considered such issues as interperson- an emergency medicine group and desire to or competition with the employer. However, you will receive equity. “Equity” generally al chemistry and location before accepting, join a primary care group, the emergency some of the termination provisions, such as means that you will be compensated in a but you also need to understand the terms of medicine employer no longer has a pro- breach of a material term, are objective. manner consistent with the other owner- the position and be sure your understanding is tectible interest in enforcing the covenant When the contract provides that it may be ter- physicians, and that you will have an interest reflected in the contract. From compensation because the services provided in the new minated upon notice of breach of a material in the assets of the entity at the time you to termination provisions, understanding the employment do not compete with the ser- term, it is reasonable for the employee to leave. There are many ways to determine terms of your employment contract will help vices of the former employer. However, if have an opportunity to cure the breach of how you will acquire equity in the practice. you avoid unpleasant surprises days, months you are terminated by a multi-office group of contract. Agreeing upon these terms prior to joining or even years down the road. primary care physicians, it is plausible the Malpractice Insurance. Another area of the group is always advisable. Compensation. It is crucial to understand practice will have a protectible interest in pre- significant concern for physicians is malprac- This article does not provide all of the how you will be paid. All too frequently, venting you from taking a position with tice insurance. The majority of employment answers or even begin to raise all of the issues physicians are surprised two or three years another primary care group in the market. contracts provide that the employer is respon- related to employment, but rather raises some into an employment contract that they were The same rules generally apply to New Jer- sible for maintaining malpractice insurance. pertinent issues faced by physicians especial- not paid in a manner consistent with their sey. There are two principal types of insurance: ly when addressing the first contract of their original expectations. Enforceability. Whether a covenant is occurrence and claims made. Occurrence career. Compensation Formula. Understanding enforceable in its geographic scope will vary insurance provides that if the act giving rise the formula, if one is offered, is the next chal- widely. In Pittsburgh, a covenant that pro- to the claim occurred during the period in Michael G. Wiethorn, Esq., is a partner lenge. Will that formula be based upon vides that the physician cannot compete with- which the contract was in force, the contract with the Pittsburgh office of Fox Rothschild, charges, collections, patient visits, relative in a 20-mile radius of a Pittsburgh hospital will cover the physician regardless of when LLP. value units or a combination of all of the may not be enforceable because the geo- above? If it is based upon revenue, does the graphic scope is too broad. For example, the formula also take into consideration an allo- patients of a primary care physician may not cation of expenses and whether these expens- choose to follow their physician outside of es are allocated on a pro-rated basis, or are the 20-mile radius in such a densely populat- Get your computers they tied into the revenue received by the ed area where there are many options for practice? Conceivably, if a physician within a medical providers, so the restriction would be three-person group is generating 50 percent too broad. However, in a more rural commu- running like the day of the revenue, that physician may also be nity, a 50-mile restrictive covenant may be responsible for 50 percent of the expenses as enforceable because the physician may be the opposed to 33 percent of the expenses. only doctor providing a certain type of spe- you bought them. Bonuses. Understanding that you will cialized care in a much broader community. receive a bonus and whether that bonus is Generally speaking, a restrictive covenant discretionary or based upon a formula is criti- in Pennsylvania that goes beyond two years, cal. Often contracts will provide that the and certainly three years, pushes the outer Little Data Centers bonus is within the employer’s discretion. In limits of enforceability. The shorter the dura- such circumstances, the newly employed tion, the more likely the covenant will be physician should rely solely upon the base enforced. The law regarding restrictive can restore the performance of your compensation for planning purposes. Having covenants varies widely from state to state, so a formula that sets forth how the bonus will it is important to understand the state law in computers and safeguard them from be determined is obviously preferable. Addi- the area where you desire to practice. tionally, you should know when the bonus Liquidated Damages. When negotiating viruses, spyware, security problems and will be paid. Is it contingent upon being restrictive covenants, one option to consider employed at a certain period of time, such as is providing for liquidated damages. If the guarantee HIPAA compliance. the last day of the fiscal year of the employer, party in breach of the covenant (the employ- or pro-rated based upon a partial year of ser- ee) pays a certain sum of money to the vice? employer, then the employee can escape the Signing Bonus. Signing bonuses can be limitations of the restrictive covenant. Liqui- offered in specialties where there is a high dated damages have to be reasonable and Call us today for a demand. Often these bonuses are paid upon have some correlation to the interest being starting work at the employer. However, the protected by the employer. free consultation. bonus may be subject to partial repayment if Termination With and Without Cause. the employee terminates the contract during a When negotiating a restrictive covenant, if certain period of time. The circumstances the employer terminates the employee with- Computer Consulting and LITTLE DATA under which the contract is terminated also out cause, arguably that covenant should not Medical Billing Specialists may play into whether or not repayment is be enforceable. However, if the employee CENTERS required. quits or is terminated for cause (breach of Restrictive Covenants. A favorite question duties, loss of license, loss of staff privileges, centers on whether a restrictive covenant is etc.), then the restrictive covenant should be (215) 739-6622 enforceable. In Pennsylvania, the answer is enforceable. yes. Whether a specific covenant is enforce- Termination Provisions. Once the com- VISIT OUR WEBSITE AT: www.littledata.com able will depend upon the facts of the situa- pensation and restrictive covenant issues are

http://www.PhysiciansNews.com January, 2009 PHYSICIAN'S NEWS DIGEST (PM) Page 11 PM JAN 2009 12/30/08 1:44 PM Page 12

PERSONAL FINANCE Capitalizing on Life Insurance Arbitrage

examples, are in reality stated in months, vidual in relatively good health who has a not years. tax deferred fund (i.e., an IRA, deferred The Opportunity Presented annuity, etc.) with a balance of $400,000 With this extremely basic explanation that is growing at a rate of 5 percent per of the industry, the arbitrage opportunity year. And assume his overall financial is still not readily apparent. One additional condition places him squarely within the factor needs to be considered. As every federal estate tax radar, and in a 28 per- Miriam Greenwald 2008

© reader of this article will appreciate, life cent income tax bracket. If that individual expectancy determinations (or opinions) were to live 18 years (to his actuarial life are not an exact science. Or in more blunt expectancy) the fund would grow to terms: none of the insurance companies approximately $900,000. If he were to have a crystal ball that tells them when then leave this fund to his heirs, those you or I might die. If they did, they would heirs would pay approximately $550,000 be substantially more profitable! in death taxes, $150,000 in income taxes, In short, each insurance company and be left with about $200,000 (out of views medical impairments differently, the $900,000). right or wrong, for better or worse. And as If this same individual were to shift the a result, each insurance company has its $400,000 to a SPIA, and utilize the after- own opinion on a potential customer’s tax cash flow produced by the SPIA to mortality. What is nothing more than a fund a life insurance policy, the action medical nuisance to some carriers (treated would have resulted in acquiring a life through medications) may be perceived as insurance policy with a guaranteed face By Russell G. Roll, CPA, JD vant medical records) determines that the “life-threatening” to other carriers (regard- amount of $1,000,000. Since the insur- insured will live 10 years, and the insured less of attention to the ailment). Again, for ance contract is guaranteed, the individu- wishes to purchase $10 million of insur- better or worse, right or wrong. And this al’s actual life span does not reduce the The word “arbitrage” is commonly ance, the company will charge $1 million does not even consider the financial con- amount ultimately going to his or her connected with “scheme” in some pejora- per year in premiums. If the insured lives siderations that carriers give to “year-end heirs. Since the IRS provides for tax free tive manner. However, the word itself is longer than 10 years, or allows the policy business opportunities” and other “busi- treatment of death proceeds under a life just a word, and is generally understood to to expire prior to his or her death, the ness” (i.e., non-medical) decisions by insurance contract, there would be income mean the purchase of a financial asset in insurance company makes a profit. underwriters. taxes payable at death. And since the one market for resale in another parallel A life-driven annuity contract is a mir- So going back to the simple example annuity’s “value” disappears at death for market to profit from pricing discrepan- ror image of a life insurance contract. above, we find an opportunity where the death tax purposes, there would be no cies between the two markets. Under this type of vehicle, the insurance insurance company we are dealing with death taxes payable. The net result of this In the financial marketplace, this con- company promises to pay a periodic annu- for life insurance (the life target carrier) technique is to take a $400,000 asset that cept is fairly easy to grasp. An investor ity (income) payment to the buyer for the views a client’s mortality at 12 years. And “grows” to $200,000 upon the individu- identifies a pricing anomaly among paral- buyer’s lifetime in exchange for an up- a (potentially but not always) different al’s death in eighteen years, and to con- lel markets, then buys in the lower market, front lump sum payment. This type of carrier (the annuity target) views the vert it to a guaranteed pool of wealth that and immediately thereafter sells in the annuity contract is commonly called a client’s mortality for annuity purposes at 8 exists and remains constant no matter how higher market. The result is an instant “single premium immediate annuity” years. Herein is the “arbitrage” that needs long the individual lives. profit. But seeing how this opportunity (SPIA). Using the same individual with a to be captured. The question becomes how The above scenario happens quite fre- exists within the life insurance industry, life expectancy of 10 years, if the buyer to capitalize on this opportunity. quently, and even without any level of life and capitalizing on it, requires some more wants to secure an annual income stream At its most basic level, the opportunity expectancy arbitrage. When life expectan- creative positioning. This is because the of $1 million per year for the remainder of can be captured by buying from the low cy arbitrage exists, this leverage appears “arbitrage” in play does not involve dol- his or her life, the insurance company bidder (the one that views life expectancy too good to be true, even though it is not. lars, but rather, it involves life expectan- would require the buyer to deposit $10 as being 8 years, the annuity company) Sometimes opportunities lie right cies. million. If the buyer lives too long, the and “selling” (although this is also techni- beneath our noses. And life expectancy Life Insurance Marketplace insurance company loses. If the buyer dies cally buying) to the high bidder (the one arbitrage is no exception. However, there I will start with explaining the basic the next day, the insurance company earns that views life expectancy as being 12 is a very real difference between seeing it nature of the life insurance industry. It a very large profit. years). The result is a positive cash flow and taking advantage of it. exists, and profits, by selling essentially The above examples are extremely to the buyer, a hedged gain to him or her, Even more so in today’s economic two mirror products or contracts – a life oversimplified to demonstrate the basic and a hedged loss to the insurance indus- environment, the fewer moving parts to a insurance contract, and an annuity. nature of the industry. There are, realisti- try. financial strategy, the more likely that In the case of a life insurance contract, cally, other important variables built into However, this strategy can be further strategy will perform as planned. As I the industry is betting that the insured is the equations, including primarily the time leveraged, in a positive way, to the buyer. hope the reader can appreciate, concepts going to live longer than he or she thinks, value of money (interest paid versus inter- And with proper structuring and planning, such as those discussed in this article have resulting in the contract either expiring est earned), and the costs of operating the this leverage may even produce positive very few such moving parts, and when before the insured (i.e., a lapse or surren- insurance company (administrative costs outcomes in the form of death tax mini- they move, they generally move together. der), or the owner paying more to the and, of course, commissions). Moreover, mization that far outweigh any potential insurance company than the insurance the examples themselves do not highlight profit from the arbitrage inherent in the Russell G. Roll, CPA, JD, is the company will have to pay to the insured’s the profit opportunity to the consumer; transaction. founder of LRA Advisors, an independent beneficiaries. As an example, if the insur- they simply point to it. Finally, life Death Tax Leverage insurance advisory firm located in Pitts- ance company (after reviewing all rele- expectancies, or the denominator in the Take as an example a 68-year-old indi- burgh, Pa. GET ACCESS TO FIVE YEARS OF

PERSONAL FINANCE COLUMNS

AT PhysiciansNews.com

Page 12 PHYSICIAN'S NEWS DIGEST (PM) January, 2009 http://www.PhysiciansNews.com PM JAN 2009 12/30/08 1:44 PM Page 13

PHYSICIAN RECRUITMENT

Classification Sequence Emergency Medicine

Addiction Medicine Hematology-Oncology Pathology Cardiovascular/ Graduate Training/ EMERGENCY MEDICINE STAFF Allergy & Clinical Infectious Disease Pediatrics Thoracic Fellowships/ PHYSICIANS - EASTERN PA - Join Immunology Internal Medicine Physical Medicine and General Residency Programs this 750+ bed institution in one of Ambulatory Medicine Neonatal-Perinatal Rehabilitation Neurological Positions Sought Pennsylvania's busiest EM Depart- Anesthesiology Medicine Primary Care Orthopedic Locum Tenens ments, treating over 105,000 patients Cardiology Nephrology Psychiatry Plastic Part-time Positions annually and serves a population of Critical Care Neurology Public Health Vascular Courses, Symposia, Dermatology Nuclear Medicine Pulmonary Disease Urology Seminars 400,000+. Set hours and no call. Endocrinology Obstetrics and Radiation Oncology Urgent Care Practices For Sale Employed situation, excellent salary Family Practice Gynecology Radiology Chiefs/Directors/ For Sale/For Rent + incentive +sign on bonus + compre- Gastroenterology Occupational Medicine Rheumatology Department Heads Wanted hensive benefits. Located just one General Practice Ophthalmology Surgery: Multiple Specialties/ Physician Services hour from center city Philadelphia Geriatrics Otolaryngology Cosmetic Group Practice Miscellaneous and the Pocono Mountains. Please respond to Margie Quinlan, Lawlor How To Advertise MasterCard. Note: The minimum charge General Policy and Associates, 800-238-7150; fax for all classified advertising is $60.00 per your CV to 610-431-4092 or email: All orders, cancellations and changes must ad. All classified advertisements are set All classified advertising requests must [email protected] be received in writing. You may fax classi- in identical typeface and format. No spe- be submitted in writing. Although Physi- fied advertisements to us at (610) 668-9177. cial typefaces are available in these ads. cian’s News Digest believes these adver- Closing dates for ad materials and prepay- For information on display advertising, tisements to be from reputable sources, ment is the 18th of the month preceding contact our Recruitment Advertising Physician’s News Digest does not assume Family Practice publication date. (Example: June 1996 issue Department by phone at (800) 220-6109; any liability concerning them. Physi- - deadline May 18, 1996.) Please be sure to by fax at (610) 668-9177 or by e-mail to cian’s News Digest strives for complete FAMILY PRACTICE - YORK, PA. - include the classification heading under [email protected]. accuracy when printing classified adver- which your classified ad should appear. If tisements. Every care is taken to avoid Office based, outpatient only Family no indication is provided, the most appro- Reply Box Service mistakes. However, Physician’s News Medicine (Pediatric to Geriatric) ser- priate position will be determined by PND. Digest cannot accept responsibility for vices with pharmaceutical and coun- Confidential reply box numbers are avail- All advertising materials should be sent to: typographical, clerical or printer’s errors seling services on-site. Totally com- able for an additional charge of $20.00 Recruitment Adv. Department, Physician’s that may occur. puterized recordkeeping. Just 30, 60 News Digest, 117 Forrest Avenue, Nar- per insertion, per issue. and 90 minutes from Harrisburg, Bal- berth, PA 19072. General Information How To Respond timore and Philadelphia respectively. To contact a Physician Recruitment Homes reasonably prices along with a Classified Advertising Rates When sending to a reply box, please send advertising representative, call (800) 220- great quality of life. Please respond to: Reply Box 0000, Physician’s News Classified ads are $2.10 per word. Bold 6109. Or fax your information to PND at Digest, 117 Forrest Avenue, Narberth, PA to Margie Quinlan, Lawlor and Asso- typeface is available at an additional (610) 668-9177. All materials being sent 19072. ciates, 800-238-7150; fax your CV to charge of $10.00 per ad, per insertion. Con- by mail or courier to should be directed to 610-431-4092 or email: fidential reply boxes are available for an We will send the responses directly to Physician’s News Digest, 117 Forrest additional charge of $20.00 per insertion. you each week, and hold your box num- Avenue, Narberth, PA 19072, Attention: [email protected] Payment may be made by check, Visa or ber open for three months. Recruitment Advertising Department.

Cardiology Emergency Medicine Emergency Medicine FAMILY PRACTICE - CENTRAL INVASIVE/NON INTERVENTION- TeamHealth East is seeking physi- Full time EM opportunities are avail- NEW JERSEY - Outstanding opportu- AL CARDIOLOGY - LANCASTER, cians for a comprehensive healthcare able at our Reading, PA medical cen- PA - Join a well established group in nity to be employed with a well institution in Syracuse, New York. ter. Candidates should be BC/BE in Lancaster offering an exceptional respected practice and weekend call The 50,000-volume ED provides 48 EM or certified in PC with ED expe- compensation package along with of 1-7. This group of four has been hours a day of physician coverage rience. This 45,000 volume medical bonus. Nuclear training a plus. established for the past fifteen years and 36 hours a day of MLP coverage. center has 48 hours of physician and Excellent referral base of Primary and seeks dynamic candidates for Care physicians. The Hospital is a Shifts are either 8 or 10 hours. Pre- 24 hours of mid-level coverage daily. their growing practice. Located in a 250 bed state of the art regional ferred qualifications are BC/BP in We are located 50 miles from down- charming suburb in Central New Jer- health center. Located 1.5 hours from emergency medicine. Considered town Philadelphia. If interested sey with an abundance of great homes Phila, Baltimore and the Pocono qualifications include BC in a prima- please contact: Michael Hahn at available. Teaching option is avail- Mountains; under 2.5 hours from ry care specialty with prior ED expe- [email protected] or 800-848- able for those interested. Great finan- NYC, Washington DC and the Jersey rience. For more information, please 3721 ext. 4355. Shore.. Please respond to Margie contact Amy Inter at 877.661.6560 or cial package, excellent location, less Quinlan, Lawlor and Associates, 800- email: [email protected] than 45 minutes from downtown 238-7150; fax your CV to 610-431- Philadelphia. Contact Richard Gorm- 4092 or email: ley, Lawlor and Associates, Phone: [email protected] 800-238-7150, Email: [email protected] Emergency Medicine Full time and part time staff opportu- nities are available at a community teaching hospital located in Wilkes- Staff opportunities are available at a Barre with an ED volume of 50,000 183-bed, acute-care teaching facility See per year. Excellent physician and which services families throughout mid-level coverage. Physicians must northwest Philadelphia and Mont- more be Board Certified in Primary Care gomery County. Candidates must be with Emergency Medicine experi- BC/EM or PC with ED experience. opportunities ence. Current ATLS, ACLS, PALS For more information, please contact required. Interested candidates should Karen-Marie Johnson at at contact Karen-Marie Johnson at 800- 1.800.848.3721 x.4348 or email: 848-3721 x4348 or email [email protected]. Sorry, no [email protected]. Sorry, no PhysiciansNews.com Visa sponsorships available. visa sponsorships available.

http://www.PhysiciansNews.com January, 2009 PHYSICIAN'S NEWS DIGEST (PM) Page 13 PM JAN 2009 12/30/08 1:44 PM Page 14

PHYSICIAN RECRUITMENT PRACTICE OPPORTUNITIES L&A LAWLOR AND ASSOCIATES Physician and Executive Healthcare

INTERNAL MEDICINE/GERIATRICIAN - SUBURBAN PHILADELPHIA Family Practice Internal Medicine Join a well-established, respected 100% Geriatrics practice. Join 3 other physicians and 5 physician's assistants; a wound care specialist; geriatric nurse and 2 social workers; The prac- FAMILY PRACTICE - CENTRAL tice is affiliated with two local hospitals and nursing home and assisted living facilities. INTERNAL MEDICINE/GERIATRI- NEW JERSEY - The Capital Health CIAN - SUBURBAN PHILADELPHIA - ORTHOPEDICS - SUBURBAN PHILADELPHIA (PHOENIXVILLE, PA) System at Hamilton, a hospital owned Join a well-established, respected 100% Geriatrics practice. Join 3 other physi- Wonderful opportunity to join a well established group of 3 in Phoenixville. Call 1:4. They are multi specialty practice seeks a fami- on staff at Phoenixville and Pottstown Hospitals. cians and 5 physician's assistants; a ly practitioner for their facility in wound care specialist; geriatric nurse and FAMILY PRACTICE – YORK, PA Hamilton, New Jersey, a premier sub- 2 social workers; The practice is affiliated Office based, outpatient only Family Medicine (Pediatric to Geriatric) services with urban area. Hospital owned and with two local hospitals and nursing home pharmaceutical and counseling services on-site. Totally computerized recordkeeping. employed in a full range practice with and assisted living facilities. The office is Just 30, 60 and 90 minutes from Harrisburg, Baltimore and Philadelphia respectively. a strong compensation package. located 10 miles from center city Philadelphia with its abundance of EMERGENCY MEDICINE STAFF PHYSICIANS - EASTERN PA Beautiful facility with outstanding amenities, offers a wonderful quality of Join this 750+ bed institution in one of Pennsylvania's busiest EM Departments, treating over office space offers additional services life. Centrally located to the Jersey 105,000 patients annually and serves a population of 400,000+. Employed situation, excel- with state of the art radiology ser- Shore; NYC; Baltimore; Washington DC lent salary. vices, endocrinology, sleep medicine and the Pocono Mountains. Contact GENERAL SURGERY; GASTROENTEROLOGY AND OTORHINOLARYNGOLOGY - and the Institute for Neurosciences. Margie Quinlan, Lawlor and Associates LITTLETON, NH Join this practice of seven physicians by phone (800-238-7150), fax (610-431- 4092) or e-mail Great opportunity to join the medical staff an "award winning" hospital in Littleton, NH. with a strong compensation package Employed position, excellent salary + bonus OR work 2 years employed and Hospital will ([email protected]). set you up on your own. Located at the Northern edge of the White Mountains and an easy including salary, productivity bonus drive to Boston, Montreal and Manchester.great quality of life and affordable housing; no and full benefits with no call. We will state income tax and the cost of living is low. consider candidates seek part time INVASIVE/NON INTERVENTIONAL CARDIOLOGY - LANCASTER, PA options as well as full time. Contact Ob-Gyn Join a well established group in Lancaster offering an exceptional compensation package Richard Gormley, Lawlor and Associ- along with bonus. Nuclear training a plus. Excellent referral base of Primary Care physi- ates, Phone: 800-238-7150, Email: OBSTETRICS - ST. ALBANS, VER- cians. The Hospital is a 250 bed state of the art regional health center. [email protected] MONT - A wonderful opportunity to OBSTETRICS - ST. ALBANS, VERMONT join the staff of a respected Medical A wonderful opportunity to join the staff of a respected Medical Center. This is an employed Center. This is an employed posi- position offering a competitive salary and wonderful comprehensive benefits. Call is 1:4. tion offering a competitive salary and Located on Lake Champlain, 30 minutes from Burlington. One hour to Montreal. wonderful comprehensive benefits. NEUROLOGY; OTORHINOLARYNGOLOGY AND UROLOGY - TOMS RIVER, NJ Gastroenterology Call is 1:4. Located on Lake Cham- We are representing the abovementioned searches.Watch next month's issue plain, 30 minutes from Burlington. for more detailed information. Great opportunity to join the medical One hour to Montreal. Contact Contact: Margie Quinlan staff an "award winning" hospital in Margie Quinlan, Lawlor and Associ- Phone: 800-238-7150 Littleton, NH. Employed position, ates by phone (800-238-7150), fax Email: [email protected] excellent salary + bonus OR work 2 (610-431-4092) or e-mail years employed and Hospital will set ([email protected]). INTERNAL MEDICINE FACULTY - CENTRAL NEW JERSEY you up on your own. Located at the A two Hospital Community Health System seeks an Internal Medicine Faculty Position that will focus on Research & Scholarly Activity in Central New Jersey. We seek an internist who is com- Northern edge of the White Moun- Otorhinolaryngology mitted to teaching in a community setting and will bring energy and enthusiasm for the pro- tains and an easy drive to Boston, gram's development and future medical education development. $45 Million dollar Hospital ren- Montreal and Manchester.great quali- Great opportunity to join the medical ovation with brand new ICU, ER &Inpatient Buildings with strong commitment from Hospital ty of life and affordable housing; no staff an "award winning" hospital in Leadership. Research/Teaching position will have secretarial and administrative support. state income tax and the cost of liv- Littleton, NH. Employed position, FAMILY PRACTICE - CENTRAL NEW JERSEY ing is low. Contact Margie Quinlan, excellent salary + bonus OR work 2 The Capital Health System at Hamilton, a hospital owned multi specialty practice seeks a Lawlor and Associates by phone years employed and Hospital will set family practitioner for their facility in Hamilton, New Jersey, a premier suburban area. you up on your own. Located at the Hospital owned and employed in a full range practice with a strong compensation package. (800-238-7150), fax (610-431-4092) or e-mail Northern edge of the White Moun- FAMILY PRACTICE - CENTRAL NEW JERSEY ([email protected]). tains and an easy drive to Boston, Outstanding opportunity to be employed with a well respected practice and weekend call of 1- Montreal and Manchester.great quali- 7. This group of four has been established for the past fifteen years and seeks dynamic candi- ty of life and affordable housing; no dates for their growing practice. Located in a charming suburb in Central New Jersey with an abundance of great homes available. state income tax and the cost of liv- ing is low. Contact Margie Quinlan, BREAST IMAGING RADIOLOGY - CENTRAL NEW JERSEY Lawlor and Associates by phone Premier 476 bed community hospital seeks a second breast imager for an employed position Internal Medicine with great salary and no call or weekends. State of the art technology and many options to live (800-238-7150), fax (610-431-4092) including shore communities, well suited for those with an outdoor lifestyle. INTERNAL MEDICINE FACULTY - or e-mail ORTHOPEDICS - AUGUSTA, GEORGIA CENTRAL NEW JERSEY - A two ([email protected]). Premier Private Practice of five seeks a general ors surgeon and a foot & ankle surgeon due to Hospital Community Health System strong growth. Enjoy the warm southern hospitality and home to the world famous Masters Golf seeks an Internal Medicine Faculty Tournament. Quick track to partnership, call of 1-5 with excellent financial compensation. Position that will focus on Research Radiology WOMAN'S IMAGING - SOUTH JERSEY & Scholarly Activity in Central New Jersey. We seek an internist who is NURSE PRACTITIONER - RADI- Cooper Health System (www.cooperhealth.org) seeks a 2nd Breast Imaging physician for a full OLOGY PRACTICE - BALTIMORE, committed to teaching in a communi- range 100% woman's imaging service. They offer a wide spectrum of breast imaging services MARYLAND - Join the intervention- with active involvement with the departments of Radiation Oncology and Hematology and a pro- ty setting and will bring energy and al radiology group at LifeBridge gressive academic program with ongoing research. enthusiasm for the program's devel- Health System, Sinai Hospital located NURSE PRACTITIONER - RADIOLOGY PRACTICE - BALTIMORE, MARYLAND opment and future medical education in Baltimore. The group seeks candi- Join the interventional radiology group at LifeBridge Health System, Sinai Hospital located in development. Position will be a mix date interested in working with a Baltimore. The group seeks candidate interested in working with a radiology group to comple- of 40% clinical, 40% research/schol- radiology group to complement their ment their practice, the practice will provide the training and teaching necessary to work in the practice, the practice will provide the arly activity and 20% administrative. radiology division. Flexible scheduling with a great financial package. training and teaching necessary to Hospital employed with excellent work in the radiology division. Flex- Contact: Richard Gormley compensation and generous benefit ible scheduling with a great financial Phone: 610-251-6852 package. Contact Richard Gormley, package. Contact Richard Gormley, Email: [email protected] Lawlor and Associates, Phone: 800- Lawlor and Associates, Phone: 800- Contact either Margie or Richard of Lawlor and Associates for more infor- 238-7150, Email: 238-7150, Email: mation at 800-238-7150; fax 610-431-4092 or email them at their respective [email protected] email addresses. Visit us on the web: www.lawlorandassociates.com [email protected]

Page 14 PHYSICIAN'S NEWS DIGEST (PM) January, 2009 http://www.PhysiciansNews.com PM JAN 2009 12/30/08 1:44 PM Page 15

PHYSICIAN RECRUITMENT Bundled Payment

Continued from page 5 physician community, which had difficul- ty understanding the reimbursement have negotiated), Prometheus believes model and said it paid much less than a that fraud and abuse laws do not affect traditional fee schedule, Vinson notes. Radiology Surgery: General providers’ ability to participate. Those concerns are still there, says Providers enter into amendments to their Vinson, and are compounded by the INTERVENTIONAL RADIOLOGIST Great opportunity to join the medical plan participation agreements to establish prospect of bundling payment to many - Radiology Group of Abington seeks staff an "award winning" hospital in the new payment model and rates. Imple- more ancillary providers involved in an a fellowship trained interventional Littleton, NH. Employed position, mentation does not require collaboration episode of care. Even though bundled radiologist to join our thriving 30 excellent salary + bonus OR work 2 among multiple payers in a market, nor payment rates of models like ACE and does it require financial integration of Prometheus incorporate severity adjust- person practice. This is a partnership years employed and Hospital will set track full time position. The practice participating providers. ment, physicians frequently treat relative- you up on your own. Located at the serves Abington Memorial Hospital Implementation of the model calls for ly small numbers of patients with the Northern edge of the White Moun- and its outpatient centers. The group payers in pilot sites to “plug into” the conditions or procedures covered, says tains and an easy drive to Boston, provides the full gamut of interven- Prometheus Payment model engine – a Vinson, and physicians would want reas- tional services and has a collegial Montreal and Manchester.great quali- ty of life and affordable housing; no relationship with Vascular Surgery. A bundled payment approach with properly aligned goals among There are 4 fellowship interventional state income tax and the cost of liv- radiologists who spend most of their ing is low. Contact Margie Quinlan, providers is “the only model that has a chance of voluntarily time in interventional but also in CT, Lawlor and Associates by phone changing the way physicians practice, because it drives dollars in US and general. Please contact John (800-238-7150), fax (610-431-4092) the correct direction and physicians derive economic benefit from W. Breckenridge, MD at 215-481- or e-mail bringing new technologies and efficiencies to the system.” 2087, [email protected]. ([email protected]). combination of claims tracking and surance to protect against outliers in the financial accounting system, along with a patient mix, which could wipe away oth- BREAST IMAGING RADIOLOGY - scorecard that uses both claims and other erwise positive returns. The challenge for CENTRAL NEW JERSEY - Premier data, including medical record data, to models like Prometheus, he says, is how 476 bed community hospital seeks a measure the quality of care that is being to build in acceptable exceptions. “There second breast imager for an employed Surgery: Orthopedic delivered to patients. Payers and are so many moving parts on this model position with great salary and no call providers will not have to modify their that it’s not surprising that physicians are or weekends. State of the art technol- ORTHOPEDICS - SUBURBAN existing claims systems to accommodate leery,” adds Vinson. ogy and many options to live includ- PHILADELPHIA (PHOENIXVILLE, implementation of the model, as the A bundled payment approach with engine will track the ECRs in the back- properly aligned goals among providers ing shore communities, well suited PA) - Wonderful opportunity to join ground and deliver quality, utilization is “the only model that has a chance of for those with an outdoor lifestyle. a well established group of 3 in Located with an 1 1/2 hours of New and payment reconciliation data to par- voluntarily changing the way physicians Phoenixville. Call 1:4. They are on ticipating payers and providers. York City and Philadelphia and ten practice, because it drives dollars in the staff at Phoenixville and Pottstown Implementation Plans correct direction and physicians derive minutes from the world famous New Hospitals. The new physician will Aetna and Independence Blue Cross economic benefit from bringing new Jersey Beaches. Contact Richard have the opportunity to have owner- both indicate they are in discussions with technologies and efficiencies to the sys- Gormley, Lawlor and Associates, Crozer Keystone Health System evaluat- tem,” says Lewis S. Sharps, M.D., past Phone: 800-238-7150, Email: ship in the surgical hospital. This is ing a pilot of the Prometheus Payment president of the Pennsylvania Orthopedic [email protected] an employed position for 2 years then model bundling hospital and physician Society and president of Positive Physi- partnership is offered. Excellent payment for knee and hip replacement cians Insurance Co., a medical liability salary +bonus +relocation and com- surgery. insurance exchange. When physicians BREAST IMAGING: SOUTH JER- prehensive benefits. Please respond “It’s a very powerful model, in con- created minimally invasive knee and SEY - Cooper Health System to Margie Quinlan, Lawlor and Asso- cept. When you look at it at the macro shoulder surgery, says Sharps, a five-day (www.cooperhealth.org) seeks a 2nd ciates, 800-238-7150; fax your CV to level, there’s nothing not to like, but it hospital stay became a two-day stay, and Breast Imaging candidate for a full 610-431-4092 or email: can break down quickly with real the only thanks physicians got from the range 100% woman's imaging ser- [email protected] patients,” if not handled correctly, traditional reimbursement system was a vice. The Department has 12 physi- according to Don Liss, M.D., Aetna’s two-thirds reduction in payments over the cians combining clinical practice and medical director for the mid-Atlantic past decade. “Physicians are trained to teaching, a New PACS system; Pet region. Even with a credible baseline rate deliver quality care. They do that auto- CT; Tessler MRI. Excellent financial of avoidable complications in a popula- matically, without being rewarded. Any package including salary, bonus with tion, says Liss, it is difficult to point to a quality and efficiency improvements that a full university benefit package. specific post-operative infection from a are brought to the table should be Located in New Jersey, minutes from hip or knee replacement and convince a shared,” says Sharps. Downtown Philadelphia Candidates physician that it was an avoidable com- Nine years ago, Sharps spearheaded an will have a tremendous selection of plication. “A leap of faith is required attempt to create an episodic care man- housing/living options. Contact between population-based outcomes and agement model for orthopedic surgery Richard Gormley, Lawlor and Asso- ORTHOPEDICS - AUGUSTA, discrete clinical cases. Physicians may be that was configured much like the ciates, Phone: 800-238-7150, Email: GEORGIA - Premier Private Practice reluctant to participate in the model, or Prometheus model, e.g., a single price [email protected] of five seeks a general ors surgeon may feel they’re getting dinged on these covering facility, surgical fee, anesthesia, complications. It’s going to be a tough pathology, radiology, medical consults, and a foot & ankle surgeon due to sell to physicians and hospitals who deal post-acute care, home care and rehab. strong growth. Enjoy the warm south- Surgery: General with skewed or smaller numbers of Unresolved contracting complexities pre- ern hospitality and home to the world cases,” adds Liss. Nevertheless, he adds, vented the model from getting off the GENERAL SURGERY LITTLETON, famous Masters Golf Tournament. “Prometheus is way ahead on these ground back then, says Sharps. NH - Great opportunity to join the Quick track to partnership, call of 1-5 issues and we are excited about its “Prometheus would work best for an medical staff an "award winning" with excellent financial compensa- prospects. We don’t know if the model is integrated delivery system, or one that is hospital in Littleton, NH. ER sees tion. Contact Richard Gormley, good enough, and the proof is in the pud- large enough to negotiate a fee and side- 9,000 visits per year. Employed Lawlor and Associates, Phone: 800- ding.” step the complexity of multiple contracts position, excellent salary + bonus OR Highmark is hesitant to jump into and fee schedules,” says Sharps. Crozer 238-7150, Email: work 2 years employed and Hospital bundled payment pilots, and is going to Keystone contracts with a private group [email protected] will set you up on your own. Locat- wait and see what happens with CMS’s of about 20 orthopedic surgeons that has ed at the Northern edge of the White ACE demonstration, says Carey Vinson, a single tax ID, which is well-configured Mountains and an easy drive to M.D., Highmark’s vice president of qual- to handle the case rate model, he Boston, Montreal and ity and medical performance manage- believes. The model could also work with Manchester...great quality of life; no ment. Ten years ago, global capitation workers’ comp, Sharp says, which uses a state income tax and the cost of liv- arrangements with hospitals faced prob- uniform fee schedule across the state and ing is low Please respond to Margie Practices Wanted lems coordinating and allocating has an internal case management infra- Quinlan, Lawlor and Associates, 800- provider payments correctly, says Vin- structure that facilitates control and fol- 238-7150; fax your CV to 610-431- PRACTICES WANTED – Retiring son. Global case rate reimbursement for low-up of cases. “A lot of reinsurers of 4092 or email: physicians, part-time or fulltime specialists never got off the ground nine worker’s comp may be interested in [email protected] practices. Call 215-669-3722. years ago, and was criticized by the doing this,” he adds.

http://www.PhysiciansNews.com PHYSICIAN'S NEWS DIGEST (PM) Page 15 21936-09-January 09 PND:Layout 1 12/15/08 4:09 PM Page 1

January 2009 TODAY PENNM E D I C I N E

PENN MEDICINE INTRODUCES THE CLYDE F. BARKER TRANSPLANT HOUSE Easing the Burden on Transplant Families

With the creation of the Clyde F. Barker Transplant House, Penn Medicine has

become one of the few centers in the region to address the economic and

emotional stresses of transplant families.

Outside of the transplant community, the efforts of transplant families are often unheralded and unrecognized. Before transplant surgery, these families share the emotional turmoil of waiting for a life-saving organ while bearing the logistical and financial burdens of providing fulltime care and support for a disabled person and maintaining a home. When the transplant occurs, a series of non-reimbursable expenses––including travel, meals, lodging and time away from work––add to the burdens that transplant families face. During the first two years post-surgery, costs accumulate as organ recipients return as often as 50 times for follow-up care. The Transplant House at Penn was designed to support, reinforce and resolve the unique challenges facing transplant families. Located just blocks from the Hospital of the University of Pennsylvania, the Transplant House Honoring a Founder and a Tradition will provide a supportive and convenient setting for transplant families at a The Clyde F. Barker Transplant House is named for the physician nominal cost. Accommodations will include furnished private bedrooms and who established the region’s first comprehensive transplant program communal meeting rooms, dining areas, kitchen and laundry facilities and and, in 1966, performed the first living donor kidney transplant at computers with internet access. There will also be a telephone liaison to the the Hospital of the University of Pennsylvania. Recently, the transplant transplant floor of the hospital and a family education center in the house. Penn’s Board of Women Visitors gave the naming gift for the Transplant donor and recipient in that historic event, brothers Joseph and House, and donations from the Philadelphia Antiques Show Committee and Howard Mehl (pictured), joined Dr. Barker for the dedication of the the entire transplant community are funding the $2 million project. facility named in his honor. Forty-three years later, Howard still has the kidney he received from Joseph, and continues to have excellent kidney function. He is now one of the longest surviving kidney

“The Transplant House at Penn represents the reality that transplant recipients in the nation. patient care extends beyond our hospital’s walls and exemplifies After five decades, Penn’s transplant service remains among the largest and most successful programs nationwide, performing our commitment at Penn Medicine to improving the patient more than 5,800 total transplants in that time. Today, Penn averages experience. We’re honored to share such an important milestone more than 400 organ transplants annually, and leads the region in care for our transplant patients and their families.” in innovative research in heart, lung, kidney, liver, pancreas and islet – Abraham Shaked, MD, cell transplantation. Chief, Division of Transplant Surgery

THIS MONTH at Penn Medicine CONTINUING MEDICAL EDUCATION An integral part of the Abramson Cancer Center PENN CLINICAL BRIEFING For physicians, the offerings from Penn’s division of Continuing of the University of Pennsylvania, the Jordan The January Penn Medicine Clinical Briefing Center for Gynecologic Cancer will open on the features an overview of Reverse Shoulder Medical Education in the months ahead include: third floor of the Ruth and Raymond Perelman Replacement Surgery, a treatment for intractable Feb 13 − 15 Mar 20 − 21 Center for Advanced Medicine in January. shoulder pain and dysfunction. Clinical Briefings Advances in Diagnosis and Treatment Sixth Penn Inflammatory Bowel The Jordan Center serves as a major referral are mailed nationally and are available online at of Sleep Apnea and Snoring Disease Symposium: Current Disney’s Boardwalk Inn Resort Update and Future Directions center for the diagnosis and treatment of patients pennhealth.com/physicianforum. Orlando, FL Four Seasons Hotel with premalignant or invasive cancers of the Bonnie Rosen Philadelphia, PA female genital tract, and has an international ReachMD on XM 157 215.662.2137 Conference Coordinator 215.898.8005 reputation for clinical and basic science research. offers a series of inter- Feb 16 − 20 With the relocation of the cancer programs to views with renowned Penn specialists, Medical Cross Sectional Imaging Mar 27 − 30 the Perelman Center, Penn Medicine will have Breakthroughs from Penn Medicine. Intercontinental Playa Bonita Resort Cardiac CT in San Juan Panama City, Panama InterContinental San Juan Resort the most comprehensive cancer care program For a limited time, register online with the code Tiffany Epps San Juan, Puerto Rico of its kind in the region. PND at www.reachmd.com to receive six months 215.662.6982 Tiffany Epps 215.662.6982 free access to ReachMD XM157 (a $23.99 value).

For consultation or referral call 800.789.PENN or visit pennhealth.com • Click on “For Health Care Professionals”