Although effective palliative care has always been a must-have for patients and caregivers facing serious illness, it hasn’t always been readily available. With the emergence of value-based healthcare models—and their potent incentives to reduce avoidable readmissions—there is renewed hope that such care will be accessible to those who need it.

Palliative and end-of-life care have long been promoted as core skills for hospitalists. The topic has regularly been included at SHM annual meetings and other prominent hospital medicine conferences, in the American Board of Internal Medicine blueprint for recognition of focused practice in hospital medicine, and in a number of influential references for hospitalists. Still, as I look at hospitalist programs around the country, there is a clear need to improve hospitalists’ delivery of palliative and end-of-life care.

Care of patients with chronic illness in their last two years of life accounts for a third of all Medicare spending.1 As hospitalists, we encounter many of these patients as they are hospitalized—and often re-hospitalized. Palliative care, which can improve quality of life and decrease costs for patients while leading to increased satisfaction and better outcomes for caregivers, can help alleviate unneeded and unwanted aggressive interventions like hospitalization.2,3

In its 2014 report, Dying in America, the Institute of Medicine (IOM) identified several areas for improvement, including better advance care planning and payment systems supporting high quality end-of-life care.4 As I write this column in mid 2016, there are two notable achievements since the IOM report: two E&M codes for advance care planning and a substantial and growing number of hospitalist patients in alternative payment models like bundled payments or ACOs.5 I believe we are entering a time when the availability of good palliative care will be accelerated due to broader forces in healthcare that for the first time align incentives between patients’ wishes and how care is paid for.

Palliative Care Skills for Hospitalists

The following are key actions for physicians in addressing palliative care for the hospitalized patient. At the risk of oversimplifying the discipline, I offer a few key actions for hospitalists to keep in mind.

Identify patients who would benefit from palliative care. The surprise question—“Would I be surprised if this patient died in the next year?”—has the ability to predict which patients would benefit from palliative care. In one observation from a group of patients with cancer, a “no” answer identified 60% of patients who died within a year.6 The surprise question has previously been shown to be predictive in other cancer and non-cancer populations.7,8

Weisman and Meier suggest using the following in a checklist at the time of hospital admission as “primary criteria to screen for unmet palliative care needs”:9

• The surprise question
• Frequent admissions
• Admission prompted by difficult-to-control physical or psychological symptoms
• Complex care requirements
• Decline in function, feeding intolerance, or unintended decline in weight

Hold a “goals of care” meeting. A notable step forward for supporting conversations between physicians and patients occurred on Jan. 1, when the Centers for Medicare & Medicaid Services (CMS) announced the Advance Care Planning E&M codes. These are CPT codes 99497 and 99498. They can be used on the same day as other E&M codes and cover discussions regarding advance care planning issues including discussing advance directives, appointing a healthcare proxy or durable power of attorney, discussing a living will, or addressing orders for life-sustaining treatment like the role of hydration or future hospitalizations. (For more information on how to use them, visit the CMS website and search for the FAQ.)

What should hospitalists concentrate on when having “goals of care” conversations with patients and caregivers? Ariadne Labs, a Harvard-affiliated health innovation group, offers the following as elements of a serious illness conversation:10

• Patients’ understanding of their illness
• Patients’ preferences for information and for family involvement
• Personal life goals, fears, and anxieties
• Trade-offs they are willing to accept

For hospitalists, an important area to pay particular attention to is the role of future hospitalizations in patients’ wishes for care, as some patients, if offered appropriate symptom control, would prefer to remain at home.

Two other crucial elements of inpatient palliative care—offer psychosocial support and symptom relief and hand off patient to effective post-hospital palliative care—are outside the scope of this article. However, they should be kept in mind and, of course, applied.

Understand the role of the palliative care consultation. Busy hospitalists might reasonably think, “I simply don’t have time to address palliative care in patients who aren’t likely to die during this hospitalization or soon after.” The palliative care consult service, if available, should be accessed when patients are identified as palliative care candidates but the primary hospitalist does not have the time or resources—including specialized knowledge in some cases—to deliver adequate palliative care. Palliative care specialists can also help bridge the gap between inpatient and outpatient palliative care resources.

In sum, the move to value-based payment models and the new advance care planning E&M codes provide a renewed focus—with more aligned incentives—and the opportunity to provide good palliative care to all who need it.

For hospitalists, identifying those who would benefit from palliative care and working with the healthcare team to ensure the care is delivered are at the heart of our professional mission. TH

References

1. End-of-life care. The Darmouth Atlas of Health Care website. Accessed June 23, 2016.
2. Gade G, Venohr I, Conner D, et al. Impact of an inpatient palliative care team: a randomized control trial. J Palliat Med. 2008;11(2):180-190.
3. Morrison RS, Penrod JD, Cassel JB, et al. Cost savings associated with US hospital palliative care consultation programs. Arch Int Med. 2008;168(16):1783-1790.
4. Institute of Medicine. Dying in America: Improving Quality and Honoring Individual Preferences near the End of Life. 2014.
5. BPCI Model 2: Retrospective acute & post acute care episode. Centers for Medicare & Medicaid Services website. Accessed June 24, 2016.
6. Vick JB, Pertsch N, Hutchings M, et al. The utility of the surprise question in identifying patients most at risk of death. J Clin Oncol. 2015;33(suppl):8.
7. Moss AH, Ganjoo J, Sharma S, et al. Utility of the “surprise” question to identify dialysis patients with high mortality. Clin J Am Soc Nephrol. 2008;3:1379-1384.
8. Moss AH, Lunney JR, Culp S, et al. Prognostic significance of the “surprise” question in cancer patients. J Palliat Med. 2010;13(7):837-840.
9. Weissman D, Meier C. Identifying patients in need of a palliative care assessment in the hospital setting: a consensus report from the Center to Advance Palliative Care. J Palliat Med. 2011;14(1):17-23.
10. Serious illness care resources. Ariadne Labs website. Accessed June 24, 2016.

Although effective palliative care has always been a must-have for patients and caregivers facing serious illness, it hasn’t always been readily available. With the emergence of value-based healthcare models—and their potent incentives to reduce avoidable readmissions—there is renewed hope that such care will be accessible to those who need it.

Palliative and end-of-life care have long been promoted as core skills for hospitalists. The topic has regularly been included at SHM annual meetings and other prominent hospital medicine conferences, in the American Board of Internal Medicine blueprint for recognition of focused practice in hospital medicine, and in a number of influential references for hospitalists. Still, as I look at hospitalist programs around the country, there is a clear need to improve hospitalists’ delivery of palliative and end-of-life care.

Care of patients with chronic illness in their last two years of life accounts for a third of all Medicare spending.1 As hospitalists, we encounter many of these patients as they are hospitalized—and often re-hospitalized. Palliative care, which can improve quality of life and decrease costs for patients while leading to increased satisfaction and better outcomes for caregivers, can help alleviate unneeded and unwanted aggressive interventions like hospitalization.2,3

In its 2014 report, Dying in America, the Institute of Medicine (IOM) identified several areas for improvement, including better advance care planning and payment systems supporting high quality end-of-life care.4 As I write this column in mid 2016, there are two notable achievements since the IOM report: two E&M codes for advance care planning and a substantial and growing number of hospitalist patients in alternative payment models like bundled payments or ACOs.5 I believe we are entering a time when the availability of good palliative care will be accelerated due to broader forces in healthcare that for the first time align incentives between patients’ wishes and how care is paid for.

Palliative Care Skills for Hospitalists

The following are key actions for physicians in addressing palliative care for the hospitalized patient. At the risk of oversimplifying the discipline, I offer a few key actions for hospitalists to keep in mind.

Identify patients who would benefit from palliative care. The surprise question—“Would I be surprised if this patient died in the next year?”—has the ability to predict which patients would benefit from palliative care. In one observation from a group of patients with cancer, a “no” answer identified 60% of patients who died within a year.6 The surprise question has previously been shown to be predictive in other cancer and non-cancer populations.7,8

Weisman and Meier suggest using the following in a checklist at the time of hospital admission as “primary criteria to screen for unmet palliative care needs”:9

• The surprise question
• Frequent admissions
• Admission prompted by difficult-to-control physical or psychological symptoms
• Complex care requirements
• Decline in function, feeding intolerance, or unintended decline in weight

Hold a “goals of care” meeting. A notable step forward for supporting conversations between physicians and patients occurred on Jan. 1, when the Centers for Medicare & Medicaid Services (CMS) announced the Advance Care Planning E&M codes. These are CPT codes 99497 and 99498. They can be used on the same day as other E&M codes and cover discussions regarding advance care planning issues including discussing advance directives, appointing a healthcare proxy or durable power of attorney, discussing a living will, or addressing orders for life-sustaining treatment like the role of hydration or future hospitalizations. (For more information on how to use them, visit the CMS website and search for the FAQ.)

What should hospitalists concentrate on when having “goals of care” conversations with patients and caregivers? Ariadne Labs, a Harvard-affiliated health innovation group, offers the following as elements of a serious illness conversation:10

• Patients’ understanding of their illness
• Patients’ preferences for information and for family involvement
• Personal life goals, fears, and anxieties
• Trade-offs they are willing to accept

For hospitalists, an important area to pay particular attention to is the role of future hospitalizations in patients’ wishes for care, as some patients, if offered appropriate symptom control, would prefer to remain at home.

Two other crucial elements of inpatient palliative care—offer psychosocial support and symptom relief and hand off patient to effective post-hospital palliative care—are outside the scope of this article. However, they should be kept in mind and, of course, applied.

Understand the role of the palliative care consultation. Busy hospitalists might reasonably think, “I simply don’t have time to address palliative care in patients who aren’t likely to die during this hospitalization or soon after.” The palliative care consult service, if available, should be accessed when patients are identified as palliative care candidates but the primary hospitalist does not have the time or resources—including specialized knowledge in some cases—to deliver adequate palliative care. Palliative care specialists can also help bridge the gap between inpatient and outpatient palliative care resources.

In sum, the move to value-based payment models and the new advance care planning E&M codes provide a renewed focus—with more aligned incentives—and the opportunity to provide good palliative care to all who need it.

For hospitalists, identifying those who would benefit from palliative care and working with the healthcare team to ensure the care is delivered are at the heart of our professional mission. TH

References

1. End-of-life care. The Darmouth Atlas of Health Care website. Accessed June 23, 2016.
2. Gade G, Venohr I, Conner D, et al. Impact of an inpatient palliative care team: a randomized control trial. J Palliat Med. 2008;11(2):180-190.
3. Morrison RS, Penrod JD, Cassel JB, et al. Cost savings associated with US hospital palliative care consultation programs. Arch Int Med. 2008;168(16):1783-1790.
4. Institute of Medicine. Dying in America: Improving Quality and Honoring Individual Preferences near the End of Life. 2014.
5. BPCI Model 2: Retrospective acute & post acute care episode. Centers for Medicare & Medicaid Services website. Accessed June 24, 2016.
6. Vick JB, Pertsch N, Hutchings M, et al. The utility of the surprise question in identifying patients most at risk of death. J Clin Oncol. 2015;33(suppl):8.
7. Moss AH, Ganjoo J, Sharma S, et al. Utility of the “surprise” question to identify dialysis patients with high mortality. Clin J Am Soc Nephrol. 2008;3:1379-1384.
8. Moss AH, Lunney JR, Culp S, et al. Prognostic significance of the “surprise” question in cancer patients. J Palliat Med. 2010;13(7):837-840.
9. Weissman D, Meier C. Identifying patients in need of a palliative care assessment in the hospital setting: a consensus report from the Center to Advance Palliative Care. J Palliat Med. 2011;14(1):17-23.
10. Serious illness care resources. Ariadne Labs website. Accessed June 24, 2016.

Although effective palliative care has always been a must-have for patients and caregivers facing serious illness, it hasn’t always been readily available. With the emergence of value-based healthcare models—and their potent incentives to reduce avoidable readmissions—there is renewed hope that such care will be accessible to those who need it.

Palliative and end-of-life care have long been promoted as core skills for hospitalists. The topic has regularly been included at SHM annual meetings and other prominent hospital medicine conferences, in the American Board of Internal Medicine blueprint for recognition of focused practice in hospital medicine, and in a number of influential references for hospitalists. Still, as I look at hospitalist programs around the country, there is a clear need to improve hospitalists’ delivery of palliative and end-of-life care.

Care of patients with chronic illness in their last two years of life accounts for a third of all Medicare spending.1 As hospitalists, we encounter many of these patients as they are hospitalized—and often re-hospitalized. Palliative care, which can improve quality of life and decrease costs for patients while leading to increased satisfaction and better outcomes for caregivers, can help alleviate unneeded and unwanted aggressive interventions like hospitalization.2,3

In its 2014 report, Dying in America, the Institute of Medicine (IOM) identified several areas for improvement, including better advance care planning and payment systems supporting high quality end-of-life care.4 As I write this column in mid 2016, there are two notable achievements since the IOM report: two E&M codes for advance care planning and a substantial and growing number of hospitalist patients in alternative payment models like bundled payments or ACOs.5 I believe we are entering a time when the availability of good palliative care will be accelerated due to broader forces in healthcare that for the first time align incentives between patients’ wishes and how care is paid for.

Palliative Care Skills for Hospitalists

The following are key actions for physicians in addressing palliative care for the hospitalized patient. At the risk of oversimplifying the discipline, I offer a few key actions for hospitalists to keep in mind.

Identify patients who would benefit from palliative care. The surprise question—“Would I be surprised if this patient died in the next year?”—has the ability to predict which patients would benefit from palliative care. In one observation from a group of patients with cancer, a “no” answer identified 60% of patients who died within a year.6 The surprise question has previously been shown to be predictive in other cancer and non-cancer populations.7,8

Weisman and Meier suggest using the following in a checklist at the time of hospital admission as “primary criteria to screen for unmet palliative care needs”:9

• The surprise question
• Frequent admissions
• Admission prompted by difficult-to-control physical or psychological symptoms
• Complex care requirements
• Decline in function, feeding intolerance, or unintended decline in weight

Hold a “goals of care” meeting. A notable step forward for supporting conversations between physicians and patients occurred on Jan. 1, when the Centers for Medicare & Medicaid Services (CMS) announced the Advance Care Planning E&M codes. These are CPT codes 99497 and 99498. They can be used on the same day as other E&M codes and cover discussions regarding advance care planning issues including discussing advance directives, appointing a healthcare proxy or durable power of attorney, discussing a living will, or addressing orders for life-sustaining treatment like the role of hydration or future hospitalizations. (For more information on how to use them, visit the CMS website and search for the FAQ.)

What should hospitalists concentrate on when having “goals of care” conversations with patients and caregivers? Ariadne Labs, a Harvard-affiliated health innovation group, offers the following as elements of a serious illness conversation:10

• Patients’ understanding of their illness
• Patients’ preferences for information and for family involvement
• Personal life goals, fears, and anxieties
• Trade-offs they are willing to accept

For hospitalists, an important area to pay particular attention to is the role of future hospitalizations in patients’ wishes for care, as some patients, if offered appropriate symptom control, would prefer to remain at home.

Two other crucial elements of inpatient palliative care—offer psychosocial support and symptom relief and hand off patient to effective post-hospital palliative care—are outside the scope of this article. However, they should be kept in mind and, of course, applied.

Understand the role of the palliative care consultation. Busy hospitalists might reasonably think, “I simply don’t have time to address palliative care in patients who aren’t likely to die during this hospitalization or soon after.” The palliative care consult service, if available, should be accessed when patients are identified as palliative care candidates but the primary hospitalist does not have the time or resources—including specialized knowledge in some cases—to deliver adequate palliative care. Palliative care specialists can also help bridge the gap between inpatient and outpatient palliative care resources.

In sum, the move to value-based payment models and the new advance care planning E&M codes provide a renewed focus—with more aligned incentives—and the opportunity to provide good palliative care to all who need it.

For hospitalists, identifying those who would benefit from palliative care and working with the healthcare team to ensure the care is delivered are at the heart of our professional mission. TH

References

1. End-of-life care. The Darmouth Atlas of Health Care website. Accessed June 23, 2016.
2. Gade G, Venohr I, Conner D, et al. Impact of an inpatient palliative care team: a randomized control trial. J Palliat Med. 2008;11(2):180-190.
3. Morrison RS, Penrod JD, Cassel JB, et al. Cost savings associated with US hospital palliative care consultation programs. Arch Int Med. 2008;168(16):1783-1790.
4. Institute of Medicine. Dying in America: Improving Quality and Honoring Individual Preferences near the End of Life. 2014.
5. BPCI Model 2: Retrospective acute & post acute care episode. Centers for Medicare & Medicaid Services website. Accessed June 24, 2016.
6. Vick JB, Pertsch N, Hutchings M, et al. The utility of the surprise question in identifying patients most at risk of death. J Clin Oncol. 2015;33(suppl):8.
7. Moss AH, Ganjoo J, Sharma S, et al. Utility of the “surprise” question to identify dialysis patients with high mortality. Clin J Am Soc Nephrol. 2008;3:1379-1384.
8. Moss AH, Lunney JR, Culp S, et al. Prognostic significance of the “surprise” question in cancer patients. J Palliat Med. 2010;13(7):837-840.
9. Weissman D, Meier C. Identifying patients in need of a palliative care assessment in the hospital setting: a consensus report from the Center to Advance Palliative Care. J Palliat Med. 2011;14(1):17-23.
10. Serious illness care resources. Ariadne Labs website. Accessed June 24, 2016.

The Meaningful Use (MU) program as doctors know it may soon be ending, but audits of past attestations are slated to continue for at least the next 6 years.

Experts offer the following guidance on how to successfully manage audits and subsequent appeals.

1. Expect an audit.

Assume that at some point, you will be audited, said Joshua J. Freemire, a health law attorney based in Baltimore who specializes in regulatory compliance matters.

“Have good procedures in place to ensure the audit is brought to the attention of management and responded to promptly,” Mr. Freemire said in an interview. “Similarly, it is important that practices understand, in advance, how information created by their EHR is stored and managed.”

Audits are not limited to the current or most recent year, he noted. Being able to promptly access the appropriate information is an important part of drafting appropriate responses.

2. Save records

Keep all relevant records electronically for at least 6 years after attestation, advised Carmiña Nitzki, a senior consultant with GE Healthcare Camden Group.

Some documentation, such as your security risk analysis, should be maintained in paper form, she added. It is also helpful to take screen shots of certain measures that address the functionality of your system.

Records should follow when a physician moves a practice or changes employment. Ms. Nitzki recently assisted a case in which an early adopter physician dissolved his practice, became employed, and moved offices. His 2011 attestation was later audited, and he did not have all of the requested information. The doctor came to Ms. Nitzki after failing an audit and being assessed an $18,000 recoupment payment. Together, they were able to recreate and locate much of the necessary records through old emails and past documentation.

“We won the appeal,” said Ms. Nitzki, who spoke about meaningful use audits at a recent American Bar Association meeting. “The takeaway is if you’re going to respond to an audit, make sure you understand everything that they’re asking for and that you’re confident that you’re responding with all of the appropriate documentation,” she said.

3. Meet deadlines

Promptly responding to audits and quickly addressing failed audits are critical, Mr. Freemire said.

“The [MU] program is very strict with regard to deadlines, and an appeal cannot be filed once the applicable deadline has passed,” he said.

Mr. Freemire said that he routinely encounters health providers who have missed deadlines or let too much time lapse after being contacted by the government. Failure to meet deadlines can result from various reasons, including that notices are not promptly brought to the physician’s attention, delays investigating the availability of requested materials, or a false assumption that the requested information is readily at hand, he said.

Ensure that all audit deadlines are recorded and work with staff and leadership to file responses on time. Factor in additional time if there could be difficulty in locating records, experts stressed.

“I see difficulty in effectively responding to audits where records are simply not maintained,” he said. “Again, this can happen for many reasons, including personnel turnover, but it can be difficult or impossible to effectively respond to audit requests” in this situation.

4. Appeal effectively

Swiftly and thoroughly appeal a failed audit.

When a doctor fails an audit, it’s usually because of incomplete responses or missing information, Ms. Nitzki said. Only those measures that were rejected or that failed to meet standards need to be addressed during an appeal. Sending a cover letter to CMS with the appeal, explaining why the doctor may have failed initially can strengthen the case, she said.

“The appeals process is done directly with CMS, so they’re a little more reasonable,” she said. “They tend to look at things on broader scale.”

Don’t wait to appeal, Mr. Freemire said. Practices have 30 days from the date of an adverse audit determination letter to submit an appeal. If time runs out, physicians must pay back any money requested by auditors, and CMS expects the recoupment in full.

“Following a negative decision, the most important step is prompt attention,” he said. “The sooner that process begins, the sooner it can be completed. The time line for audit appeals is not generous and providers need to ensure they react promptly to a negative finding.”

5. Get help

Ms. Nitzki recommends that physicians obtain professional assistance when responding to an audit.

Practices can hire a consulting company or find audit resources from their specialty society or state medical association. The American Academy of Family Physicians provides a tip sheet on responding to audits. Some state organizations, such as the Texas Medical Association, offer a helpline for doctors to call and ask questions related to meaningful use.

“Unless they have a very savvy person in their office who has taken care all of their meaningful use attestations and documentation, we recommend they get help because it’s in the details where they could fail,” she said.

Seeking help after a failed audit is also essential, notes Mr. Freemire. Experts who are familiar with the program and its requirements and procedures can be of great assistance when it comes organizing the facts into a persuasive argument, he said.

“A cost/benefit is necessary – as it is with all service providers,” he said. “But a provider’s chances for a successful appeal are increased when that appeal is prepared by someone who understands the history and intention behind program requirements, who can best identify and present the necessary evidence of compliance, and who can make a compelling argument as to the provider’s satisfaction of program requirements.”

[email protected]

On Twitter @legal_med

The Meaningful Use (MU) program as doctors know it may soon be ending, but audits of past attestations are slated to continue for at least the next 6 years.

Experts offer the following guidance on how to successfully manage audits and subsequent appeals.

1. Expect an audit.

Assume that at some point, you will be audited, said Joshua J. Freemire, a health law attorney based in Baltimore who specializes in regulatory compliance matters.

“Have good procedures in place to ensure the audit is brought to the attention of management and responded to promptly,” Mr. Freemire said in an interview. “Similarly, it is important that practices understand, in advance, how information created by their EHR is stored and managed.”

Audits are not limited to the current or most recent year, he noted. Being able to promptly access the appropriate information is an important part of drafting appropriate responses.

2. Save records

Keep all relevant records electronically for at least 6 years after attestation, advised Carmiña Nitzki, a senior consultant with GE Healthcare Camden Group.

Some documentation, such as your security risk analysis, should be maintained in paper form, she added. It is also helpful to take screen shots of certain measures that address the functionality of your system.

Records should follow when a physician moves a practice or changes employment. Ms. Nitzki recently assisted a case in which an early adopter physician dissolved his practice, became employed, and moved offices. His 2011 attestation was later audited, and he did not have all of the requested information. The doctor came to Ms. Nitzki after failing an audit and being assessed an $18,000 recoupment payment. Together, they were able to recreate and locate much of the necessary records through old emails and past documentation.

“We won the appeal,” said Ms. Nitzki, who spoke about meaningful use audits at a recent American Bar Association meeting. “The takeaway is if you’re going to respond to an audit, make sure you understand everything that they’re asking for and that you’re confident that you’re responding with all of the appropriate documentation,” she said.

3. Meet deadlines

Promptly responding to audits and quickly addressing failed audits are critical, Mr. Freemire said.

“The [MU] program is very strict with regard to deadlines, and an appeal cannot be filed once the applicable deadline has passed,” he said.

Mr. Freemire said that he routinely encounters health providers who have missed deadlines or let too much time lapse after being contacted by the government. Failure to meet deadlines can result from various reasons, including that notices are not promptly brought to the physician’s attention, delays investigating the availability of requested materials, or a false assumption that the requested information is readily at hand, he said.

Ensure that all audit deadlines are recorded and work with staff and leadership to file responses on time. Factor in additional time if there could be difficulty in locating records, experts stressed.

“I see difficulty in effectively responding to audits where records are simply not maintained,” he said. “Again, this can happen for many reasons, including personnel turnover, but it can be difficult or impossible to effectively respond to audit requests” in this situation.

4. Appeal effectively

Swiftly and thoroughly appeal a failed audit.

When a doctor fails an audit, it’s usually because of incomplete responses or missing information, Ms. Nitzki said. Only those measures that were rejected or that failed to meet standards need to be addressed during an appeal. Sending a cover letter to CMS with the appeal, explaining why the doctor may have failed initially can strengthen the case, she said.

“The appeals process is done directly with CMS, so they’re a little more reasonable,” she said. “They tend to look at things on broader scale.”

Don’t wait to appeal, Mr. Freemire said. Practices have 30 days from the date of an adverse audit determination letter to submit an appeal. If time runs out, physicians must pay back any money requested by auditors, and CMS expects the recoupment in full.

“Following a negative decision, the most important step is prompt attention,” he said. “The sooner that process begins, the sooner it can be completed. The time line for audit appeals is not generous and providers need to ensure they react promptly to a negative finding.”

5. Get help

Ms. Nitzki recommends that physicians obtain professional assistance when responding to an audit.

Practices can hire a consulting company or find audit resources from their specialty society or state medical association. The American Academy of Family Physicians provides a tip sheet on responding to audits. Some state organizations, such as the Texas Medical Association, offer a helpline for doctors to call and ask questions related to meaningful use.

“Unless they have a very savvy person in their office who has taken care all of their meaningful use attestations and documentation, we recommend they get help because it’s in the details where they could fail,” she said.

Seeking help after a failed audit is also essential, notes Mr. Freemire. Experts who are familiar with the program and its requirements and procedures can be of great assistance when it comes organizing the facts into a persuasive argument, he said.

“A cost/benefit is necessary – as it is with all service providers,” he said. “But a provider’s chances for a successful appeal are increased when that appeal is prepared by someone who understands the history and intention behind program requirements, who can best identify and present the necessary evidence of compliance, and who can make a compelling argument as to the provider’s satisfaction of program requirements.”

[email protected]

On Twitter @legal_med

The Meaningful Use (MU) program as doctors know it may soon be ending, but audits of past attestations are slated to continue for at least the next 6 years.

Experts offer the following guidance on how to successfully manage audits and subsequent appeals.

1. Expect an audit.

Assume that at some point, you will be audited, said Joshua J. Freemire, a health law attorney based in Baltimore who specializes in regulatory compliance matters.

“Have good procedures in place to ensure the audit is brought to the attention of management and responded to promptly,” Mr. Freemire said in an interview. “Similarly, it is important that practices understand, in advance, how information created by their EHR is stored and managed.”

Audits are not limited to the current or most recent year, he noted. Being able to promptly access the appropriate information is an important part of drafting appropriate responses.

2. Save records

Keep all relevant records electronically for at least 6 years after attestation, advised Carmiña Nitzki, a senior consultant with GE Healthcare Camden Group.

Some documentation, such as your security risk analysis, should be maintained in paper form, she added. It is also helpful to take screen shots of certain measures that address the functionality of your system.

Records should follow when a physician moves a practice or changes employment. Ms. Nitzki recently assisted a case in which an early adopter physician dissolved his practice, became employed, and moved offices. His 2011 attestation was later audited, and he did not have all of the requested information. The doctor came to Ms. Nitzki after failing an audit and being assessed an $18,000 recoupment payment. Together, they were able to recreate and locate much of the necessary records through old emails and past documentation.

“We won the appeal,” said Ms. Nitzki, who spoke about meaningful use audits at a recent American Bar Association meeting. “The takeaway is if you’re going to respond to an audit, make sure you understand everything that they’re asking for and that you’re confident that you’re responding with all of the appropriate documentation,” she said.

3. Meet deadlines

Promptly responding to audits and quickly addressing failed audits are critical, Mr. Freemire said.

“The [MU] program is very strict with regard to deadlines, and an appeal cannot be filed once the applicable deadline has passed,” he said.

Mr. Freemire said that he routinely encounters health providers who have missed deadlines or let too much time lapse after being contacted by the government. Failure to meet deadlines can result from various reasons, including that notices are not promptly brought to the physician’s attention, delays investigating the availability of requested materials, or a false assumption that the requested information is readily at hand, he said.

Ensure that all audit deadlines are recorded and work with staff and leadership to file responses on time. Factor in additional time if there could be difficulty in locating records, experts stressed.

“I see difficulty in effectively responding to audits where records are simply not maintained,” he said. “Again, this can happen for many reasons, including personnel turnover, but it can be difficult or impossible to effectively respond to audit requests” in this situation.

4. Appeal effectively

Swiftly and thoroughly appeal a failed audit.

When a doctor fails an audit, it’s usually because of incomplete responses or missing information, Ms. Nitzki said. Only those measures that were rejected or that failed to meet standards need to be addressed during an appeal. Sending a cover letter to CMS with the appeal, explaining why the doctor may have failed initially can strengthen the case, she said.

“The appeals process is done directly with CMS, so they’re a little more reasonable,” she said. “They tend to look at things on broader scale.”

Don’t wait to appeal, Mr. Freemire said. Practices have 30 days from the date of an adverse audit determination letter to submit an appeal. If time runs out, physicians must pay back any money requested by auditors, and CMS expects the recoupment in full.

“Following a negative decision, the most important step is prompt attention,” he said. “The sooner that process begins, the sooner it can be completed. The time line for audit appeals is not generous and providers need to ensure they react promptly to a negative finding.”

5. Get help

Ms. Nitzki recommends that physicians obtain professional assistance when responding to an audit.

Practices can hire a consulting company or find audit resources from their specialty society or state medical association. The American Academy of Family Physicians provides a tip sheet on responding to audits. Some state organizations, such as the Texas Medical Association, offer a helpline for doctors to call and ask questions related to meaningful use.

“Unless they have a very savvy person in their office who has taken care all of their meaningful use attestations and documentation, we recommend they get help because it’s in the details where they could fail,” she said.

Seeking help after a failed audit is also essential, notes Mr. Freemire. Experts who are familiar with the program and its requirements and procedures can be of great assistance when it comes organizing the facts into a persuasive argument, he said.

“A cost/benefit is necessary – as it is with all service providers,” he said. “But a provider’s chances for a successful appeal are increased when that appeal is prepared by someone who understands the history and intention behind program requirements, who can best identify and present the necessary evidence of compliance, and who can make a compelling argument as to the provider’s satisfaction of program requirements.”

[email protected]

On Twitter @legal_med

FROM THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY: IN PRACTICE

Siblings of children with food allergy should not be screened routinely for such allergies before food introduction, results of a large cohort study suggest.

In a study of 478 food-allergic children and 642 of their siblings, 53% of the siblings were sensitized without clinical reactivity and only 13.6% were found to have a clinically reactive food allergy, wrote Ruchi S. Gupta, MD, of Northwestern University, Chicago, and her associates.

The investigators noted that their findings support current guidelines from the National Institute of Allergy and Infectious Diseases to not screen siblings based on another sibling having a food allergy.

“Given the lack of a dramatically increased risk of food allergy in siblings, compared with that of the general population, as well as the high rate of what are falsely positive diagnostic test results among siblings of a food allergic child, [these siblings] should not have routine screening for food allergy before food introduction,” the investigators concluded. “Such siblings are likely to be mislabeled as allergic when they are actually tolerant to the food, which may lead to an increased risk of developing allergy via avoidance,” and both quality of life and nutrition may be adversely impacted.

Dr. Gupta has received research support from Mylan, Food Allergy Research and Education, and United Health Care.

Read the full study here (http://dx.doi.org/10.1016/j.jaip.2016.04.009)

[email protected]

FROM THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY: IN PRACTICE

Siblings of children with food allergy should not be screened routinely for such allergies before food introduction, results of a large cohort study suggest.

In a study of 478 food-allergic children and 642 of their siblings, 53% of the siblings were sensitized without clinical reactivity and only 13.6% were found to have a clinically reactive food allergy, wrote Ruchi S. Gupta, MD, of Northwestern University, Chicago, and her associates.

The investigators noted that their findings support current guidelines from the National Institute of Allergy and Infectious Diseases to not screen siblings based on another sibling having a food allergy.

“Given the lack of a dramatically increased risk of food allergy in siblings, compared with that of the general population, as well as the high rate of what are falsely positive diagnostic test results among siblings of a food allergic child, [these siblings] should not have routine screening for food allergy before food introduction,” the investigators concluded. “Such siblings are likely to be mislabeled as allergic when they are actually tolerant to the food, which may lead to an increased risk of developing allergy via avoidance,” and both quality of life and nutrition may be adversely impacted.

Dr. Gupta has received research support from Mylan, Food Allergy Research and Education, and United Health Care.

Read the full study here (http://dx.doi.org/10.1016/j.jaip.2016.04.009)

[email protected]

FROM THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY: IN PRACTICE

Siblings of children with food allergy should not be screened routinely for such allergies before food introduction, results of a large cohort study suggest.

In a study of 478 food-allergic children and 642 of their siblings, 53% of the siblings were sensitized without clinical reactivity and only 13.6% were found to have a clinically reactive food allergy, wrote Ruchi S. Gupta, MD, of Northwestern University, Chicago, and her associates.

The investigators noted that their findings support current guidelines from the National Institute of Allergy and Infectious Diseases to not screen siblings based on another sibling having a food allergy.

“Given the lack of a dramatically increased risk of food allergy in siblings, compared with that of the general population, as well as the high rate of what are falsely positive diagnostic test results among siblings of a food allergic child, [these siblings] should not have routine screening for food allergy before food introduction,” the investigators concluded. “Such siblings are likely to be mislabeled as allergic when they are actually tolerant to the food, which may lead to an increased risk of developing allergy via avoidance,” and both quality of life and nutrition may be adversely impacted.

Dr. Gupta has received research support from Mylan, Food Allergy Research and Education, and United Health Care.

Read the full study here (http://dx.doi.org/10.1016/j.jaip.2016.04.009)

[email protected]

Angina is underrecognized by cardiologists in clinic visits, compared with assessments made by the patients themselves, suggesting that a standard screening tool be used to improve accuracy.

Researchers conducted a survey of 1,257 patients and their 155 doctors at 25 cardiology outpatient practices in 19 states. All patients had documented coronary artery disease and completed the Seattle Angina Questionnaire (SAQ) before their office visits to assess angina symptoms and frequency. Right after they left, their cardiologists estimated and recorded their idea of how often their patients had heart pain and what their symptoms were.

Patient and physician estimates didn’t match: 411 patients (33%) reported at least one bout of angina in the previous month, but their physicians estimated a frequency of 14% (173 patients). Heart failure patients were more than three times as likely to have their angina underestimated, and patients who reported a single bout of angina per month were about 70% less likely than those who reported daily or weekly attacks.

Years in practice and the number of angina patients in the case load didn’t seem to make a difference. Patient demographics, atypical symptoms, and comorbidities besides heart failure didn’t either. “Some physicians were much better at recognizing the frequency of patients’ angina,” said lead investigator Suzanne Arnold, MD, a cardiologist at Saint Luke’s Mid America Heart Institute in Kansas City, Mo., and her associates.

“Evaluation of angina is subject to limitations inherent in history taking, including pre-existing biases and time constraints on the part of physicians and patients. ... Under-recognition of angina by physicians may result in under treatment with revascularization or medications that could improve patients’ quality of life,” and it wastes healthcare dollars, they said.

The team concluded that angina needs to be assessed directly from patients with a standardized survey like the Seattle Angina Questionnaire (SAQ). “We still routinely depend solely on an unstructured interview instead of directly asking patients using standardized assessments,” the investigators noted. “A more systematic approach is needed for eliciting a history and assessing angina in patients with coronary artery disease to appropriately guide further testing and treatment. ... The use of a validated, patient-centered tool for eliciting patients’ angina, such as the SAQ, should be tested in routine clinical care to see if it improves angina recognition, treatment, and outcomes,” the study team said (Circ Cardiovasc Qual Outcomes. 2016 AUG 16;doi: 10.1161/CIRCOUTCOMES.116.002781).

Patients in the study were, on average, 69 years old, and the majority were white men. About 40% reported previous myocardial infarctions, and more than half were stented. Well over three quarters were on beta-blockers for angina.

The senior investigator, John Spertus, MD, holds a copyright on the SAQ used in the study. Gilead Sciences funded the work. Investigators reported ties to Gilead, Abbvie, Genentech, Glumetrics, Maquet, Sanofi, AstraZeneca, Edwards Life Sciences, Roche, St. Jude Medical, Regeneron, Lilly, and ZS Pharma.

[email protected]

Angina is underrecognized by cardiologists in clinic visits, compared with assessments made by the patients themselves, suggesting that a standard screening tool be used to improve accuracy.

Researchers conducted a survey of 1,257 patients and their 155 doctors at 25 cardiology outpatient practices in 19 states. All patients had documented coronary artery disease and completed the Seattle Angina Questionnaire (SAQ) before their office visits to assess angina symptoms and frequency. Right after they left, their cardiologists estimated and recorded their idea of how often their patients had heart pain and what their symptoms were.

Patient and physician estimates didn’t match: 411 patients (33%) reported at least one bout of angina in the previous month, but their physicians estimated a frequency of 14% (173 patients). Heart failure patients were more than three times as likely to have their angina underestimated, and patients who reported a single bout of angina per month were about 70% less likely than those who reported daily or weekly attacks.

Years in practice and the number of angina patients in the case load didn’t seem to make a difference. Patient demographics, atypical symptoms, and comorbidities besides heart failure didn’t either. “Some physicians were much better at recognizing the frequency of patients’ angina,” said lead investigator Suzanne Arnold, MD, a cardiologist at Saint Luke’s Mid America Heart Institute in Kansas City, Mo., and her associates.

“Evaluation of angina is subject to limitations inherent in history taking, including pre-existing biases and time constraints on the part of physicians and patients. ... Under-recognition of angina by physicians may result in under treatment with revascularization or medications that could improve patients’ quality of life,” and it wastes healthcare dollars, they said.

The team concluded that angina needs to be assessed directly from patients with a standardized survey like the Seattle Angina Questionnaire (SAQ). “We still routinely depend solely on an unstructured interview instead of directly asking patients using standardized assessments,” the investigators noted. “A more systematic approach is needed for eliciting a history and assessing angina in patients with coronary artery disease to appropriately guide further testing and treatment. ... The use of a validated, patient-centered tool for eliciting patients’ angina, such as the SAQ, should be tested in routine clinical care to see if it improves angina recognition, treatment, and outcomes,” the study team said (Circ Cardiovasc Qual Outcomes. 2016 AUG 16;doi: 10.1161/CIRCOUTCOMES.116.002781).

Patients in the study were, on average, 69 years old, and the majority were white men. About 40% reported previous myocardial infarctions, and more than half were stented. Well over three quarters were on beta-blockers for angina.

The senior investigator, John Spertus, MD, holds a copyright on the SAQ used in the study. Gilead Sciences funded the work. Investigators reported ties to Gilead, Abbvie, Genentech, Glumetrics, Maquet, Sanofi, AstraZeneca, Edwards Life Sciences, Roche, St. Jude Medical, Regeneron, Lilly, and ZS Pharma.

[email protected]

Angina is underrecognized by cardiologists in clinic visits, compared with assessments made by the patients themselves, suggesting that a standard screening tool be used to improve accuracy.

Researchers conducted a survey of 1,257 patients and their 155 doctors at 25 cardiology outpatient practices in 19 states. All patients had documented coronary artery disease and completed the Seattle Angina Questionnaire (SAQ) before their office visits to assess angina symptoms and frequency. Right after they left, their cardiologists estimated and recorded their idea of how often their patients had heart pain and what their symptoms were.

Patient and physician estimates didn’t match: 411 patients (33%) reported at least one bout of angina in the previous month, but their physicians estimated a frequency of 14% (173 patients). Heart failure patients were more than three times as likely to have their angina underestimated, and patients who reported a single bout of angina per month were about 70% less likely than those who reported daily or weekly attacks.

Years in practice and the number of angina patients in the case load didn’t seem to make a difference. Patient demographics, atypical symptoms, and comorbidities besides heart failure didn’t either. “Some physicians were much better at recognizing the frequency of patients’ angina,” said lead investigator Suzanne Arnold, MD, a cardiologist at Saint Luke’s Mid America Heart Institute in Kansas City, Mo., and her associates.

“Evaluation of angina is subject to limitations inherent in history taking, including pre-existing biases and time constraints on the part of physicians and patients. ... Under-recognition of angina by physicians may result in under treatment with revascularization or medications that could improve patients’ quality of life,” and it wastes healthcare dollars, they said.

The team concluded that angina needs to be assessed directly from patients with a standardized survey like the Seattle Angina Questionnaire (SAQ). “We still routinely depend solely on an unstructured interview instead of directly asking patients using standardized assessments,” the investigators noted. “A more systematic approach is needed for eliciting a history and assessing angina in patients with coronary artery disease to appropriately guide further testing and treatment. ... The use of a validated, patient-centered tool for eliciting patients’ angina, such as the SAQ, should be tested in routine clinical care to see if it improves angina recognition, treatment, and outcomes,” the study team said (Circ Cardiovasc Qual Outcomes. 2016 AUG 16;doi: 10.1161/CIRCOUTCOMES.116.002781).

Patients in the study were, on average, 69 years old, and the majority were white men. About 40% reported previous myocardial infarctions, and more than half were stented. Well over three quarters were on beta-blockers for angina.

The senior investigator, John Spertus, MD, holds a copyright on the SAQ used in the study. Gilead Sciences funded the work. Investigators reported ties to Gilead, Abbvie, Genentech, Glumetrics, Maquet, Sanofi, AstraZeneca, Edwards Life Sciences, Roche, St. Jude Medical, Regeneron, Lilly, and ZS Pharma.

[email protected]

Perhaps it’s the northern climate. Perhaps it’s that people at my office work a lot in the absence of office windows. But there are a lot of seasonal affective disorder lamps around me.

The one in my office turns on automatically (frequently in my absence), and the eerie blue light from my office floods the cubicles outside my door.

At a social gathering the other day, I related the story of my “moody blues office,” and somebody asked if the blue light for seasonal affective disorder was better than the white light. I did not know, so I did some reading.

It turns out that there is a retinal photoreceptor in the ganglion cells with a maximum sensitivity of 470-490 nm to blue light. These non-image–forming photoreceptors play a role in regulating the biological clock. Experiments have been conducted evaluating the impact of different wavelengths of light on symptoms of SAD.

In a study of people with subsyndromal SAD, investigators randomized 48 participants to bright white fluorescent light or narrow-band blue light (peak LED wavelength, 470 nm). Patients were exposed to the light for 20 minutes on 5 consecutive days. Standard scales measuring mood and fatigue were administered (BMC Psychiatry. 2016 Feb 18;16:27).

Investigators did not detect differences between the groups, and the authors concluded they had comparable efficacy.

Although the sample size is small, the data suggest that blue light is comparable to white light. I will start needing to pay attention if the folks in the cubicles outside my office are less depressed.

Dr. Ebbert is professor of medicine, a general internist at the Mayo Clinic in Rochester, Minn., and a diplomate of the American Board of Addiction Medicine. Dr. Ebbert has no relevant financial disclosures about this article.

Perhaps it’s the northern climate. Perhaps it’s that people at my office work a lot in the absence of office windows. But there are a lot of seasonal affective disorder lamps around me.

The one in my office turns on automatically (frequently in my absence), and the eerie blue light from my office floods the cubicles outside my door.

At a social gathering the other day, I related the story of my “moody blues office,” and somebody asked if the blue light for seasonal affective disorder was better than the white light. I did not know, so I did some reading.

It turns out that there is a retinal photoreceptor in the ganglion cells with a maximum sensitivity of 470-490 nm to blue light. These non-image–forming photoreceptors play a role in regulating the biological clock. Experiments have been conducted evaluating the impact of different wavelengths of light on symptoms of SAD.

In a study of people with subsyndromal SAD, investigators randomized 48 participants to bright white fluorescent light or narrow-band blue light (peak LED wavelength, 470 nm). Patients were exposed to the light for 20 minutes on 5 consecutive days. Standard scales measuring mood and fatigue were administered (BMC Psychiatry. 2016 Feb 18;16:27).

Investigators did not detect differences between the groups, and the authors concluded they had comparable efficacy.

Although the sample size is small, the data suggest that blue light is comparable to white light. I will start needing to pay attention if the folks in the cubicles outside my office are less depressed.

Dr. Ebbert is professor of medicine, a general internist at the Mayo Clinic in Rochester, Minn., and a diplomate of the American Board of Addiction Medicine. Dr. Ebbert has no relevant financial disclosures about this article.

Perhaps it’s the northern climate. Perhaps it’s that people at my office work a lot in the absence of office windows. But there are a lot of seasonal affective disorder lamps around me.

The one in my office turns on automatically (frequently in my absence), and the eerie blue light from my office floods the cubicles outside my door.

At a social gathering the other day, I related the story of my “moody blues office,” and somebody asked if the blue light for seasonal affective disorder was better than the white light. I did not know, so I did some reading.

It turns out that there is a retinal photoreceptor in the ganglion cells with a maximum sensitivity of 470-490 nm to blue light. These non-image–forming photoreceptors play a role in regulating the biological clock. Experiments have been conducted evaluating the impact of different wavelengths of light on symptoms of SAD.

In a study of people with subsyndromal SAD, investigators randomized 48 participants to bright white fluorescent light or narrow-band blue light (peak LED wavelength, 470 nm). Patients were exposed to the light for 20 minutes on 5 consecutive days. Standard scales measuring mood and fatigue were administered (BMC Psychiatry. 2016 Feb 18;16:27).

Investigators did not detect differences between the groups, and the authors concluded they had comparable efficacy.

Although the sample size is small, the data suggest that blue light is comparable to white light. I will start needing to pay attention if the folks in the cubicles outside my office are less depressed.

Dr. Ebbert is professor of medicine, a general internist at the Mayo Clinic in Rochester, Minn., and a diplomate of the American Board of Addiction Medicine. Dr. Ebbert has no relevant financial disclosures about this article.

Cognitive impairment in individuals at the time of multiple sclerosis diagnosis imparts a significantly higher risk for disability progression, transition to secondary progressive disease, and cortical thinning, according to results from a retrospective, 8-year, longitudinal observational study.

The results, note first author Marco Pitteri, PhD, of the University of Verona (Italy) and his colleagues, “confirm and extend previous studies showing that cognitive impairment could represent a clinical marker of more aggressive gray matter pathology,” and also identified cortical thinning as a neuroimaging correlate of cognitive impairment that was detected only at follow-up between the cognitively impaired and cognitively normal patients who were otherwise similar at baseline.

©Zerbor/thinkstockphotos.com

The study involved 78 consecutive patients with relapsing-remitting multiple sclerosis who underwent neurologic exams during 2015 at a single center in Italy. They all had a cognitive assessment and an MRI scan at the time of diagnosis and at least 8 years of clinical follow-up, including neurologic examination every 6 months. At the time of enrollment into the study, most patients were taking immunomodulatory therapy: 38 were treated with interferon beta-1a, 14 with interferon beta-1b, 15 with glatiramer acetate, and 6 with azathioprine, and 5 were untreated.

At baseline, 39 cognitively normal patients had a mean age of about 36 years, none had conversion to secondary progressive disease, and just 15% had disability progression on the Expanded Disability Status Scale (EDSS). Cortical thickness changed a mean of 3.6%.

The 26 patients with mild cognitive impairment (classified as failure of up to two tests on the Brief Repeatable Battery) were 38 years old at baseline, and only 4 transitioned to secondary progressive disease. Just over half experienced EDSS progression (an average of 0.85 points) and cortical thickness changed by an average of 17%.

The 13 remaining patients with severe cognitive impairment at baseline (three or more failed tests) were about 44 years of age on average and nearly all (92%) experienced EDSS progression, which averaged 1.31 points. Cortical thickness also changed a mean of 34%. Relapsing disease converted to secondary progressive disease in a total of six patients with severe cognitive impairment.

Patients with severe cognitive impairment at baseline had more severe white matter lesion volume at baseline than did others, but there was no difference in the accumulation of white matter lesions during follow-up between patients with normal cognition, mild cognitive impairment, and severe cognitive impairment, which corroborates previous studies. However, the predictive ability of early cognitive impairment in identifying patients with disability progression on the EDSS and cortical thinning “is in line with several previous longitudinal studies showing a strong relationship between gray matter damage and the development of cognitive impairment,” the authors wrote (Brain. 2012 Oct;135[Pt 10]:2952-61 and Neurology. 2013 Nov 12;81[20]:1759-67).

Although the administration of neuropsychological batteries is time consuming and requires expertise, the authors argued that their results “underline the need of using extended screening neuropsychological batteries instead of brief screening batteries, at least at the time of diagnosis, in order to increase the probability to detect even mild forms of cognitive impairment as early as possible in the disease course.”

Read the full paper online in Multiple Sclerosis (2016 Aug 15. doi: 10.1177/1352458516665496).

[email protected]

Cognitive impairment in individuals at the time of multiple sclerosis diagnosis imparts a significantly higher risk for disability progression, transition to secondary progressive disease, and cortical thinning, according to results from a retrospective, 8-year, longitudinal observational study.

The results, note first author Marco Pitteri, PhD, of the University of Verona (Italy) and his colleagues, “confirm and extend previous studies showing that cognitive impairment could represent a clinical marker of more aggressive gray matter pathology,” and also identified cortical thinning as a neuroimaging correlate of cognitive impairment that was detected only at follow-up between the cognitively impaired and cognitively normal patients who were otherwise similar at baseline.

©Zerbor/thinkstockphotos.com

The study involved 78 consecutive patients with relapsing-remitting multiple sclerosis who underwent neurologic exams during 2015 at a single center in Italy. They all had a cognitive assessment and an MRI scan at the time of diagnosis and at least 8 years of clinical follow-up, including neurologic examination every 6 months. At the time of enrollment into the study, most patients were taking immunomodulatory therapy: 38 were treated with interferon beta-1a, 14 with interferon beta-1b, 15 with glatiramer acetate, and 6 with azathioprine, and 5 were untreated.

At baseline, 39 cognitively normal patients had a mean age of about 36 years, none had conversion to secondary progressive disease, and just 15% had disability progression on the Expanded Disability Status Scale (EDSS). Cortical thickness changed a mean of 3.6%.

The 26 patients with mild cognitive impairment (classified as failure of up to two tests on the Brief Repeatable Battery) were 38 years old at baseline, and only 4 transitioned to secondary progressive disease. Just over half experienced EDSS progression (an average of 0.85 points) and cortical thickness changed by an average of 17%.

The 13 remaining patients with severe cognitive impairment at baseline (three or more failed tests) were about 44 years of age on average and nearly all (92%) experienced EDSS progression, which averaged 1.31 points. Cortical thickness also changed a mean of 34%. Relapsing disease converted to secondary progressive disease in a total of six patients with severe cognitive impairment.

Patients with severe cognitive impairment at baseline had more severe white matter lesion volume at baseline than did others, but there was no difference in the accumulation of white matter lesions during follow-up between patients with normal cognition, mild cognitive impairment, and severe cognitive impairment, which corroborates previous studies. However, the predictive ability of early cognitive impairment in identifying patients with disability progression on the EDSS and cortical thinning “is in line with several previous longitudinal studies showing a strong relationship between gray matter damage and the development of cognitive impairment,” the authors wrote (Brain. 2012 Oct;135[Pt 10]:2952-61 and Neurology. 2013 Nov 12;81[20]:1759-67).

Although the administration of neuropsychological batteries is time consuming and requires expertise, the authors argued that their results “underline the need of using extended screening neuropsychological batteries instead of brief screening batteries, at least at the time of diagnosis, in order to increase the probability to detect even mild forms of cognitive impairment as early as possible in the disease course.”

Read the full paper online in Multiple Sclerosis (2016 Aug 15. doi: 10.1177/1352458516665496).

[email protected]

Cognitive impairment in individuals at the time of multiple sclerosis diagnosis imparts a significantly higher risk for disability progression, transition to secondary progressive disease, and cortical thinning, according to results from a retrospective, 8-year, longitudinal observational study.

The results, note first author Marco Pitteri, PhD, of the University of Verona (Italy) and his colleagues, “confirm and extend previous studies showing that cognitive impairment could represent a clinical marker of more aggressive gray matter pathology,” and also identified cortical thinning as a neuroimaging correlate of cognitive impairment that was detected only at follow-up between the cognitively impaired and cognitively normal patients who were otherwise similar at baseline.

©Zerbor/thinkstockphotos.com

The study involved 78 consecutive patients with relapsing-remitting multiple sclerosis who underwent neurologic exams during 2015 at a single center in Italy. They all had a cognitive assessment and an MRI scan at the time of diagnosis and at least 8 years of clinical follow-up, including neurologic examination every 6 months. At the time of enrollment into the study, most patients were taking immunomodulatory therapy: 38 were treated with interferon beta-1a, 14 with interferon beta-1b, 15 with glatiramer acetate, and 6 with azathioprine, and 5 were untreated.

At baseline, 39 cognitively normal patients had a mean age of about 36 years, none had conversion to secondary progressive disease, and just 15% had disability progression on the Expanded Disability Status Scale (EDSS). Cortical thickness changed a mean of 3.6%.

The 26 patients with mild cognitive impairment (classified as failure of up to two tests on the Brief Repeatable Battery) were 38 years old at baseline, and only 4 transitioned to secondary progressive disease. Just over half experienced EDSS progression (an average of 0.85 points) and cortical thickness changed by an average of 17%.

The 13 remaining patients with severe cognitive impairment at baseline (three or more failed tests) were about 44 years of age on average and nearly all (92%) experienced EDSS progression, which averaged 1.31 points. Cortical thickness also changed a mean of 34%. Relapsing disease converted to secondary progressive disease in a total of six patients with severe cognitive impairment.

Patients with severe cognitive impairment at baseline had more severe white matter lesion volume at baseline than did others, but there was no difference in the accumulation of white matter lesions during follow-up between patients with normal cognition, mild cognitive impairment, and severe cognitive impairment, which corroborates previous studies. However, the predictive ability of early cognitive impairment in identifying patients with disability progression on the EDSS and cortical thinning “is in line with several previous longitudinal studies showing a strong relationship between gray matter damage and the development of cognitive impairment,” the authors wrote (Brain. 2012 Oct;135[Pt 10]:2952-61 and Neurology. 2013 Nov 12;81[20]:1759-67).

Although the administration of neuropsychological batteries is time consuming and requires expertise, the authors argued that their results “underline the need of using extended screening neuropsychological batteries instead of brief screening batteries, at least at the time of diagnosis, in order to increase the probability to detect even mild forms of cognitive impairment as early as possible in the disease course.”

Read the full paper online in Multiple Sclerosis (2016 Aug 15. doi: 10.1177/1352458516665496).

[email protected]

A Danish population-based cohort study identified a significant association between patients who have rosacea and their risk of having certain other gastrointestinal diseases – specifically, celiac disease, Crohn’s disease, ulcerative colitis, and irritable bowel syndrome.

“While a co-occurrence of rosacea and gastrointestinal disorders has previously been evaluated, the topic remains controversial,” wrote the authors, led by Alexander Egeberg, MD, of the department of dermatology and allergy, Herlev and Gentofte Hospital, Hellerup, Denmark (Br J Dermatol. 2016 Aug 8. doi: 10.1111/bjd.14930).

Dr. Egeberg and his coinvestigators conducted a nationwide cohort study of adults aged 18 years and older from national administrative registers, starting on Jan. 1, 2008, through Dec. 31, 2012. In total, 49,475 rosacea patients were included, with 4,312,213 individuals from the general population who were used as controls. The outcomes were any occurrences of celiac disease (CeD), Crohn’s disease (CD), ulcerative colitis (UC), and irritable bowel syndrome (IBS), Helicobactor pylori (HP) infection, and small intestinal bacterial overgrowth that occurred during the study period, conditions that were chosen “due to their potential mechanistic and pathogenic overlap with rosacea,” they wrote.

At baseline, the prevalence of CeD, CD, UC, HP infection, small intestinal bacterial overgrowth, and IBS was significantly higher among the patients with rosacea, compared with the controls.

Adjusted hazard ratios showed a significant association between patients with rosacea and one of the following GI diagnoses: CeD (Hazard ratio, 1.46), CD (HR, 1.45), UC (HR, 1.19), and IBS (HR, 1.34). However, no significant association was found between rosacea and HP infection or small intestinal bacterial overgrowth.

“The findings from this study raise an important question about the pathogenic overlap between the studied gastrointestinal disorders and rosacea,” Dr. Egeberg and his coauthors wrote. Most of the outcomes examined in the study, they noted, “carry several autoimmune characteristics and, although speculative, it is possible that shared autoimmune susceptibility may provide a link between rosacea and the examined gastrointestinal disorders.”

No funding was received for this study. Dr. Egeberg and his coauthors reported no relevant financial disclosures.

[email protected]

A Danish population-based cohort study identified a significant association between patients who have rosacea and their risk of having certain other gastrointestinal diseases – specifically, celiac disease, Crohn’s disease, ulcerative colitis, and irritable bowel syndrome.

“While a co-occurrence of rosacea and gastrointestinal disorders has previously been evaluated, the topic remains controversial,” wrote the authors, led by Alexander Egeberg, MD, of the department of dermatology and allergy, Herlev and Gentofte Hospital, Hellerup, Denmark (Br J Dermatol. 2016 Aug 8. doi: 10.1111/bjd.14930).

Dr. Egeberg and his coinvestigators conducted a nationwide cohort study of adults aged 18 years and older from national administrative registers, starting on Jan. 1, 2008, through Dec. 31, 2012. In total, 49,475 rosacea patients were included, with 4,312,213 individuals from the general population who were used as controls. The outcomes were any occurrences of celiac disease (CeD), Crohn’s disease (CD), ulcerative colitis (UC), and irritable bowel syndrome (IBS), Helicobactor pylori (HP) infection, and small intestinal bacterial overgrowth that occurred during the study period, conditions that were chosen “due to their potential mechanistic and pathogenic overlap with rosacea,” they wrote.

At baseline, the prevalence of CeD, CD, UC, HP infection, small intestinal bacterial overgrowth, and IBS was significantly higher among the patients with rosacea, compared with the controls.

Adjusted hazard ratios showed a significant association between patients with rosacea and one of the following GI diagnoses: CeD (Hazard ratio, 1.46), CD (HR, 1.45), UC (HR, 1.19), and IBS (HR, 1.34). However, no significant association was found between rosacea and HP infection or small intestinal bacterial overgrowth.

“The findings from this study raise an important question about the pathogenic overlap between the studied gastrointestinal disorders and rosacea,” Dr. Egeberg and his coauthors wrote. Most of the outcomes examined in the study, they noted, “carry several autoimmune characteristics and, although speculative, it is possible that shared autoimmune susceptibility may provide a link between rosacea and the examined gastrointestinal disorders.”

No funding was received for this study. Dr. Egeberg and his coauthors reported no relevant financial disclosures.

[email protected]

A Danish population-based cohort study identified a significant association between patients who have rosacea and their risk of having certain other gastrointestinal diseases – specifically, celiac disease, Crohn’s disease, ulcerative colitis, and irritable bowel syndrome.

“While a co-occurrence of rosacea and gastrointestinal disorders has previously been evaluated, the topic remains controversial,” wrote the authors, led by Alexander Egeberg, MD, of the department of dermatology and allergy, Herlev and Gentofte Hospital, Hellerup, Denmark (Br J Dermatol. 2016 Aug 8. doi: 10.1111/bjd.14930).

Dr. Egeberg and his coinvestigators conducted a nationwide cohort study of adults aged 18 years and older from national administrative registers, starting on Jan. 1, 2008, through Dec. 31, 2012. In total, 49,475 rosacea patients were included, with 4,312,213 individuals from the general population who were used as controls. The outcomes were any occurrences of celiac disease (CeD), Crohn’s disease (CD), ulcerative colitis (UC), and irritable bowel syndrome (IBS), Helicobactor pylori (HP) infection, and small intestinal bacterial overgrowth that occurred during the study period, conditions that were chosen “due to their potential mechanistic and pathogenic overlap with rosacea,” they wrote.

At baseline, the prevalence of CeD, CD, UC, HP infection, small intestinal bacterial overgrowth, and IBS was significantly higher among the patients with rosacea, compared with the controls.

Adjusted hazard ratios showed a significant association between patients with rosacea and one of the following GI diagnoses: CeD (Hazard ratio, 1.46), CD (HR, 1.45), UC (HR, 1.19), and IBS (HR, 1.34). However, no significant association was found between rosacea and HP infection or small intestinal bacterial overgrowth.

“The findings from this study raise an important question about the pathogenic overlap between the studied gastrointestinal disorders and rosacea,” Dr. Egeberg and his coauthors wrote. Most of the outcomes examined in the study, they noted, “carry several autoimmune characteristics and, although speculative, it is possible that shared autoimmune susceptibility may provide a link between rosacea and the examined gastrointestinal disorders.”

No funding was received for this study. Dr. Egeberg and his coauthors reported no relevant financial disclosures.

[email protected]

Colorectal cancer in men was not significantly associated with baseline plasma levels of three inflammatory markers – C-reactive protein, interleukin-6, and tumor necrosis factor receptor 2 (TNFR-2), investigators reported online in Cancer Epidemiology.

The nested case-control study included 268 colorectal cancer (CRC) cases and 446 controls matched by age and smoking status from the Physician’s Health Study, a prospective, randomized, placebo-controlled aspirin trial. High TNFR-2 levels were significantly linked with CRC risk in the placebo arm (relative risk, 1.77; 95% confidence interval, 1.02-3.06; P = .02) of the study, and not in the aspirin arm (P = .72), Chul Kim, MD, of University of Minnesota, Minneapolis, and his associates noted. “This may suggest that aspirin exerts its carcinoprotective effect by blocking the TNF-alpha pathway,” they added, noting that in mice, blocking this pathway helps prevent CRC secondary to chronic colitis. However, a test for interactions yielded no evidence that aspirin significantly modifies the relationship between TNFR-2 and CRC, they said (Cancer Epidemiol. 2016;44:65-70).

Courtesy Wikimedia Commons/nephron/Creative Commons License

Chronic inflammation is thought to promote carcinogenesis, including CRC, which is associated with inflammatory bowel disease. Studies have shown that long-term nonsteroidal anti-inflammatory and aspirin therapy attenuates CRC risk, but have not clarified the relationship between baseline plasma inflammatory markers and CRC. Dr. Kim and associates controlled for known CRC risk factors, including body mass index, alcohol consumption, physical activity level, multivitamin use, and dairy intake. In contrast to their findings in men, the Nurses’ Health Study did find a significant link between TNFR-2 levels and CRC risk in women, they noted (RR, 1.67; 95% CI, 1.05-2.68; P = .03).

They acknowledged several limitations. A single inflammatory marker test “may not represent a person’s inflammatory status during the development of colorectal cancer,” and marker levels were assayed during the run-in period of the trial, when all participants received aspirin, they said. Furthermore, the trial only ran for 5 years, after which more than 70% of patients took aspirin, which “would have significantly attenuated the true association that we would observe in this study.”

The National Cancer Institute, National Heart, Lung, and Blood Institute, National Cancer Institute of Canada, and National Institutes of Health provided funding. The authors had no disclosures.

Colorectal cancer in men was not significantly associated with baseline plasma levels of three inflammatory markers – C-reactive protein, interleukin-6, and tumor necrosis factor receptor 2 (TNFR-2), investigators reported online in Cancer Epidemiology.

The nested case-control study included 268 colorectal cancer (CRC) cases and 446 controls matched by age and smoking status from the Physician’s Health Study, a prospective, randomized, placebo-controlled aspirin trial. High TNFR-2 levels were significantly linked with CRC risk in the placebo arm (relative risk, 1.77; 95% confidence interval, 1.02-3.06; P = .02) of the study, and not in the aspirin arm (P = .72), Chul Kim, MD, of University of Minnesota, Minneapolis, and his associates noted. “This may suggest that aspirin exerts its carcinoprotective effect by blocking the TNF-alpha pathway,” they added, noting that in mice, blocking this pathway helps prevent CRC secondary to chronic colitis. However, a test for interactions yielded no evidence that aspirin significantly modifies the relationship between TNFR-2 and CRC, they said (Cancer Epidemiol. 2016;44:65-70).

Courtesy Wikimedia Commons/nephron/Creative Commons License

Chronic inflammation is thought to promote carcinogenesis, including CRC, which is associated with inflammatory bowel disease. Studies have shown that long-term nonsteroidal anti-inflammatory and aspirin therapy attenuates CRC risk, but have not clarified the relationship between baseline plasma inflammatory markers and CRC. Dr. Kim and associates controlled for known CRC risk factors, including body mass index, alcohol consumption, physical activity level, multivitamin use, and dairy intake. In contrast to their findings in men, the Nurses’ Health Study did find a significant link between TNFR-2 levels and CRC risk in women, they noted (RR, 1.67; 95% CI, 1.05-2.68; P = .03).

They acknowledged several limitations. A single inflammatory marker test “may not represent a person’s inflammatory status during the development of colorectal cancer,” and marker levels were assayed during the run-in period of the trial, when all participants received aspirin, they said. Furthermore, the trial only ran for 5 years, after which more than 70% of patients took aspirin, which “would have significantly attenuated the true association that we would observe in this study.”

The National Cancer Institute, National Heart, Lung, and Blood Institute, National Cancer Institute of Canada, and National Institutes of Health provided funding. The authors had no disclosures.

Colorectal cancer in men was not significantly associated with baseline plasma levels of three inflammatory markers – C-reactive protein, interleukin-6, and tumor necrosis factor receptor 2 (TNFR-2), investigators reported online in Cancer Epidemiology.

The nested case-control study included 268 colorectal cancer (CRC) cases and 446 controls matched by age and smoking status from the Physician’s Health Study, a prospective, randomized, placebo-controlled aspirin trial. High TNFR-2 levels were significantly linked with CRC risk in the placebo arm (relative risk, 1.77; 95% confidence interval, 1.02-3.06; P = .02) of the study, and not in the aspirin arm (P = .72), Chul Kim, MD, of University of Minnesota, Minneapolis, and his associates noted. “This may suggest that aspirin exerts its carcinoprotective effect by blocking the TNF-alpha pathway,” they added, noting that in mice, blocking this pathway helps prevent CRC secondary to chronic colitis. However, a test for interactions yielded no evidence that aspirin significantly modifies the relationship between TNFR-2 and CRC, they said (Cancer Epidemiol. 2016;44:65-70).

Courtesy Wikimedia Commons/nephron/Creative Commons License

Chronic inflammation is thought to promote carcinogenesis, including CRC, which is associated with inflammatory bowel disease. Studies have shown that long-term nonsteroidal anti-inflammatory and aspirin therapy attenuates CRC risk, but have not clarified the relationship between baseline plasma inflammatory markers and CRC. Dr. Kim and associates controlled for known CRC risk factors, including body mass index, alcohol consumption, physical activity level, multivitamin use, and dairy intake. In contrast to their findings in men, the Nurses’ Health Study did find a significant link between TNFR-2 levels and CRC risk in women, they noted (RR, 1.67; 95% CI, 1.05-2.68; P = .03).

They acknowledged several limitations. A single inflammatory marker test “may not represent a person’s inflammatory status during the development of colorectal cancer,” and marker levels were assayed during the run-in period of the trial, when all participants received aspirin, they said. Furthermore, the trial only ran for 5 years, after which more than 70% of patients took aspirin, which “would have significantly attenuated the true association that we would observe in this study.”

The National Cancer Institute, National Heart, Lung, and Blood Institute, National Cancer Institute of Canada, and National Institutes of Health provided funding. The authors had no disclosures.

I’ve written quite a lot over the past few years about the trend toward soloists and small groups selling their practices to hospitals, multispecialty groups, or larger practices. And I’ve made it fairly clear that I don’t think it’s a particularly good thing that the medical profession is going the way of the corner gas station and the mom-and-pop grocery store; it’s not good for physicians, patients, or private practice.

That said, if retirement looms with no individual buyers in sight, or your overhead is getting out of hand, selling to a larger entity is an option that you may need to consider. Too often, though, sellers are not receiving a fair return on the equity they have worked so hard to build over several decades, either because they have waited too long and must accept what is offered, or because they simply take the buyer’s word for their practice’s value. Don’t put yourself in either of those positions; and don’t entertain any offers until you obtain an objective appraisal from a neutral party.

Of course, a medical practice is trickier to value than is an ordinary business and usually requires the services of an experienced professional appraiser. Entire books have been written about the process, so I can’t hope to cover it completely in 850 words; but three basic yardsticks are essential for determining the equity, or book value, of a practice:

• Tangible Assets: equipment, cash, accounts receivable, and other property owned by the practice.

• Liabilities: accounts payable, outstanding loans, and anything else owed to others.

• Intangible Assets: sometimes called “good will” – the reputation of the physicians, the location and name recognition of the practice, the loyalty and volume of patients, and other, well, intangibles.

Valuing tangible assets is comparatively straightforward, but there are several ways to do it, and when reviewing a practice appraisal, you should ask which of them was used. Depreciated value is the book value of equipment and supplies as determined by their purchase price, less the amount their value has decreased since purchase. Remaining useful life value estimates how long the equipment can be expected to last. Market (or replacement) value is the amount it would cost on the open market to replace all equipment and supplies.

Intangible assets are more difficult to value. Many components are analyzed, including location, interior and exterior decor, accessibility to patients, age and functional status of equipment, systems in place to promote efficiency, reasons why patients come back (if in fact they do), and the overall reputation of the practice in the community. Other important factors include the “payer mix” (what percentage pays cash, how many third-party contracts are in place, and how well they pay, etc.), the extent and strength of the referral base, and the presence of supplemental income streams, such as clinical research.

It is also important to determine to what extent intangible assets are transferable. For example, unique skills with a laser, neurotoxins, or filler substances, or extraordinary personal charisma, may increase your practice’s value to you, but they are worthless to the next owner, and he or she will be unwilling to pay for them unless your services become part of the deal.

Once again, there are many ways to estimate intangible asset value, and once again, you should ask which were used. Cash Flow Analysis works on the assumption that cash flow is a measure of intangible value. Capitalization of Earnings puts a value, or capitalization, on the practice’s income streams using a variety of assumptions. Guideline Comparison uses various databases to compare your practice with other, similar ones that have changed hands in the past.

Two newer techniques that some consider a better estimate of intangible assets are the replacement method, which estimates the costs of starting the practice over again in the current market; and the excess earnings method, which measures how far above average your practice’s earnings (and thus its overall value) are.

Asset-based valuation is the most popular – but by no means the only – method available. Income-based valuation looks at the source and strength of a practice’s income stream as a creator of value, as well as whether or not its income stream under a different owner would mirror its present one. This in turn becomes the basis for an understanding of the fair market value of both tangible and intangible assets. Market valuation combines the asset-based and income-based approaches, along with an analysis of sales and mergers of comparable practices in the community, to determine the value of a practice in its local market.

Whatever methods are used, it is important that the appraisal be done by an experienced and independent financial consultant, that all techniques used in the valuation be divulged and explained, and that documentation is supplied to support the conclusions reached. This is especially important if the appraisal will be relied upon in the sale or merger of the practice.

Dr. Eastern practices dermatology and dermatologic surgery in Belleville, N.J. He is the author of numerous articles and textbook chapters, and is a long-time monthly columnist for Dermatology News. Write to him at [email protected].

I’ve written quite a lot over the past few years about the trend toward soloists and small groups selling their practices to hospitals, multispecialty groups, or larger practices. And I’ve made it fairly clear that I don’t think it’s a particularly good thing that the medical profession is going the way of the corner gas station and the mom-and-pop grocery store; it’s not good for physicians, patients, or private practice.

That said, if retirement looms with no individual buyers in sight, or your overhead is getting out of hand, selling to a larger entity is an option that you may need to consider. Too often, though, sellers are not receiving a fair return on the equity they have worked so hard to build over several decades, either because they have waited too long and must accept what is offered, or because they simply take the buyer’s word for their practice’s value. Don’t put yourself in either of those positions; and don’t entertain any offers until you obtain an objective appraisal from a neutral party.

Of course, a medical practice is trickier to value than is an ordinary business and usually requires the services of an experienced professional appraiser. Entire books have been written about the process, so I can’t hope to cover it completely in 850 words; but three basic yardsticks are essential for determining the equity, or book value, of a practice:

• Tangible Assets: equipment, cash, accounts receivable, and other property owned by the practice.

• Liabilities: accounts payable, outstanding loans, and anything else owed to others.

• Intangible Assets: sometimes called “good will” – the reputation of the physicians, the location and name recognition of the practice, the loyalty and volume of patients, and other, well, intangibles.

Valuing tangible assets is comparatively straightforward, but there are several ways to do it, and when reviewing a practice appraisal, you should ask which of them was used. Depreciated value is the book value of equipment and supplies as determined by their purchase price, less the amount their value has decreased since purchase. Remaining useful life value estimates how long the equipment can be expected to last. Market (or replacement) value is the amount it would cost on the open market to replace all equipment and supplies.

Intangible assets are more difficult to value. Many components are analyzed, including location, interior and exterior decor, accessibility to patients, age and functional status of equipment, systems in place to promote efficiency, reasons why patients come back (if in fact they do), and the overall reputation of the practice in the community. Other important factors include the “payer mix” (what percentage pays cash, how many third-party contracts are in place, and how well they pay, etc.), the extent and strength of the referral base, and the presence of supplemental income streams, such as clinical research.

It is also important to determine to what extent intangible assets are transferable. For example, unique skills with a laser, neurotoxins, or filler substances, or extraordinary personal charisma, may increase your practice’s value to you, but they are worthless to the next owner, and he or she will be unwilling to pay for them unless your services become part of the deal.

Once again, there are many ways to estimate intangible asset value, and once again, you should ask which were used. Cash Flow Analysis works on the assumption that cash flow is a measure of intangible value. Capitalization of Earnings puts a value, or capitalization, on the practice’s income streams using a variety of assumptions. Guideline Comparison uses various databases to compare your practice with other, similar ones that have changed hands in the past.

Two newer techniques that some consider a better estimate of intangible assets are the replacement method, which estimates the costs of starting the practice over again in the current market; and the excess earnings method, which measures how far above average your practice’s earnings (and thus its overall value) are.

Asset-based valuation is the most popular – but by no means the only – method available. Income-based valuation looks at the source and strength of a practice’s income stream as a creator of value, as well as whether or not its income stream under a different owner would mirror its present one. This in turn becomes the basis for an understanding of the fair market value of both tangible and intangible assets. Market valuation combines the asset-based and income-based approaches, along with an analysis of sales and mergers of comparable practices in the community, to determine the value of a practice in its local market.

Whatever methods are used, it is important that the appraisal be done by an experienced and independent financial consultant, that all techniques used in the valuation be divulged and explained, and that documentation is supplied to support the conclusions reached. This is especially important if the appraisal will be relied upon in the sale or merger of the practice.

Dr. Eastern practices dermatology and dermatologic surgery in Belleville, N.J. He is the author of numerous articles and textbook chapters, and is a long-time monthly columnist for Dermatology News. Write to him at [email protected].

I’ve written quite a lot over the past few years about the trend toward soloists and small groups selling their practices to hospitals, multispecialty groups, or larger practices. And I’ve made it fairly clear that I don’t think it’s a particularly good thing that the medical profession is going the way of the corner gas station and the mom-and-pop grocery store; it’s not good for physicians, patients, or private practice.

That said, if retirement looms with no individual buyers in sight, or your overhead is getting out of hand, selling to a larger entity is an option that you may need to consider. Too often, though, sellers are not receiving a fair return on the equity they have worked so hard to build over several decades, either because they have waited too long and must accept what is offered, or because they simply take the buyer’s word for their practice’s value. Don’t put yourself in either of those positions; and don’t entertain any offers until you obtain an objective appraisal from a neutral party.

Of course, a medical practice is trickier to value than is an ordinary business and usually requires the services of an experienced professional appraiser. Entire books have been written about the process, so I can’t hope to cover it completely in 850 words; but three basic yardsticks are essential for determining the equity, or book value, of a practice:

• Tangible Assets: equipment, cash, accounts receivable, and other property owned by the practice.

• Liabilities: accounts payable, outstanding loans, and anything else owed to others.

• Intangible Assets: sometimes called “good will” – the reputation of the physicians, the location and name recognition of the practice, the loyalty and volume of patients, and other, well, intangibles.

Valuing tangible assets is comparatively straightforward, but there are several ways to do it, and when reviewing a practice appraisal, you should ask which of them was used. Depreciated value is the book value of equipment and supplies as determined by their purchase price, less the amount their value has decreased since purchase. Remaining useful life value estimates how long the equipment can be expected to last. Market (or replacement) value is the amount it would cost on the open market to replace all equipment and supplies.

Intangible assets are more difficult to value. Many components are analyzed, including location, interior and exterior decor, accessibility to patients, age and functional status of equipment, systems in place to promote efficiency, reasons why patients come back (if in fact they do), and the overall reputation of the practice in the community. Other important factors include the “payer mix” (what percentage pays cash, how many third-party contracts are in place, and how well they pay, etc.), the extent and strength of the referral base, and the presence of supplemental income streams, such as clinical research.

It is also important to determine to what extent intangible assets are transferable. For example, unique skills with a laser, neurotoxins, or filler substances, or extraordinary personal charisma, may increase your practice’s value to you, but they are worthless to the next owner, and he or she will be unwilling to pay for them unless your services become part of the deal.

Once again, there are many ways to estimate intangible asset value, and once again, you should ask which were used. Cash Flow Analysis works on the assumption that cash flow is a measure of intangible value. Capitalization of Earnings puts a value, or capitalization, on the practice’s income streams using a variety of assumptions. Guideline Comparison uses various databases to compare your practice with other, similar ones that have changed hands in the past.

Two newer techniques that some consider a better estimate of intangible assets are the replacement method, which estimates the costs of starting the practice over again in the current market; and the excess earnings method, which measures how far above average your practice’s earnings (and thus its overall value) are.

Asset-based valuation is the most popular – but by no means the only – method available. Income-based valuation looks at the source and strength of a practice’s income stream as a creator of value, as well as whether or not its income stream under a different owner would mirror its present one. This in turn becomes the basis for an understanding of the fair market value of both tangible and intangible assets. Market valuation combines the asset-based and income-based approaches, along with an analysis of sales and mergers of comparable practices in the community, to determine the value of a practice in its local market.

Whatever methods are used, it is important that the appraisal be done by an experienced and independent financial consultant, that all techniques used in the valuation be divulged and explained, and that documentation is supplied to support the conclusions reached. This is especially important if the appraisal will be relied upon in the sale or merger of the practice.

Dr. Eastern practices dermatology and dermatologic surgery in Belleville, N.J. He is the author of numerous articles and textbook chapters, and is a long-time monthly columnist for Dermatology News. Write to him at [email protected].

Seventy-four percent of physician specialties saw increases in their compensation in 2015, led by emergency medicine, according to the American Medical Group Association.

Overall, the weighted average increase in median compensation across all physician specialties was 3.1%, according to the 2016 Medical Group Compensation and Productivity Survey. Results were based on responses from 260 medical groups representing more than 92,000 providers.

thinkstockphotos.com

“Once again, we see that physician compensation in general has remained relatively flat, with an average increase around 3.0%,” AMGA President and CEO Donald Fisher, PhD, said in a statement.

“We’ve seen peaks in certain specialties, and dips in others, and much of this reflects the cyclical nature of health care economics,” he added. For example, data from the 2014 survey saw gastroenterology had the largest year-over-year increase and in the 2016 survey, it was one of four specialties to see a decrease in compensation.

Individual specialties seeing the largest median total compensation increase year over year include emergency medicine (9.65% to $355,280), cardiac/thoracic surgery (8.12% to $645,112), cardiology (6.88% to $483.653), and hypertension and nephrology (6.72% to $329,750). Total compensation captures base and variable compensation plus all voluntary salary reductions, but excludes fringe benefits and employer payments to any type of retirement, pension, SERP or tax-deferred profit-sharing plan.

Four specialties saw median decreases in their compensation, including dermatology (–4.27% to $434,520), ophthalmology (–4.17% to $385,149), cardiology-cath lab (–0.81% to $584,118), and gastroenterology (–0.16% to $505,194).

[email protected]

Seventy-four percent of physician specialties saw increases in their compensation in 2015, led by emergency medicine, according to the American Medical Group Association.

Overall, the weighted average increase in median compensation across all physician specialties was 3.1%, according to the 2016 Medical Group Compensation and Productivity Survey. Results were based on responses from 260 medical groups representing more than 92,000 providers.

thinkstockphotos.com

“Once again, we see that physician compensation in general has remained relatively flat, with an average increase around 3.0%,” AMGA President and CEO Donald Fisher, PhD, said in a statement.

“We’ve seen peaks in certain specialties, and dips in others, and much of this reflects the cyclical nature of health care economics,” he added. For example, data from the 2014 survey saw gastroenterology had the largest year-over-year increase and in the 2016 survey, it was one of four specialties to see a decrease in compensation.

Individual specialties seeing the largest median total compensation increase year over year include emergency medicine (9.65% to $355,280), cardiac/thoracic surgery (8.12% to $645,112), cardiology (6.88% to $483.653), and hypertension and nephrology (6.72% to $329,750). Total compensation captures base and variable compensation plus all voluntary salary reductions, but excludes fringe benefits and employer payments to any type of retirement, pension, SERP or tax-deferred profit-sharing plan.

Four specialties saw median decreases in their compensation, including dermatology (–4.27% to $434,520), ophthalmology (–4.17% to $385,149), cardiology-cath lab (–0.81% to $584,118), and gastroenterology (–0.16% to $505,194).

[email protected]

Seventy-four percent of physician specialties saw increases in their compensation in 2015, led by emergency medicine, according to the American Medical Group Association.

Overall, the weighted average increase in median compensation across all physician specialties was 3.1%, according to the 2016 Medical Group Compensation and Productivity Survey. Results were based on responses from 260 medical groups representing more than 92,000 providers.

thinkstockphotos.com

“Once again, we see that physician compensation in general has remained relatively flat, with an average increase around 3.0%,” AMGA President and CEO Donald Fisher, PhD, said in a statement.

“We’ve seen peaks in certain specialties, and dips in others, and much of this reflects the cyclical nature of health care economics,” he added. For example, data from the 2014 survey saw gastroenterology had the largest year-over-year increase and in the 2016 survey, it was one of four specialties to see a decrease in compensation.

Individual specialties seeing the largest median total compensation increase year over year include emergency medicine (9.65% to $355,280), cardiac/thoracic surgery (8.12% to $645,112), cardiology (6.88% to $483.653), and hypertension and nephrology (6.72% to $329,750). Total compensation captures base and variable compensation plus all voluntary salary reductions, but excludes fringe benefits and employer payments to any type of retirement, pension, SERP or tax-deferred profit-sharing plan.

Four specialties saw median decreases in their compensation, including dermatology (–4.27% to $434,520), ophthalmology (–4.17% to $385,149), cardiology-cath lab (–0.81% to $584,118), and gastroenterology (–0.16% to $505,194).

[email protected]