2011_APMSA

2 0 1 1APMSA

NEWPRACTITIONER’S

GUIDE

When they come to you ...

1 RITA. Research and Innovative Technology Administration, Bureau of Transportation Statistics.http://www.transtats.bts.gov/Oneway.asp? Display_Flag=0&Percent_Flag=0. Accessed Aug 24, 2010.

Instant Coupon available at www.NaftinCoupons.com or by calling 1 888 296 1852

IndicationNaftin® (naftifine HCl 1%) Cream and Gel are indicated for the topical treatment of tinea pedis, tinea cruris and tinea corporis caused by Tricho-phyton rubrum, Trichophyton mentagro phytes, Epidermophyton floccosum and Trichophy ton tonsurans (Gel only).

Important Safety Information Naftin® Cream and Gel are contraindicated in individuals who have shown hypersensitivity to any of their components and are for topical use only. The most commonly reported side effects of Naftin® are burning/stinging, dryness, redness, itching, and local irritation.

Many eligible patients will receive the Naftin 90gm size at No Out-of-Pocket Cost!**

Please see adjacent page for Full Prescribing Information

UP TO $100 OFF * INSTANTLY FOR ANY NAFTIN (naftifine HCl 1%)

* Subject to eligibility. Restrictions apply.

** Average co-pay shown verified as of August 2010 based on reports from 380 health plans (eg. HMO, PPO, IPA, etc.) inclusive of all benefit designs/co-pay tiers.

On average, over 20 million people will board airplanes each month around the world.1 Some will walk barefooted through airport security which may expose them to tinea pedis.

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Now that you have completed your residency, you are responsible for .

A.) Taking a long, leisurely vacation.

B.) Having a life again.

C.) Making sure you have the proper malpractice insurance coverage before you see a patient.

Podiatry Insurance Company of America (PICA) was founded by podiatrists, for podiatrists over 30 years ago. PICA is podiatry-focused and the nation’s top podiatric malpractice insurance provider. We are endorsed by APMA and offer generous new practitioner discounts. PICA, however, cannot provide accommodations for a long vacation or assist you with your social calendar.

One Last Quiz

For all of your malpractice insurance needs, visit us online at picagroup.com or call (800) 251-5727 option 3, option 2.

Please see adjacent page for Full Prescribing Information1 RITA. Research and Innovative Technology Administration, Bureau of Transportation Statistics.http://

www.transtats.bts.gov/Oneway.asp? Display_Flag=0&Percent_Flag=0. Accessed Aug 24, 2010.


IndicationNaftin® (naftifine HCl 1%) Cream and Gel are indicated for the topical treatment of tinea pedis, tinea cruris and tinea corporis caused by Trichophyton rubrum, Trichophyton mentagro phytes, Epidermophyton floccosum and Trichophy ton tonsurans (Gel only).








Rx ONLY

INDICATIONS AND USAGE: Naftin® Cream, 1% is indicated for the topical treatment of tinea pedis, tinea cruris, and tinea corporis caused by the organisms Trichophyton rubrum, Trichophyton mentagrophytes, and Epidermophyton floccosum. Naftin® Gel, 1% is indicated for the topical treatment of tinea pedis, tinea cruris, and tinea corporis caused by the organisms Trichophyton rubrum, Trichophyton mentagrophytes, Trichophyton tonsurans*, Epidermophyton floccosum*.

* Efficacy for this organism in this organ system was studied in fewer than 10 infections.

CONTRAINDICATIONS: Naftin® Cream and Gel, 1% are contraindicated in individuals who have shown hypersensitivity to any of their components.

WARNINGS: Naftin® Cream and Gel, 1% are for topical use only and not for ophthalmic use.

PRECAUTIONS: General: Naftin® Cream and Gel, 1%, are for external use only. If irritation or sensitivity develops with the use of Naftin® Cream or Gel, 1%, treatment should be discontinued and appropriate therapy instituted. Diagnosis of the disease should be confirmed either by direct microscopic examination of a mounting of infected tissue in a solution of potassium hydroxide or by culture on an appropriate medium.

Information for patients: The patient should be told to:1. Avoid the use of occlusive dressings or wrappings unless otherwise directed by

the physician.2. Keep Naftin® Cream and Gel, 1% away from the eyes, nose, mouth and other

mucous membranes.

Carcinogenesis, mutagenesis, impairment of fertility: Long-term studies to evaluate the carcinogenic potential of Naftin® Cream and Gel, 1% have not been performed. In vitro and animal studies have not demonstrated any mutagenic effect or effect on fertility.

Pregnancy: Teratogenic Effects: Pregnancy Category B: Reproduction studies have been performed in rats and rabbits (via oral administration) at doses 150 times or more than the topical human dose and have revealed no evidence of impaired fertility or harm to the fetus due to naftifine. There are, however, no adequate and well-controlled studies in pregnant women. Because animal reproduction studies are not always predictive of human response, this drug should be used during pregnancy only if clearly needed.

Nursing mothers: It is not known whether this drug is excreted in human milk. Because many drugs are excreted in human milk, caution should be exercised when Naftin® Cream or Gel,1% are administered to a nursing woman.

Pediatric use: Safety and effectiveness in pediatric patients have not been established.

ADVERSE REACTIONS: During clinical trials with Naftin® Cream, 1%, the incidence of adverse reactions was as follows: burning/stinging (6%), dryness (3%), erythema (2%), itching (2%), local irritation (2%). During clinical trials with Naftin® Gel, 1%, the incidence of adverse reactions was as follows: burning /stinging (5.0%), itching (1.0%), erythema (0.5%), rash (0.5%), skin tenderness (0.5%).

G E L C R E A M

Manufactured for Merz Pharmaceuticals, Greensboro, NC 27410© 2010 Merz Pharmaceuticals Rev 3/10

BRIEF SUMMARY

APMSANewPractitioner’s Guide 2011

Cover design services were provided through the generosity and support of the Podiatry Insurance Company of America (PICA) by graphic designer Vanessa Multon.

Advancing Podiatric MedicineThrough Excellence and Unity

Editor — Dorothy Cahill McDonald

APMSA Class of 2011 Delegates

Lindsey Calligaro — NYCPMMark B. Ellis — CPMSZackary B. Gangwer — AZPODBlair Jolley — TUSPMLena Keester — SCPMCharles Lee — NYCPMLucinda Malvitz — SCPMBrian Oase — AZPODDerek Pantiel — OCPMPatrick Qualtire — CSPMJasmaine Shelford — BUSGM

As an APMA Member, you qualify for a multitude of benefits including:

� Marketing Tools for your practiceincluding the Footprints newsletterand PowerPoint presentations, all customizable and free of charge

� PR Tools including press releases and office brochures

� Access to the Coding Resource Center

� APMA News and The Journalof the APMA

� Reduced pricing to attend “The National,” APMA’s annual scientific meeting

For more information or to speak directly to a Membership Specialist, please contact APMA at:

1-800-ASK-APMA or www.apma.org

Your BenefitsAbound

DedicationThe APMSA 2011

New Practitioner’s Guide is dedicated to the accomplishments,

past and future, of the podiatric medical

student class of 2011.

“To furnish the means of acquiring knowledge is ... the greatest benefit that can be conferred upon mankind. It prolongs life itself and enlarges the sphere of existence.”

—John Quincy Adams

Performance is our heritage, commitment, and the force behind New Balance Total Fit. New Balance personally

selects dealers with the proper expertise and an extensive selection to ensure you get the right shoe and right fit for

your active lifestyle. Find a Procare dealer near you now: newbalance.com/shop/procare

Shoes That Fit Better PERFORM BETTER

©2011 All rights reserved.

APMSA 2011 .indd 1 2/2/11 4:20 PM

From the Editor

Congratulations to the class of 2011 on the successful completion of your degree in podiatric medicine, and to those beginning to navigate the journey into the practice of podiatric medicine. We trust that this publication will serve as a valuable resource for you during residency and in the first few years of practice.

I extend my sincere appreciation to the following individuals and organizations for their advice, support and contributions to the APMSA 2011 New Practitioner’s Guide.

Susan AustinAPMA Staff and Board of TrusteesMeredith ChurchJo DeckertMary Jane DorrJackie HardyVanessa MultonPodiatry Insurance Company of America (PICA)Teresa Russell

To my family, Jr., Grace, Meredith, and Shane, I am so blessed that you are mine.

Dorothy Cahill McDonaldEditorAPMSA Executive Director

Spenco_APMSA2011_out.pdf 3/1/11 9:53:20 AM

“Advancing Podiatric Medicine Through Excellence and Unity”

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For over 25 years, the APMSA Corporate Advisory Board (CAB) has supported the APMSA and podiatric medical students. The APMSA is grateful to the following APMSA CAB members who have supported a broad range of student programs and projects’ including the APMSA New Practitioner’s Guide and the APMSA Residency Survey:

For over 60 years, Aetrex has pioneered the application of pedorthic expertise to high performance foot care products and technologies. Aetrex offers doctors unique products that truly address the specific needs of their patients. The Aetrex development team includes over 25 certified pedorthists. Aetrex proudly supports the American Podiatric Medical Students’ Association and looks forward to working with all graduates throughout their career.

ASICS is an acronym derived from the Latin phrase Anima Sana In Corpore Sano - a sound mind in a sound body. Staying true to this philosophy, every ASICS innovation, concept, and idea is intended to create the best athletic products. We pledge to continue to make the best product; striving to build upon our technological advances and pushing the limits on what we can learn from the body and its needs in athletic gear. We pledge to bring harmony to the body and soul.

Bako Podiatric Pathology Services is a physician-owned provider of a wide array of pathology services ranging from histopathologic examination of bone, soft tissue, and skin/nail unit, to microbiology and epidermal nerve fiber density testing. We pride ourselves on providing the best available customer service, concise reports with therapeutic options, photomicrographic imaging, compliant and patient-friendly billing policies, internet-based report access, and a client/patient comes-first business model. At Bako Pathology Services, we're not just providing a premium pathology service; we're dedicated to the advancement of this great profession through Education, Research, and Financial Support. 877-DPM-PATH www.bakopathology.com

Crocs™ Footwear has become a bona-fide phenomenon, universally accepted as an all purpose shoe for comfort and fashion. Despite our rapid success, we still stand behind the core values of Crocs™ Footwear. We are committed to making a lightweight, comfortable, slip-resistant, fashionable and functional shoe, which can be produced quickly and at an affordable price to our customers. We thank you for your support and look forward to providing you with exciting new Crocs™ Shoe designs in the years to come.

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In 2010, DARCO International, Inc. is celebrating its 25th year as a leading provider of post op, trauma and wound care solutions to the global foot and ankle community. DARCO’s reputation is founded on the unyielding pursuit of developing innovative, high-quality products that bring exceptional value to the podiatric practitioners and their patients. Since the beginning, DARCO has been a loyal supporter of the podiatric profession.

Gill Podiatry Supply and Equipment Company is solely dedicated to providing products and services to the podiatrist. We’re a full service company that offers quality products at competitive prices. We offer one-step shopping carrying all the instruments, supplies and equipment you need. Gill’s professional staff is available to advise and assist you in making your purchases. Whether your purchase is a single item, class purchase or setting up your entire office, Gill is there to help you. 800-321-1348; www.gillpodiatry.com.

Gordon Laboratories has been a member of CAB since its inception in 1985. The company has played an integral role in podiatry since manufacturing the first topical pharmaceutical product line for the profession more than a half century ago. Today the company manufactures the largest selection of quality podiatric pharmaceuticals for all types of topical conditions. Gordon’s ongoing commitment to the profession includes: in-office dispensing assistance, educational/scholarship aid, and funding for student projects.

Biofreeze Pain Reliever is the most frequently used and #1 recommended topical pain reliever by hands-on healthcare professionals. For over 18 years, Biofreeze products have been helping people mange their discomfort by offering a variety of benefits that assist in exercise/training, pain relief, therapy and overall comfort. Using natural menthol as the active ingredient, Biofreeze products act quickly, helping to prevent or relieve pain. www.biofreeze.com 800-246-3733.

Since 1969 Langer Biomechanics, Inc. has upheld a reputation as a leading manufacturer of lower extremity care products, including custom orthotics, ankle foot orthoses, Durable Medical Equipment and PPT. We are confident that our experienced staff and constantly evolving product line will provide patients with the highest quality care possible. We are committed to ensuring positive patient outcomes and still adhere to the belief that practitioners are dedicated to providing what is best for their patients. Langer is honored to work with the APMSA and looks forward to serving as both an educational resource and provider of high quality orthopedic products.

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Moore Medical, LLC is a leading distributor of medical-surgical supplies, equipment, furniture and pharmaceuticals in podiatry that has been serving the industry for over 60 years. Our experienced podiatry team includes sales and market specialists who understand your needs and are constantly searching for new and better solutions to help you succeed. Moore Medical has over 15,000 products available through our national distribution network including over 1,200 in our exclusive Moore Brand product line. Empowering you with the supplies, tools, information and resources you need to support the health and care of your patients - and your business - is our main purpose. Over 100,000 health care professionals nationwide trust Moore Medical as a partner and a valued resource. Call us at 800.234.1464; or visit: www.mooremedical.com.

Privately held Boston-based New Balance has grown from a small company to an industry leader in both footwear and apparel by remaining committed to teamwork, technological innovation, width-sizing, domestic manufacturing, grassroots promotions, and strong retailer partnerships. Footwear product categories include running, cross-training, walking, tennis, adventure sports, team and kids. New Balance also supports a family of brands including Aravon, Dunham, PF Flyer, Warrior and Brine.

Pedinol Pharmacal Inc. would like to congratulate podiatry school graduates of 2009 on completing their podiatric medicine education. As a podiatry specific pharmaceutical company since 1925, Pedinol is excited to have you join the profession of podiatric medicine. We look forward to providing you and your patients with safe and effective treatments. Please visit us at www.pedinol.com. Congratulations and best of luck from everyone at Pedinol!

Podiatry Insurance Company of America (PICA) is the nation's leading provider of professional liability insurance for podiatric physicians. We offer excellent new practitioner discounts with no finance charges for newly practicing doctors. We support your profession with scholarships for students and sponsorship of the APMSA and APMA Young Members' Program. In addition, we are endorsed by the APMA and the ACFAS.

PRESENT e-Learning Systems is dedicated to improving the knowledge and skills of medical professionals throughout the world by providing high quality medical education programming via the Internet and by fostering collaboration with their peers at worldwide centers of excellence. www.presentelearning.com

ProLab Orthotics is an orthotic industry leader, incorporating evidence-based medicine and clinical expertise into our orthotic design for optimal patient outcomes. Partner with ProLab for exceptional products, free clinical consultations with our team of podiatrists, and to access our

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extensive scientific and educational resources. For more information, call (800)477-6522 or go to www.prolaborthotics.com.

Promet has been making custom foot orthotics for podiatry since 1992. Promet is owned and operated by founder Dave Krueger, a Certified Pedorthist and University of Minnesota graduate, with an extensive background in orthopedic footwear and athletics. Our staff is a crew of highly experienced and talented technicians who have demonstrated great loyalty to our company and our customers in our sixteen years of service. Our devices will be made exactly the way you want them, or we can suggest a device that will fit your needs.

Nature intended us to be barefoot. However, we need shoes to protect our feet. The next best thing to barefoot is a good comfortable shoe. SAS creates each new shoe with only one thing in mind…you. We could use cheaper materials - but you’d feel the difference. We work overtime working out comfort issues because your day doesn’t always end at 5. Obsessive? Maybe…we historically take the hard road so you don’t have to. www.SASshoes.com.

Straight Arrow Products, Inc., are the providers of unique therapeutic skin care products, such as Foot Miracle®, Urea Care® and Hoofmaker®, that have garnered a loyal following in the podiatric world over twenty years. www.straightarrowinc.com.

Swede-O, Inc has been recognized the worldwide leader in providing innovative products designed to prevent or rehabilitate ankle related injuries for over 25 years. Numerous independent clinical studies have proven the effectiveness of Swede-O ankle braces in preventing ankle injuries and that they are equal to or better than professionally applied tape for ankle support. We recently expanded our product offerings to include a patented line of orthopedic supports designed to prevent, treat and rehabilitate most any part of the body. Swede-O remains the first choice for ankle protection.

Upsher-Smith is pursuing improved drug therapies to improve people’s lives. The evolution of our company is driven by the ever-changing needs of patients, physicians, pharmacists, and healthcare organizations. Our perspective is not “more products,” but the right products that make people’s lives better. At every level of our business, we are driven to be the best. We promise to provide reliable, affordable products that have a daily impact to improve lives.

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APMSA 2011 NEW PRACTITIONER’S GUIDE TABLE OF CONTENTS PAGE I. PRACTICE PREPARATION/GETTING STARTED 17 A Message from the APMA 19 APMA Young Member Membership 22 APMA State Component Associations 27 APMA Affiliated and Related Organizations 36 Pre-Practice Preparation Checklist 40 Drug Enforcement Agency Information 46 National Provider Identifier 48 State Licensing Terms/Resources/Scope of Practice 55 State Licensing Information and Requirements 59 II. DEBT MANAGEMENT 81 Navigating the Repayment Process 83 Your Rights and Responsibilities 84 Loan Programs 86 Repayment Strategies 91

Selecting a Financial Advisor 103 Resources/Definition of Terms and Conditions 108

III. GOVERNMENT REGULATIONS 119 Security Policies and Procedures – The Final Hurdle 121 Taking the Mystery Out of OSHA 126 Electronic Medical Records 130 E-Prescribing 131 APMA Coding Manual and Medicare Resources 132 IV. PRACTICE OPTIONS, MANAGEMENT & RESOURCES 135 Practice Options and Management 137 Opening a Podiatry Practice 142 Motivating Your Staff 154 How to Connect With a New Patient in Sixty Seconds 156 Give Your Patient a Pound of Gold in a One-Ounce Bag 158 Customer Service and Continuous Quality 163 Improvement to Enhance Patient Care How to “Step up” Assistant Efficiency 168 APMA Private Insurance Resource Guide 171

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V. PODIATRIC MARKETING 175 Practical Marketing Tips for Private Practice 177 Enhancing Your Patient Relations - The Many Uses 183 of a Practice Brochure Establishing a Broad Patient Referral Base 187 Winning the Physician Referral Game 195 Strategies for Internal Marketing of Your Practice 202 The Essentials of Web Site Marketing 209 VI. ESTABLISHING AND BUYING A PRACTICE 211 Financing a Podiatric Practice 213 Five Common Myths of New Practitioners 214 The How, When, Where and Why of Associates and Buy-ins 218 Factors to Consider in Compensating a New Associate 224 Buying and Selling a Medical Practice 227 More Than Money 233 Employment Agreement 234 VII. INSURANCE 239 Insurance for the New Practitioner 241 Insurance Action Plan 248 Malpractice Insurance: What You Should Know 251 VIII. OFFICE SUPPLIES AND SET-UP 253 Podiatric Supplies 257 Top Ten Ways to Improve Exam Room Efficiency 261 Office Furnishings and Supply Costs 262 Medical Equipment for the New Practitioner 263 IX. DURABLE MEDICAL EQUIPMENT AND ORTHOTICS 265 Durable Medical Equipment, Prosthetics, Orthotics, and Supplies 267 In-Office Dispensing 269 Orthotic in Your Practice 271 Getting Started with Orthotics 272

Orthotic Tips 274 Making the Most of the Medicare Therapeutic Shoe Program 275

INDEX OF ADVERTISERS 279 INDEX OF APMSA CORPORATE ADVISORY BOARD (CAB) 10

I.Practice

Preparation/Getting Started

American Society of

ASPSPodiatricSurgeons

An affiliate of APMA

Free Membershipfor Students andResidentsThe American Society of Podiatric Surgeons(ASPS) is proud to recognize the value andunique needs of students and residents byoffering free membership.

ASPS also recognizes the challenges facingnew podiatric surgeons by offering value-added discounted dues for young members.

Join APMA’s surgical affiliate and becomea part of an organization that is definingthe future for podiatric surgeons and othersinterested in foot and ankle surgery.

� Enjoy complimentary registration to ASPS work-shops and seminars.

� Gain access to the ASPS member-exclusive onlineeducation resource, ASPS University.

� Benefit from an affordable dues structure, includingfree dues for students and residents and significantlydiscounted dues for young members.

� Gain access and information about the highest-qual-ity continuing podiatric medical education programsrelated to surgery.

� Help influence the future of the profession.

Why ASPS?

To learn more about ASPS and apply online, visit the ASPS Web sitewww.aspsmembers.org.

real world

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The American Board of PodiatricOrthopedics and Primary Podiatric Medicine(ABPOPPM) is one of only two certifyingboards recognized by the AmericanPodiatric Medical Association. TheABPOPPM conducts a board certificationprocess in the specialty of PodiatricOrthopedics and Primary PodiatricMedicine. It represents the specialtyconcerned with providing comprehensiveprimary podiatric medical care...the specialtyencompassing at least eighty percent ofpractice activity in most successful podiatricpractices…the specialty that represents the

of podiatric practice.

Podiatric Orthopedics and PrimaryPodiatric Medicine integrates the biological,biomechanical, rehabilitative, clinical andbehavioral sciences and encompasses firstcontact and continuous care in generalpodiatric practice.

The Council on Podiatric MedicalEducation (CPME), through its JointCommittee on the Recognition of SpecialtyBoards (JCRSB), authorizes the ABPOPPMto qualify and certify podiatric medical andorthopedic expertise. The ABPOPPM alsohas ongoing representation and

membership on the Joint ResidencyReview Committee of the CPME in thedevelopment of requirements for podiatricresidency education and in the evaluationof residency training programs, thus bothdefining and assessing compliance withthe competencies established by thisboard for residency education.

Board certification by the ABPOPPMprovides assurance to the general public,as well as to the medical community, thatyou have been judged by your peers tohave demonstrated – through a rigorousexamination and peer review process – alevel of professionalism as a genuinespecialist in your field – enhancing thecredibility of your existing credentials andpromoting your professional image.

The ABPOPPM certificate is time-tested. Join an organized tradition ofexcellence in Podiatry.

ABPOPPM Certificationradition of Excellence in our Profession

The American Boardof Podiatric Orthopedics

and Primary Podiatric Medicine

3812 Sepulveda Boulevard, Suite 530Torrance, CA 90505

Phone: (310) 375-0700 • Fax: (310) 375-1386www.abpoppm.org

Congratulations to the Class of 2011 from

APMA’s Young Members’ Program

PUTTING THE PIECES TOGETHER FOR YOUR SUCCESS!The Young Members’ Program serves the needs andinterests of the APMA Young Members (students,post-graduates, and young practitioners with fouryears or fewer of practice).

By joining APMA you automatically become a member of the Young Members’ Program.

• FREE APMA Membership for first year residents

• APMA Young Members’ Salary and Benefits Assessment

• Tailored track of lectures/seminars during the APMA Annual Scientific Meeting and regional meetings

• Complimentary registration for the APMA Annual Scientific Meeting for student and resident members

• Discounted registration fees for Podiatry Institute Seminars

JOIN APMA TODAYAND TAKE AN

ACTIVE INTEREST IN YOUR FUTURE

AND YOUR ASSOCIATION!

Podiatry Insurance Company of America, the founding partner of the Young Members’ Program

Contributing partners of the Young Members’ Program

More Podiatrists are choosing

GILL PODIATRYfor their equipment and

supplies everyday!

More Podiatrists are choosing

GILL PODIATRYfor their equipment and

supplies everyday!

PODIATRY SUPPLY& EQUIPMENT CO.

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Joining the American Podiatric Medical Association APMA recognizes that residents have unique concerns deserving special attention. We understand that the health care environment you encounter is constantly changing, sometimes unpredictable, and often confusing. APMA has multiple resources for residents, and your APMA membership gives you direct access to all of these:

• Publications: APMA News, our twice-weekly digital News Brief, and the Journal of the American Podiatric Medical Association

• Exclusive members-only content on our website • APMA HIPAA Privacy Manual and APMA HIPAA Security Manual • APMA State Reference Manual • APMA Hospital Privileging and Credentialing Resource Guide • APMA Coding Resource Center • APMA Private Insurance Resource Guide • APMA Insurance Complaint Survey • APMA Medicare Compliance Manual

• Educational tracks at the APMA Annual Scientific Meeting

• Practice marketing tools, including PowerPoint presentations, APMA apparel, decals, membership certificates, downloadable APMA logos, and a customizable member/patient informational newsletter

Membership in your professional association is an important part of your postgraduate training and future success. This is why APMA is offering all DPMs in their first year of residency training national membership at NO CHARGE! The process is easy!

• Complete the abbreviated membership application included in this graduation handbook. Please complete all areas. An incomplete application can delay processing.

• Mail the completed application to APMA. The postage is prepaid for your convenience. Your application will be processed as soon as possible, and your APMA benefits will start immediately.

• Because dual membership with the state component is required, APMA will forward a copy of your application to the appropriate state component.

Let APMA help you begin your career equipped with the best possible resources available to the podiatric physician. For more information, contact APMA membership services at 800-ASK-APMA.

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State Component Associations and Societies - March 2011

* Indicates the membership contact. For updated information visit:www.apma.org/statecomponents

Alabama Podiatric Medical Association - http://alapma.org Kent Martin, DPM, President 426 Cox Blvd. Sheffield, AL 35660 Phone: 256-389-1990

*Debbie Hancock, Executive P.O. Box 81 Locust Fork, AL 35097 Phone: 205-680-5518

Alaska Podiatric Medical Association *Kenneth Swayman, DPM, President 2741 Debarr Rd., #C-315 Anchorage, AK 99508 Phone: 907-562-4958; [email protected]

Arizona Podiatric Medical Association Mark Forman, DPM, President 8585 E. Bell Road #A101 Scottsdale, AZ 85260 Phone: 480-423-8400

Spencer Niemann, DPM, Secretary 444 W. Osborn Rd. #301 Phoenix, AZ 85013 Phone: 602-264-1031

Arkansas Podiatric Medical Association Richard Alex Dellinger, DPM, President 3 Athena Ct. Little Rock, AR 72227 Phone: 501-350-3088

*Angela Pinkston-Ayson, DPM, 11 Halsted Cir. #E Rogers, AR 72756 Phone: 479-636-3668/ 888-396-3668

California Podiatric Medical Association http://www.calpma.org/ Michael Cornelison, DPM, President 10353 Torre Avenue #C Cupertino, CA 95014 Phone: 408-446-5811 Fax: 408-996-1637

Jon Hultman, DPM, Exec Director 2430 K St., Suite 200 Sacramento, CA 95816 Phone: 916-448-0248 [email protected]

Colorado Podiatric Medical Association - www.colopma.org Frederick Mechanik, DPM, President P.O. Box 422 Fountain, CO 80817 Phone: 719-526-7435 Fax: 719-526-7377

*Anne-Marie Zuccarelli, Exec Dir. 3080 S. Fulton Court Denver, CO 80231 303-881-8837; [email protected]

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Connecticut Podiatric Medical Association Marc Lederman, DPM President & Executive Director 2531 Albany Ave. West Hartford, CT 06117 Phone: 860-236-2564

*Eva Storrs, Association Manager 342 N. Main Street West Hartford, CT 06117 Phone: 860-586-7512 [email protected]

Delaware Podiatric Medical Association Jason Kline, DPM, President 2600 Glasgow Avenue #107 Newark, DE 19702 Phone: 302-834-3575

Christopher Savage, DPM, Exec Dir. 1010 N. Bancroft Pkwy. Wilmington, DE 19805 Phone: 302-658-1129

DC Podiatric Medical Association - http://www.dcpma.org Howard Osterman, DPM, President 8630 Fenton St., #1 Silver Spring, MD 20910 Phone: 301-587-5666 Fax: 301-589-4479

Ken Silverstein, Ex. Dir. 17825 Sandcastle Ct. Olney, MD 20832 Phone: 301-260-9700 [email protected]

Federal Services Podiatric Medical Association *Joyce Kubu, APMA Membership Services Rep 9312 Old Georgetown Rd. Bethesda, MD 20814 Phone: 301-581-9273/800-ASK-APMA, ext. 273 [email protected]

Gene Goldman, DPM, President 8500 Marsh Point Dr. Montgomery, AL 36117 Phone: 334-356-1959

Jack Bois, DPM 2409 Fairoak Ct. San Jose, CA 95125 Phone: 650-493-5000, ext. 64922;[email protected]

Florida Podiatric Medical Association - www.fpma.com Robert Iannacone, DPM, President 691 SW Port St. Lucie Blvd. Port Saint Lucie, FL 34953 Phone: 772-878-0040 Fax: 772-878-4265

Michael Schwartz, Ex. Dir. 410 N. Gadsden St. Tallahassee, FL 32301 Phone: 850-224-4085 or 800-277-3338 [email protected]

Georgia Podiatric Medical Association - http://www.gapma.com/

Sarvepalli Jokhai, DPM, President 204 Pinnacle Ct. Macon, GA 31206 Phone: 912-475-9968

*Wesley Daniel, DPM, Ex. Dir. 1975-B Beverly Rd. Gainesville, GA 30501 Phone: 770-536-9908

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Hawaii Podiatric Medical Association Gregory Morris DPM, President 1329 Lusitana St. #802 Honolulu, HI 96813 Phone: 808-528-4144 Fax: 808-525-6868

*Tyler Chihara, DPM, Treasurer 3-3420 Kuhio Hwy. #B Lihue, HI 96766 Phone: 808-245-1523 [email protected]

Idaho Podiatric Medical Association Randal Wraalstad, DPM, President 562 Shoup Ave., W Twin Falls, ID 83301 Phone: 208-734-3455 Fax: 208-733-7389

*Connie Searles, Exec. Dir. 270 N. 27th St., #B Boise, ID 83702 Phone: 208-345-3072 [email protected]

Illinois Podiatric Medical Association - www.ipma.net Marlene Reid, DPM, President 640 S. Washington Street #240 Naperville, IL 60540 Phone: 630-355-4336 Fax: 630-355-3016

Mary Feeley, Exec. Dir. 122 S. Michigan Ave., #1441 Chicago, IL 60603 Phone: 312-427-5810 [email protected]

Indiana Podiatric Medical Association Jane Koch, DPM, President 4640 W. Lloyd Expressway Evansville, IN 47712 Phone: 812-422-4336 Fax: 812-421-0991

*Ginny Jewell, Exec. Dir. 101 W. Ohio St., #780 Indianapolis, IN 46204 Phone: 317-222-3847 [email protected]

Iowa Podiatric Medical Association -www.ipms.org Eugene L. Nassif, Jr., DPM 1215 Blairs Ferry Rd. Marion, IA 52302 Phone: 319-363-8854

Kevin Kruse, Executive Director 525 S.W. 5th St., #A Des Moines, IA 50309 Phone: 515-282-8192

Kansas Podiatric Medical Association Warren Abbott, DPM, President PO Box 67143 Topeka, KS 66667 Phone: 785-273-3500

*Scott McKenzie, Exec. Dir. 1603 S.W. 37th St. Topeka, KS 66611 Phone & Fax: 785-267-5400 [email protected]

Kentucky Podiatric Medical Association - [email protected] Ann Farrer, DPM, President 2148 Ami Lane Lexington, KY 40516 Phone: 859-299-8646

John Underwood, Ex. Dir. 1501 Twilight Trail Frankfort, KY 40601 Phone: 502-223-5322

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Louisiana Podiatric Medical Association Amy Schunemeyer-Prudy, DPM, Pre. 521 N. Lewis Avenue #A New Iberia, LA 70560 Phone: 337-365-70560

*Mack Jay Groves, DPM, Treasurer 802 W. 10th Avenue #2 Covington, LA 70433 Phone: 985-867-9605

Maine Podiatric Medical Association Michelle Kurlanski, DPM, President 15 Sewell St., #2 Portland, ME 04102 Phone: 207-846-9190 [email protected]

*James Whipple, DPM, Ex. Dir. 60 Pineland Dr., #210 New Gloucester, ME 04260 Phone & Fax: 207-688-8990 [email protected]

Maryland Podiatric Medical Association - www.marylandpodiatry.org Stephen Palmer, DPM, President 6100 Day Long Ln., Suite 102 Clarksville, MD 21029 Phone: 443-535-8770 Fax: 443-535-8775 [email protected]

Richard Bloch, Executive Director 600 Baltimore Ave., Adams Bldg. #301 Towson, MD 21204 410-332-0736/800-560-1818 [email protected]

Massachusetts Podiatric Medical Society - www.massdpms.org Alfred Phillips, DPM, President 1493 Cambridge St., #781 Cambridge, MA 02139 Phone: 617-665-3570 Fax: 617-665-3598

Gary Adams, Executive Director 10 Maple St., #301 Middleton, MA 01949 Phone: 978-646-9671 [email protected]

Michigan Podiatric Medical Society - www.mpma.org Jodie Sengstock, DPM, President 49450 Hudson Dr. Canton, MI 48188 Phone: 734-397-1396

Christian Kindsvatter, Ex. Dir. 1000 W. Joseph St., #200 P.O. Box 15339 Lansing, MI 48901 517-484-6762/800-968-6762 [email protected]

Minnesota Podiatric Medical Association Michelle Barrette, JD, Executive Director Sievertson & Barrette 1465 Arcade St. St. Paul, MN 55106 Phone: 651-778-0575 [email protected]

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Mississippi Podiatric Medical Association B. Tipton Sullivan, DPM, President 1915 Dunbarton Dr. Jackson, MS 39216 Phone: 601-982-3338 Fax: 601-982-2253

*Amy DeGirolamo, DPM Secretary/Treasurer 1306 Belk Ave. Oxford, MS 38655 Phone: 662-513-6600

Missouri Podiatric Medical Association Anthony Lombardo, DPM, President 12255 DePaul Dr., #470 Bridgeton, MO 63044 Phone: 314-739-8863

Steve Carroll, Executive Director 215 E. Capitol Jefferson City, MO 65102 573-761-5952

Montana Podiatric Medical Association - http://www.mtfootandankle.com Todd Storm, DPM 931 Highland Ave., #3310 Bozeman, MT 59715 Phone: 406-587-8478 Fax: 406-582-0730

*Marti Wangen, CAE, Exec. Dir. 36 S. Last Chance Gulch, Ste A Helena, MT 59601 Phone: 406-443-1160 [email protected]

Nebraska Podiatric Medical Association - http://www.nefootandankle.org/ Mark Willats, DPM, President 2 W. 42nd St. #2700 Scottsbluff, NE 69361 Phone: 308-532-3600

*Chad Summy, DPM, Treasurer 2705 Samson Way Bellvue, NE 68123 Phone: 402-331-6387

Nevada Podiatric Medical Association - http://www.nvpma.com/ Jeremy Wood, DPM, President 3777 Pecos-McLeod, #103 Las Vegas, NV 89121 Phone: 702-434-2023 Fax: 702-434-1976

*Michael Kooyman, DPM 2649 W. Horizon Ridge Pk #100 Henderson, NV 89052 Phone: 702-565-6641 [email protected]

New Hampshire Podiatric Medical Association Edward Newcott, DPM, President 102 Pleasant St. Concord, NH 03301 Phone: 603-228-3008 Fax: 603-228-7095

*Stanley Gorgol, DPM, Ex. Dir. 198 Main St. Salem, NH 03079 Phone: 603-898-5864 [email protected]

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New Jersey Podiatric Medical Society – www.njpms.org James Ricketti, DPM, President 2273 Route 33 #204 Hamilton Square, NJ 08690 Phone: 609-587-1674

Herman Hammerschmidt 2 King Arthur Ct., #C North Brunswick, NJ 08902 732-967-9003/888-FIT-FEET [email protected]

New Mexico Podiatric Medical Association – www.nmpma.com Steve Wrege, DPM, President 3908 Juan Tabo Blvd. NE Albuquerque, NM 87111 Phone: 505-271-9900 Fax: 505-271-0217

*Janet Simon, DPM, Exec Dir. 8300 Carmel Avenue, NE #501 Albuquerque, NM 87122 Phone: 505-797-1001 [email protected]

New York State Podiatric Medical Association - www.nyspma.org

Robin Ross, DPM, President PO Box 1023, 2A Hudson Avenue Shelter Island, NY 11964 Phone: 631-749-2222

Leonard Thaler, Ex. Dir. 1255 5th Ave. New York, NY 10029 Phone: 212-996-4400 [email protected]

North Carolina Podiatric Medical Association - www.ncfootandankle.org James Judge, DPM, President 833 Wake Forest Business Park #C Wake Forest, NC 27587 Phone: 919-570-9061 Fax: 919-570-9064

Eleanor Upton, Ex. Dir. P.O Drawer 40399 Raleigh, NC 27629 919-872-2224/866-898-2224 [email protected]

North Dakota Podiatric Medical Association Timothy Uglem, DPM, President 2400 32nd Avenue S Fargo, ND 58103 Phone: 701-250-8637 Fax: 701-250-1237

*Tracy Alan Hjelmstad, DPM 101 3rd Ave., S.W. - West Minot, ND 58702 Phone: 701-857-3584 Fax: 701-857-3566

Ohio Podiatric Medical Associatio - www.opma.org Alan Block, DPM, President 1930 Crown Park Ct #120 Columbus, OH 43235 Phone: 614-293-3668

Jimelle Rumberg, Ex. Dir. 1960 Bethel Rd., Suite 140 Columbus, OH 43220-1815

Oklahoma Podiatric Medical Association - www.okpma.org M. Derek Smith, DPM, President 1700 N. 5th Street Ponca City, OK 74601 Phone: 918-274-1557

Michael Clark, Executive Director 3233 E. Memorial Rd., #103 Edmond, OK 73013 Phone: 405-286-2800 [email protected]

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Oregon Podiatric Medical Association Thomas Melillo, DPM, President 9900 SW Hall Blvd. #100 Tigard, OR 97223 Phone: 503-245-2420 Fax: 503-245-2445

*Christopher Seuferling, DPM 7940 S.E. Division St., #E Portland, OR 97206-1046 Phone: 503-775-5846 Fax: 503-775-8054 [email protected]

Pennsylvania Podiatric Medical Association - www.ppma.org Robert W. Herpen, DPM, President 148 N. 8th Street Philadelphia, PA 19107 Phone: 215-625-5215 [email protected]

Michael Davis, Executive Director 757 Poplar Church Rd. Camp Hill, PA 17011 Phone: 717-763-7665 [email protected]

Puerto Rico Podiatric Medical Association Sara Lopez Torres, DPM, President 400 Avenue FD Roosevelt #100M San Juan, PR 00918 Phone: 787-753-2626

*Edgardo Morales, DPM P.O. Box 2582 Guaynabo, PR 00970 Phone: 787-636-3763

Rhode Island Podiatric Medical Association Mark Enander, DPM, President 17 Parker St. Lincoln, RI 02865 Phone: 401-725-8989

*Clyde Fish, DPM 1050 Centerville Rd. Warwick, RI 02885 Phone: 401-821-6238

South Carolina Podiatric Medical Association – www.scpma.org Trenton Statler, DPM, President 49 Grand Oaks Way Beaufort, SC 29907 Phone: 843-322-0900

*Sam Christiano, Ex. Dir. P.O. Box 11096 Columbia, SC 29211 Phone: 803-926-7488

South Dakota Podiatric Medical Association *Jennifer Ryder,DPM, Sec/Treasurer 2820 Mt. Rushmore Rapid City, SD 57701 Phone: 605-342-3280 [email protected]

Rylan Johnson, DPM, President 16639 Elk Horn Rd Piedmont, SD 57769 Phone: 605-718-3300 [email protected]

Tennessee Podiatric Medical Association Paul W. Hutchison, DPM, President 7878 Winchester Rd. Memphis, TN 38125 Phone: 901-365-3668 Fax: 901-362-7099

*Gary Odom, Executive Director P.O. Box 50437 Nashville, TN 37205 Phone: 615-353-0046 [email protected]

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Texas Podiatric Medical Association - www.txpma.org Samuel Nava, DPM, President 2001 N. MacArthur Blvd. #300 Irving, TX 75061 Phone: 972-254-0680 Fax: 972-254-0683

Don Canada, Executive Director 918 Congress Ave., Suite 200 Austin, TX 78701 Phone: 512-494-1123 [email protected]

Utah Podiatric Medical Association - www.utpma.org Randy Rhodes, DPM, President 333 s. 900 E. Salt Lake City, UT 84102 Phone: 801-766-0606

Candace Daly 1296 W. 475 S. Farmington, UT 84025 Phone: 801-599-8519 [email protected]

Vermont Podiatric Medical Association *Craig Schein, DPM, President 331 Summer St. St. Johnsbury, VT 05819 Phone: 802-748-9400 Fax: 802-748-9010

Nicholas Benoit, DPM, Vice President 200 Russ Hill Rd. South Royalton, VT 05068 Phone: 802-522-4366

Virginia Podiatric Medical Association - www.vpma.org Annik Adamson, DPM, President 6355 Walker Lane #503 Alexandria, VA 22310 Phone: 703-822-0895

*Jean Kirk P.O. Box 40399 Raleigh, NC 27629 Phone: 877-406-8762 [email protected]

Washington State Podiatric Medical Association - www.wspma.org Richard Frost, DPM, President 400 E. 5th Ave., P.O. Box 3649 Spokane, WA 99220 Phone: 509-838-2531 Fax: 509-459-1595

*Susan Scanlan, DPM, Ex. Dir. P.O. Box 22368 Seattle, WA 98122 866-343-6999 or 206-922-3587 [email protected]

West Virginia Podiatric Medical Association Richard Rauch, DPM, President 123 Health Care Ln. Martinsburg, WV 25401 Phone: 304-267-5544

*Carrie Ann Lakin, DPM 1313 Quarrier St., #B Charleston, WV 25301 Phone: 304-347-3668

Wisconsin Society of Podiatric Medicine - http://www.wisconsinpodiatrists.com Steven Merckx, DPM, President 6 Drumhill Circle Madison, WI 53717

Steven Frydman, DPM, Ex. Dir. 7929 N. 76th St. Milwaukee, WI 53223 Phone: 414-371-1000

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A leader in innovative interprofessional medical education

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Wyoming Podiatric Medical Society *Timothy Fisher, DPM, President 1303 E. Grand Ave. Laramie, WY 82070 Phone: 307-721-0022 Fax: 307-721-4866

1/2 page black/white Des Moines University email/ftp

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APMA Affiliated Organizations – March 2011 For updated information visit: www.apma.org/affiliated

Specialty Organizations

American College of Foot and Ankle Orthopedics and Medicine- www.acfaom.org

Kirk Geter, DPM, President 2041 Georgia Avenue, NW Washington, DC 20060 Phone: 202-865-1441

Norman Wallis, PhD, Executive Director 5727 River Rd., Suite 630 Bethesda, MD 20816 Phone: 301-718-6539 Fax: 301-656-0989 [email protected]

American Society of Podiatric Surgeons - www.aspsmembers.org Kathleen Pyatak-Hugar, DPM, President 142 Chenoweth Lane Louisville, KY 40207 Phone: 502-897-1616

Tiffany Kildale, Association Manager 9312 Old Georgetown Road Bethesda, MD 20814 Phone: 301-581-9214 [email protected]

Clinical Interest Organizations American Academy of Podiatric Sports Medicine www. aapsm.org

Karen Langone, DPM, President 365 County Road, 39A #9 Southampton, NY 11968 Phone: 631-287-1818

Rita Yates, Executive Director 109 Greenwich Dr. Walkersville, MD 21793 Phone: 301-845-9887 or 888-854-FEET Fax: 301-845-9888 [email protected]

American College of Foot and Ankle Pediatrics Yaron Raducanu, DPM, President 936A General Booth Blvd. Virginia Beach, VA 23451 Phone: 757-228-1955 Fax: 757-228-3095

Debi Grinberg, Secretary/Treasurer 2221 Glenrose Ct. Virginia Beach, VA 23456 Phone/Fax: 757-416-9000 [email protected]

American Society of Podiatric Dermatology M. Joel Morse, DPM, President 3301 New Mexico Avenue, NW #228 Washington, DC 20016 Phone: 202-686-0932 [email protected]

American Society of Podiatric Medicine Elliott Udell, DPM, President 120 Bethpage Rd. Hicksville, NY 11801 Phone: 516-935-1113 Fax: 516-349-8153

Warren Simmonds, DPM, Secretary 1111 Kane Concourse, Suite 111 Bay Harbor, FL 33154 Phone: 305-866-9608 Fax: 305-866-1750

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Related Organizations American Academy of Podiatric Practice Management- www.aappm.com Jeffrey Frederick, DPM, President 27901 Woodward Avenue, Suite 110 Berkley, MI 48072 Phone: 248-545-0100 Fax: 248-545-1285

Christian Kindsvatter, Executive Director 1000 W. St Joseph Highway #200 Lansing, MI 48915 Phone: 517-484-1930; Fax: 517-485-9408 [email protected]

American Association for Women Podiatrists—www.americanwomenpodiatrists.com Sheryl Strich, DPM, President 6042 Sierra Siena Road Irvine, CA 92603 Phone: 949-854-3636; Fax: 949-854-3637

American Association of Colleges of Podiatric Medicine---www.aacpm.org Michael Trepal, DPM, Chairperson 115 Henry Street Brooklyn, NY 11201

Moraith North, Executive Director 15850 Crabbs Branch Way, Suite 320 Rockville, MD 20855 Phone: 301-948-9760 Fax: 301-948-1928

American Association of Hospital and Healthcare Podiatrists---www.hospitialpodiatists.org Lawrence Santi, DPM, President 240 E. 5th St. Brooklyn, NY 11218 Phone: 718-435-1031 Fax: 718-435-9617

Frank Rinaldi, DPM, Executive Director 8508 18th Ave. Brooklyn, NY 11214 Phone: 718-259-1822 Fax: 718-259-4002

American Podiatric Medical Students' Association – www.apmsa.org Adam Siegel, President 2936 N. Clark St. #4F Chicago, IL 60657 [email protected]

Dorothy Cahill McDonald, Executive Director 9312 Old Georgetown Rd. Bethesda, MD 20814 Phone: 301-581-9263;[email protected]

American Podiatric Medical Writers’ Association Howard Malin, DPM, President 2250 Bear Den Rd., #210 Frederick, MD 21701 Phone: 301-668-1941

Barry Block, DPM, JD, Executive Director P.O. Box 750129 Forest Hills, NY 11375 Phone: 718-897-9700

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American Society of Podiatric Medical Assistants - www.aspma.org Anna Fabach, PMAC, President c/o Dr. Maria Cohen, 414 Oak Park Avenue Seattle, WA 98122

American Society of Podiatric Executives Susan Scanlan, DPM, President P.O. Box 22368 Seattle, WA 98122 Phone: 206-922-3587 Fax: 206-922-3587 [email protected]

APHA APMA Chapter p/u from 2010

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Join The Podiatry Section Today atwww.apha.org/about/membership/

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Pre-Practice Year Preparation Checklist

Task Resources Cost Time Frame Practice options/job opportunities

APMA News classifieds and eNews, www.apma.org, YM lectures and Salary/Benefits Assessment, AAPPM, PM News

Start ASAP. Begin applying 12-18 months before end of residency

CV YM Exchange Aug/Sept 2005 (available at www.apma.org under Young Members section)

Complete while in residency and update frequently

State Licensing/ PMLexis

www.apma.org/stateboards under Young Members’ section

$900 PM Lexis dates and processing time vary per state- check ~1 yr in advance (can take up to 6 months)

ABPS/ABPOPPM See next page and www.abps.org www.aspsfellows.org www.abpoppm.org

ABPS: $800 FF $1400 FF & RF ABPOPPM: $200

ABPS: Register: ~March Exam: ~May/June ABPOPPM: Register: ~April Exam: ~June

Contracts/Business Plan

Contact a lawyer who specializes in this area, also AAPPM

various Start early, leave time to negotiate

Apply for DEA # http://www.deadiversion.usdoj.gov/onlineforms.htm and/or see DEA license info in this guide

$551 (for 3 years)

~6 weeks (need state license)

Insurance plans Company specific- need hospital privileges first if going solo

Apply as soon as you have license & know your practice area

CAQH (Council for Affordable Quality Healthcare)

https://www.caqh.org (need a provider ID from an insurance co. first)

Helps to eliminate extra paperwork with insurance credentialing

Medicare/Medicaid Provider #

http://www.cms.hhs.gov Applications: http://www.cms.hhs.gov/CMSforms/downloads/cms10115.pdf

Process takes at least 3 months, can retro-bill up to 90 days

NPI # (National Provider Identifier)

https://nppes.cms.hhs.gov/NPPES/StaticForward.do?forward=static.instructions http://www.cms.hhs.gov/cmsforms/downloads/CMS10114.pdf

Must have state license

Malpractice/ disability Insurance

See advertisers in this guide and contact state society

varies 30 days prior to practicing

Hospital Privileges Location specific- need residency certificate but start process before completion

varies Process can take several months

DME Provider # (Durable Medical Equipment)

http://www.cms.hhs.gov/cmsforms/downloads/cms855s.pdf

Only one is needed per office, may need if going solo

Association Membership

www.apma.org www.aspsmembers.org

varies Remember to join or continue membership at start of practice

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Additional Information To simplify processes and for subsequent applications, keep copies of your state medical license, state drivers license/state ID, DEA card, proof of malpractice insurance, residency completion certificate, and letter of hospital staff privileges. In addition, here are other important pre-practice items for consideration:

� License to Practice/PM Lexus Scores The actual license to practice podiatric medicine is issued by the State Board. Since states vary in their individual requirements for licensure and practice, it is a good idea to research their regulations well in advance. It is advisable to send a registered letter to the state board of licensing of your choice to inform them of your status in training and your intentions, to request an application, and to become familiar with any additional procedural requirements. This is typically handled in conjunction with Boards Part III. Contact the NBPME at www.nbpme.org for more Part III information about testing sites, deadlines and fees. To request PM Lexus scores, contact the Federation of Podiatric Medical Boards at www.fpmb.org or call 561-752-3735. � Association Membership Membership in your national (APMA), state, and local associations provides many resources of benefit to you as you progress in your career. Complete the enclosed coupon to receive membership information and to take advantage of complimentary first year resident membership. APMA and its Young Members’ program will help you transition from a resident to a successful practicing podiatric physician. Each state has their own set of processing procedures for obtaining membership as a practicing podiatric physician. It is important to know these procedures so you may expedite your application process. You can view these procedures by visiting www.apma.org/MembershipProcess. � Supportive Professional Contacts Three specific contacts that are crucial prior to establishing a practice include an attorney, an accountant, and a banker. The attorney handles personal as well as business matters. Early establishment of this relationship is especially beneficial as an attorney can review any contract proposals and aid in the formation of a contract acceptable to all parties. The accountant’s role may be expanded beyond the obvious to include managerial advice and in-office support. The banker’s position is essential in obtaining an initial office loan and may establish the relationship often necessary for subsequent credit and loans. A word of caution must be given to those considering the use of close friends or relatives in any of these positions. What seems advantageous at first can cause hardship later. � Office/Malpractice Insurance

It is recommended that an insurance study be completed prior to joining or opening a practice. To insure the practitioner and the office of adequate coverage, inclusions not to be overlooked are adequate health insurance, life insurance, business premises (fire and theft), personal liability, worker’s compensation, and personal disability policies. Malpractice insurance must also be obtained and is often available at reduced rates for the new practitioner. Check the advertisers listed in this guide and with APMA and your state component for suggestions on insurers. Be sure to get cost quotes. This process can take

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2-6 weeks. You will need insurance before applying for any hospital privileges or other health insurance companies. � Hospital/Surgical Center Affiliations

In an effort to assist APMA members in resolving difficulties that arise during privileging and credentialing processes, APMA, has developed a Hospital Privileging and Credentialing Resource Guide (Guide) to provide APMA members with tools and suggested approaches that will help them obtain appropriate hospital privileges. · Part One of the Guide provides an overview of podiatric medicine, including the education, training, and experience of podiatric physicians. This information will assist the podiatric physician in educating the hospital and the medical staff about the podiatric medical profession. · Part Two provides an overview of state and federal laws and regulations that govern hospitals and the privileging process, and will help APMA members to understand their rights and responsibilities. · Part Three focuses on the organization of hospitals and medical staffs and provides the podiatric physician seeking privileges a guide on how to effectively navigate internal hospital procedures. Part Three also provides suggestions on how to become an active member of the medical staff and how to advance the podiatric medical profession from inside the hospital. · Part Four offers suggestions on how to advocate beyond the hospital setting, including when and how to seek legal, regulatory, or legislative remedies. · The Appendix provides issue briefs, model bylaws, and other resources that podiatric physicians can use in their advocacy efforts. The Guide is only available on the APMA Members website at www.apma.org/hospitalguide. While not all practitioners seek privileges at the local hospital facility, staff membership is beneficial to some. In addition to being a site for surgical procedures, the hospital serves as a source of physician and staff referrals. You should decide early whether or not to seek hospital privileges since the application and processing time is very time-consuming. Keep in mind that most, if not all, surgery centers require hospital privileges for a least one hospital in order to receive surgery center privileges. This is in the event that a patient is admitted directly from a surgery center in case of an unforeseen emergent need. Allow 3-5 months for submission approval. For more information on hospital privileges visit: http://www.apma.org/HospitalPrivileges.

� Durable Medical Equipment Provider Number

You will need a DME number if you plan on dispensing any “durable goods” from your office (i.e. pre-fab orthotics, cam boots, ankle braces, crutches, etc). Only one DME number is allowed per office, so you probably won’t need to apply for one unless you are opening a practice or buying a solo practice. For more information, go to http://www.cms.hhs.gov/cmsforms/downloads/cms855s.pdf

� Health Insurance Credentialing

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This is often the last thing that you can do after completing all of the steps above if going solo – many insurance companies will require that you be on staff at a hospital prior to giving you your provider number and fee schedule. If you hire a billing company, many will handle the insurance company credentialing and fee schedule negotiations for you (for a fee). They will also know which insurance companies can be applied to prior to hospital staffing. This can take up to 1 year in some cases, but typically 3-6 months for processing on most insurance companies. The CAQH application (described above) can simplify this process. Be aware that some insurance companies may be closed to new providers; this is often where a billing company may be able to help you as well or working part-time with an established group.

� Referral List It is important to establish a list of potential referral contacts prior to entering practice. The list should include all local physicians as well as any physicians you have met and/or worked with, shoe stores, pharmacies, and other beneficial businesses. In addition, make contact or become an active participant in neighboring community service organizations such as the Lions Club, Kiwanis Club, Shriners, and the local YMCA. � APMA Affiliated and State Component Membership A complete contact listing of various professional and state organizations is maintained by the American Podiatric Medical Association at www.apma.org and is also available in this Guide. The affiliate organizations provide expertise and information about dermatology, orthopedics, surgery, radiology, podopediatrics, and more. � Advertising Public relations is crucial to any successful practice. Though this topic is quite broad, a few essentials must be addressed, such as telephone service and listing, WebMD little blue book, office signs and printing, business cards, and announcement letters. You might also want to consider a website if one is not already established. Keep in mind that the fastest and least expensive approaches are not always the best available options. � ABPOPPM Board Certification The American Board of Podiatric Orthopedics and Primary Podiatric Medicine (ABPOPPM) offers a comprehensive board qualification and certification process in podiatric medicine and orthopedics. Podiatric Medicine and Orthopedics is the medical specialty concerned with the comprehensive and continuous foot health care of patients. It integrates the biological, biomechanical, rehabilitative, clinical and behavioral sciences and encompasses first contact care, continuous care, long term care and general medicine. For more information on ABPOPPM and Board Qualification and Certification as wells as resources such as case studies, indexes, worksheets, study guides, visit www.abpoppm.org � ABPS Board Certification

You are now board QUALIFIED, and you are about to begin practice and try to figure out how to treat patients, bill, and, oh yes, somewhere along the way you have to gather cases to submit to the American Board of Podiatric Surgery to become board CERTIFIED. Since you just finished studying for the computer board qualification test… the certification test probably isn't the first thing on your mind the first day of practice. But, with just a small

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about of knowledge you can make your life a lot easier when putting together your cases in the next 7 years.

Here are the top ten things to remember when starting your surgical practice for your case log:

1. Log onto ABPS.org and print out and thoroughly review the ABPS 220 document. This is a document with instructions for preparing the application and case documentation. This explains everything you need to know. It is important to review this document prior to sitting down and tackling daunting task of gathering cases.

2. Print out the ABPS 210 document. This is the format for the list of cases that you will send ABPS. You can make a draft copy in pencil of your best cases for each category. Patients are divided into categories of surgery and include: Name, age, gender, date of Surgery, and location of surgery (i.e. hospital name). Keep a detailed log/spreadsheet of all cases and notes if you believe it is potential board quality. This will make it much easier for you to sort your cases after a few years have passed since you initially reviewed them.

3. Make sure you have good pre-operative x-rays before surgery and must include: patient name, right or left marker radiograph date and facility where taken (not too dark or too light and the pathology must be clearly shown, remember the reviewers can't see the actual patient clinically so the x-rays and notes must provide an accurate representation.)

4. Take good post-operative x-rays in the OR. X-rays are required within the first 72 hours and chances are you won't be seeing your patient back in the office in this time frame. Don't forget to take home your copy of the x-ray for your chart because you never know what can happen to that c-arm picture after surgery and over the next couple of years. You must also have x-rays at least 4 weeks out and radiographs showing final healing.

5. Make sure you obtain copies of and review the operative reports and you must be listed as the surgeon, not assistant or co-surgeon.

6. Obtain and save all copies of your surgical patients MRI/CT scans. You may have to submit the actual film or digital copies… not just the report.

7. Keep thorough detailed office notes on all your surgical patients.

8. Write good hospital progress notes. If your patient stays in the hospital greater than 24 hours you will need to submit all your notes written for that patient.

9. Documentation needed for every case includes:

� Podiatric history and physical Operative report � Anesthesia Record or Circulators notes � Pre-op labs � Progress Notes � Discharge Summary � Radiographs/Imaging

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10. Remember you need to show variety in your procedure knowledge and case selection. For example, 30 first ray procedures are required; some need to be Hallux Valgus surgery, some Hallux limitus, and some "other" first ray. The exact numbers are listed in the ABPS 220 document.

Stay on top of this information from the start and you will increase your chances of having your cases accepted and this will ease the stress when it comes to organizing your cases.

NJ Podiatric Medical Assn Hard copy Attached ¼ page black and white

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Obtaining A DEA Number

Most new residents need a Drug Enforcement Agency (DEA) number during residency while others can wait until the final year of residency to apply. For most jobs you will need to have both a DEA and NPI number to start and/or apply for hospital privileges. Visit the DEA web site diversion control program section www.deadiversion.usdoj.gov for an online application. The process takes 6-10 weeks and here’s some of the information you will find.

Registration Number

Toll Free: 1-800-882-9539

REGISTRATION SUPPORT

Save time by applying for your DEA Registration on-line. Data will be

entered through a secure connection to the ODWIF on-line web application system. Minimum requirements: Credit Card and a web browser that

supports 128-bit encryption.

New DEA Number Assignment for Type A (Practitioners) Registrants

To Apply for New Applications for Registration On-Line To Apply for Registration by Mail

For Registration Changes (Address, Drug Codes, Name, Schedules)

Duplicate Certificates Order Forms

For Registration Matters 1-800-882-9539

NEW APPLICATIONS DEA-224 Retail Pharmacy, Hospital/Clinic, Practitioner, Teaching Institution,

or Mid-Level Practitioner. MINIMUM ON-LINE REQUIREMENTS

The DEA Forms listed are for those applying to DEA for a controlled substance registration. Data will be entered through a secure connection to the ODWIF on-line web application

system. Your web browser must support 128-bit encryption. You will need to have the following information on hand to complete the form:

Tax ID number and/or Social Security Number State Controlled Substance Registration Information

State Medical License Information Credit Card (VISA, MasterCard, Discover or American Express)

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Tamper-Resistant Prescription Pad Features Required Effective April 2008, all written prescriptions for Medicaid recipients must be on paper with at least one tamper-resistant feature as outlined by Centers for Medicare and Medicaid Services (CMS) and defined by a physician’s state and must be on paper that meets all three baseline characteristics of tamper-resistant pads. CMS has outlined these characteristics as those that: 1. Prevent unauthorized copying of a completed or blank prescription form 2. Prevent the erasure or modification of information written on the prescription by the prescriber 3. Prevent the use of counterfeit prescription forms. States are responsible for defining specific features that meet the baseline characteristics in order for a prescription to be considered tamper-resistant in that state. Therefore, Review your states web site for guidance on acceptable tamper-resistant features. Additional information on CMS’ requirements can be found at: http://www.cms.hhs.gov/MLNMattersArticles/downloads/SE0736.pdf Please note that prescriptions that are electronic, faxed, or sent via telephone are exempt from this requirement. CMS states that failure to comply with this requirement could result in a withholding of Medicaid reimbursement.

Arizona College of Podiatric Medicine ¼ page black/white/via email

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National Provider Identifier

The Center for Medicare & Medicaid Services (CMS) has announced the availability of a new health care identifiers for use in the Health Insurance Portability and Accountability Act of 1996 (HIPAA) standard transactions. HIPAA mandated that the Secretary of Health and Human Services adopt a standard unique health identifier for health care providers. The NPI must be used by covered entities under HIPAA (generally, health plans, health care clearinghouses, and health care providers that conduct standard transactions). The NPI identifies health care providers in the electronic transactions such as claims, eligibility inquiries and responses, claim status inquiries and responses, referral, and remittance advices. The NPI replaces health care provider identifiers used today in standard transactions. Implementation of the NPI eliminates the need for health care providers to use different identification numbers to identify them when conducting HIPAA standard transactions with multiple health plans. All health plans (including Medicare, Medicaid, and private health plans) and all health care clearinghouses must accept and use NPIs in standard transactions. The NPI Application Process The NPI application is free and you may apply for your NPI in one of three ways: 1. You may apply through an easy-to-use Web based application process. The web

address is https://nppes.cms.hhs.gov 2. You may complete a paper application and send it the Enumerator. A copy of the

application, including the Enumerator’s mailing address (where you will want to send it) will be available on https://nppes.cms.hhs.gov or you can call the Enumerator (Fox Systems, Inc.) to receive a copy. The phone number is 1-800-465-3203.

3. With your permission, an organization may submit your application in an electronic file. This could mean that a professional association, or perhaps a health care provider who is your employer, could submit an electronic file containing your information and the information of other health care providers.

When gathering information for your application, be sure that all of your information, such as your social security number and the Federal Employer Identification Number, are correct. Once you receive your NPI, safeguard its use. APMA has collected important information for its members. Below are answers to commonly asked questions as well as useful tips to ease the continuing transition to the NPI. Frequently Asked Questions QUESTION: What is the format of the NPI? ANSWER: NPI is all numeric and is 10 positions in length: the first 9 positions are the identifier and the last position is a check digit. The check digit helps detect invalid NPIs. There is no embedded intelligence in the NPI with respect to the health care provider that it identifies.

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QUESTION: What is the purpose of the NPI? Who must use it and when? ANSWER: The purpose of the NPI is to uniquely identify a health care provider in standard transactions, such as health care claims. NPIs may also be used to identify health care providers on prescriptions, in internal files to link proprietary provider identification numbers and other information, in coordination of benefits between health plans, in patient medical record systems, in program integrity files, and in other ways. HIPAA requires that covered entities (i.e., health plans, health care clearinghouses, and those health care providers who transmit any health information in electronic form in connection with a transaction for which the Secretary of Health and Human Services has adopted a standard) use NPIs in standard transactions by the compliance dates. The compliance date was May 2008 and the NPI will now be the only health care provider identifier that can be used for identification purposes in standard transactions by covered entities. QUESTION: What is a Medicare legacy number? ANSWER: Legacy provider identifiers include: Online Survey Certification and Reporting (OSCAR) system numbers; National Supplier Clearinghouse (NSC) numbers; Provider Identification Numbers (PINs); and Unique Physician Identification Numbers (UPINs) used by Medicare. Legacy provider identifiers do not include: Employer Identification Numbers (EINs); or Social Security Numbers (SSNs). QUESTION: Will a health care provider continue to use other numbers besides the NPI to identify itself in standard transactions? ANSWER: Only the NPI may be used for identification purposes for a health care provider in standard transactions; legacy identifiers (such as the UPIN, Medicaid Provider Number, Medicare Provider Number, and others) may not be used. Where a health care provider must be identified in standard transactions for tax purposes, it would use its Taxpayer Identifying Number as required by the implementation specifications. Health care provider identification numbers other than the NPI may continue to be used in the internal processes and files of health plans or health care clearinghouses if they wish to continue to use those identification numbers in those internal processes and files. QUESTION: Will a health care provider’s NPI ever change? ANSWER: The NPI is meant to be a lasting identifier, and would not change based on changes in a health care provider’s name, address, ownership, membership in health plans, or Healthcare Provider Taxonomy classification. There may be situations where use of an NPI for fraudulent purposes results in a health care provider requesting a different NPI; such situations will be investigated and a different NPI may be assigned to the requesting health care provider. QUESTION: Should I keep a copy of the NPI notification that I received from the National Plan and Provider Enumeration System (NPPES)? ANSWER: Yes. You will need the NPI notification when you enroll or make a change to your Medicare enrollment information. Be aware that applying for an NPI does not replace any enrollment or credentialing processes with any health plans, including Medicare.

Search and Review NPIs for Free Looking up National Provider Identifiers (NPIs) of other providers is a free service from the federal government. The Centers for Medicare & Medicaid Services (CMS) offers two

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different ways to access the information: an online NPI Registry and a downloadable data file. Both methods reveal provider information from the National Plan & Provider Enumeration System (NPPES) database, and neither requires a password or payment. The data were collected when providers applied for NPIs. For more information on NPIs, visit http://www.cms.hhs.gov/NationalProvIdentStand. Providers can apply for an NPI online at https://nppes.cms.hhs.gov or can call the NPI enumerator to request a paper application at 1-800-465-3203. Two new educational products have been posted to the CMS Web site:

� For Providers who are Organizations

http://www.cms.hhs.gov/NationalProvIdentStand/Downloads/NPI_FactSheet_Org_Provi_web_07-03-07.pdf

� For Providers who are Sole Proprietors

http://www.cms.hhs.gov/NationalProvIdentStand/Downloads/NPI_FactSheet_Sole_Prop_web.pdf

CMS has posted several documents to help providers understand what the downloadable file will look like, including a “Read Me” file, Header File, and Code Value document for the downloadable file on the CMS NPI Web site at http://www.cms.hhs.gov/NationalProvIdentStand/06a_DataDissemination.asp. Podiatric physicians may wish to review their own information which can also be found in the database. Podiatrists can correct your own information, if necessary, by obtaining and submitting an NPI application/update form (CMS-10114). Providers who need assistance can contact the NPI Enumerator at [email protected] or (800) 465-3203. The NPI Registry enables users to search by NPI or by the name of the provider. See https://nppes.cms.hhs.gov/NPPES/NPIRegistryHome.do for the service. The downloadable data file includes a very large amount of data (300-800MB) that can be viewed by a variety of software programs but may require some technical skills to navigate. See http://nppesdata.cms.hhs.gov/cms_NPI_files.html for the latest update. http://www.cms.hhs.gov/NationalProvIdentStand/06a_DataDissemination.asp#TopOfPage This site has more information about the NPPES and NPI data dissemination policies and procedures. In Other NPI News Effective March 2008, the Centers for Medicare & Medicaid Services (CMS) began rejecting Part B and durable medical equipment (DME) claims that do not have a National Provider Identifier (NPI) in the primary provider field. For professional claims, the primary provider fields are the “Billing,” “Pay-to,” and “Rendering” provider fields. If the pay-to provider is the same as the billing provider, the pay-to provider does not need to be identified.

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Claims can include so-called “legacy” provider numbers in other non-primary fields, but those claims will continue to be rejected if the NPI and legacy numbers do not match in the Medicare NPI crosswalk. If your claims with an NPI are not being paid, you may need to correct information in the NPI records or Medicare enrollment records to facilitate the crosswalk. If your claims with an NPI and legacy number are paid, then it is recommended you submit a small batch of claims with only the NPI. If those test claims are not paid, contact the Medicare carrier. Medicare claims must only use an NPI.

Match Type 2 NPIs to IRS Data or Risk Rejection

In an effort to ensure that the data submitted to the National Plan and Provider Enumeration System (NPPES) for organization healthcare providers (type 2 National Provider Identifiers) is accurate, the CMS initiated an NPPES-IRS data match to ensure the legal business name (LBN) and employer identification number (EIN) in NPPES are consistent with IRS data. CMS has notified organization healthcare providers that have an EIN/LBN combination in NPPES that are different from the information maintained by the IRS requesting providers review and update their LBN and EIN in NPPES. If organization providers can not furnish data that are consistent with the IRS, CMS will deactivate the NPI in NPPES. CMS will continue to match these provider data in NPPES against IRS data to ensure the accuracy of NPPES data. Medicare is rejecting claims that include legacy identifiers in any primary or secondary provider fields. Additional Information Visit http://www.cms.hhs.gov/hipaa/hipaa2 on the web Visit https://nppes.cms.hhs.gov or call the Enumerator at 1-800-465-3203 For HIPAA information, you may call the HIPAA Hotline: 866-282-0659 or write to: [email protected] on the web

53

American Board of Podiatric Surgery

Full Page Color

P/u 2008

American College of Foot and Ankle Surgeons

Proven leaders. Lifelong learners. Changing lives.

Congratulations Graduates!

Who joins ACFAS? Only the best.

A S A N E W D P M I N Y O U R R E S I D E N C Y, N O W I S T H E T I M E T O S TA RT

Y O U R E V O L U T I O N T O WA R D A C H I E V I N G B O A R D C E RT I F I C AT I O N A S

A F O O T A N D A N K L E S U R G E O N . A N D N O O R G A N I Z AT I O N C A N H E L P

M E N T O R Y O U M O R E I N T H E N E X T F E W Y E A R S T H A N A C FA S .

Please accept a complimentary first-year resident membership in the College … where you’ll rub shoulders with the best and the brightest foot and ankle surgeons … and the wisdom they’ve acquired over the years in ACFAS.

As a resident member of ACFAS, you have access to better resources and better means of preparing yourself to pass ABPS board exams than those provided by any other organization. And you’ll have access to the College’s Journal of Foot & Ankle Surgery, advanced CME training, special residents-only credit union services, and all regular member benefits.

But beyond the practical tools and resources is the imprimatur of the ACFAS brand, the prestige, and the in-demand status that is associated with it.

Join your new community of proven leaders: ACFAS. Joining is easy — just go to www.acfas.org/residents to apply, or contact the College using the enclosed coupon in your APMSA Guide, and an application will be sent to you.

Again, Congratulations — ACFAS looks forward to helping you on your way to a successful career as a foot and ankle surgeon!

1 year complimentary membership

Get a

complimentary

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www.acfas.org/residents

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State Licensing Terms, Resources, Scope of Practice

1. NATIONAL BOARDS: National Podiatric Medical Board Examinations (NBPME). Passing Scores; passing requires a grade of at least 75; the numerical grades received on failed subjects are indicated on the score report. Call 814-357-0487 or visit www.nbpme.org for more information on fees, deadlines, scores, testing sites and dates, Part III exam, etc.

2. STATE EXAM/PM LEXUS: States may require written, oral or practical

examinations. "None" means the state has no exam; PM Lexis administered by the National Board of Podiatric Medical Examiners/Federation of Podiatric Medical Boards); means that the state uses the clinical competency exam. Contact the FPMB at www.fbmb.org or 561-752-3735 to request a form to the release PM Lexus scores.

3. POST-GRADUATE TRAINING: If a state requires a podiatric residency or

preceptorship, the required length of the program is indicated; if the state has indicated that legislation is pending regarding this requirement, it is noted. "None" means no post-graduate training is required in that state.

4. APPL.DEADL/EXAM DATE: Application Deadline/Examination Date. Some states

accept applications continually throughout the year; others have definite deadline dates by which ALL application material must be received.

5. FEES: The initial application/examination/license costs are indicated, as well as

renewal fees, if provided. 6. DURATION OF LICENSE: "1 year" means that the license must be renewed

annually; or as otherwise stated. 7. STATE LICENSE: Contact the state licensing board to apply for a state license.

This is typically done in conjunction with Part III of the Boards. 8. DOCUMENTATION NEEDED:

Undergraduate Transcripts: Official transcripts sent from the undergraduate and graduate institutions attended prior to podiatric medical school.

Podiatric College Certification: Podiatry college certification of attendance/ graduation/miscellaneous information which is either on the application or on a separate form.

Photograph(s): One or more photographs must accompany the application; often the photo must be certified by the Office of Student Records or notarized by a Notary Public as to its authenticity.

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Podiatry Diploma: Most states require only a copy of the D.P.M. diploma to be sent to the licensing board; some states require the applicant to bring the original diploma with him/her during the oral interview/examination.

Pod. Col. Transcripts: Official transcripts from the podiatric medical school (usually with the D.P.M. degree indicated). Again, transcripts with the degree indicated cannot be issued before graduation; letters, however, can be sent indicating the person is scheduled to graduate.

Character References: Reference letters or forms attesting to good moral/ethical/ professional character usually completed by a licensed podiatrist or other physician.

OTHER IMPORTANT RESOURCES: APMA STATE REFERENCE MANUAL

The APMA State Reference Manual is a selective compilation of the state laws that regulate the nation's health care system including scope of practice and nondiscrimination sections as a resource to assist members in understanding state laws since the number and complexity of state laws governing the managed care industry and the practice of medicine is so overwhelming.

The manual provides the exact statutory text and corresponding legal citations for state scope of practice and nondiscrimination laws, along with any relevant amendments, noteworthy court cases, and opinions of attorneys general.

Created by the APMA for its members, this manual to be used as a general resource for members about state statutes pertinent to the practice of podiatric medicine and surgery. However, APMA is not offering legal or other professional advice, and the material is not a substitute for the services of an attorney in a particular jurisdiction. APMA encourages users of the State Reference Manual who need legal advice on issues that evoke state statutes to consult with a competent attorney. Additionally, since state law is subject to change, guide users should refer to state governments and case law for current or additional applicable material.

APMA’s State Reference Manual features include:

“Prompt Payment Provisions” is a compilation of state laws requiring healthcare insurers to make timely payments for insurance claims, and it can be viewed at http://www.apma.org/PromptPaymentProvisions, or on a state-by-state basis at http://www.apma.org/StatutesbyState.

“Ankle and Amputation Provisions” and the “Scope of Practice Statutes and Regulations Comparative Study” are available at http://www.apma.org/ScopeofPracticeProvisions.

“State Ankle Provisions” is a map of the 43 states in this Guide that include the ankle in the scope of practice for podiatric physician and is also available on the scope of practice Web site.

“Hospital Privileges and Medical Staff Provisions” was recently added to the APMA State Reference Manual. The provisions refer to the category of state laws and regulations that governs the medical staff and the hospital privileging process. Although the majority of hospitals in the US credential podiatric physicians, some

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hospitals either provide limited privileges that do not meet the education, training, and experience of the DPM applicants or mandate conditions, such as co- admittance or restrictions on H&P. The APMA surveyed the laws and regulations of 50 states and the District of Columbia and found that 35 states and the District of Columbia have statutory or regulatory provisions governing the treatment of non- MD/DO in the hospital privileging process. For more information on hospital privileges visit: http://www.apma.org/HospitalPrivileges. APMA also has added profiles of state legislatures and links to state governments, legislatures, and licensing agencies to the web pages dedicated to state statutes: http://www.apma.org/StatutesbyState.

Now available are two recently updated comprehensive charts on Scope of Practice and Podiatric Medical Licensure laws and regulations. The scope of practice chart provides APMA members with statutes and regulations on the definition of DPM, scope of practice, supervision authority over physician extenders, and prescription authority. This compilation provides the scope of practice provisions for podiatric physicians in all 50 states, the District of Columbia, and Puerto Rico. The content is based on the language found in the practice act for podiatric physicians in each state.

Histology Associates B/W ¼ Page P/u 10

Histology Associates ½ page ad—B/W P/U 2008

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76

Temporary License Information

State Is a training, temporary or limited license

required by your state for residency training?

Type of license required

Alaska* yes tempArkansas* yes tempCalifornia yes residency (training-limited)Colorado yes trainingConnecticut yes interim permitDelaware yes podiatry in trainingDistrict of Columbia no fullFlorida yes tempIdaho* no fullIowa yes tempLouisiana yes podiatry in trainingMaryland yes registeredMichigan yes residency limited trainingMinnesota yes podiatry in residencyMississippi* yes limitedMissouri yes limitedMontana* yes limitedNevada* yes permitNew Hampshire* yes permitNew Mexico yes trainingNew York no fullNorth Carolina* yes limitedOhio yes limited/tempOklahoma yes tempPennsylvania yes academicTennessee yes tempVirginia yes residency licenseWest Virginia* yes provisionalWisconsin yes limitedWyoming* yes temporary or full

* These states have no podiatric training

Source: AACPM Office of Graduate Services, July 2010

Temporary License Information



Type of license required

Alaska* yes tempArkansas* yes tempCalifornia yes residency (training-limited)Colorado yes trainingConnecticut yes interim permitDelaware yes podiatry in trainingDistrict of Columbia no fullFlorida yes tempIdaho* no fullIowa yes tempLouisiana yes podiatry in trainingMaryland yes registeredMichigan yes residency limited trainingMinnesota yes podiatry in residencyMississippi* yes limitedMissouri yes limitedMontana* yes limitedNevada* yes permitNew Hampshire* yes permitNew Mexico yes trainingNew York no fullNorth Carolina* yes limitedOhio yes limited/tempOklahoma yes tempPennsylvania yes academicTennessee yes tempVirginia yes residency licenseWest Virginia* yes provisionalWisconsin yes limitedWyoming* yes temporary or full

* These states have no podiatric training


77

State Is a training, temporary or limited license required by

your state for residency training?

If yes, type (full,

other)

Is passage of Part I of the

ABPME exam required for a

training license?

Is passage of Part II of the ABPME

exam required for a training license?

California yes yes yesColorado yes yes yesConnecticut yes yes yesDelaware yes yes yesDistrict of Columbia no full yes yesFlorida yes yes yesIowa yes yes yesLouisiana yes yes yesMichigan yes yes yesMinnesota yes yes yesMissouri yes no response no responseNew York no full yes yesPennsylvania yes yes yesTennessee yes yes yesVirginia yes yes yes

Sources: Direct calls to State Podiatric Licensing Boards State Podiatric Licensing Board Websites States Not Offering Podiatric Residency Training have not been included


Passage of NBPME for Residency Training Licensure

State Is a training, temporary or limited license required by

your state for residency training?

If yes, type (full,

other)

Is passage of Part I of the

ABPME exam required for a

training license?

Is passage of Part II of the ABPME

exam required for a training license?

California yes yes yesColorado yes yes yesConnecticut yes yes yesDelaware yes yes yesDistrict of Columbia no full yes yesFlorida yes yes yesIowa yes yes yesLouisiana yes yes yesMichigan yes yes yesMinnesota yes yes yesMissouri yes no response no responseNew York no full yes yesPennsylvania yes yes yesTennessee yes yes yesVirginia yes yes yes

Sources: Direct calls to State Podiatric Licensing Boards State Podiatric Licensing Board Websites States Not Offering Podiatric Residency Training have not been included


Passage of NBPME for Residency Training Licensure

78



If YES, type Is passage of Part I of the NBPME exam

required for a training license?

Is passage of Part II of the NBPME exam

required for a training license?

Alabama noArizona noGeorgia noIllinois noIndiana noKentucky noMaryland yes no noMassachusetts noNew Jersey noNew Mexico yes training no noNorth Carolina yes limited no noOhio yes limited/temp no noOklahoma yes temp no noOregon noRhode Island noTexas noUtah noVermont noWashington noWisconsin yes limited no no

Sources: Website/Direct Calls to State Podiatric Licensing BoardsNote: Some individual institutions may require passage even if the state does not.

States Without Podiatric Residencies (Not Included Above)

*Alabama AlaskaArkansas HawaiiIdaho KansasMaine *MarylandMississippi MontanaNebraska NevadaNew Hampshire *New Mexico*North Carolina North DakotaPuerto Rico South CarolinaSouth Dakota *Tennessee*Vermont West VirginiaWyoming * Military or VA Training Only


States Not Requiring Passage of NBPME Parts I and II for Residency Training

ASICS® IS A PROUD CORPORATE MEMBER OF THE APMA

running releases more than just sweat.the gel-kayano® 17. biomechanically engineered for your foot.

Congratulations Class of 2011 Best wishes for your future career

from the entire TUSPM community!

II.Debt Management

Congratulations and best of luck to the class of 2011!

Harold Glickman, DPMWashington, DC

Congratulations and welcome to the profession. Be involved, be active, and give back!

Matthew Garoufalis, DPMChicago, IL

83

Navigating the Repayment Process

Understanding your loan portfolio is the first step towards effectively managing its repayment. Each of your loans will have its own set of repayment terms and conditions to consider. We have designed the following information to provide you with the basics of student loan repayment. Once you have reviewed the information, you will have the knowledge needed to develop and implement your own personal repayment strategy. Having a strategy is the key to your success. Consider the following questions about your loan portfolio as you read through the information:

What are your payments, and when are the payments due?

Can you afford these payments?

Do you have loans with different interest rates?

What is your lender/servicer’s capitalization policy?

Are your current loans eligible for borrower benefits?

Do you have federal educational loans? Private education loans? Other debt?

Do you know who your lender/servicer(s) are?

Who did you borrow from? Who do you pay back?

Have you updated your school, lender/servicer with any address or name changes?

One of the most common reasons borrowers default on student loans is failing to update their address with their lender/servicer(s). Managing your student loans and other personal finances effectively will influence how quickly you achieve your financial and professional goals in the future. Your lenders/servicers, professional associations and financial aid office can be essential resources as you begin to navigate the repayment process.

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Your Rights and Responsibilities

As a borrower, you are required to: � Repay your student loan according to the agreed repayment schedule

� Notify your loan servicer of anything that affects your ability to repay or which may

impact your eligibility for deferment or cancellation of the loan As a borrower, you have a right to: � Written information on loan obligations, including consolidation

� An explanation of default and its consequences � A copy of your promissory note and return of the original note when the loan is paid in full � Prior to repayment, request balance information and repayment schedule � Be notified if your loan is sold, with information on the new holder � A federal subsidy, if eligible � A grace period, if applicable � Prepay your loan early without penalty � A deferment, if eligible � Request forbearance

Federal Student Aid Ombudsman An ombudsman resolves disputes from a neutral, independent viewpoint and will informally conduct impartial fact-finding about your complaints. U.S. Department of Education FSA Ombudsman 830 First Street, NE, 4th Fl. Washington, DC 20202-5144 877-557-2575; www.ombudsman.ed.gov

Tracking Your Loans National Student Loan Data System (NSLDS) Phone: 800-4-FED-AID www.nslds.ed.gov NSLDS is the U.S. Department of Education’s central database for student aid. It receives data from schools, guarantee agencies, and other Department of Education programs. NSLDS provides a centralized, integrated view of Title IV loans that are tracked through

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85

their entire cycle; from aid approval through closure. Use this website to make inquiries about your Title IV loans. The site displays information on loan amounts, outstanding balances, loan statuses, disbursement, and lender/servicer contact information.

Paying Your Debt Wisely

Debt does not usually happen overnight. It takes time often building gradually over a period of time. And that is the best way to get out of debt – slowly, over a period of time.

~ Prioritize Your Debt ~ List all your debts; then rank them according to the rate of interest (if you are unsure of the rate, check your loan statement or contact your lender). Concentrate on paying off the higher interest debt first while continuing to pay the minimum amount due on all other debt. Once the highest rate debt is paid off, add the total you were paying on this debt to the next one on your list. This way, you will have more to pay off each debt on your list, with the benefit that these payments are already built into your budget. Be sure to continue paying the minimum amount due on your remaining debts so that it does not affect your credit. The recommended pay-off method for debt:

1. Credit Cards 2. Residency/Relocation and/or Private 3. Grad PLUS 4. Unsubsidized Stafford 5. Subsidized Stafford 6. Perkins, HPSL, Institutional 7. Consolidation (depending on the interest rate)

Grace Period

Many student loans provide a “grace period” immediately following graduation. This is a time when payments are not required, and on subsidized loans, interest does not accrue. The grace period must be used before you can obtain deferments. Below is a listing of grace periods for various loan programs.

Loan Program Grace Period Perkins 9 months HPSL 12 months Institutional 12 months Stafford 6 months Grad PLUS (disbursed after July 1, 2008)

6 months

Federal Consolidation No Grace Residency/Relocation Check with Lender Private Check with Lender

86

Loan Programs

If you took a leave of absence from your education, your loans were placed in grace at that time. Whether or not you receive another grace period upon graduation depends on the length of time you are away from school and the policies of the individual loan program. The status of your grace period is vitally important since it usually affects when your deferment period begins (if applicable) and ultimately, when actual loan repayment begins.

Stafford Loan (Federal) 6 month grace period Loans disbursed after July 1, 2006 have a fixed interest rate at 6.8% Loans disbursed prior to July 1, 2006 have variable interest rate, capped at

8.25% Subsidized Stafford is interest free during school and grace periods Unsubsidized Stafford accrues interest during school and grace periods Mandatory forbearance for internship/residency available Various repayment options available Consolidation available Borrower benefits may be available (check with lender) No penalty for pre-payment

Grad PLUS Loan (Federal) Loans disbursed after July 1, 2008 have a 6 month grace period Loans disbursed prior to July 1, 2008 have no grace period and must enter

repayment immediately after graduation (or apply for deferment or forbearance) Interest rate fixed at 8.5% Mandatory forbearance for internship/residency available Various repayment options available Consolidation available Borrower benefits may be available (check with lender) No penalty for pre-payment

Consolidation Loan (Federal) No grace period Interest rate fixed based on weighted average of loans at time of consolidation

rounded up to nearest 1/8 of 1% (capped at 8.25%) Consolidated subsidized Stafford is interest free during school. Consolidated

unsubsidized Stafford, Perkins, and HPSL loans accrue interest during school Mandatory forbearance for internship/residency available Various repayment options available No penalty for pre-payment

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Perkins and Health Profession Student Loan (Federal) � Perkins – 9 month grace period � HPSL – 12 month grace period � Interest rate fixed at 5% � Subsidized during in-school and grace periods � HPSL has unlimited residency deferment (if qualified) � Consolidation option available � Perkins has mandatory forbearance for internship/residency � Perkins has loan forgiveness (if qualified) � No penalty for pre-payment

The two primary factors that contribute to the overall cost of your loans are:

1) Interest is what the lender charges you to use their money. Different loans carry

different interest rates. Interest on all federal loans borrowed is calculated on a simple daily basis. The following formula demonstrates how the simple interest is calculated between payments:

Average daily balance between payments x Interest rate x Number of days between payment (365.25)

The loan holder first applies your payment to late charges or collection costs on your account (if any), and then to the interest that has accumulated (accrued interest). The remainder of the payment is then applied to the principal balance. Just as the accrued interest varies monthly (depending on how many days elapse between the receipts of payment), the amount of a payment applied to accrued interest and the amount applied to principal also will vary monthly. A breakdown of how your payments are applied should be on your billing statement. If not, ask your loan holder/servicer.

2) Capitalization occurs when a lender adds any accrued and unpaid interest to the principal balance of your loan (The principal of your loan is the amount you originally borrowed). Therefore, the balance of your loan increases and, in turn, it causes the principal to grow significantly. The effect of capitalization is that your interest begins to accrue interest. This can be a costly process for you, so you will want capitalization to occur as infrequently as possible. Several tips to reduce the cost of capitalization include: � Contact your lender to determine their capitalization policy. This allows you to

understand when your loans are scheduled to capitalize.

� Pay off accruing interest prior to capitalization. This may mean making partial or full interest-only payments each month while you are in residency.

� File deferment forms on time. Late forms may result in capitalization earlier than

you expected.

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___________________________________________Loan Programs________

Note that some interest rates are fixed and other change monthly, quarterly or annually. Interest rates can vary depending upon if you are in repayment or deferment status. Financial quarters are the first day of January, April, July, and October; federal annual interest rate changes are set July 1. Go to www.bankrate.com for current financial index rates.

Loan Program Fixed or variable?

Interest formula while in

deferment

Interest formula while in repayment

Subsidized Stafford

Disbursed prior to July 1, 2006

Variable annually Subsidized (0%) 91-day Treasury Bill + 2.3%

Subsidized Stafford

Disbursed after July 1, 2006

Fixed Subsidized (0%) 6.8%

Unsubsidized Stafford

Disbursed prior to July 1, 2006

Variable annually

91-day Treasury Bill + 1.7% 91-day Treasury Bill + 2.3%

Unsubsidized Stafford

Disbursed after July 1, 2006

Fixed 6.8% 6.8%

Grad PLUS Fixed 8.5% 8.5%

Private Variable monthly Check with lender Check with lender

Perkins Fixed Subsidized (0%) 5%

Federal Consolidation

Loan Fixed

Based on weighted average of loans being consolidated, rounded to the nearest 1/8th of one percent. Only the

Subsidized Stafford portion of consolidated loan is subsidized (0%) while in deferment.

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Deferment Eligibility Chart

Type Max Time Stafford Loans PLUS Loans Consolidation Loans Perkins Loans

Old Borrower

1 7/1/87 to 6/30/93

New Borrower

2 7/1/93

New Borrower 2

7/1/93

Borrower Consolidates

Before 7/1/93

New Borrower

2 7/1/93

New Borrower 2

Full-Time Student None � � � � � � Half-Time Student None � � � � � �

Graduate Fellowship None � � � � � � Rehabilitation

Training None � � � � � �

Military or Public Health Services (1)

3 Years �

Military (loans disbursed 7/1/2001 or

later) 3 Years � � � �

Nat’l Oceanic and Atmospheric Admin.

Corp. (1) 3 Years �

Peace Corps, Domestic and Tax-Exempt Org.

Volunteer 3 Years �

Teacher Shortage 3 Years � Internship/Residency

Training 2 Years � �

Temporary Total Disability (2) 3 Years � �

Unemployment 2 Years � � Unemployment 3 Years � � � �

Parental Leave (3) 6 Months � Mother Entering/Re-entering Workforce

1 Year �

Economic Hardship** 3 Years � � � � Military Service (4) None � � � � � �

Military Active Duty Student (5)

None � � � � � �

This chart is to be used only as a guide. Please contact your loan servicer(s) to determine eligibility

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A - Old Borrower: Individuals who borrowed their first FFEL loan before July 1, 1993 and had an outstanding balance prior to taking out a new Stafford loan after that date.

B - New Borrower: A borrower who received an FFEL loan with a first disbursement on or

after July 1, 1993. The borrower has no outstanding principal or interest balance on a FFEL loan as of July 1, 1993, or on the date the borrower obtains a loan on or after July 1, 1993. This includes a borrower who obtains a Federal Consolidation loan on or after July 1, 1993, if the borrower has no other outstanding FFEL loan when the Federal Consolidation loan was made.

(1) - Borrowers are eligible for a combined maximum of 3 years of deferment for service in NOAA, PHS, and Armed Forces. (2) A deferment may be granted during periods when the borrower is temporarily totally

disabled or during which the borrower is unable to secure employment because the borrower is caring for a dependent (including the borrower’s spouse) that is temporarily totally disabled.

(3) A parental leave deferment may be granted to a borrower in periods of no more than 6 months each time the borrower qualifies. (4) A deferment may be granted to a borrower who is serving on active duty during a war or

other military operation or national emergency (including qualifying National Guard duty). (5) A deferment may be granted to a borrower called to active National or State duty who is

a member of the National Guard or Reserves (including retired members) and who was enrolled at least half time at an eligible school at the time of, or within 6 months prior to, being activated.

Mandatory Forbearance (Residency)

Podiatric residents are eligible for Mandatory Forbearance during their residency years. Mandatory Forbearance requires that your lender allow you to postpone payment of your loans during your additional years of training. While this alleviates your monthly payment obligation, interest is still accruing on the entire balance of your student loans and will be capitalized upon entering repayment. Federal law mandates that though you are required to request mandatory forbearance, lenders must grant it on loans for the entire duration of your residency. This mandatory forbearance is a viable option to postpone making payments during residency. We encourage you to keep accurate records concerning your student loans as this will help you to be aware of forbearance end dates so that you can (re)apply for them in a timely manner. This will assist you in avoiding unnecessary interest capitalization, delinquency and default due to missed payments on your student loan obligations. Mandatory Forbearance requires the following:

� Annual Application

� Continuous Periods to Avoid Capitalization

� Interest Accrues on Subsidized and Unsubsidized

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Repayment Strategies It is important to note that forbearance provisions might differ on some loans, such as the Federal Perkins (which requires you to pay at least some interest during forbearance). Be sure to find out what your loans’ provisions are, and remember that interest is accruing on all of the loans during periods of forbearance.

No Prepayment Penalty

All Federal education loans allow prepayment without penalty. For loans that are not in default, any excess payment is applied first to interest and then to principal. However, if the additional payment is greater than one monthly installment, you must include a note with the payment telling the processor whether you want your prepayment to be treated as a reduction in the principal. Otherwise, the lender will treat it as though you paid your next payment(s) early, and will delay your next payment due date as appropriate. It is best to tell them to treat it as a reduction to principal, since this will reduce the amount of interest you will pay over the life of the loan. Check with your servicer for private and institutional loans prepayment policies.

Repayment Options

There are five basic options available to you throughout the repayment of your federal student loans. These plans were designed to make your payments more manageable by providing you with financial flexibility. Whether your debt is large or small, the repayment plan you select will impact the overall cost of those loans.

1) Standard Repayment - When you choose this repayment plan, your payment amounts will be equal throughout the term of the loan. In comparison to the other options, the Standard repayment plan provides higher payments, but this means lower interest costs. Standard is the option that allows borrowers to pay education debt in the most proactive manner. If you do not notify your servicer otherwise, the Standard Repayment plan is the default plan for loan repayment. Best Option For: Borrowers whose primary goal is to minimize the total interest cost of student loan debt. 2) Graduated Repayment - The Graduated Repayment plan allows you to begin with smaller monthly payments that will gradually increase over time so your loan is repaid by the end of the repayment term. Though graduated repayment offers lower initial monthly payments than standard repayment, it may lead to higher interest costs over the life of the loan because the principal of the loan is not paid off as quickly. Best Option For: Borrowers seeking temporary relief from their higher loan payments and expecting an increase in their income in the next few years. 3) Income-Sensitive / Income-Contingent Repayment - When a borrower selects Income-Sensitive (FFELP option) or Income-Contingent (Direct Loan option) as a repayment plan, the borrower must provide documentation of their expected income — the monthly payment amount will be based on a percentage of the expected total gross monthly income received from all sources. This plan must be reapplied for each year and income

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documentation will be required. If this plan does not meet a borrower’s needs, the Income-Based Repayment may offer additional flexibility with lower payment amounts. Best Option For: Borrowers that have a lower income, or are experiencing a financial hardship, and need assistance making their monthly payment. 4) Income-Based Repayment - Income-based repayment basically means that the amount of your monthly payment is calculated based on your current income and is evaluated each year. The Income Based Repayment (IBR) Plan takes effect on July 1, 2009 and applies to Federal Stafford, Graduate PLUS, or Consolidation Loans made under the FFEL or Direct Loan Programs. Best Option For: Borrowers who are looking for a lower monthly payment. This option works well for those pursuing careers in public service or that have lower incomes and need assistance in making their monthly payments. 5) Extended Repayment - The Extended Repayment plan allows a borrower to stretch their current repayment term, which is usually 10 years, up to 25 years allowing for a lower monthly payment. Before opting to extend your repayment term, consider the impact on your overall interest costs. Qualifications for Extended Repayment include:

• The borrower must have an outstanding balance of principal and interest totaling more than $30,000 in either FFEL or Direct Loans

• All loans must have been issued on or after October 7, 1998.

Best Option For: Borrowers seeking to lower their monthly payment (without consolidating).

Comparing Repayment Plans

The following table compares each of the major repayment plans with standard ten year repayment. As the table illustrates, increasing the loan term reduces the size of the monthly payment but at a cost of substantially increasing the interest paid over the life of the loan. For example, increasing the loan term to 20 years may cut about a third from the monthly payment, but it does so at a cost of more than doubling the interest paid over the life of the loan. This table is based on the unsubsidized Stafford Loan interest rate of 6.8%.

Repayment Plan and Loan Term

Reduction in Monthly Payment

Increase in Total Interest Paid

Extended Repayment – 12 yrs 12% 22% (factor of 1.22) Extended Repayment – 15 yrs 23% 57% (factor of 1.57) Extended Repayment – 20 yrs 34% 118% (factor of 2.18) Extended Repayment – 25 yrs 40% 184% (factor of 2.84) Extended Repayment – 30 yrs 43% 254% (factor of 3.54)

Graduated Repayment 50% initial payment 38% average

reduction 89% (factor of 1.89)

Income Contingent Repayment (salary = initial debt, 4% annual

raise)

41% declining to 33%

37% average reduction

178% (factor of 2.78)

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For example, suppose you borrow a total of $20,000 at 6.8% interest. The following table shows the impact of switching from standard 10 year repayment to 20 year extended repayment.

Repayment Plan And Loan Term

Monthly Payment Total Interest Paid

Standard Repayment – 10 yrs $230.16 $7,619.31

Extended Repayment – 20 yrs $152.67 $16,639.74

DIFFERENCE $77.49 reduction $9,020.43 increase

FinAid offers several calculators for evaluating the tradeoffs of different repayment plans. Log on to www.finaid.org/calculators/.

Switching Repayment Plans

If you want to switch from one plan to another, you can do so once per year, so long as the maximum loan term for the new plan is longer than the amount of time your loans have already been in repayment. In other words, if you are in year 26 of a 30-year extended repayment plan, you cannot switch to the income contingent repayment plan and have the remaining balance written off.

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Monthly Payment Estimator Federal Stafford Loans with 6.8% fixed annual interest

STANDARD GRADUATED EXTENDED INCOME-BASED (IBR) FORBEARANCE

Stafford Loan

Amount

Balance at the end of grace or interest

capitalization

10-yr repay term

Years 1-4

(interest only)

Years 6-10

25-yr repay term

Years 1-4

Balance (after a 4

yr residency)

10-yr Standard payment (after 4 yrs of IBR)

Year 1-4

Balance (after a 4

yr residency)

10-yr Standard payment

(after 4 yrs of Forbearance)

$75,000 $82,377 $948 $467 $1,397 $572

$350-$500 per mo.

$83,566 $962

$0

$104,783 $1,206

$80,000 $88,276 $1,016 $500 $1,497 $613 $90,302 $1,039 $112,287 $1,292

$90,000 $100,075 $1,152 $567 $1,697 $695 $104,636 $1,204 $127,296 $1,465

$100,000 $111,875 $1,287 $634 $1,897 $776 $119,113 $1,371 $142,304 $1,638

$110,000 $123,674 $1,423 $701 $2,097 $858 $133,691 $1,539 $157,313 $1,810

$120,000 $135,473 $1,559 $768 $2,297 $940 $148,344 $1,707 $172,321 $1,983

$130,000 $147,272 $1,695 $835 $2,497 $1,022 $163,054 $1,876 $187,330 $2,156

$140,000 $159071 $1,831 $901 $2,697 $1,104 $177,809 $2,046 $202,339 $2,329

$150,000 $170,870 $1,966 $968 $2,897 $1,186 $192,598 $2,216 $217,347 $2,501

$160,000 $182,670 $2,102 $1,035 $3,097 $1,268 $207,416 $2,387 $232,356 $2,674

$162,000 $185,029 $2,129 $1,048 $3,137 $1,284 $210,382 $2,421 $235,357 $2,708

$170,000 $194,469 $2,238 $1,102 $3,297 $1,350 $222,257 $2,558 $247,364 $2,847

$180,000 $206,268 $2,374 $1,169 $3,497 $1,432 $237,117 $2,729 $262,373 $3,019

These figures are intended to provide a borrower with estimates of balances and monthly payment amounts — actual amounts may vary. (Values are rounded to the nearest dollar.) Please contact your lender/servicer(s) to discuss your balance and payment amounts.

All values above are based on the following assumptions: • Stafford loans (Federal or Direct) with a fixed interest rate of 6.8% and no fees. For all loan

amounts, $34,000 is subsidized with the remainder unsubsidized. • Four years of medical school then a 6-month grace period after graduation with the

capitalization of all accrued interest occurring at the end of the grace period Forbearance values are based on the following assumptions: • No payment of any kind during a 4-year residency • After the 4-year residency, borrower changes the repayment option to Standard and

accrued interest capitalizes at that time

Per IBR guidelines, IBR repayment amounts are based on federal poverty guidelines, family size, and stipend/salary. The IBR values above are based on the following assumptions: • Family size of 1 in the 48 contiguous states • Monthly payment amounts increase gradually each year starting at an

estimated $375/month in year one up to an estimated $500/month in year four (based on median stipend amounts from the AAMC Survey of Resident/Fellow Stipends and Benefits). Actual monthly IBR amounts will vary depending on borrower salary/stipend.

• After the 4-year residency, borrower changes the repayment option to Standard and accrued interest capitalizes at that time

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Federal Loan Consolidation

Consolidation Loans combine several student loans into one bigger loan from a single lender, which is then used to pay off the balances on the other loans. It is very similar to refinancing a mortgage. Consolidation loans are available for most federal loans, including Family Federal Education Lending Program (FFELP), Perkins, Health Professional Student Loans, and Direct loans. Most FFELP lenders are no longer offering consolidation loans because these loans are no longer profitable. Students can still consolidate their loans with the US Department of Education's Federal Direct Loan Consolidation program at www.loanconsolidation.ed.gov. Interest Rates – The interest rate on a consolidation loan is the weighted average of the interest rates on the loans being consolidated, rounded up to the nearest 1/8 of a percent and capped at 8.25%. When to consider consolidation:

� Variable rates are low � Multiple lenders to repay � To obtain Public Service Loan Forgiveness � To make Perkins loans eligible for IBR

Effects of consolidating in today’s environment:

� Longer term = increased interest costs � Possible forfeiture of borrower benefits � Rounding may result in higher rate

Private loan consolidation – BE CAREFUL

� Understand all fees and costs involved � Do NOT include Federal Loans or all rights will be lost (tax deduction, forgiveness,

subsidies) Forbearance

Forbearance is the period of time, often following grace or deferment, during which a borrower may either:

� Make payments lower than those scheduled � Delay repayment completely for a designated period of time, usually 6 months to

one year During forbearance interest accrues on ALL loans including loans formerly subsidized, so it is important to remember that any interest not paid during forbearance will be capitalized at the end of the forbearance period – making this a potentially costly way to postpone payments. You must apply with your loan servicer, and they will determine the length of the forbearance period.

Avoiding Delinquency and Default

Typically borrowers run into difficulty because they do not open their mail, do not keep in touch with their loan servicers, or are late in filing deferment or forbearance forms.

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Delinquency — means you are late in making a scheduled loan payment. A late payment may be reported to a credit bureau, and if so, will decrease your credit score and will remain a part of your credit history for years to come. Additionally, any borrower benefits that you may have had will likely be forfeited. Default — means you are 270 days or more late on making your loan payment. This can result in or more of the following actions being taken against you: immediate payment in full, wages garnished and federal income tax returns, and even take you to court. A default will hurt you well into the future, record of defaulted loans remains on a credit report for at least seven years. Heading Toward Delinquency or Default? If you have trouble making your loan payment, contact your loan servicer(s) immediately. Your servicer(s) knows all of the options available to you and will help you devise a plan to avoid delinquency and default, maintain your good credit rating, and successfully complete the repayment of your student loans.

Loan Forgiveness Programs Public Service Loan Forgiveness The Public Service Loan Forgiveness Program was created to encourage individuals to enter and continue to work full-time in public service jobs. Under this program, you may qualify for forgiveness of the remaining balance due on your eligible federal student loans after you have made 120 payments on loans under certain repayment plans while employed full time by certain public service employers. In general, only borrowers who are making reduced monthly payments through the Direct Loan income-contingent or income-based repayment plans will have a remaining balance after making 120 payments on a loan. In other words, only borrowers with a high debt-to-income ratio or consistently very low income will qualify for loan forgiveness under the Loan Forgiveness for Public Service Employees Program. Effective Dates: Borrowers must have made 120 monthly payments after October 1, 2007 in the William D. Ford Federal Direct Loan (Direct Loan) Program. Therefore, the first cancellations of loan balances will not be granted until October 2017 at the earliest. Eligible Loans: Although loan cancellation is only available for loans made and repaid under the Direct Loan Program, borrowers with loans made under other federal student loan programs may be eligible if they consolidate those loans into the Direct Loan Program. However, only payments made on the Direct Consolidation Loan will count toward the required 120 monthly payments. Federal Family Education Loan (FFEL) Program loans are eligible for consolidation into the Direct Loan Program. This includes Stafford, Grad PLUS, Consolidation, Perkins and HPSL loans. NOTE: Borrowers may have to meet additional eligibility requirements to consolidate these loans into a Direct Consolidation Loan. If you are unsure about what kind of loans you have consult the National Student Loan Data System at http://nslds.ed.gov. How do I apply for public service loan forgiveness? Although loan forgiveness under this program is available only for loans made and repaid under the Direct Loan Program, loans made under other federal student loan programs may

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qualify for forgiveness if they are consolidated into a Direct Consolidation Loan. To apply for Direct Loan Consolidation log on to http://www.loanconsolidation.ed.gov. Eligibility Requirements – Repayment Plans: To be eligible to have remaining balances cancelled, the borrower must not be in default on the eligible loans and must have made 120 monthly payments on the eligible loan(s) beginning after October 1, 2007. Payments must have been made under any one or a combination of the following Direct Loan Program repayment plans:

� Standard Repayment Plan with a 10-year repayment period � Income Contingent Repayment (ICR) Plan – not available to parent Direct PLUS

loan borrowers � Income Based Repayment (IBR) Plan – not available to parent Direct PLUS loan

borrowers � Other Direct Loan repayment plans, but only payments that are at least equal to

the amount that would be required under the 10-year Standard Repayment Plan may be counted toward the required 120 payments.

Eligibility Requirements – Employment in Public Service Job The borrower must be employed full time (in any position) by a public service organization, or must be serving in a full-time AmeriCorps or Peace Corps position. For purposes of this program, the term “public service organization” means –

� A federal, state, local, or Tribal government organization, agency, or entity (includes most public schools, colleges and universities)

� A public child or family service agency

� A non-profit organization under section 501(c)(3) of the Internal Revenue Code

that is exempt from taxation under section 501(a) of the Internal Revenue Code (includes most not-for-profit private schools, colleges, and universities)

� A Tribal college or university

� A private organization that is not a for-profit business, a labor union, a partisan

political organization, or an organization engaged in religious activities (unless the qualifying activities are unrelated to religious instruction, worship services, or any form of proselytizing) and that provides the following public services –

� Emergency management � Military service � Public safety � Law enforcement � Public interest law services � Early childhood education (including licensed or regulated health care, Head

Start, and state-funded pre-kindergarten)

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� Public service for individuals with disabilities and the elderly � Public health (including nurses, nurse practitioners, nurses in a clinical

setting, and full-time professionals engaged in health care practitioner occupations and health care support occupations)

� Public education � Public library services � School library or other school-based services � Indian Health Service (HIS) � Centers for Disease Control � National Institutes of Health

Additional loan forgiveness programs: NIH Loan Repayment Programs – www.irp.nih.gov NHSC Repayment Program – www.nhsc.hrsa.gov/loanrepayment U.S. Department of Health and Human Services – www.hrsa.gov/help/healthprofessions.htm

Loan Discharge It's possible to have your student loan debt discharged (canceled) or reduced, but only under certain specific circumstances:

� You die or become totally and permanently disabled

� You file for bankruptcy. (This cancellation is rare and occurs only if a bankruptcy court rules that repayment would cause undue hardship.)

Effective July 1, 2006: A false certification discharge was created authorizing discharge if the borrower's loan was falsely certified as a result of a crime of identity theft. Until the discharge regulations can be developed, lenders may provide administrative forbearance and guaranty agencies may suspend default collections if a borrower presents evidence showing that the borrower's loan may have been falsely certified as a result of a crime of identity theft. The lender or guaranty agency must believe the evidence is reasonably persuasive. Note: that you can't cancel a federal student loan because you're having some financial difficulty, unless you qualify for a bankruptcy discharge. Applying For a Discharge If you qualify for a loan discharge, you must apply for one:

� Federal Perkins Loan borrowers must apply to the school that made the loan or to the loan servicer the school has designated

� FFEL Stafford and PLUS Loan borrowers should contact the lender or agency

holding the loan. You can also find a number of discharge forms online If you're not sure what type of loan you have or who holds it, go to www.nslds.ed.gov. The holder of your loan can answer any questions you have about loan discharge. Making Payments on Your Loan While Your Discharge Application is Reviewed

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Until you hear whether your discharge has been approved, you should continue making payments on your loan to prevent it from going into default or accruing (accumulating) additional interest. However,

� If you have a FFEL Stafford Loan, you can be granted forbearance. The holder of your Stafford Loan should grant forbearance until a decision is made on your application. If forbearance is granted, no one is permitted to collect on your loan until the holder of your promissory note determines whether you are eligible for a loan discharge

� If you have a Federal Perkins Loan, schools must automatically defer your loans if

you are performing service that will qualify you for loan cancellation. You don't need to apply for this deferment. Schools may grant such a deferment for up to 12 months at a time.

Approval of a Loan Discharge If you qualify for a complete discharge of your loan, you are no longer obligated to make loan payments. Depending on the type of loan discharge program you may be eligible for, the holder of the loan may be required to refund to you some or all of the monies you paid on the loan. In addition, the loan holder may be required to delete any adverse credit record related to a default, and no tax refund offset or wage garnishment will take place to collect on the discharged loan. If the loan was in default, the discharge may erase the default status. If you have no other defaulted loans, you regain eligibility for federal student financial assistance. Your loan holder can answer any questions you may have regarding your eligibility for a refund. Denial of Loan Discharge For most all discharges, the holder of your loan makes the final decision on whether to discharge the loan—you cannot appeal the decision to the U.S. Department of Education. The two exceptions are false certification and forged signature discharges for a FFEL or Direct Stafford Loan (see "School-Related Discharges" below). If you receive these types of discharges, you may ask the Department to review the denial. If your loan discharge is denied, you remain responsible for repaying the loan. Talk to your loan holder about repayment options if you have a FFEL Stafford Loan. If your loan is in default, ask about loan rehabilitation and loan consolidation. If your school has closed, you should also explore the following options if your discharge application is denied: � Contact the state licensing agency and ask if there is a tuition recovery fund or

performance bond that will cover your damages based on the school closure. � If the school filed bankruptcy, you should file a claim for your loss in the bankruptcy

proceeding. You also might want to consult an attorney about any options you may have through the court system.

Death Discharge Cancellation because of the borrower's death (or, in the case of PLUS Loans, the death of the student for whom the parent borrowed) is based on an original or certified copy of the death certificate submitted to the school (for a Federal Perkins Loan) or to the holder of the loan (for a FFEL or Direct Stafford Loan).

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Total and Permanent Disability Discharge Total and permanent disability is the inability to work and earn money because of an injury or illness that is expected to continue indefinitely or to result in death. You must submit a physician’s certification of total and permanent disability. The physician must certify that you are 100 percent disabled according to the definition of disability above. As of July 1, 2002, if you are determined to be totally and permanently disabled, you will have your loan placed in a conditional discharge period for three years from the date you became totally and permanently disabled. During this period, you don't have to pay principal or interest. If you continue to meet the total-and-permanent disability requirements during, and at the end of, the three-year conditional period, your loan will be canceled. If you don't continue to meet the cancellation requirements, you must resume payment. For more information on qualifying for this discharge, contact your loan holder. Note: Your loan cannot be discharged because you weren't satisfied with the school's services. Your loan can't be discharged solely because you believe the school:

� provided poor training or had unqualified instructors or inadequate equipment � did not provide job placement or other services that it promised � Engaged in fraudulent activities (other than falsely certifying the loan)

Also, a loan discharge can’t be granted because you attended an ineligible program of study offered by the school. The state licensing and accrediting agencies for the school are responsible for the quality of educational services the school provides. The U.S. Department of Education does not endorse the school's educational programs or guarantee the school will deliver the services for which a student contracted.

Maintaining Financial Records

You have received a lot of paperwork over the years from your lenders and servicers, before you pack up and move, take the time to organize your financial aid paperwork. The following are suggestions to assist you in organizing your borrowing portfolio: Keep up with your exit interview information: Prior to graduation from school, you will receive detailed accounting of all your educational loans. Keep this information with you, not in Mom’s attic or in a storage unit somewhere. Be sure that the information makes every move with you throughout your years of repayment, residency, fellowship, and/or practice. Keep up with your mail: As previously noted, open and read all your mail when it arrives. Do not miss a deadline or a notice regarding a change in the status of your loans by tossing an unopened envelope into a drawer or a box. Lenders expect you to stay abreast of the details regarding your loans. Missing a deadline can eventually throw you into a default status.

Set up a logical filing system that works for you: Up to now, you have probably filed all your financial aid papers by academic year so they would be easy to refer to while you were in school. It is time now to change that filing system so that it will help you remain aware of lenders and due dates. Make a file folder for each lender/servicer. (Note: you may deal with a servicer hired by your lender to service your loans). Put into this file the promissory note and other papers relating to each loan you received from that lender. Keep a record of each lender’s address and phone number(s) in the file.

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Keep accurate, complete records: Put a log sheet into each lender’s file, and use it to make notes about every phone call you make or receive and each form you mail to the lender/servicer. Jot down the date, amount, and number of the check you write when you make every payment. These canceled checks can prove when payments were made, and they may be essential for taking advantage of tax benefits for loan repayment. Keep track of the dates, the names of people you contact, what was discussed, and who is supposed to do what next. Knowing the name of the person you spoke with the first time will make follow-up calls easier and less stressful for you and for the customer service representatives as well. Always, always keep a photocopy of any form you mail to your lender/servicer. Note the date when you mailed it. Consider using registered mail, and a return reply card, so that you know when your mail was delivered and who signed for it. This may require a little more time and a little extra expense up-front, but it may save you lots of money and anguish later on. Set up a long-range calendar: Set up a calendar that covers at least enough years to get you through residency. Mark on the calendar the dates you need to submit forbearance or deferment forms. Keep in mind that grace periods and deferments vary in length. Remember that most forms must be submitted annually, and you are not likely to get a reminder from your lender/servicer. Do not wait to request school/hospital forms. Keep this calendar in a prominent place, and make a habit of referring to it regularly.

Keep your lenders/servicers informed of changes: Be certain that you notify your lender/servicer when you change your address, telephone number, or name. Undeliverable mail can quickly become stumbling blocks for your financial future.

Student Loans and Your Credit Rating Your student loans are reported to the three national credit agencies. It is important to understand that if you are late in filing paperwork or making a payment, your delinquency will be reported. How do I obtain a credit report? Consumers have the opportunity to receive free credit reports once a year from the Annual Credit Report Request Service. This is the only centralized credit reporting service authorized by Equifax, Experian and TransUnion to provide free credit reports. Don’t confuse this program with the many paid services available to consumers to monitor your credit, or the now antiquated services that provide you with credit reports from all three agencies at one “low price.” You can go online to request, view, and print all three free credit reports: www.annualcreditreport.com FICO fundamentals: A FICO score is a three-digit number that determines the interest rate you will pay on your credit cards, car loan, and home mortgage, as well as whether you will be able to get a cell phone or have your application for a rental apartment accepted. FICO stands for Fair Isaac Corporation, the firm that created the formula that seems to lord over your financial life. The way the business world sees it, your FICO score is a great tool to size up how good you will be at handling a new loan or credit card, or whether you’re a solid citizen to rent an apartment to. A high FICO score gives you a great reputation with the business world; you’ll get the best deals. A lower FICO score translates into paying higher interest rates on cards

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and loans. Your credit history can even affect your auto insurance premiums or your ability to get that job you applied for.

Your: Accounts for this percent of your FICO score

Record of paying your bills on time (payment history)

35

Total balance on your credit cards and other loans compared to your credit limit

30

Length of credit history 15 New accounts and recent applications for credit 10 Mix of credit cards and loans 10

Fair Isaac uses a formula to come up with a score for you that can range from 300 to 850. Anything between 300 and 500 means you are a toxic financial risk and you are going to be hard-pressed to find any business that will want to work with you. Scores between 500 and 850 are sliced and diced to fall into six ranges; the exact cutoffs for those ranges can vary from lender to lender, but typically this is what you may encounter.

The FICO Ranges 720-850 Best 700-719 675-699 620-674 560-619 500-559 Worst

The range your score falls into ultimately determines the interest rate that you will pay on loans. Other factors, such as your employment history and salary, will affect the deal you get, but your FICO score is a major component in determining the interest rate you pay. How will consolidation impact my credit rating? Your new consolidation loan will be reported to the credit agencies. It is important that you verify that your credit report was correctly updated. The loans you consolidated should show a $0 balance, as these loans were paid off by your consolidation loan. If the credit report does not show a $0 balance, it will appear that you have double the amount of student loans. Your total debt burden is a part of your overall credit rating, and therefore this mistake could impact your credit score. What should I do if there is an error on my credit report? If you find an error on your credit report, contact the appropriate credit agency directly: Equifax (800) 685-1111 www.equifax.com Experian (888) 397-3742 www.experian.com TransUnion (800) 888-4213 www.transunion.com These credit bureaus do not cross verify information, so errors may exist on one but not the other. Submit a dispute to each credit bureau and the lender who provided the erroneous information. You should get copies of all three credit reports, and report errors immediately and dispute each one separately. Agencies are required to investigate/respond within 45 days.

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Selecting a Financial Advisor

You may be considering seeking help from a financial planner for a number of reasons—for example, deciding whether to buy a new home, setting up a practice or partnership, planning for retirement or your children’s education, or, more commonly, simply not having the time or expertise to keep your finances in order. Whatever your needs or reasons, working with a financial planner is a helpful step in securing your financial future. There are several questions you should ask, and steps you can take on your own, before choosing the financial planner who will help you meet your short-term needs, as well as your long-term goals. Asking the right questions and following these steps should result in a successful partnership. What experience do you have? Find out how long the planner has been in practice, as well as the number, and types, of companies he or she has worked with. Choose a planner with a minimum of three years’ experience in counseling individuals on their financial needs. Most importantly, you want to choose a planner who has extensive experience in, if not specialization in, working with physicians. What are your qualifications and credentials? Many financial professionals use the term “financial planner.” Ask the planner whether he or she holds a financial planning designation, such as CLU (Certified Life Underwriter), ChFC (Chartered Financial Consultant), CFP (Certified Financial Planner), RIA (Registered Investment Advisor), or PFS (Personal Financial Specialist). If the planner holds one of these designations, check on his or her background with the CFP board or other relevant professional organization. You may also ask for references, from current clients and other professionals, such as accountants and attorneys that the planner has worked with. Find out if the planner has ever been fined, reprimanded, or suspended by contacting your State Insurance and Securities Departments, the NASD, or the SEC What services do you offer? These will vary, depending on a number of factors, including professional credentials, license, and areas of expertise. Ask yourself if this planner offers services that are compatible with your immediate and long-term needs. Review a sample of a completed plan, to determine whether the planner offers the particular services that meet your personal financial needs. What is your approach to financial planning? Ask the planner about the types of clients and financial situations that he or she typically likes to work with. Make sure the planner’s viewpoint on investing is not too cautious, or too aggressive, for you. Will you be the only person working with me? The planner may work with you alone, or have others in the office assist. You may want to meet everyone who will be working with you. If the planner works with professionals outside

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his or her practice (e.g., attorneys, insurance agents, tax specialists), get a list of their names and check on their backgrounds. How will I pay for your services? Planners can be paid in several ways. They can be salaried, commission-only, fee-only, or compensated through some combination of commission and fee. As part of your financial planning agreement, the planner should disclose to you clearly—in writing—how he or she will be paid for the services to be provided.

How much do you typically charge? While the amount you pay will depend on your particular needs, the planner should be able to provide you with an estimate of possible costs, based on the work to be performed. Could anyone besides me benefit from your recommendations? Some business relationships that a planner already has in place could bias his or her professional judgment while working with you, thereby inhibiting the planner from acting in your best interest. Ask the planner to provide you with a written description of his or her conflicts of interest. Don’t hesitate to walk away from any planners who promote only their own financial products, or those of the companies with whom they have a business relationship or partnership. Can I have it in writing? Ask the planner to provide you with a written agreement that details the services that will be provided. Keep this document in your files for future reference. A qualified financial planner will have a proven track record, and should welcome these questions. It’s critical to feel confident that you can trust the planner to handle your personal/business finances in an ethical, confidential manner. Keep in mind that you want to be working with this person for many years—perhaps, for the rest of your life. Above all, you should feel comfortable in the relationship. To check the professional record of a financial planner, contact:

� Certified Financial Planner Board of Standards, Inc. 800-487-1497 • www.cfp.net

� North American Securities Administrators Association 202-737-0900 • www.nasaa.org

� National Association of Insurance Commissioners

816-842-3600 • www.naic.org

� National Association of Securities Dealers - FINRA 301-590-6500 • www.finra.org

� Securities and Exchange Commission 888-SEC-6585 • www.sec.gov

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To find a financial planner in your area, contact the following organizations:

� Financial Planning Association 800-322-4237 • www.fpanet.org

� National Association of Personal Financial Advisors 847-483-5400 • www.napfa.org

� The Society of Financial Service Professionals 610-526-2500 • www.financialpro.org

Educational Tax Benefits

The Lifetime Learning Tax Credit The Lifetime Learning credit is available for all types of post secondary education, unlike the other credits. Use the Lifetime credit once you have exhausted your eligibility for more advantageous credits. This credit may be particularly helpful to graduate students. You can claim a tax credit of up to $2000 per tax return (not per student). The maximum is $4,000 if at least one family member was a student in a Midwestern disaster area school. The qualifying student(s) can be anyone in the family. The Lifetime Learning credit is non refundable— the maximum credit that you can receive is limited to the amount of tax you owe. You are eligible for the credit if your modified adjusted gross income is $60,000 or less (for married couples filing a joint return, $120,000 or less). Qualifications: � Expenses that count towards this credit are tuition, fees, and amounts required to be

paid to the institution for books, supplies and equipment (less the amount of certain scholarships and grants received) during 2009 for yourself, your spouse, or someone whom you claim as a dependent on your tax return. If a student attended school in a Midwestern disaster area, other expenses may be included.

� You don't have to be pursuing a degree or certificate to qualify for the Lifetime Learning Credit. You can claim it for all years of post secondary education and for courses to acquire or improve job skills.

� You must file a federal income tax return and have a 2009 income tax liability of any amount to get the credit. If you are claimed as a dependent on someone’s tax return, only the person who claims you can apply for the credit.

� If you claim the American Opportunity credit or the Hope credit for one or more

students in your family, you can't use their expenses to figure your Lifetime Learning Credit. You can still take a Lifetime Credit for family members for whom you are not claiming the other credits.

Unlike other credits, students who have felony drug convictions do qualify to take the Lifetime Learning credit.

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How to Claim Tax Credits To claim any of the three tax credits, you must report the amount of your qualified expenses (less certain scholarships, grants, and untaxed income) on IRS Form 8863 - Education Credits. Complete instructions for using this form and more details are available from the IRS. Tuition and Fees Tax Deduction The Tuition and Fees tax deduction can reduce your taxable income by as much as $4,000. This deduction may be helpful to you if you are not eligible to take one of the tax credits. It is taken as an adjustment to income, which means you can claim this deduction even if you do not itemize deductions on Schedule A of Form 1040. You are eligible to take the deduction if your modified adjusted gross income is $80,000 or less ($160,000 if filing a joint return). The amount of the Tuition and Fees deduction you are eligible for depends on the amount of qualified tuition and related expenses paid for eligible students. Tuition and Fees Tax Deduction Qualifications: � Expenses that you can deduct are tuition, fees, and amounts required to be paid to the

institution for books, supplies and equipment (less the amount of certain scholarships and grants received) during 2009 for yourself, your spouse, or someone whom you claim as a dependent on your tax return. The expenses must have been for a student enrolled in one or more courses at an eligible* educational institution.

� You can't claim both an education credit and the tuition and fees deduction for the

same student for the same year, but you can take the deduction for one student and a credit for another.

� You can't take this deduction if you deduct tuition and fees expenses under any other

provision of the law (for example, as a business expense). � You can't claim this deduction if your filing status is married filing separately or if

another person can claim you as a dependent on his or her tax return. Student Loan Interest Deduction The Student Loan Interest tax deduction can reduce your taxable income by as much as $2500. It is taken as an adjustment to income, which means you can claim this deduction even if you do not itemize deductions on Schedule A of Form 1040. You can deduct interest paid on a student loan for yourself, your spouse, or your dependents. You are eligible to take the deduction if your modified adjusted gross income is $75,000 or less ($150,000 if filing a joint return). The amount of the Student Loan Interest deduction you are eligible for depends on the amount of interest paid and your income. Qualifications: � Qualified student loans must have been used to fund educational expenses such as

tuition, room and board, fees, and books for a student enrolled at least half-time and pursuing a degree, certificate, or similar program at an eligible* institution.

� You cannot claim this deduction if your filing status is married filing separately or if another person can claim you as a dependent on his or her tax return.

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Taxability of Loan Forgiveness Programs If you've received a student loan that states it can be forgiven, cancelled, or paid if you work for a certain period of time, in certain professions, for any of a broad class of employers, then the amounts forgiven may qualify for tax-free treatment. For complete information on educational tax benefits, see the IRS Publication 970 on the IRS website: www.irs.gov. *An eligible educational institution is any college, university, vocational school, or other post secondary educational institution eligible to participate in a student aid program administered by the U.S. Department of Education. According to the IRS, "it includes virtually all accredited, public, nonprofit, and proprietary post secondary institutions." The educational institution should be able to tell you if it is an eligible educational institution. Certain educational institutions located outside the United States also participate in the U.S. Department of Education’s Federal Student Aid (FSA) programs Swede-O ½ page b/w p/u 10 CAB logo

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Resources and Definition of Terms/Conditions

The following is a list of helpful links. When in doubt, these experts can help you sort through all your financial questions. Accountants: American Institute of Certified Public Accountants http://www.aicpa.org/yellow/ypascpa.htm Automobiles: Kelley Blue Book www.kbb.com Edmunds.com www.edmunds.com Bonds: Bond Market Association www.investinginbonds.com Financial Calculators: Nolo's Plain English Law Centers www.nolo.com FinAid www.finaid.org/calculators Sallie Mae www.salliemae.com/tools/calculators/repayment Data Masters: This calculator provides salary and cost-of-living calculators http://www.datamasters.com/

Financial Planners: Financial Planning Association (FPA) www.fpanet.org/plannersearch/plannersearch.cfm National Association of Personal Financial Advisors (NAPFA) www.napfa.org House Stipend Survey: http://www.aamc.org/data/stipend/2009_stipendreport.pdf

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Insurance: Insurance Information Institute www.iii.org Interactive Budget Worksheet: http://www.aamc.org/programs/first/facts/budget_worksheet.pdf Interest rates: Bankrate.com www.bankrate.com WebMath.com www.webmath.com/simpinterest.html Lawyers: Martindale-Hubbell's Martindale.com http://lawyers.martindale.com/marhub Search for a lawyer in your area, by name, by specialty, by firm, and more.

Money-Market Rates: iMoneyNet;www.ibcdata.com Search for the best money-market mutual fund rates, both taxable and tax-free; learn the basics of money-market fund investing. Mortgage Calculators: Interest.com www.interest.com/calculators HSH Associates, Financial Publishers www.hsh.com/calculators.html Mutual Funds: Morningstar.com www.morningstar.com Savings Bonds and Treasuries: US Department of the Treasury's Bureau of the Public Debt www.publicdebt.treas.gov State Insurance Departments: National Association of Insurance Commissioners http://www.naic.org/state_web_map.htm

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Stocks: Quicken www.quicken.com/investments Morningstar.com www.morningstar.com Taxes: Internal Revenue Service www.irs.gov Zero-Coupon Bonds: Bonds Online www.bondsonline.com/asp/treas/zeros.asp

Glossary

Borrower – The person who receives the loan. Capitalized Interest – Accrued interest added to the outstanding principal. Subsequent interest accrues on the new total principal balance, which includes any capitalized interest. Consolidation – Refinancing multiple education loans into a single new loan. This can result in a different interest rate and/or longer repayment period. Co-signer – A creditworthy individual who agrees to be responsible for repaying a private loan if the primary borrower does not. A loan borrower who is not eligible on the basis of their own credit may become eligible with a co-signer. The co-signer must be a U.S. citizen or national, a U.S. permanent resident, or other eligible non-citizen.

Cost of Attendance (COA) – The total cost of attending a post-secondary institution for one academic year. The budget usually includes tuition, fees, room, board, supplies, transportation, and personal expenses. Credit Check – The process of obtaining information about an individual’s borrowing habits and money-management skills. Lenders use credit reports to determine if they should approve a loan and to set the terms (interest rate, fees, and length) of the loan. Default – A failure to repay a student loan according to the agreed-upon terms of a promissory note. Deferment – The temporary postponement of payments on a loan. Subsidized loans, including Perkins Loans, will not be charged interest during the deferment. Unsubsidized loans will continue to accrue interest during the deferment. Unpaid interest will be capitalized and increase the amount that must be repaid. Delinquent – The status of a loan that begins the day after the due date of payment when the borrower fails to make the equivalent of one full payment.

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Electronic Signature – The process by which a document is signed via the Web. Submitting an electronic signature eliminates the need to print and mail the document and expedites the approval process. Endorser – A creditworthy individual who agrees to be responsible for repaying a Federal PLUS loan if the primary borrower does not. A PLUS loan borrower who is not eligible on the basis of their own credit may become PLUS eligible with an endorser. The endorser must be a U.S. citizen or national, a U.S. permanent resident, or other eligible non-citizen. The dependent undergraduate student for whom a parent is pursuing a PLUS loan cannot be the endorser. Endorser Addendum – An addendum to the Federal PLUS Loan Application and Master Promissory Note (MPN) signed by the borrower of the Federal PLUS Loan. When signing the Addendum, the endorser is agreeing to repay only the loan that is identified in the addendum, if the borrower does not repay the loan. Expected Family Contribution (EFC) – The amount a family is expected to contribute to a student's education. Expected family contribution is calculated based on family earnings, net assets, savings, and size of family and number of students in college. Graduate students are considered Independent so the EFC is based solely off of the student’s earnings, net assets, savings, and size of family. Federal Default Fee – The fee that guarantors are required to deposit into a federally-owned reserve fund. This fee is used to reserve funds to reimburse lenders if a student or parent borrower fails to repay a loan. Federal PLUS Loan – A low interest federally sponsored loan available to credit eligible graduate students and credit eligible parents of undergraduate dependent students. Federal Stafford Loan – A federally guaranteed loan program that allows students to borrow funds. Stafford loans allow a student to defer payments while they are in school. Stafford loans can be either subsidized or unsubsidized. FFELP – Federal Family Education Loan Program. A federal student loan program that provides students and their parents with access to low cost student loans, including subsidized and unsubsidized Federal Stafford loans, Federal PLUS loans, and Federal Consolidation loans. Forbearance – A temporary cessation or reduction of payments due to financial difficulty. The borrower is responsible for all accrued interest during a forbearance period. Unpaid interest may be capitalized quarterly or at the end of the forbearance. Free Application for Federal Student Aid (FAFSA) – The application for federal student financial aid, processed at no cost to the applicant. It is used to determine a student’s eligibility for federal grants, loans and work-study. Guarantor or Guarantee Agency – The state agency or private non-profit institution that has an agreement with the U.S. Secretary of Education to administer a loan guarantee program under the Higher Education Act. Interest – A fee charged to the borrower for use of a lender's money.

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Lender – The institution that originates your funds. Master Promissory Note (MPN) – A contract the student signs when taking out either a Federal Stafford or Federal PLUS loan. The Federal Stafford MPN is used for the subsidized/ unsubsidized loans the student may receive for the same enrollment period. If the student is attending a four-year or graduate school, the Federal Stafford MPN or Federal PLUS MPN also covers loans of the same type the student may receive for future enrollment periods. Origination Fee – A fee withheld from the principle disbursement amount by the lender at each disbursement of funds to the school to cover the costs of originating the loan. Private Loans – A type of loan that provides supplemental funding when other financial aid does not cover costs. Banks or other financial institutions and schools offer these loans (not sponsored by government agencies). Promissory Note – A legally binding agreement the borrower signs to obtain a loan, in which the borrower repays the loan (with interest and applicable late fees and/or collection costs) in periodic installments. The agreement also includes information about any grace period, deferment, or cancellation provisions and the borrower's rights and responsibilities in respect to the loan. Servicer – The institution that you will work with in repayment (i.e. where you will make payments, file deferments, etc.). Subsidized Loan – A need-based loan which is eligible for interest benefits paid by the federal government. The federal government pays the interest that accrues on subsidized loans during in-school, grace, authorized deferment, and (if applicable) post-deferment grace periods if the loan meets certain eligibility requirements. Unsubsidized Loan – A non need-based loan which accrues interest from the date of disbursement until the loan is paid in full. The borrower is responsible for repaying the interest on an unsubsidized loan during in-school, grace, and deferment periods, in addition to repayment periods.

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Podiatry School Financial Aid Offices BUSGMS NYCPM 305-899-3123 212-410-8006 www.barry.edu/podiatry www.nycpm.edu CSPM OCPM 510-869-1550 216-231-3300 www.samuelmerritt.edu/podiatric_medicine www.ocpm.edu CPMS TUSPM 515-271-1470 215-625-5447 800-240-2767 x-1470 http://podiatry.temple.edu www.dmu.edu/cpms SCPM AZ MIDWESTERN 847-578-3217 623-572-3321 www.rosalindfranklin.edu/scholl www.midwestern.edu WESTERN 800-346-1610 www.westernu.edu

Works Cited FinAid. 1994. December 2009 <www.finaid.org>. Orman, Suze. "Young, Fabulous and Broke." Orman, Suze. U.S. Department of Education. 2/26/10. <www.studentaid.ed.gov>. Important: All information and estimates are based on interpretation of federal regulations as of December 2009 and are subject to change. These are estimates only. Graduates should always contact their lender/servicer(s) to discuss exact loan balances and repayment options.

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The APMSA extends its appreciation to the American Academy of Podiatric Practice Management

(AAPPM) and the following contributors:

John Guiliana, DPM, MS Jason Kraus

Jane Graebner, DPM Kris Titko, DPM

Gayle Johnson, PMAC Jeffrey Lafferty, JD

Charley Greiner, DPM Bill McCann, DPM Ray Posa, MBA

Gayle Johnson, PMAC Louis DeCaro, DPM Mike Crosby, CPA

Hal Ornstein, DPM Jeffrey Frederick, DPM Jasen Langley, DPM

Phillip Ward, DPM SuEllen Dercher

Josh White, DPM, CPed David Dercher

Rich Levin, DPM Mark Sherrod

Peter Paicos, DPM Jeff Lafferty, JD

Kevin McDonald, DPM Debra Womick, DPM

Les Appel, DPM Charles R. Young, DPM

Barry Mullen, DPM Meri Kuvent

Bob Kuvent, DPM Craig Thomajan, DPM Animesh Bhatia, DPM

You’ve learned how to be a great doctor – Now we’ll teach you how to build a great practice.

Whether you are a podiatry student, resi-dent or in practice as a new practitioner, the American Academy of Podiatric Prac-tice Management (AAPPM) can help you maximize your success. The AAPPM is podiatry’s premier practice management association that provides its member, both doctors and podiatric sta� mem-bers, with exceptional, real-world prac-tice management education, skills and resources to help them practice more e ciently, enjoyably and pro�tably.

Through the unique, highly interactive small group roundtables at AAPPM edu-cational meetings, our free peer to peer mentoring, teleconferencing, Webinar educational programs and informa-tion packed website, will give students, residents and new practitioners unique access to the best and brightest experts in the podiatric world who willingly share their “pearls” of success.

Students can join the AAPPM Practice Management Clubs at their schools and share with other students their passion to be a podiatrist. Joining and participating in AAPPM student clubs is the �rst step towards building your future in podiatric medicine. As your school builds a foun-dation of podiatric medicine, the shared value in participating in your club school will build that same foundation in your future practice.

For more information on the many bene�ts of AAPPM membership, or about the Practice Management Club at your school, visit www.AAPPM.org.

1000 W. St. Joseph Hwy, Suite 200 | Lansing, MI 48915-1695 | T (517) 484-1930 | F (517) 485-9408 | email: o [email protected] | www.aappm.org

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Rockwood Programs has partnered with Ironshore Specialty Insurance Company to offer an insurance product tailored to address the unique liability exposures facing Podiatric Physicians today! Consider some of these unique coverage features:

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Security Policies and Procedures – The Final Hurdle The Centers for Medicare and Medicaid Services (CMS) has released an introductory overview of the Health Insurance Portability and Accountability Act (HIPAA) 5010. The implementation of HIPAA 5010 will require changes to the software, systems, and perhaps procedures that physicians use for billing Medicare and other payers. It is essential that DPMs are aware of these HIPAA changes and that they plan for their implementation.

The best way to address HIPAA compliance is to treat the regulation as a single integrated entity. By keeping your eye on the total picture, you won’t have to waste time, effort and money to readdressing items at a later date. You should have a total integrated HIPAA plan and work it into your daily routine. Make it second nature and compliance will be much less burdensome. While the privacy requirements lend themselves well to boilerplate policies and procedures requiring only minor adjustments for your practice; Security will be a horse of a different color. The security requirements are so specific to your practice that writing policies and procedures to address security issues in your practice will require much more thought and effort. With HIPAA privacy components, most offices only had to take existing ways of doing business and put it in writing, print up their NPP, display it in the waiting room, post it on its web site and distribute to patients; done. Security on the other hand will require much more. Security is going to get into areas that most practices have never thought of and don’t even have a foundation to build on. Security will deal with the physical facility, the computer system, computer user procedures and practice contingency plans among others. While many have accomplished the privacy portion of HIPAA without conducting a Gap analysis; with the security portion a Gap analysis will be essential for the following reason: Privacy compliance required little or no expenditures in order to be compliant, security however may require investing quite a bit of money in software, hardware and facilities upgrades. By conducting a Gap analysis you can identify areas needing attention and then work out a long term plan to address these issues. The key here is that you are proactive. You have identified and are working toward mitigating the problem areas. That being said, if there is a breach in your security you are still responsible. The difference is in the amount of your liability. If you have identified problem areas and have an existing plan to address then you will be in a better position than being caught with a security breech and having no knowledge of the breech, or corrective plans. Again we come back to our favorite HIPAA buzz word MITIGATION. HIPAA is all about making reasonable efforts to reduce the risk of having PHI falling into the wrong hands.

The requirements for compliance under the security provisions of HIPAA, unlike privacy which many practices took a cookie cutter approach to, will be so practice specific that it is unlikely that you will be able to meet the requirements with anything less than a well executed, highly individualized policy and procedures manual. Some of the areas that must be addressed are data backups, intrusion detections / prevention and access control to data.

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Data Backups

Have you ever thought about a parachute? It’s a nice invention. Could you image having to wear one all the time? It would be cumbersome and awkward, but could you imagine not having one when jumping from an airplane. Computer backup systems are the same way. They can be a nuisance and a bit of a bother, but like a parachute when you need one nothing else will do. I have seen so many cases over the years where clients blindly put tapes into their backup units, assume they work and the next day switch tapes and just go about their business. As a matter of sound business practice you need to test and verify your backups to make sure that they are actually backing up your data properly and the information is without errors. Under HIPAA security rules, not only are you required to perform regular backups but you are also required to test and verify that the backup was successful. Also, you must also have a procedure to make sure you can restore the data and you must also have a provision to ensure you keep a copy safe and off site. Conventional tape backups are fairly easy to use but making sure that they are meeting the contingency requirements of HIPAA can be a laborious effort for your staff and may even be beyond what the staff can do. To every HIPPA problem there seems to be a HIPAA solution. Actually, this solution has been around for several years but is now finding a new niche in the medical field, especially in small offices, where data backup is essential. There are many companies offering web based backup services. The services operate in the following manner: special client backup software is installed on your computer; the software runs a batch of data every night, similar to how a tape system operates; the backup software takes the backup data and compresses it, while performing a 428-bit data encryption; the compressed and encrypted data is then sent to a remote server, where it is received and processed; to verify the data, the remote server opens the files and compares it to a known copy in your folder; the server then recovers a file from your backup to ensure file integrity; the remote server then compiles a report including all integral information pertaining to your backup and e-mails you a report. Daily, you will receive e-mails confirming that the data backup has been done successfully, and that the data can be restored. These services address several points of concern in HIPAA security compliance. They provide a safe, hands off approach to backing up your data, they keep your data safe and off-site, they provide you with documentation that you are meeting and exceeding the HIPAA mandates, and they relieve your staff of the responsibility of performing the backups.

Anti-Virus Software and Operating System Patches

Anti-virus software is so essential in today’s computer environment; so much so that I tell clients to not even bother running their PC’s if they are not running up-to-date virus software. Why, because viruses are so prolific that in a very short time you WILL get one. Anti-virus vendor watchdog groups are reporting that new virus activity was up 17.5 percent over the past six months, and viruses are getting more sophisticated, with more sophisticated targeting.

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Just to demonstrate this fact for my clients, my anti-virus program has an audible alert option that I can switch on for demonstration purposes; it goes off every time a virus attempts to enter my system. When activated, it will beep every 5 to 10 seconds all day every day, that’s how prominent viruses are in today’s world. Some users believe it won’t happen to them or they can’t afford the software or the update subscriptions. The cost of repairing a system after being infected will cost much more than even the most expensive anti-virus software; plus you can’t even put a monetary value on the cost of lost data. I consider the money paid for anti-virus software to be part of the operating expense of a computer, just like electricity. Under HIPAA security requirements you are required to safeguard your systems from outside intrusion and failing to do so is a violation. Virus attacks and outside hacks are considered “common knowledge” and you are responsible to implement procedures to prevent intrusions. Just installing anti-virus software is not enough. You must configure it so that it will quarantine the virus and /or delete it. You need to also make sure the virus patterns that the manufacture provides are up to date. Once you have your anti-virus software installed and configured and getting its updates, you’re done, right? Wrong. There is another key component that must also be done; that is updating your operating system. You should be checking for Windows updates on a daily basis. In Windows 98 and later, Windows has a scheduler feature whereby Windows will automatically go to the Microsoft update site and find any new critical updates and download them for you. It will then have a little pop up alert letting you know that the updates are downloaded and ready to be installed. This is important because many viruses are written to exploit vulnerabilities in Windows. Even though you have anti-virus software if you have critical holes in Windows you are still subject to getting a virus. The anti-virus software also depends upon the operating system being secure.

Firewalls

In addition to anti-virus software to keep out malicious email and software attacks, Firewalls keep out direct intrusions as well as blocking some virus exploits. The firewall is one of the most overlooked pieces of security. Firewalls are designed to prevent unauthorized access to your computers from the web. The broadband explosion has provided Internet users with a better, faster solution than the traditional dial-up connections we've been used to. That's the good news. The bad news is broadband connections have some drawbacks, the most serious of which is the fact that they are "always on." A connection that never shuts off is a hacker's dream. Hackers like "always-on" connections like DSL, cable modems and T1 lines because they're always there and they're predictable. This isn't to say that broadband connections are bad--quite the contrary. Broadband is a great technology. Users just need to make sure they're using the appropriate level of protection that a firewall solution can offer. Without a firewall in place hackers can access your PHI and either use it for their own purposes or disseminate it to the world at-large. Firewalls are a great way to protect your practice’s computers from intruders. They are designed to defend against attack by implementing a series of rules that permit, or deny, traffic to pass between your network

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and the Internet. Based on the way these rules are set, the inbound and outbound flow of information maybe extremely tight or very relaxed. The trick is to maintain a balance between your practice’s need for security and your employees' need to get their work done without interference. Firewalls are absolutely necessary and are not very expensive. I would strongly suggest having the firewall installed by an expert. While anyone can take it out of the box and plug it in. The trick is to configure it properly or it becomes a useless piece of hardware sitting on your network not protecting you and only providing you a false sense of security until your network is compromised.

Access Control Using Biometrics

Biometrics are any security device that uses unique physical attributes of the user to identify themselves. There are currently face scanners, palm scanners, retina scanners and finger print scanners on the market today. For our purposes I will contain this discussion to finger print scanners. The finger print scanners are the least expensive of the biometric devices yet still offer outstanding security. The way the fingerprint biometric systems work is as follows. The scanners come bundled with security software that acts as an overlay on your desktop. The software intercepts the login procedure and requires a fingerprint input in order to proceed. The software also has a registration process that scans each person’s fingerprints and digitally records the fingerprints as an algorithm, so it never keeps a "picture" of your actual fingerprint. The scanning software then works in conjunction with the Windows operating system security and allows you to assign rights and permissions to each user. It is really a fascinating piece of technology. Under the security rules of HIPAA, you are required to secure all your computers by the following means: 1). Each user has their own unique login name and password of a minimum of 6

characters. 2). No users shall know or use another person's password. 3). The passwords must be changed at least every 90 days. 4). The passwords must have the proper access level assigned to them based upon the

persons job function. The reality of the situation is that if you use complex passwords and change them frequently, people will forget them; then the system administrator has to recreate the users account and setup a new password. Worse yet, if they can't remember the password, they will write them on a sticky note and put them where they can find it easily, like on the screen. Also in a small office, people are close and share information and they will share their passwords. By using the fingerprint scanners you eliminate all of that and actually make logging in fast and easy. The person just touches the fingerprint scanner and in about a second they are logged in. It takes no thought, just press and go. The scanner's software knows who it is that is logging in and gives them the rights and permissions that they are allowed. You can't lose your password, you can't forget it, and you can't give it to someone else.

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Access Control to Discarded PHI - Office Shredders

One of the most overlooked security flaws in a practice is the waste paper basket. If your office is not currently using a shredder then please by all means at the end of the day take a look through your waste paper basket, especially at the front desk. You may find an abundance of PHI in there. You may think that this is a bit paranoid to go through the trash, but in Philadelphia there was a crew that was working with insiders in an HMO and they were putting patient PHI in the trash. Their accomplices would then go through the trash and remove the PHI, and then was set up with some very elaborate devices for making forged credit cards and documents. This crew would then open charge cards, make mortgages and even purchase automobiles all with the forged documents. The bottom line is that the HMO will have serious liability because they have an obligation to HIPAA policies and procedures in place to prevent this kind of activity.

The Final Step – Keeping It All Together

The most effective way to keep track of your HIPAA data is with the use of a HIPAA tracking tool. There are many good one on the market. Look for a tool that provides a thorough review of your practice of every section of the HIPAA regulations. Make sure it produces Gap analysis reports, year to year trending reports, mitigations action plans, work flow plans, incident tracking and graph reports showing all results. In the final phase of HIPPA you will find that an electronic HIPAA compliance tracking tool will be worth its weight in gold. For more information contact: The American Podiatric Medical Association 800-275-2762 www.apma.org CMS HIPAA Site: http://www.cms.hhs.gov/hippa/hipaa2/default.asp HIPAAlert: http://www.hipaadvisory.com/alert

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Taking the Mystery Out of OSHA The Occupational Safety and Health Administration (OSHA) was created to ensure safe workplace conditions for employees of all industries, including health care. Employers who don’t comply with OSHA regulations will pay the penalties in both time and money. An employer who knowingly falsifies OSHA records faces a possible $10,000 fine and up to six months in jail, for example. Other violations carry fines as high as $70,000, depending on whether the violation was willful. In addition, the legal fees an employer incurs when contesting a fine often total tens of thousands of dollars depending on the complexity of the legal issues involved and the duration of representation. For podiatrists, OSHA doesn’t have to be a mystery. Officials at the Occupational Safety and Health Review Commission (OSHRC), which enforces OSHA regulations and adjudicates disputes, insist that their agency is not interested in staging witch hunts. “OSHRC is physician-friendly,” says Linda Whitsett, the agency’s director of public affairs. She explains that just as OSHA’s purpose is to prevent workplace injuries, OSHRC would rather foster good-faith compliance than issue fines. And OSHRC, a relatively young agency that has endured its share of growing pains, has heard numerous complaints from managers in private industry about its modus operandi over the past decade. OSHRC has thus instituted changes to make compliance easier. For one, OSHA regulations are now written in plain English, not in legal jargon, so that any worker or employer can quickly interpret them. The agency also has implemented a phone/fax response line for small businesses. A podiatrist who has a complaint filed against him/her can now fax evidence to OSHRC to attempt to prove that his/her practice is complying. You can make OSHA regulations appear even less intimidating just by becoming more familiar with them. For the sake of discussion, OSHA’s purview can be divided into the following three categories: general standards, health care standards and the unknown. General Standards There is some confusion about which occupational incidents need to be documented, partly because the regulations define only certain events as reportable. To be safe, you should report all events, from those requiring medical attention to those involving routine first aid. When in doubt, report. Also, guard yourself and your staff from the obvious sources of potential danger. Equip your practice with safety eyewear, footwear, hand protection, respiratory aids, back protection, railings on stairs, safety clothing and other protective gear as necessary. Then turn your attention to the less obvious breeding grounds for danger, such as parking lots, break rooms, elevators and hallways. Because OSHA compliance is an ongoing responsibility, you must check and maintain your safety equipment periodically. Store and use all chemicals, including cleaning products, in a safe spot according to directions on the label to avoid injury. To further ensure protection, eating and drinking should not be allowed in the patient care area. Have your office manager or other staff member thoroughly document your compliance. If you operate a multiple-office practice, each office must keep separate records.

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Blood Borne Pathogens All employees have the right to know and understand the circumstances surrounding exposure. Universal precautions should be used to prevent contact with blood or other potentially infectious material. All body fluid shall be considered potentially infectious if differentiation of contaminated versus non-contaminated is impossible. Each employer should ensure that a copy of the Exposure Control Plan is accessible to all employees. The Exposure Control Plan should be reviewed and updated manually to reflect new and modified procedures. An employer who has an employee with an occupational exposure must prepare an exposure determination. An exposure determination includes a list of job classifications, task, and procedures in which the exposure occurred. Work Practice Controls (i.e. hand washing, proper disposal of contaminated needles and sharps, labeled/color-coded objects, etc.) are used to eliminate and minimize employee exposure Health Care Standards These requirements, which specifically target the well-being of you and your staff, include the following: Medical waste disposal: While the EPA governs disposal of medical waste from the facility, OSHA governs its handling inside the building. Both OSHA and the EPA enforce the same basic regulations concerning medical waste, with some subtle variations. For example, some practices sterilize their medical waste and place it in the regular garbage. While the EPA allows this with some types of medical waste, OSHA mandates that this step must not place employees at greater risk either from contracting disease, or from injury due to increased exposure to autoclaves and the chemicals used to clean them. You most likely store used needles in a sharps container placed in a safe location. But under OSHA Guidelines, you also must implement written procedures for the safe handling of used needles. OSHA also requires podiatrists to adopt its universal precautions to protect employees from blood borne pathogens and bodily fluids. This includes offering vaccinations and providing protective clothing (i.e. gowns, gloves, eyewear, etc.) to avoid possible exposure. Employee vaccinations: OSHA requires you to offer staff members the Hepatitis B vaccination. If a staffer declines, make sure you get a signed statement to that effect from the employee and keep the document on file. Learning to handle chemicals properly: OSHA’s Hazard Communication Standard requires you to undergo a hazardous chemical handling training program, maintain safety data sheets, and properly label chemicals for use. Administering medical care: You must also be prepared to administer medical care if an employee is injured on the job. First-aid kits are only required if the podiatrist’s practice is located more than fifteen miles from the nearest hospital. Turning from the legal to the practical, however, every practice should have a least one staff member who is trained in administering first aid.

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Eye protection: Safety eyewear is required by all practices that carry laser equipment. OSHA requires you to also keep eyewash on hand if employees are exposed to corrosive chemicals or blood borne pathogens. Physical considerations: Oxygen and gas tanks must be properly chained down or secured by another method. Exits must be clearly marked. Having fire extinguishers on hand is a basic rule of thumb, but it is not enough for OSHA. They must be readily available, and staff members must be trained on how to use them. Also, posters spelling out OSHA regulations must be prominently displayed in the employee area. Record keeping: This is a hot topic. The regulations require you to keep a former employee’s medical records for five years after that staffer’s termination date, unless he or she was employed for less than a year and receives the records. All other records must be stored for 30 years beyond the reported event. This time frame is the subject of much protest from the American Medical Association and from other affected industries. Still, there is no indication that the 30-year rule will be changed anytime soon. Concerning employee complaints, OSHRC officials are quite aware that disgruntled former employees lodge many of the complaints against businesses. Although OSHA mandates that all alleged violations be investigated, the scope of these inquiries is limited if the complaint appears to have been filed for harassment purposes. To guard against such a needless case, keep all administrative files out of your employees’ reach. If a staffer must for some reason see his or her file, take precautions to insure confidentiality. The Unknown Because regulations are constantly being developed and changed, it is difficult to predict how OSHA’s standards will affect podiatry in the future. For the time being, here are some general observations: 1. More and more research links the wearing of latex gloves to health effects ranging

from a simple dermatitis to more serious medical consequences. The reason is that latex is made from more than 200 different proteins, some of which trigger serious reactions. What is more, health care professionals have increased their use of latex gloves dramatically in recent years to shield themselves against exposure to the HIV virus, Hepatitis B&C and tuberculosis. As a result, look for OSHA to mandate the use of non-latex gloves under latex gloves in the coming years.

2. Airborne nail dust and smoke plumage from cautery also will be addressed within the next ten years. Podiatrists should now get ready to address this concern.

Simple Steps Toward Compliance You don’t need to take a crash course in public safety, or to spend both day and night scouring your practice for potential hazards, to satisfy OSHA requirements. Just follow these simple steps: 1. Develop and maintain an OSHA manual with policies and procedures. 2. Attend seminars as your schedule permits. Don’t deputize your office manager or

podiatric assistant, because any fine assessed to your practice will still come out of your pocket.

3. Know where your OSHA records are kept. Often podiatrists who delegate the OSHA record keeping detail to their office manager don’t think of asking this simple question. What if that staffer who is the only person in your practice who can locate the records, suddenly quits? You don’t have time to look in a thousand places if, for whatever reasons, OSHRC suddenly asks you to produce documentation.

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4. Maintain membership in the APMA and other professional associations and societies. Aside from being a great source of updated information, they employ lobbyists to address the issues that confront your profession.

5. Read OSHA handbooks. Many are available and they are easy to read. 6. Maintain regular contact with OSHRC. If you are unsure about an OSHA regulation,

just ask. Don’t worry that the question might seem too obvious, or that your inquiry will raise a red flag against your practice.

7. Know where material safety data sheets are located and have them readily available.

For more information regarding regulations and compliance contact:

The American Podiatric Medical Association 800-275-2762 www.apma.org

The Occupational Safety and Health Administration

800-321-6742 www.osha.gov

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Electronic Medical Records Electronic Medical Records (EMR) are a good way to save money by decreasing documentation costs, keep reliable records, and to meet the Health Insurance Portability and Accountability Act (HIPPA) standards. Other advantages to going electronic include: access to patient information and the ability to share information with other health care providers, to make your office more efficient, and to improve care for your patients. With an increased focus on patient privacy and security under HIPPA, patient information must be kept under strict confidence. Electronic records must fit under the HIPPA standards and protect personally identifiable health information (PHI). When searching for medical software, always check to see if HIPPA standards are met. When choosing an EMR system, there are a few decisions you have to make: 1) Decide what you expect the system to do for you.

� Do you want to incorporate the front office and scheduling? � Do you expect billing software to be included? � Do you just need an electronic record? � Do you want dictation included?

2) Why you want EMR? � Do you feel comfortable with computer use? � Is the system user friendly? � Will this decrease costs and increase efficiency after the staff is trained on the system?

3) Are you going to run the system on individual computers or inter-office networks, or an application service provider (ASP)?

� ASPs let the practice “rent” software from vendors and to access networks from outside locations with networking and security managed by the ASP provider but the disadvantage is the data isn’t solely under your control.

4) Is the system HIPPA compliant? 5) Is the system secure? 6) What is the data backup system? 7) Can you upgrade in the future if needed? 8) Can more than one user access the system at the same time? 9) How is the data structured? Can you find patient data easily and quickly? 10) Determine whether the transcription system should be included or not in the EMR

system. � Does the transcription system work for you? � Do you want interaction with the EMR?

EMR systems are standard in health care today. Educate yourself in the benefits and decide whether you plan to use them in your office. References: Reeves, CS. Managing the Medical Practice, 2nd edition. American Medical Association, 2003. www.elmr-electronic-medical-records-emr.com www.physiciansnews.com

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E-Prescribing Medicare started a new financial incentive program to encourage physicians to adopt electronic prescribing systems. Incentive payments are available now for physicians who meet the requirements of the program. The initiative is part of Medicare's broader efforts to accelerate the adoption of health information technology (IT) and the establishment of a healthcare system based on value. According to the Institute of Medicine (IOM), more than 1.5 million Americans are injured each year by drug errors. Medicare believes e-prescribing can help deliver safer, more efficient care to patients. In 2008, APMA surveyed members and vendors on their use of electronic health records (EHR) and electronic medical records (EMR). Survey results indicated that electronic prescription writing is included in 83 percent of the EHR/EMR systems used by respondents. Beginning in 2010, for four years Medicare will provide incentive payments to eligible professionals (this includes podiatric physicians) who are successful e-prescribers. Eligible professionals will receive a 2 percent incentive payment in 2009 and 2010; a 1 percent incentive payment in 2011 and 2012; and a one half percent incentive payment in 2013. Beginning in 2012, eligible professionals who are not successful e-prescribers will receive a reduction in payment. Eligible professionals may be exempted from the reduction in payment, on a case-by-case basis; if it is determined that compliance with requirement for being a successful prescriber would result in significant hardship. To participate in e-prescribing, eligible professionals must use a qualified e-prescribing system. A qualified e-prescribing system or program is able to perform the following tasks:

� Generate a complete active medication list using electronic data received from applicable pharmacies and pharmacy benefit managers (PBM), if available.

� Allow eligible professionals to select medications, print prescriptions, transmit prescriptions electronically, and conduct all alerts. Alerts include automated prompts that offer information on the drug being prescribed and warn the prescriber of possible undesirable or unsafe situations, such as potentially inappropriate dose or route of administration of the drug, drug-drug interactions, allergy concerns, or warnings/cautions.

� Provide information on lower-cost, therapeutically appropriate alternatives, if any. Beginning 2010, a system that can receive tiered formulary information, if available, from the PBM would satisfy this requirement.

� Provide information on formulary or tiered formulary medications, patient eligibility, and authorization requirements received electronically from the patient's drug plan (if available).

� Meet the Part D specifications for messaging began on April 2010. For more information about the new Part D requirements, please see www.regulations.gov and search for "Part D prescribing."

To read more about Medicare's electronic prescribing program, see the Health and Human Services Fact Sheet at www.hhs.gov/news/facts/eprescribing.html. For more information on APMA's EHR/EMR study, visit www.apma.org/EMEHRinformation.

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APMA Coding Resource Center and Medicare Resources

The APMA Coding Resource Center

APMA’s Coding Resource Center, is a fully-integrated online coding and reimbursement procedure which includes: · The 2011 foot, ankle, leg-relevant CPT© codes and guidelines; · The 2011 ICD-9-CM code "Quick List" (complete ICD-9 Volume 1, 2 listings); · The 2011 foot, ankle, leg-relevant HCPCS Level II codes; · Current foot, ankle, leg-relevant Medicare National Correct Coding Initiative (CCI) edits; · CPT© RVUs, Medicare assistant surgeon code designations, and Medicare global period designations; · Individual state Local Coverage Determination (LCD) links for foot, ankle, leg-relevant procedures/treatments; · DME references and coverage guidelines and links; · APMA Coding article archive (searchable); · Medicare references and citations, including E/M coding and documentation guidelines; and much more. APMA Coding Resource Center paid subscriptions are available to APMA members. For more information visit www.APMACodingRC.org.

Medicare Resources The Centers for Medicare and Medicaid Services (CMS) has announced the scheduled release of modifications to the Healthcare Common Procedure Coding System (HCPCS) code set. These changes have been posted to the HCPCS Web site http://www.cms.hhs.gov/HCPCSReleaseCodeSets/ANHCPCS. All changes were effective January 1, 2010, unless otherwise indicated in the effective date column.

The Centers for Medicare & Medicaid Services (CMS) is also offering a Tool Kit for the 2008 Physician Quality Reporting Initiative (PQRI) that is designed to assist eligible professionals— DPMs are eligible—with successful reporting. The Tool Kit consists of some existing educational resources plus new measure-specific worksheets to walk the user step-by-step through reporting for each measure. To access the Tool Kit, visit http://www.cms.hhs.gov/PQRI, and scroll down to the PQRI Tool Kit tab. The page serves as a “Read This First” Guide to the resources that are available to download. The Tool Kit consists of the following: 1. 2008 PQRI Physician Quality Measures 2. 2008 Coding for Quality Handbook 3. 2008 Code Master 4. MLN Matters Article 5640 - Coding & Reporting Principles 5. Data Collection Worksheets According to CMS, The Tool Kit will be expanded as new educational resources become available.

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Also available is a Medicare Physician Guide: A Resource for Residents, Practicing Physicians, and Other Health Care Professionals, 9th edition, electronic version revised October 2009, is available in downloadable format on the Medical Learning Network (MLN) publication page at www.cms.hhs.gov on the Centers for Medicare & Medicaid web site. The Guide was prepared as a tool to assist providers and is not intended to grant rights or impose obligations. It is a general summary that explains certain aspects of the Medicare program, but is not a legal document. The official Medicare program provisions are contained in the relevant laws, regulations and rulings. The Medical Physician Guide provides necessary information including an introduction to the Medicare program, how to become a Medicare provider or supplier, Medicare reimbursement, payment policies, evaluation and management as well as a valuable reference section.

CMS Signature Requirements In April 2010, the Center of Medicare and Medicaid Services (CMS) introduced new rules on signatures designed to reduce the CERT (Comprehensive Error Rate Test) errors found in medical record reviews. The CMS CERT report stated that violators risk auditor rejection of claims and demands for repayments. In its latest error rate report, CMS' CERT review of signatures on medical records revealed that the error rate more than doubled to 7.8 percent in 2009. To help providers, CMS has detailed new rules on signatures. Eight suggestions for providers to meet signature requirements on medical records include: · Provide a legible full signature · Provide a legible first initial and last name. · Write an illegible signature over a typed or printed name. · Write an illegible signature on letterhead with information indicating the identity of the signer. · Use an illegible signature accompanied by a signature log or attestation statement. · Write initials over a typed or printed name. · Write initials not over a typed or printed name, but accompanied by a signature log or attestation. · Neglect to sign a portion of a handwritten note, but other entries on the same page in the same handwriting are signed. Medical records-including physician orders and prescriptions-without valid signatures will be rejected by CERT auditors, and the claim will be denied for lack of medical necessity. It should be noted that signature requirements written in national and local coverage determinations (NCDs and LCDs) trump CMS's signature requirements. For example, signatures on plans of care must be signed before those services are rendered. CMS acknowledges that there are existing policies that don't require signatures. For example, orders for clinical diagnostic tests are not required to be signed. Medical documentation, such as a progress note, can support the order. However, the note must have a valid signature.

California School of Podiatric Medicine

The Samuel Merritt University

Board of Regents, administration, faculty and staff wishes to extend congratulations

to the graduates of the Class of 2011

The California School of Podiatric Medicine (CSPM) is committed to providing excellent education and training of podiatric physicians, quality health care,

meaningful community service, and innovative research.

IV.Practice Options,

Managementand Resources

A�liated Foot and Ankle Center

Alison DeWaters, DPMHal Ornstein, DPM

Howell, NJ

Best of luck in your career. You have chosen a wonderful profession.

Advanced Foot Care, LLPIra Kraus, DPM

Fort Oglethrope, GA

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Practice Options and Management Introduction The option of solo practice is less likely for the graduating podiatric physician than in previous years. The increasing cost of podiatric medical education and the debt incurred by students make it difficult but not impossible for the new practitioner to follow this path. This chapter presents some alternatives to traditional solo practice, how to locate available positions, and how to evaluate their costs. The APMA commissioned a work force study to explore the decrease in applications to podiatric medical schools in the late 1990s that resulted in the decline in the number of podiatric physicians per capita in the US. A summary of the study, “Projections for the Supply of and Demand for Podiatric Physicians in the United States, 2005 to 2030, was published in the Journal of The American Podiatric Medical Association (July/August 2008) and concludes that the growing supply-demand gap revealed important challenges for the podiatric medical profession to overcome during the next couple of decades. The study has important practice considerations such as projections, population aging and growth, supply, geographic penetration, salary, and capacity. You will also want to review the pre-practice preparation checklist in Chapter III. Practice Options (See Figure 1)

Solo Practice This is becoming exceedingly rare due to the difficulty of obtaining appropriate finances. The biggest advantage is autonomy which also happens to be the reason many choose medicine in the first place. In solo practice, the physician is “the boss” and controls all aspects of the business. However, along with autonomy comes liability. All investments, expenses, and losses are incurred solely by the physician. Associateship Leading to Full Ownership This is commonly referred to as a “buy-out.” One physician wishes to leave or retire from a practice while another wishes to enter the practice with the intention to own. This may or may not require a large initial investment. An alternative is to “work off” a down-payment by accepting a reduced salary for a specific duration of time. Additional payments in the form of one payment (lump sum) or multiple payments (installments) may be required at the time of the actual take-over. The advantage of this arrangement is the new practitioner receives some guidance until eventually becoming owner of a solo practice. The new physician/owner can then change any aspect of the practice to his/her specifications. Disadvantages of this arrangement, other than those associated with any solo practice, include lack of growth potential. It is therefore crucial to fully evaluate the growth potential of a practice prior to any purchase agreements. One must also consider the patient population. An associateship prior to full ownership allows both patients and the new physician to acclimate. While some patients may be lost in the transition, others will be gained. Associateship Leading to Partnership This option is appealing to many who are uninterested in solo practice. Partnership allows for shared liabilities within the business. To be successful, however, partners

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must share similar values and philosophies. If personalities conflict, it is likely that business choices will be difficult. Serious consideration should be given to entering a contract where one partner will own the controlling interest thus maintaining greater power in any decision-making process. Finally, there must be potential for growth income. This ensures that one partner will not work twice as hard and still receive only 50% of the revenue. These provisions are routinely included but may vary from contract to contract. Associateship This agreement is for a set amount of time, often 2-5 years, and does not require any monetary investment in the business aspect of the practice. An associate can be equated to an employee, although a good contract will include provisions for bonuses. For example, if an associate earns more than a specified amount, he/she is entitled to a percentage of that extra income. While this option may be beneficial to a new practitioner with no long-term plans, five years may be a very long time to grow financially and professionally.

Figure 1: Comparison of Practice Options

Autonomy Large investmen

t

Instant Income

Leads to Ownership

Liability risks + costs

Benefits (Health etc.)

Solo Practice

YES YES NO YES SOLO You Pay

Associate to

Ownership

YES, eventually

At some point

YES, but lesser

amount

YES Shared, then solo

MAYBE

Associate to Partner

NO - will have some

SOME - depends

on contract

YES Only part Shared Usually paid while associate

Associate only

NO NO YES NO NONE Usually paid

Group Practice

SOME Depends on group

Depends on group

Part Shares in

group

SHARED Usually group pays

Employee

NO NO YES NO NONE Paid

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Group Practice

Group Practice is becoming more common in the modern profession. Groups may be strictly podiatric physicians or multidisciplinary. Multidisciplinary group practice can afford the new practitioner the benefits of cost-sharing on rent, utilities, supplies, and staff. In addition, an instant referral base is available. Participation in a multidisciplinary group offers slightly more in that there is little or no competition for patients as well as instant access to other fields of medical expertise. The disadvantage to group practice is that there are more people involved and thus more potential conflicts in decision-making. The initial investment and profit-sharing varies widely depending on the group arrangements. There may be great financial independence for each practitioner or there may be group profit-sharing. It has been suggested in medical practice management literature that some solo practitioners have found it advisable to form groups with other like-minded individuals. Keith Borglum, a senior consultant with Professional Management and Marketing, Santa Rosa, CA shares his view that “two is a team, three is a crowd, and four is often a split decision. Five, however, fosters good office dynamics.” Regardless of the final number of partners, the take-home message is that group practice and solo aspirations may very well find a lucrative common ground, depending largely on the flexibility of the participants. Employee Not everyone wants to deal with the headaches and risks of running their own business. There is another option and that is to practice as an employee. Many corporations, hospitals and HMO's are hiring their own podiatric physicians. They are salaried, have paid vacations and benefits. This produces the instant income many new practitioner’s need and requires no initial investment. The disadvantage to being an employee is that you will have little or no say in how the corporation is run and may have little opportunity for growth. Unless profit sharing or incentives are offered, you will not improve your income much by working hard. Because you get paid the same no matter how hard you work or don’t work, this might actually be viewed by some as a benefit. But be aware of the corporation and the patient load. If there are many patients to see, you might end up working very hard without additional financial compensation.

Finding Opportunities Location

This may be one of the most important factors in deciding in what type of situation you want to practice. If you want to go back to your hometown in rural Kentucky, for example, you may have no option but to practice solo if there is no one else there, or maybe buy out the retiring local podiatrist who convinced you to go into this profession in the first place. On the other hand, if you want to practice in Manhattan, you may have to go into a group just to afford the rent. It is important to decide first where you want to live. If a particular city isn't really important but you want a lifestyle that includes skiing, or scuba diving use that to guide you. What looks like a really great opportunity may not be such if you are unhappy in that location, especially if it is for a lifetime.

Also, beware of people telling you not to go to a certain area because it is oversaturated. That may not be completely true, so evaluate each area yourself.

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Even in a heavily saturated area, if you have something special to offer, the patients will come. It may, however, be tougher to make a good living than if you are the only podiatrist in town.

American Podiatric Medical Association (APMA)

The APMA can help you locate physicians who want to sell their practice and/or hire associates through classified ads in the APMA News. APMA continually updates and seeks new information for new practitioner’s looking for positions. State associations may also have classified advertising.

Residency Programs

Many practice options come from contacts made during your residency. Residency directors can be particularly helpful. You may also connect with physicians practicing out of the same hospital who are looking for an associate or partner.

School and Alumni

Your school can help you locate opportunities. Physicians selling their practices will often contact the school's graduate placement director. Faculty is another great resource as they may know of colleagues seeking an associate or wanting to sell. If you have a good relationship with a faculty member, ask for help in locating a position or getting in contact with someone who might be able to assist you. Also, check with the Alumni Affairs Office at your school to see if there are alumni practicing in the area you want to live. Hospitals/Local Physicians If you have a specific city in mind, contact the local hospital to see if they are in need of your services. In an underserved area, you may get help opening a clinic in or near the hospital. Contact local physicians in the town and ask them if they are looking for an associate or partner. Your persistence might prove to them your commitment to the area.

Evaluating Contracts

Advice The most important thing to remember when looking at a contract offer is to seek advice before signing anything. Have a lawyer review the contract and an accountant make sure all the numbers add up. It may also be helpful to have a practicing podiatrist review it as well. Have someone you know who has either been an associate or has employed associates review the offer with you; perhaps a faculty member from your school or your residency director can help. Do not negotiate a contract with a joint attorney. If the other party is paying the lawyer, you know which side will be favored. Protect your interests by having your own attorney! Even if the contract sounds simple, and especially if it sounds too good to be true, hire your own lawyer. You are a doctor and not a lawyer. Income and Profits Perhaps one of the biggest mistakes a new practitioner can make is underestimating his/her own worth. After being a student and resident for so long, it is hard for a new practitioner to estimate his or her own value. This is compounded by the increasing debt of education and the fear of impending loan repayments. Remember the attitude that "something is better than nothing" is not always true. Don't accept the first offer if it sounds too low or has unfavorable conditions simply because you are

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excited to have any offer. Don’t panic if the right offer doesn't come right away. You can always seek further loan deferments or take a position with a shorter term contract. The amount you will be paid will vary depending on your situation and that of the practice. Will you be offered straight salary; commission based percent salary and/or a bonus? You may be asked what you need to cover your expenses and then will be paid some amount above that. Have this information worked out beforehand so you won't be caught taking less than you need to pay your bills. This is where an accountant comes in handy.

Additional Benefits

Evaluate the contract for additional benefits such as paid malpractice insurance, health benefits, CME reimbursement, cell/pager costs, national and local membership dues, license and/DEA fees, vacation time, profit sharing or retirement plans to name a few. Equate these to a monetary value when evaluating your contract. If the pay is just okay but the contract offers great fringe benefits, it may be far better than more money but no extras, all of which you will have to pay for. Term of Contract As an associate, a short term contract is better. Avoid contracts longer than 2-3 years. If you are happy after that time, you can re-negotiate. It is very difficult to get out of a contract once you have entered into it. After a few years of practice and some more experience, your goals and philosophy of practice may change. If you are buying out a practice, try to keep the same time frame so you will not become discouraged waiting for the practice to become yours. Non-Competitive Clauses Many contracts have a non-competitive clause included to protect the original practitioner. A non-competitive clause means that if you should leave the practice for any reason, you cannot practice in the local area for a certain number of years. The actual specifics of the size of area (i.e. 10-15 mile radius from existing practice) and number of years will vary with each contract. Watch out for this in your contract if you have plans to open up your own practice in the same area after completing an associateship. A Bad Deal? What if after taking all precautions you still get into a bad deal? Much depends on your contract so before you sign, ascertain if there are provisions for a partner or associate wanting to leave. A properly written contract should not have a loophole but a lawyer may be able to help you negotiate dissolution of the contract. You may be able to sell your interests in the contract to the other party. If there is no way out, you may have to endure. Hopefully, you did not sign a long term contract. Sample contracts See Section: Establishing and Buying a Practice

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Opening a Podiatry Practice Many practitioners master the art of medicine yet fail to master the economics of their own medical practice. In fact, few physicians are aware of the basic economics of their profession. Understanding practice management and medical economics is critical to a successful practice. As Horace Cotton, a certified professional business consultant, puts it, "Management, know- how, skilled help, and modern tools are prerequisites for building a modern private practice. Without the above, the hottest of the hotshots is apt to end up in the wrong town, the wrong office, with the wrong help, wrong equipment, charging wrong fees and wondering why all the ink is red." As a new practitioner, you can avoid the mistakes that may lead you and your practice down the wrong pathway. The following pages will help introduce you to the secrets of successful practice management. Forward This information is organized to guide you through the stages of establishing a practice. It progresses from choosing a location to presenting yourself to the community as a professional: organized, staffed and equipped to provide definitive podiatric care. The emphasis of the article is on locating trades, professionals, and materials. From the beginning, you must understand that YOU, not someone you hire, are responsible for each decision, each light switch, each sink, each chair, and that each will be purchased with your money. Consultants and employees can be a great asset, but remember that they are not podiatrists. Do not hesitate to call on experienced members of your OWN profession for that advice --- they have been in your shoes and will help all that they can. Ultimately the practice is yours. The successful practitioner draws on his/her own experience, training, advice from colleagues, local trades, suppliers, and other professions. I. Office Selection and Location

The first major consideration for the new practitioner is office location. Rule number one: go where you are needed! Your practice is a business. Before any businessman establishes his business he first performs a market analysis. Choose a state or area where you would like to practice. Be sure that the cultural, recreational and social structure of the community is one where you and your family will be happy. Remember, that once established, it is very difficult to move from the area and expect the majority of your patients to follow you. Select an area that you think will be permanent, where there is room to expand if necessary and where you can become a part of the medical community. After narrowing your office location choices to several areas, you need to perform two tasks: l) collect necessary “paperwork” and 2) visit the areas. To collect the necessary paperwork you should contact your national and state organizations and request statistical information on the areas of interest (current number of podiatrists in the area, growth of the community, prepaid health plans). The greater the number of patients that are controlled by such programs as HMOs, PPOs, etc., the fewer the patients available to the new practitioner. Additionally, you can look through the APMA News for want ads of interest to you.

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Of course, there may be external pressures from family and friends to establish yourself in their city. This pressure may be welcome, and the close family ties may be important enough that you will weigh this heavily in your decision. Remember, it is your decision and multiple factors play a role in the final analysis. Do not be afraid to open your practice in an area where other podiatrists are already practicing. If the patient population is there, you will all make a good living. You may determine that your methods of practice are different than your podiatric colleagues and you will attract a different type of patient. Always visit the areas you are considering. During your visit to the areas you have selected, stop at the:

County Medical Society which will have information regarding the local professional climate, e.g. whether or not there are large group practices in the area.

Local Health Department - A public health officer usually is cognizant of the area's health strengths and weaknesses. He can provide you with accurate local statistics. For example, he will be able to brief you on the local welfare services and possibly age demographics.

Local Hospitals - Write or phone the hospital administrator prior to your visit to the hospital(s) and set up an appointment. Ask for a tour of the facility, procedures and qualifications necessary to obtain hospital privileges. Ask him for information regarding local medical groups and third party coverage in the area. City Hall - A city hall visit will provide you with information regarding public schools, police, fire, water, transportation, and property taxes. Chamber of Commerce - The Chamber of Commerce will provide you with data on the town's trade pattern, its industry and prospects for the future. Information on churches, libraries, clubs, shopping facilities and recreational activities is also available. A Real Estate Office and a visit with a broker will give you the opportunity to question an expert about the surrounding areas, neighborhoods, zoning, rentals, and market values. Local Podiatric and Non-Podiatric Physicians may contribute valuable information. Another quote from Horace Cotton, author of Medical Practice Management, "Realize picking the wrong place to practice isn't just bad management, it's also bad medicine because somewhere there are lots of patients who really need your services."

II. Office Site

After deciding on a city or town, you must choose an office site. Start by locating a law firm which has partners specializing in real estate, corporate, and litigation law. A reputable law firm may fill all of your other future legal needs and provide important business and political links. Such connections may help in the selection of

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contractors, accountants and even office help. Although political connections may seem irrelevant, they often are helpful later in your career. Obviously a reputable real estate group is invaluable in the selection of an office location. They have a solid awareness of a specific location's personality, its growth potential, and specifics about the population in that particular sector of town. Be sure to utilize their expertise in this phase of setting up shop. A podiatry office should have easy access with an absolute minimum of steps. A second floor walk-up location should be the last resort. If space is not available on the first floor of the building that you are considering, an elevator is a necessity. Remember that many of your patients will be unable to climb stairs. Whether you decide to build, purchase, or rent an existing medical office, make sure you have enough rooms. A doctor's office should have a patient waiting area to comfortably seat patients and their guests. Many successful practitioners entertain the idea of ‘one room, one job’. For instance, have a business office, a mini surgery room, several examining rooms and a consultation room. Don't forget to set up a space for your nursing staff. Hall corridors should be four to five feet wide to allow two way traffic and wheel chair access. For some practitioners, a home-office location works well and may provide major tax advantages. The home-office lifestyle does not suit every family. Talk to other practitioners, with different styles of offices and practices and then decide. Renovation costs are often much higher than expected so a written estimate from two or more general contractors is a must before finalizing purchase or lease. In a lease arrangement, the renovation costs should be covered in the contract, i.e. who pays for what, restrictions regarding contractors, building codes, etc. In a purchase, the lawyer will help in determining these things.

III. Financing

A commercial bank is your best bet for financing. Be prepared when approaching a bank finance officer for a loan by having a basic knowledge of the current interest rates, bank financing policies and other such financial matters. A referral to the loan officer by the bank manager, your lawyer or accountant, another doctor or a business associate is the best way to handle arranging an appointment.

Currently, banks are not as willing to lend money to fledgling doctors as they have been in the past. They must see you as a good investment. Therefore, be prepared to use your credentials. Podiatrists are successful practitioners and can be a valuable asset to the community, and an important part of the health delivery team. Podiatrists are employers, consumers, and investors. When you walk into the bank, have the self-confidence to project that image. Make the bank representatives aware of your potential; you are going to become a responsible customer. A bank will invariably make the loan you're seeking if you provide acceptable collateral. You may want to ask for alternative low-grade collateral such as title to an automobile under two years old, etc.

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You should consult with more than one bank since different banks may have different options and different levels of willingness to invest in you. You may receive multiple offers but select the best one to meet your needs. A good corporate lawyer may suggest a bank that has full services and a reputation of dealing with professionals. The financial and other agreement terms are vital when opening a new office. This can be "make or break time." Therefore, this is a critical time to consider advice, opinions, and consultations before signing on the dotted line. All decisions are ultimately your responsibility; however, it is best to use the experience and expertise of other professionals.

IV. Accounting Firm

An accounting firm should have a good community reputation with a number of clients in health professions to be familiar with the specific needs and requirements of the health care professional. Experienced accounting firms should have the capability to prepare a draft budget of your requirements. The first budget item should be accounting fees with their charges fully explained. Items such as rent, renovation costs, equipment, auto expenses, insurance, telephone, property taxes, utilities, and office salaries can be estimated very closely with the firm’s experience. Several recurring expenditures such as office and medical supplies will have to be estimated along with your own salary or other expenses that only you can determine. Make sure all the personal needs of your family are accounted for in your budget, including your student loans.

V. Summation for Banking Purposes

When putting together a financial package for presentation to a bank, a simple outline can serve as a useful guide. A well prepared, well documented, and detailed portfolio can be your best ammunition in securing a loan or line of credit to establish your practice and assure that you will be able to meet your financial obligations. The following is an example.

Part I: Cover Sheet Purpose of Loan: These funds are required to set up a private practice in podiatric medicine and surgery. The office address is: ________. These funds will be used to decorate, furnish, purchase necessary equipment, keep office overhead current, and provide living expenses for a family of (x) until the practice supports a profit. Part II: Table of Contents 1. Curriculum vitae 2. Personal financial data (assets, liabilities, and net worth) 3. Itemized estimate of starting up a practice 4. Projected budget 5. Demographics 6. Fee schedule 7. Last two years' tax returns Of course, each item within the table of contents should have its corresponding section within the body of the portfolio. The way the presentation is drafted is a matter of personal preference, but these are the basic items necessary for a bank to consider

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before granting a loan or line of credit. In addition, requesting an appointment with a senior vice president in commercial lending may be an advantage. This individual can consider your proposal and make a decision without consulting a loan committee. Come prepared with the details a bank needs to approve the loan and your chances for success improve dramatically. For more information, see the Establishing and Buying a Practice section of this Guide. VI. Constructing an Office

Once you have established the amount of funds needed to build, equip and supply your office, it is time to turn to your lawyer, accountant and banker for referrals to competent builders, general contractors and architects. In some cases, your construction crew will be predetermined by the building management. Once you have completed the plans/layout of your office with the architect or space planner, it is important to visit the space periodically to check on progress and determine that the work is being completed to your specifications. Do not hesitate to contact management if you are unsatisfied with any details. This will be your office for many years to come -- get it right the first time.

VII. Architects

The traditional role for an architect/space planner is to prepare drawings with specifications as to materials and construction techniques. Architects are responsible for inspecting the site at various stages of construction. The architect provides guidance for the general contractor. When the work is completed, the architect gives the client a written review and certification that the work has been satisfactorily completed; the specifications have been followed and the premises are ready for occupancy. The fee for these services is an agreement which is typically a fixed percentage of the contract price. For an agreed lower price, architects may only do the drawings and list the specifications. In some regions, there has been a trend in the last few years for architects to act as contract managers. In this arrangement, the architect will do the drawings and specifications and call for lenders either on a general contract basis or on a trade (i.e., plumber, electrician, carpenter, dry wall, etc.) basis, with the final selection being made by you. The architect then follows the traditional role of supervisor.

VIII. Design Corporation

Professional office planning consultants can offer a variety of planning services. They will have drawings prepared either by an architect or by their own drafting staff. They will do detailed interior design specifications and generally supply all materials, furnishings and fixtures including wallpapers, carpet, paint, cabinets, furniture, office machines and, in some cases, even your professional supplies and equipment. Their scope is quite broad and they often act as either contract managers or as general contractors. These firms always work on a pre-set contract price, with any additional work or supplies being priced individually. As professionals, they also can offer discounted pricing, a wider variety and a higher quality of interior decorating materials and furnishings.

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If the firm is well established, with a good reputation, it is very often the most satisfactory method of preparing an office. These designers can work economically if they perceive that you are diligently supervising all expenditures. On the other hand, if you insist on only the best and most expensive materials, they will tend to consider their services in the same light and final contract prices can be unreasonably high. Some or all of these costs may be picked up by the building management but these determinations must be made prior to the contract.

IX. General Contractors

The role of the general contractor is to act as the project manager and troubleshooter between you and the individual building trades. Contractors usually act in one of two methods. The contractor will estimate the work to be completed and prepare an agreement usually adding a managing fee to handle supervising and coordinating the trades and building supplies. A general contractor may also call for bids from each trade and then review them with you and then make certain that the work completed is to the specification and satisfaction of the architect. The general contractor is paid at specified stages of completed work. The fee may be negotiated or simply a 10-15% addition to each trade and supply item.

X. Self-Contracting

Without a doubt, this is the most exciting and involved method of having your own construction project completed. The drawings are prepared with specifications by you and/or your architect. This concludes the architect's responsibility. From here on you act as your own general contractor. You are responsible for supervising each trade, assuring that workers show up on time, complete all work, and adhere to specifications. You will also be responsible for making certain that each trade's work is inspected and approved by municipal officials. Real savings can be made with this method of contracting, but you must be sure that you have enough background in the building business to deal with each trade and sufficient composure to keep calm when there is time lost, supplies stolen or broken or when difficulties with building inspectors occur. You will eventually have the satisfaction of seeing your own ideas realized, but you must also be prepared to live with each problem that occurs. The person who can handle self-contracting is rare.

XI. In-House Contractor

Many office buildings are owned or managed by general contracting companies. These companies often hire their own tradesmen for maintenance purposes as mentioned earlier. They can justify their retention by having tradesmen do renovations in these buildings from time to time. For this reason, they may insist that all work done in their building be done by their own trade’s people. They may even require that the office layout be prepared by their office, and that fixtures and furnishings be similar to the other office suites.

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This often applies to floor coverings, window treatments, wall coverings and plumbing fixtures. In this situation, there may be an allowance in the lease for some building renovations, with any extra charges being incorporated into the lease. These extra charges will need to become part of your loan request to the bank.

XII. Podiatric Medical Planners

Many podiatric medical supply houses offer free planning services. In return for your patronage, they will prepare drawings with some general specifications at no cost. With square footage at the price it is today, be sure that a plan, regardless of who prepares it, understands the per square foot cost of space and uses space efficient Remember that the supplier may specify as many of his supplies as possible including cabinetry, fixtures, and equipment. This is only reasonable, and calls upon your discretion to separate the need from the greed.

XIII. General Comments

The most common problem that occurs among those not in the contracting business is lack of understanding of building codes. Insist that your designer or architect spell out that the drawings are in compliance with the building code and that any renovations or adjustments required to meet specifications are the designer's responsibility. Make sure that major electrical and all plumbing installations are grouped for efficiency and cost savings. If you can arrange to have all of your plumbing along one wall of the office for example, you will save a significant amount of money on plumbing charges. Finally, remember that almost no building project goes smoothly no matter how carefully you plan or select your contractors or trades people. Be realistic and be persistent, but be patient.

XIV. Office Time Management

“Time is money” is a well-known adage that can work for you or against you depending on your time management skills. At an annual meeting of the American Academy of Family Physicians, Keith Borglum, a senior consultant in professional management and marketing, had the following advice with respect to time management: Find ways to minimize staff costs: For every $1 your office brings in, staff costs eat up 23-25 cents. If you're regularly paying employees for overtime, your financial picture is probably even worse. “Regular overtime is an indication of a problem,” Borglum says. “Do nurses stay late because they feel guilty leaving before the receptionist? Fix it.” Schedule visits efficiently: Give your scheduler guidelines about the number of minutes typically required for seeing a particular type of patient. That way, you can schedule an efficient mix of shorter and longer patient visits and avoid bottlenecks that will slow down the receptionist and the billing staff. According to Borglum, “by spending one hour a week meeting with your office staff to work out problems and

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two minutes a day reviewing your schedule to plan your time, you could increase your profitability by $500-$1000 per month.” Delegate anything that doesn’t require your medical degree: Example: Are you spending $200 an hour to open your own office mail? Use your accountant less: By moving your accounting in-house and making it part of your accounts payable system, you'll be able to save $500-$1000 a year, he said. Use a financial software package to handle your own profit and loss statements and reserving your accountant's time for preparing your taxes and providing advice will help your bottom line. Extend your office hours: Consider opening your office earlier and closing it later. You'll win points with working patients, and simultaneously, you'll be able to add more patients. This does not necessarily mean, however, that doctors and staff must correspondingly lengthen their workday. Borglum suggests creating a split-shift schedule, where some physicians and employees work from 7:00 a.m. to 1:00 p.m. and other work from 1:00 p.m. to 7:00 p.m. Alternate different days, if you prefer. “This makes for great marketing," he says. “Just make sure you don't put a night person on the morning shift and vice-versa.” Taking the little extra time it requires to determine good teamwork groups and personal productivity profiles will prove most profitable in this scenario.

XV. Office Supplies and Equipment

Unless there is a dramatic difference in price, it is advantageous to purchase general office equipment and supplies from a general office supplier in your city. Again, rely on your contacts and check with several other people to direct you to the best supplier in your area. One respected supplier can usually give you good pricing when handling the whole office. Moreover, this supplier will establish an individual account so that you will not need to use petty cash for sundry items that may be needed on a weekly basis. The key again in purchasing supplies is to order only what you can use in the near future. A “band-and-tag” approach can make reordering of supplies more efficient. This simple technique involves putting rubber bands around each set of items in your supply closet, along with tags describing the supplies and how many are in the set. Once one set has been used, its tag should be placed in a central envelope. At the end of the month, tags can be tallied, and reorders can be placed at one time.

XVI. Computers

All new practitioners should have computers. The technology and programming of these units has changed so rapidly in the past five years that they are now a viable, affordable and necessary concept for each podiatry office. Obviously the initial investment can be quite high, but the benefits to your practice will soon have the computer paying for itself. Some computer capabilities to consider include: billing patients; following up delinquent accounts; preparing health insurance claim forms; maintaining a running analysis of office productivity (where profits and losses are generated); patient distributions, including age, sex, diagnosis, and treatment; scheduling; payroll; tax returns; and bookkeeping.

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The variety of work done by computers is limited by the programming, its functions, and the selection of the proper hardware. There is now a number of software companies with packages specifically designed for podiatrists. These companies attend most of the large podiatry conventions and are more than willing to discuss your needs at that time. Careful research in advance will allow you to choose the best system for your office now and in the future.

XVII. Podiatry Equipment and Supplies A good podiatry supply house can fill all of your equipment and supply needs. Moreover, with an initial set up order, these houses will often offer a discount, and establish credit on future orders. Choose your suppliers and then maintain a good relationship with them to assure good credit, service and delivery. When choosing your supplier, meet with several different representatives before making your final decision. You may determine that price is solely what you are looking for, or you may decide that a good service record and pleasant working relationship with the company is more important. A good question to ask is, "Does the supplier's representative want me to succeed or just make a sale? Do they support the APMA and the profession? To reduce overhead costs initially, buying good used equipment or supplies can be a very wise approach. Don't be afraid to contact other practitioners and explore this possibility with them. It can be a good deal for both parties but always remember to check expiration dates.

XVIII. Advertising

Many years ago, advertising by members of the medical community was considered unprofessional. Today, most podiatrists do some advertising and many derive the majority of their patients from ads. There are numerous ways in which to advertise in a professional manner. First, determine what is consistent in your community. You may choose to have a general advertising campaign, consisting of a combination of yellow pages, newspaper and other types of promotional materials. Before doing so, check to be sure you are on solid legal and ethical grounds. Any advertising program that is not professionally prepared, ethical and in good taste will not generate a good return, and may cause tension between you and the other area practitioners.

XIX. Marketing In “Is There Life After Residency?” Hal Ornstein, DPM, outlined a clear difference between marketing and advertising. “As a new associate, you need to be marketing savvy. Marketing does not equal advertising. Marketing is meeting local doctors or public speaking, and advertising is a newspaper ad. Marketing can further be broken down into external and internal marketing. External is that which promotes the practice outside the office and internal is how the patients are handled and marketed to within the office, such as with patient welcome letters.” Coupling these skills with use of the proper media can be a real boost to a new practitioner. The techniques learned and the contacts made will help throughout your practice life. The easiest and most accessible medium is through presentations to local clubs and groups. Community, civic and service clubs are regularly searching for guests to

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speak at their meetings. You may not see immediate results from this type of marketing, but the benefits can be great later in your practice. These groups want a presentation that will give them direct, useful tips and insights. Keep the talk simple, short and pointed. If you are using audio or visual aids have them complement, not supplant your address. Always see that printed material is handed out to reinforce the presentation. Pamphlets are available for use as handouts from the APMA or you can prepare a few pointers on your letterhead. Of greater importance is that you make yourself available to those in attendance, staying for a reasonable period of time to answer personal questions. Notice of your presentation can be treated as a news item in your community paper if you prepare a summary sheet and send or deliver it to the paper one week before the event. All significant points should be mentioned in 300-800 words in a form the newspaper can print directly. If possible, have pictures sent to the paper after the presentation; papers are often looking for visuals. An important reminder about marketing: remember the largest supplier of patients may be HMOs and PPOs so market to them as well.

XX. Using the Media

The media (including the local newspapers, magazines, community handouts, radio and television) are commercial enterprises competing for readership, listeners, and viewers. The material they present must be colorful, controversial, or both. If you submit articles to the local paper, be aware that most editors will change and edit submitted material at their discretion, which is within their right. Many professionals hesitate to approach the media for fear of being misquoted. On the other hand, if you learn the technique of giving the media what they want through an exciting presentation, you can have no better friends in the community. Live radio conversation shows are another good means of exposure for a new practitioner. If you know your subject well and have a good delivery, you may find this type of media exposure to your liking. In summation, make yourself available to the public. To do this professionally it takes preparation and education on communications. Approach these situations seriously and positively -- they will help your practice and can be a lot of fun.

XXI. Referrals

Referrals are an important aspect of any podiatric practice. Following are some effective rules to abide by if you'd like to attract referrals:

1. Report back to the practitioner promptly after seeing the patients. 2. Return patients to their referring doctor. 3. Make personal contact with potential referring doctors.

4. Offer the referring doctor an active role. 5. Build your reputation ethically.

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XXII. Staff A new solo practice office will only require one full or part-time employee. He/she must function as host, chair-side assistant, typist, bookkeeper, and housekeeper. Any future staff you require should be able to fill any of these posts, even though their individual duties may become more specialized day by day. It is important to note that your office manager should be a highly qualified and experienced individual. Patients are most impressed on the first visits. The office and its staff, including you, should have a neat and clean appearance and exude friendliness, with some professional reserve. The staff you hire must be able to project that image. Assistant duties can be learned on the job. Suggested criteria: 1. First and foremost, motivation and enthusiasm. 2. A demonstrated ability to type, and to transcribe dictation from a dictating

machine (if applicable). 3. A neat and clean appearance with a friendly and professional demeanor. 4. Character references which mention honesty, promptness, and good work ethic. 5. Intelligence, and manual dexterity displayed during the interview, that in your judgment will allow the assistant to learn and execute duties satisfactorily.

During the interview allow sufficient time to conduct the interview, generally 15-30 minutes. If, while interviewing, you discover the applicant will not do, cut the interview off politely. You should have a mental picture of the type of employee you are looking for in detail. Be sure to include questions relating to education/work history background. Open-ended questions should be utilized. After you have chosen a candidate, it is wise to offer the new employee a trial period of ninety days.

Your staff should become enthusiastic about podiatry, and the services that are rendered. They deserve to be treated with respect. The salary paid should be in line with community standards, their abilities, and enthusiasm. Don't be cheap, but do keep in mind that studies have shown that money is not the only factor in employee satisfaction. The working conditions and environment on the job actually have been found to be more significant to employee dedication and satisfaction than a slightly higher salary. Extra benefits are best avoided because individual preferences and family situations make them difficult to administer, and of little value to one staff member, while of real value to another. An exception is a flexible pension plan. Every employee appreciates a portable, flexible retirement fund.

XXIII. Informed Consent

Ultimately, the most important relationship in one's practice is that between the doctor and the patient. Podiatry is a field with both medical and surgical applications in daily practice. The tenets of informed consent are crucial in establishing a relationship based on trust and understanding. The following list may be helpful in evaluating if you are upholding your end of that communication: The Physician's Checklist for Informed Consent

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1. Make sure the patient understands the nature of his or her medical condition. 2. Make sure the patient understands the nature of the proposed treatment or

procedure. 3. Make sure the patient understands the possible alternative treatments or

procedures. 4. Make sure the patient understands the medically significant risks of the

proposed and alternative treatments. 5. Make sure the patient understands the chances of success or failure of the

proposed and alternative treatments. 6. Disclose the identity of the chief surgeon when he or she is other than the

attending physician. 7. Disclose any risk of death or serious harm.

8. Disclose the peculiar risks associated with a specific treatment or procedure. 9. Disclose risks to a greater extent when the proposed treatment or procedure

is experimental, new, novel, high-risk, capable of altering sexual capacity or fertility, or purely cosmetic in nature.

10. Disclose the intent to perform procedures incidental to the principle procedure.

11. Make the disclosure yourself and do not ask or expect the nurses or assistant to handle this for you.

12. Follow the rule “the greater the risk the less the chance of therapeutic benefit, and the more you should explain to the patient to obtain his or her consent.”

13. Act as if you or your family were on the receiving end of the treatment procedure.

14. Record your disclosures and the consent in a permanent way, either by a detailed writing in the medical or hospital records of what you disclosed or by using an explanatory written consent form.

15. Make sure you fill in the blanks where the operative procedure or proposed treatment should be indicated.

16. Don't say you are going to do a routine operation, as none is routine. 17. Don't inform the patient that the treatment procedure is simple. 18. Don't tell the patient that no complications will occur because complications

may occur. 19. Don't expect to obtain informed consent by merely answering the patient's

questions because he/she won't necessarily ask you the right questions. 20. Don't expect a patient's signature on a consent form that was given to him or

her just moments before the procedure. XXIV. Insurance Before opening your practice, be sure you are properly protected by several forms of insurance. The following is a checklist of the different types of insurance that should be purchased: commercial, tenants, homeowner's, auto, malpractice liability, personal health insurance, income disability, office overhead, and life insurance. For more information, see the Insurance section of this Guide.

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Motivating Your Staff

The success of any medical practice begins and ends with the staff. A well-motivated, excited and enthusiastic staff is the key to a successful marketing program. Your best presentation at a community service meeting can be an absolute failure if the receptionist shoves the sign-in sheet at a new patient and then slams the opaque window in his or her face. All your best efforts of establishing good physician referrals could be wasted if you have rude staff who takes the attitude that they are doing referred patients a favor by giving them appointments in four weeks instead of sometime that very week. There are two different attitudes your employees can have toward their jobs. The first attitude: your employees don't like to work and avoid work whenever possible. They have no ambition. The only thing they look forward to is payday and vacations. The second attitude: your employees enjoy their work and find themselves seeking more responsibility. They are self-starters and need only to be pointed in the right direction to get the work done. Obviously, you would like to have employees who matched the second description working in your medical practice. Unfortunately, many medical practices and doctor's offices are run with employees who match the first attitude description. These employees generally have limited job descriptions, are over-managed, are given little real responsibility, and have limited incentive to accomplish tasks above and beyond their job description. Abraham Maslow identified the "hierarchy of needs" and theorized that human beings have basic physiologic needs that they are driven to satisfy such as hunger, thirst, air to breath, shelter, and sex, and after these basic needs are met, certain social needs become motivating factors for behavior. These social needs identified by Maslow are acceptance, recognition, status, and prestige. He feels that by directing your attention as an employer to these social needs, you can build a team of employees who are motivated to do ordinary jobs in an extraordinary fashion. Before you can focus on the individual social needs of your employees, you must have a staff comprised of employees who are capable of being enthusiastically motivated. As an employer, you must be able to identify these types of people in the initial interview. It is possible to stimulate some individuals to a higher level of motivation, but often it is very hard to maintain this higher level of motivation if it is unnatural. Therefore, this capacity for change on one's motivational attitude must be available within the individual to allow for success. A medical office can indeed be a conductive environment for stimulating employee enthusiasm and motivation. However, before this effect can occur among the staff there must be a few criteria presently existing in the office. First, there must be a good rapport between the employer and the staff. Second, there should be a friendly atmosphere in the office. Lastly, a respectful attitude regarding the services rendered must be present. It is very difficult to encourage enthusiastic motivation in your staff if there is an unfriendly or tense atmosphere in your office. It is also important to note that if you are able to maintain good rapport between the practitioner and the staff members, you will keep the lines of communication wide open which invites personal motivation.

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Employees must also feel as if they are an integral part of the larger health care unit and be proud of their association with it. This type of feeling is generally developed with conceptual agreements and respect between the employer and employee. Without this feeling, motivation can only be occasional outbursts, but with this feeling, an outpouring of motivation can result. Another method of producing and sustaining enthusiastic motivation in your office is by goal setting. The practitioner can encourage the staff members to set short and long term goals. These goals can either be focused on their individual work or could pertain to the medial office as a whole. Either way, you are establishing an atmosphere that encourages personal pride and personal achievement therefore, establishing personal enthusiasm and motivation in the medical office. Practice management is actually a conglomerate of principles and guidelines that help the practitioner maximize both office efficiency and productivity. The staff is the primary vehicle through which all these principles and guidelines are executed. This task of practice management is much easier if you are dealing with staff members who are enthusiastic and motivated in their daily work.

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How to Connect with a New Patient in Sixty Seconds

According to many studies, we all determine whether we like or have confidence in someone within seconds of the first meeting. Your patient’s level of acceptance is often set with signals you send immediately upon entering the treatment or consultation room. This first sixty seconds with a new patient is your opportunity to lay the foundation for your successful relationship during the entire course of treatment. Have you taken a critical look at what you say or do the first sixty seconds you are with a new patient? Too often we have our eyes looking into the patient chart as we quickly get into questions about the chief complaints without forming that all-so-important “personal bond.” Although you are providing medical services, your comments, body language and demeanor those first sixty seconds set a generic stage common to all delivering a service to customers. You are constantly confronting patients who are not like you; they all have different strengths and weaknesses. The mistake we make is that we too often think everyone thinks and reacts like us and they clearly do not. They present with a high degree of anxiety and a fear of the unknown even though they appear calm and in control. Most patients, due to their previous experiences and prejudices, come to our offices with a preconceived notion that the doctor may lack a degree of personal skills. This first sixty seconds is your opportunity to break through this barrier and gain this patient’s trust by showing them that you are a caring human first and then a doctor! First and foremost, when first speaking with patients focus on eye contact, the most fundamental skill taught but often not put into practice. If you have a hard time doing this, practice for a week, noticing the eye color of everyone you come in contact with. Eye contact is important throughout the entire patient visit, especially when you are presenting your treatment plan. Focus on controlling distractions that can cause your eyes to sway or head to turn, losing important eye contact. Smiles Count The universal language spoken in any land is a smile. It’s amazing how barriers are broken down when you enter the treatment room with a simple smile and what can be called a “connecting comment” such as “How are you today? It’s nice to have you in our office. I am Dr. Sullivan.” This is so much more powerful than the canned, “Hi, I am Dr. Sullivan, what can I do for you today?”

You must believe you are on stage and everything is being evaluated in hyper speed leading to a bottom-line conclusion about your personality, body language, personal hygiene and caring. This is your opportunity to let your personality shine and break the stereotype of the “cold doctor.” A funny thing happens when you smile: others do too.

Be a Good Listener Some brief thoughts about the remainder of your patient visit beyond these first sixty seconds. Listening is one of the most important skills that will result in winning your patients’ trust and earning you high marks. Listen to others and they will listen to you; you will get to know more with improved accuracy and you will gain their confidence. Letting

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others finish before you begin to speak delivers the message that you are sincerely listening. Acknowledge that you are actively listening with a small nod of your head, an occasional “yes” or “uh-um” and occasionally repeating back what your patient just told you in short form. Once again listen with your eyes by focusing on that all-so-important eye contact. It is quite the challenge to change how we behave and react. But if there is just one thing you take from this article, spend a portion of that first sixty seconds to speak with your new patient as if you were meeting him/her at a party. Speak about anything other than why they are in your office, such as how they heard of the office, what they do for a living, what a beautiful day it is, something you have in common...just anything but their feet! I challenge you to focus on these first sixty seconds for the next two weeks and see how you spend this time with your patient. Have your assistants observe you and provide feedback. Getting on the same wavelength with your patients for those sixty seconds is a skill that any doctor or medical assistant can learn. Do not underestimate the power of sixty seconds.

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Give Patients a Pound of Gold in a One-Ounce Bag The Physicians’ Role The perception of time spent with your patient is related to your energy directed toward them. Their psychological and medical needs can be fulfilled in a short time with simple techniques. This starts with their perception and expectations. Their expectations can be exceeded by making their perceptions reality. Much of this information shows common courtesies our parents taught us as children, which are frequently lost in adulthood. This section will discuss the role of the physician in delivering your patient a pound of gold in a one-ounce bag. Each and every patient encounter should begin with eye contact and a friendly smile as you cross the doorway into the room. Follow this with a handshake even if you’ve seen the patient a hundred times This delivers a clear message of warmth and caring and helps to reduce the fear factor patients often experience. This opens their minds and ears to what you then tell them about their conditions. These simple skills say to the patient that you are friendly and relate to them at the same level, not on the ivory tower many physicians seat themselves. As you begin to speak with them place both hands on their feet. Studies have consistently proven that human touch portrays compassion. Begin your conversation with a question relating to their overall well being such as “how have you been?” This may lead to an extended conversation so be sure to control the conversation by switching to how their podiatric problem is doing, i.e. “so, how’s the heel feeling?” At this point LET THEM SPEAK and get it all out. The typical patient will do this fairly quickly. However, if you interrupt them early on in the encounter to move the visit along they will feel you are rushing. If they speak their peace, the rest is yours to control. Patients comprehend significantly better with their eyes than ears. Each treatment room should have:

� a poster sized picture of common foot and ankle conditions (professionally framed) which can be purchased from Krames and Anatomical Chart Company

� foot bones � 8 ½ x 11 tear-off pads with conditions and anatomical outlines to write on � a large board with erasable marker available through podiatric supply companies

By the patient visualizing their condition, their questions are reduced and they leave with a better understanding. Before discussing the patient’s condition, have them read a brochure outlining their condition, etiology and treatments. Information on the patient’s related condition will reduce the amount of questions and will further reduce anxiety. The patient may also review this information at home with their spouse, neighbors, and friends. Time spent with the patient will be reduced if you take control of the visit. This sounds obvious but too often, the patient leads the visit. The patient is in the office because you are the expert. Deliver your treatment plan with confidence and the patient will more likely accept and follow your recommendations. Stay away from statements such as “you may benefit from…” and “I think this may work…” Emphasize the importance of the treatment by using phrases like, “this is critical for you to have relief or “this will make a significant difference in how you’re feeling, and our goal is to get you better as quickly as possible so you can return to your normal activities and reduce the chance of surgery.”

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A key factor of your patient’s perception of time spent with them is your energy delivered also known as charisma. Of all the skills taught and learned, this is the most difficult to acquire yet it delivers the strongest message of compassion, caring and making the patient feel that you value their relationship. This perceived energy creates the “Halo Effect” that creates a good feeling on the patient that they are part of your successful practice and does not require much of your time to feel fulfilled. Consider each time you walk through the door of a treatment room the spotlight goes on and you are on stage. Mary Kay Ash, founder of Mary Kay Cosmetics, has said to make believe everyone has a sign around their neck that says, “Make me feel important”. There is a direct relationship to patient waiting time and the amount of time a patient expects to spend with the physician. There is no magic pill to lessen waiting time however, after analyzing many different practices, one of the most common problems among all of them is lack of productivity due to inefficiency. Many offices do not effectively utilize and empower their back office staff to serve in the role of “physician assistants”. An assistant should serve as an extension of the doctor with the ability to effectively answer questions, perform functions, and free up the doctor’s time to move into the next room. In chemistry, we learned that the rate limiting factor, which equates to the physician, is the primary provider of care. If there are four treatment rooms, the most important two rooms are the one the doctor is in and the next one they are going into. This topic can be an article in itself but in a nutshell, each doctor in the practice should have a second back- office assistant in the room during the visit to act as an extension of the doctor, and ready to work directly with the patient (within the assistant’s scope), after the doctor leaves to room. Done correctly, there is not loss of quality of care or delivery of customer service. In most cases quality of both are improved. Moreover, be sure to train them through observation, seminars, reading and membership in the American Society of Podiatric Medical Assistants (www.aspma.org). If you will be writing a letter to their primary care physician, let the patient know this is being done to keep their physician informed about their health. The patient greatly appreciates this and it shows you are thorough. A common compliant with patients is that the doctor did not answer all their questions. This issue can simply be addressed by asking this open-ended question at the end of each encounter “What other questions do you have?” Ask this while looking at them in the eyes with your hands lying on their feet. Be sure to thank their patient for coming in to your office. They appreciate being recognized and valued as lending to the success of your practice. A comment like “enjoy the rest of the day” or “looking forward to seeing you next time” ends the visit on a positive note.

The Assistant’s Role When an assistant looks at their job as a career, and genuinely enjoys what they do, they actually become self-motivated and want to contribute to the overall success of “their” practice in much the same way as a physician does. They take ownership and pride in making it successful. Under the tutelage and support of a very nurturing doctor, the assistant may participate in building mutual practice philosophies and goals: they are not satisfied with just sitting back and waiting for things to happen, but have a desire to pitch in, take action, and MAKE them occur. The synergistic attitude that develops as a result of this energized doctor/assistant team ultimately ends up benefiting not just each other – but in a bigger, better way – their patients. And don’t be fooled…your patients know the difference between those offices that “have it” and those that merely pretend!

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An assistant can contribute to making the patient feel important in three major areas. Think of these as the “1-2-3 winning combination”… or (to steal a common sport terminology) the “hat trick” combination. They are:

1. Using their TIME more functionally to fine-tune the efficacy and productivity of the office

2. Contributing to raise the standards of QUALITY OF PATIENT CARE through the advancement of their own skills and proficiency

3. Creating a POSITIVE ENVIRONMENT by personally focusing on and involving the patient

Breaking this winning formula down will show how each one can maximize your practice operations. TIME: When we talk about using time more functionally, should the greater emphasis be placed on your (time) or your assistant’s? The answer is both. With respect to patient care, you can utilize your assistant’s time in such a way that allows you the necessary freedom to generate more revenue elsewhere. For example, consider delegating some of the habitual “typical” organizational duties that you might normally do, such as explaining (and many times explaining again) pre-op, post-op, surgical expectations, at home re-dressings, orthotic instructions, prescriptions, hospital test preparations, (e.g. MRIs, bone scans, Doppler studies, lab tests) and even directions to the hospital. Having a well-trained assistant right in the room with you can help to develop this concept to an even greater level. For example, you no longer have to call your assistant into the room to verbally delegate these tasks. Their mere presence automatically begins the process. They hear you tell your patient, “Mrs. Jones, I am going to start you on an oral antifungal which will help your nail condition.” Immediately, the assistant begins writing the prescription as well as a lab order for blood work, discusses with the patient a convenient facility to have the lab work done, makes the appointment for them (if necessary), gives them instructions and directions to the facility, helps them with their shoes and socks (if they require assistance) and reschedules another office appointment for follow-up. NOTHING further needs to be said by the doctor – communication has already begun and work is in progress. This is just one scenario. There are many other conditions that when precipitated by the doctor’s conversation with the patient, can spur certain customized protocol. Take as another example - heel spurs. This particular conversation might stimulate the assistant’s preparation of an injection (which could be prepared in advance, dated and labeled for added efficiency), X-rays, physical therapy, preparation and/or application of bandages (including the care of the bandage), review and demonstration of exercises, writing and explaining an anti-inflammatory prescription, recommendation of a water-resistant bandage cover (purchased at your office) and rescheduling the next appointment. Once this becomes the “new” routine, and the doctor is confident that the assistant can competently handle the situation, (s) he will feel comfortable enough to leave the treatment room and move on to the next patient, knowing that the patient will not feel slighted in any way by their departure. For this one patient, the time saved for the doctor has been substantial. Imagine how the duplication of the same procedure can affect the flow and revenue of an entire day? CONTRIBUTING TO QUALITY PATIENT CARE: A motivated assistant can go beyond the duties described above, adding another whole dimension of professionalism to your practice. Involving them in direct (non-invasive) patient care will instill in that assistant positive feelings of growth, self-worth and accountability – all vital to job satisfaction. Anyone that has had difficulty retaining staff knows that staff turnover is a very costly endeavor.

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Trusting them to carry out certain agreed-upon clinical responsibilities (such as castings, bandaging, removing of sutures, etc.) can be as equally rewarding to them personally as it can be to the practice reputation. Additionally, it will ignite patient satisfaction, respect and trust, making the patient more acceptable of allowing the assistant to perform activities that would normally be performed by the doctor. Depending on their level of proficiency, training, and eagerness to learn, the assistant can be phased-in to the actual hands-on care of the patient with great success. Under your direct guidance and through regular in-service training workshops, they can be taught to deliver exceptional “assistance” above and beyond the monotonous “housekeeping” obligations of merely cleaning whirlpools and filling drawers. CREATING A POSITIVE ENVIRONMENT: Patient satisfaction undoubtedly starts with a good attitude and loyalty. The attitude you want your office to project, “must start at the top”. If you choose to have a good attitude each day, the assistants are bound to “catch” it and before you know it, the trickle-down effect soon touches the patient. In this kind of environment, giving becomes almost as natural as breathing and from it, patient satisfaction increases substantially. Once again, we will focus on the assistant’s role and how they can help improve patient relations through effective communications. A familiar passage written by Robert Fulghum comes to mind called, “All I Really Know I Learned in Kindergarten.” Summarized, Mr. Fulghum reminds us that our lives should constantly mirror the basic common courtesies we were taught as a child – among them, to share, be fair, be nice, don’t steal, say you’re sorry, don’t hurt others, maintain personal hygiene and have fun. Unfortunately, many times they are lost and forgotten; however, if we make this universal philosophy the active, driving force of our overall practice goals, we would not limit ourselves to just providing good patient care, rather we could deliver SUPERIOR customer service… and with very little effort!! The patient-assistant relationship only has to start with a phone call from a frightened patient. From that point, the assistant’s ability to satisfactorily answer their questions, soothe their concerns, and make every attempt to pleasantly accommodate their schedule, will guide them another step towards the door. When entering the office door, the assistant is the first to greet them with a warm, welcoming smile, a personal hello and an extended hand – a concentrated effort to emotionally “touch” the patient and expand upon their already positive first impression. A heartwarming story, a lending ear, a comforting shoulder, and genuine humor allow the relationship to mature. Combine all these elements with proficiency and professionalism and G – O – A – L! Your assistant has just helped in scoring a HAT TRICK in healthcare management for your practice. In conclusion, mining for and delivering that pound of gold requires teamwork. It has long been known that a team approach to healthcare maximizes patient satisfaction and patient outcomes. Each member of a team has their special abilities. Know your staff well. Determine each member’s strengths and weakness as well as likes and dislikes. If all staff is empowered to deliver those essential ingredients those patients come to need and desire, a tremendous amount of synergy will ensue. Some beneficial results include: � Higher team satisfaction � Lower employee turnover � Higher patient satisfaction � Higher patient compliance � Lower litigation

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� Improved outcomes � Improved community standing � Lower operating costs � Higher profitability � Lower organizational stress The practice of medicine is as much an art as it is a science. Physicians and their staff must strive to understand patients from a psychological as well as physical standpoint. Never underestimate the power of patient perceptions. During patient encounters, you must eliminate all negativity from your conscious mind such as office issues, personal problems, and dislike of the patient. The art of a “golden touch” is often only delivered by an enlightened hand. And finally, remember that “they may forget what you said, but they will never forget how you made them feel!” APHA Public Health ¼ ad Black white Pu 10 (this ad repeats x3)

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Customer Service and Continuous Quality Improvement to Enhance Patient Care

Not too long ago, a colleague asked me what the term “practice management” meant to me. I suppose that this term can take on many definitions. My answer started out by stating what practice management did not mean to me. While “improved revenue” or “increased profit” is the outcome of good practice management, it is not what defines it.

“Practice management” should have a patient-focused definition. Customer service enhancement, improved efficiency, patient satisfaction, staff management, business administration skills, and cost containment are all integral parts of my definition of practice management. Even the latter few, while sounding more financially-focused than patient-focused, have an indirect, yet profound effect on patient care. All, of course, lead to the outcome of improved profits.

All processes within a medical office have an impact on customer service. Direct patient contact is not required. Telephone personnel, billing and collection personnel, outside vendors, labs, as well as hospital and surgical facilities all have an impact on your perceived quality.

10 PRACTICAL PRACTICE MANAGEMENT TIPS

� Recognize that every employee in your practice has an impact on customer service and the patient’s perception of your quality.

� When addressing problems, “frame” your reply in a positive manner rather than a negative one. Rather than saying “it’s against our office policy to do that”, reframe it with an alternative by saying “what I will do is…”

� Use the patient’s name when communicating with them. � Remain calm. Respond rather than react. The former is based on

intellect while the later, on emotion. � Keep your internal problems internal. Patients have enough

problems of their own! � Recognize that you have primary customers (the patient),

secondary customers (the primary care physicians), and tertiary customers (the insurance company).

� Educate your patients as much as possible. Occasionally, a lack of information has an adverse effect on the patient’s perception of your quality.

� Explain all delays. � Smile! � End all encounters with “do you have any other questions” and

“thank you”.

THE ALARMING FACTS:

� Research has demonstrated that a typical satisfied customer will tell 2-3 people about their experience while a dissatisfied customer tells 9-10! � It costs six times more to obtain a new customer than it does to satisfy and keep

an existing one!

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An important aspect of good practice management, perhaps as a subset of customer service, is the concept of Continuous Quality Improvement (C.Q.I). W. Edward Deming was perhaps the “father” of C.Q.I. His concepts, while developed and applied to the manufacturing industry, now permeate many organizations, including healthcare.

Continuous quality improvement is an approach to quality management that focuses on “processes” rather than the individual. While there are many well known customer service techniques that circulate around most management programs, medical offices are in need of some simple tools to help quantify and develop continuous quality improvement strategies.

IMPORTANT DEFINITIONS WITHIN CQI

Incident: An unusual or undesirable event that disrupts an organization, or is not consistent with normal patient care. It may involve a significant violation of established policies and procedures.

Sentinel Event: An unexpected occurrence involving death or serious injury.

Root Cause Analysis: A process that identifies the underlying cause of an incident or sentinel event designed to prevent a reoccurrence.

Dissatisfiers: A dissatisfier is the absence of 'expected quality'. Customers expect products to be essentially flawless, and if they are not, they are dissatisfied. Customers usually don't tell us what their 'expected quality' is because they take for granted that we will provide it. Examples of dissatisfiers would include custom orthotics that are a poor fit and instruments that are unclean.

Satisfiers: A satisfier is something that customers want in their products, and usually ask for. The more we provide a satisfier, the happier customers will be. Examples of satisfiers are increased office hours, greater after-hour accessibility, and written information regarding their condition.

Delighters: Delighters are product attributes or features that are pleasant surprises to customers when they first encounter them. A typical customer reaction to a delighter is to say to a friend, 'Hey, take a look at this!' The needs that delighters fill are often called 'latent' or 'hidden' needs. An example of a delighter would be a post operative get-well card or flowers.

These definitions demand a few strategies from practitioners. An incident, by definition, can never be documented without the existence of written practice policies and procedures. It is crucial for practices to have an employee manual.

To understand what is important to patients, an annual satisfactory survey should be performed with results reviewed with your staff and responses planned.

The sometimes exhausting search for the truth is also important. The root cause of a problem often lies deep to the surface. With the relentless search for “why”, we may begin to understand the true cause of a particular problem. As an example, a telephone that seems to ring busy too often may easily be attributed to its operator. The root cause, however, may be an insufficient number of incoming telephone lines.

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CORE CONCEPTS OF CQI

� Quality is defined as meeting and/or exceeding the expectations of our customers.

� Success is achieved through meeting the needs of those we serve.

� Most problems are found in processes, not in people. CQI does not seek to blame people, but rather to improve processes.

� Unintended variation in processes can lead to unwanted variation in outcomes, and therefore we should seek to reduce or eliminate unwanted variation.

� It is possible to achieve continual improvement through small, incremental changes using a scientific method.

� Continuous improvement is most effective when it becomes a natural part of the way everyday work is done.

CORE STEPS FOR CONTINUOUS IMPROVEMENT

� Form a team that has knowledge of the process needing improvement.

� Define a clear goal and objective.

� Understand the needs of the people who are served by the system (our patients).

� Identify and define the measures of success.

� Brainstorm potential change strategies for producing improvement.

� Plan, collect, and use data for facilitating effective decision making.

� Apply a scientific method to test and refine changes.

The Failure Mode and Effect Analysis (FMEA) is an interesting CQI tool that is already being employed by many health care facilities. It may be modified and applied to private offices to assist in a quality improvement program. It is a simple, yet proactive view of “potential events” and should become part of our daily normal practice management protocol. Normally, when a problem arises, we look back to establish a root cause. It would be far more efficient, however, if we could prevent things from going wrong in the first place. That is the purpose of the Failure Mode Effect Analysis. It looks at a process and asks “what if”? A process is placed “under the microscope” with the intent of precluding potential problems. Placing each process step on a graph helps to identify the points of potential failure. The likelihood of the failure is evaluated: 1= Remote/no known occurrence 2= Uncommon occurrence 3= Occasional occurrence 4= Frequent occurrence

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The severity of the possible failure is categorized: 1= Minor or no impact 2= Moderate impact 3= Major impact 4= Catastrophic, long term impact The level of risk is then determined by calculating a hazard score (probability of failure x severity). Severity > Probability v

(4) Catastrophic

(3) Major

(2) Moderate

(1) Minor

(4) Frequent 16 12 8 4 (3) Occasional 12 9 6 3 (2) Uncommon 8 6 4 2 (1) Remote 4 3 2 1 Attention is placed on the failures with the highest hazard scores (as an example 8 or above). As a working example of how the FMEA may assist in office quality improvement, let’s consider the process of dictation/transcription. The steps of the process are graphed: Potential for Failure

1. 1a. Doctor behind on dictation 1b. Doctor forgets to dictate

1c. Dictation incomplete 2. 2a. Transcription lost

3. 3a. Delay at transcription

3b. Incomplete/mistakes in transcription

4. 4a. Transcription lost

5. 5a. Placed in wrong 5b. Chart missing/delay 6. Hazard Score: (Hypothetical scores for step 1 only) SEVERITY PROBABILITY HAZARD SCORE 1a. Doctor behind 2 4 8 1b. Doctor forgets 4 2 8

Patient seen-note dictated

Tape removed- sent to transcription

Tape transcribed

Transcription sent to office

Transcription placed in chart

Chart filed again

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1c. Incomplete 4 3 12 In this example, all potential failures in this step had a hazard score which warrants further study. Incomplete dictations demonstrated the highest hazard score (12) and should be given priority in establishing the root cause and possible solutions. Once your team identifies the process step needing improvement, another tool may be employed to facilitate change. Developed by statistician Walter Shewart in the 1920s, The Shewart Cycle (or PDCA cycle) is a straightforward protocol designed to implement a change. The cycle consists of Planning, Doing, Checking, and Acting.

Plan: The team brainstorms to develop an improved step. The step with the highest hazard score is addressed first.

Do: The improved step is implemented. Check: The revised step is studied to determine its success. patient satisfactory surveys may be needed. Act: The revised step, if successfully improved, is maintained. If the attempt is unsuccessful, returning back to the planning step is warranted.

Another useful and practical quality improvement tool is the S.W.O.T. Analysis: Strengths, Weaknesses, Opportunities and Threats of your practice. Some question examples: STRENGTHS � What are your

advantages? � What do you

do well? � What

resources do you have?

� What do others see as your strengths?

WEAKNESSES

� What could you improve?

� What do you do poorly?

� What should you avoid?

� What do others cite as your weaknesses?

OPPORTUNITIES

� What possible opportunities could arise?

� Are there any interesting trends? � Are there any possible technology/ procedural opportunities?

THREATS � Any

possible changes in govern-ment policies?

� What is your competitor doing?

� Cash flow problems?

The SWOT Analysis allows you to visualize both internal (you and your staff) as well as external (patient satisfactory survey) data. Annual data review data should be followed by corrective action. Consistent utilization of these simple tools of quality improvement will greatly enhance your practice. They can be applied to any of the numerous processes that a podiatric practice consists of. They have a significant effect on patient satisfaction, efficiency, costs, and yes…even profits!

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How to “Step up” Assistant Efficiency

Efficiency is finding a new approach, in the most productive way, in the least amount of time; a concept built by proficiency, organization and innovation. Most times when you give staff a job to do, unless directed otherwise, they are inclined (sometimes strongly encouraged) to do it exactly the way they are taught, which by the way may not always be the most effective. Sticking to this one-way method, while considered “workable,” closes off doors of opportunities for change and leads to stagnation on many levels, for the assistant (personally and professionally) and for the practice. It is only after staff is given permission to actually take control of their job and “own” it, that they are motivated to develop new methods that will not only result in the same outcome (maybe even a better one) but quicker and with greater satisfaction. It’s called job challenge. Self-determination allows them to become the architect of an all new improved way, through careful re-organization and innovative strategies. I might suggest that rather than observe efficiency from the perspective of “what can my assistants do to be more productive for me?” it becomes all the more valuable to ask instead “what can I do that will give my assistants the necessary space to allow them to be their most productive?” What’s essential is understanding that everyone has their own unique way of arriving at the desired outcome with the emphasis not so much on how we arrive there, but that we ultimately arrive. In my presentations, I try to drive this point home by displaying on the screen a number of illusions. Each of these visuals can be viewed one of two ways. As in this illustration below, one person may clearly see a duck at first glance (looking left) while another may see a rabbit (looking right.) Who’s wrong? Neither. It’s not a question of “right” or “wrong” - it simply becomes a matter of “perspective.” So, just as the same visual can be seen two different ways, so can two people see different ways to arrive at the a similar outcome.

It’s all about empowerment. The efficiency concepts above are not possible if the doctor does not first put a great deal of trust in their staff or allow them complete ownership in a project. Managing does not mean looking over their shoulder and telling them how something should be done. Managing is empowering them to set their own pace and find their own way. It is important to set goals and desired outcomes for your practice. Then step back and give your staff the space they need to implement their own innovative ideas. They want to succeed, for themselves and for the practice. Without the freedom to try new things, the positive process known as “efficiency” is stifled. With it, they have an excellent opportunity to grow and produce in a nurturing environment. I’d like to share with you some ideas that I encourage you to share in turn with your staff. Maybe they are already doing them with great satisfaction; maybe they will take one of these ideas and “go with it;” make it even better. These are only ideas, not solutions. Give them the opportunity to take them in their own direction, increase their own efficiency and make them worthwhile realities for your practice.

� Make the time to properly train your assistant to where you can delegate more hands-on responsibility which in turn will help to free up more quality patient time for you. Delegating a minute here and a minute there adds up and before you know

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it, the possibility of seeing one patient more per hour exists. There are many duties you can delegate such as reviewing instructions with the patients for a number of things e.g., prescriptions, pre or post op care, orthotic wear and care, getting injections, casting for orthotics, how to wear a pneumatic boot, injury care, etc. Encourage assistants to make suggestions of other areas that they feel they could help and together discuss the possibilities of making that happen. Keep in mind that allowing your assistants to participate and contribute in this way not only frees up more of your time, but also relates to your assistant a feeling of trust while elevating their professional image to your patients. It’s a win-win all the way around.

� Review with assistants the proper way to respond to patient questions, such as “Why

do you need to take all this information regarding my medical background?” or “Why should I have the doctor make these orthotics for me, when I can get them cheaper at the sports store down the street?” Together, develop a canned response which will address patient concerns, but make sure it is rehearsed in such a way that the assistant can deliver the response as naturally as their own name.

� Encourage assistants to develop whatever new forms are necessary to help them

better organize the office. One example might be a form which clearly directs them through certain processes such as obtaining patient insurance verification or a surgery check list to verify contacts and make sure everything is ready to go when the day of surgery arrives.

� Allow assistants to develop their own pattern in which to organize patient charts, so

that everyone knows immediately when opening a chart where to find what. For example, one side might contain all medical information, while the other side all billing info. Because patients seem to always be changing their health insurance, we “mark” the newest copy of their insurance card with a neon-colored sticky note folded over one side. When we open the chart, we don’t need to flip through all the sheets to find their card, we all know it’s the one that sticks out with the neon note attached to it.

� Have a referenced list of “most used” prescriptions handy, so that assistants can

write them for you as they hear you discussing treatment plans with the patient. � Make it a point to have assistants review all patient charts prior to beginning the

day. Stopping to request a lost test result or failure to contact a patient whose referral is not up to date can severely interrupt patient flow. Knowing what the day holds (patient-wise) will allow everyone to better plan their day.

� Encourage assistants to ergonomically and effectively re-arrange their office space to

where things are more convenient and comfortable for them…e.g., have the things they use most often, such as the copy machine or the shredder placed in close proximity to their desk. Arrange things so that they are within easy reach and always find ways to save steps whenever possible!

� Encourage them to make folders for items that they use on a daily basis; label them

however they wish and place them where they are easily accessible. This keeps loose paperwork off the desk and organized. I use color coded folders and place them in a graduated file holder on top of my desk for easy viewing.

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� Save time when a new patient presents to your office by mailing them a registration form ahead of time to fill out at home. (We’ve even incorporated an address label right into the form itself, so when we fold it up to mail it, the patients name and address is visible.) Now, in addition to being able to see this patient on time (instead of waiting for them to fill it out in the reception room), it also allows them to provide a more concise list of their meds, certain telephone numbers they might not have with them and it gives the elderly patients the ability to have someone at home help them fill it out.

� Keep a dated telephone log to record all incoming and outgoing telephone messages.

This also serves as a reminder to document things patients say to you, a reference for phone numbers not yet recorded and it keeps all messages together, eliminating the clutter of scattered post-it notes.

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THE APMA PRIVATE INSURANCE RESOURCE GUIDE

Given the current managed-care environment in which policies of private payers are in a constant state of flux, dealing with private payers can be as difficult as navigating in open water. In response to this challenge, the APMA Health Systems Committee (HSC) developed the Private Insurance Resource Guide (Guide) for APMA members as a compass for seasoned and new practitioners, to chart the unfamiliar territory. The Guide is available in electronic format only at: http://www.apma.org/PrivateInsuranceResourceGuide

The Guide provides invaluable practical and easily accessible information for insurance-related challenges that may arise from the time when a patient sets foot in the office to when the podiatric physician receives the appropriate reimbursement for care rendered. The Guide is an exhaustive resource containing practice management information and state statutes pertinent to the practice of podiatric medicine. Contributors include HSC Committee members, practice management experts, health law attorneys, and APMA staff.

The Guide is organized with the objective of a practicing podiatric physician in mind: “What should I do when a claim for a covered service is rejected based on medical necessity while the private insurer persistently delays the processing of the claim?” “What should I do when subjected to an unfair discount on reimbursements?” The Guide is organized by subject and should be read in conjunction with the state laws available in the APMA State Reference Manual (www.apma.org/StateReferenceManual) and other official pronouncements.

Each chapter covers one subject area and provides background information as well as recommended short and long term solutions. Because numerous factors may affect the success of a claim, some repetition in the subjects covered among different chapters can be expected.

Chapter 1 - Private Insurance Internal Claims Appeal - This section includes two complementary articles. “Decoding Coverage Decisions” outlines different types of utilization reviews employed to review medical claims submitted to private insurers. “Private Insurance Appeals” provides an algorithm for podiatric physicians to address denied or delayed claims systematically. The two articles are complementary in that “Decoding Coverage Decisions” enables podiatric physicians to identify reasons for claim denials correctly, while “Private

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Insurance Appeals” enables the physicians to initiate and sufficiently prepare for effective internal claim appeals. “Private Insurance Appeals” also discusses the Private Insurance Advisory Committee (PIAC) process that the APMA, in conjunction with state podiatric medical associations, has established to resolve members’ private insurance concerns. Knowing and utilizing the state-appointed PIAC representative may help in getting access to the medical director and his or her management team in a more timely fashion. An APMA PIAC directory also is included in this section. The PowerPoint presentation “Appealing Denied or Modified Claims: Getting Paid for What You Do” integrates concepts introduced in the two earlier articles with other aspects pertinent to a successful medical claim, such as state utilization review laws (see Chapter 9), correct coding practices, using the Correct Coding Initiatives (CCI) edits, and other tips.

Chapter 2 - Managed-Care Contracting – Can be lengthy and seemingly impossible to interpret; as a result, many podiatric physicians recoil at the prospect of having to review and understand them. Although reviewing these contracts is not pleasant, failing to do so carefully may expose podiatric physicians to significant liabilities. This section includes articles, a PowerPoint presentation, and sample letters to provide detailed, step-by-step information on how to protect a practice through contract negotiation.

Chapter 3 – Recoupment - Recoupment occurs when private insurance companies request the repayment of previously paid claims for a variety of reasons. In this section, attorneys identify different reasons for recoupment. Additionally, it provides a detailed discussion on the implications of state laws and insurers’ contractual provisions on different types of recoupment, timeframes, and procedures. Furthermore, it provides a model recoupment legislation and a checklist designed to help podiatric physicians and state podiatric medical associations review the provisions in their provider contracts that may affect an insurer’s ability to request the repayment of previously paid claims.

Chapter 4 – ERISA - Since its passage, the Employee Retirement Income Security Act of 1974 (ERISA) continues to be the most litigated managed care issue. In addition to ERISA’s preemptive effect on state laws, an employer-sponsored ERISA plan must establish and maintain reasonable procedures governing the filing of benefit claims, notification of benefit determinations, and appeal of adverse benefit determinations. Included in this section is a PowerPoint presentation, a fact sheet published by the U.S. Department of Labor (DOL) discussing patients’ rights claims procedures regulation under ERISA, and an advisory opinion from the DOL regarding claim procedures under ERISA. Additionally, it includes a discussion on the importance of obtaining a valid ERISA assignment from a patient in order for the practitioner to defeat unlawful payment denials successfully.

Chapter 5 – Antitrust - The purpose of antitrust laws is to constrain certain types of concerted activities among competitors, which in turn promotes competition and enables consumers and competitors to have fair market access. This section discusses how frustrated providers may have more ability to work together than they think when dealing with managed care organizations without violating federal and state antitrust laws.

Chapter 6 - Economic Credentialing – Is the process of determining a physician’s qualifications to participate in a health plan network or [to receive] privilege[s] by a hospital, based in whole or in part on utilization of health care services and lower cost of care, without regard to the appropriateness of the care furnished” (APMA Position Statement on Economic Credentialing). In its purest form, economic credentialing measures a provider’s performance on the basis of his or her use and utilization of resources, unrelated

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to the quality of care or professional competence. This section provides an overview of when and how economic credentialing may occur.

Chapter 7 - Silent PPOs - Is any type of arrangement that results in an insurer paying a physician a discounted fee even though the physician is not a member of the insurer’s preferred provider network and does not have a contract directly with the insurer. This section provides a comprehensive discussion on when and how a podiatric physician may be subjected to unfair discounts and appropriate steps to avoid them.

Chapter 8 - Third-Party Administrators (TPAs) - Refers to an administrative organization that processes and pays claims and that may provide other administrative services on behalf of payers, such as self-insured employers and associations. This section includes a comprehensive study of TPAs that addresses the unfair practices of TPAs and other intermediary entities, such as down coding, arbitrary reimbursement changes, procedure denials, and network participation decisions.

Chapter 9 - State Laws - This section provides summaries of state statutes governing the practice of podiatric medicine and managed care. The section also includes laws that protect the right of podiatric physicians to provide healthcare in various settings and the right to just and prompt reimbursement. The overview of state statutes in this section only highlights important elements in the statute and is a supplement to the APMA State Reference Manual, which is a compilation of statutory text.

Chapter 10 - Medicare Advantage Plans - The increasing number and types of Medicare Advantage plans presents both challenges and opportunities for podiatric physicians. In this section, Kelli Back, JD, discusses the Medicare Advantage program, including the way that Medicare Advantage plans are regulated, as well as podiatric physicians’ rights and responsibilities with regard to treating members of such plans, either as a participating provider or an out-of-network provider.

Chapter 11 - Out-of-Network Provider - When a podiatric physician renders care as an out-of-network provider, that physician’s right to payment and obligations are not set forth clearly in a written agreement, such as that between an in-network provider and the contracted private insurer. This article outlines strategies and factors to consider when seeking payment as an out-of-network provider.

Chapter 12 - Sample Letters - Medical offices devote countless hours and human power to appeal denied claims. A medical office’s ability to appeal a denied claim effectively and obtain a favorable outcome improves the financial well-being of the practice, and allows the podiatric physician/staff to conserve time and energy to provide healthcare. Included samples commonly encountered issues with managed care organizations and serve as a starting point to initiate communication with private insurers.

Chapter 13 - Frequently Asked Questions - In this chapter, the HSC has compiled scenarios podiatric physicians encountered when dealing with managed care organizations and proposed strategies that enable podiatric physicians to advocate for their rights to provide medical services and to receive reimbursement.

In addition to the above-mentioned sections, the Guide includes other reference materials in the appendix, which includes a managed care glossary and a list of commonly used acronyms, ERISA statutory and regulatory text, and information on private insurance companies and state insurance commissioners.

The discipline of learning. The art of caring.

Western University of Health Sciences

College of Podiatric Medicine 309 East Second Street

Pomona, California 91766-1854 909-706-3933

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V.PodiatricMarketing

A�liates in Foot Care

Peter Paicos, DPMLieke Lee, DPMStoneham, MA

Congratulations and welcome into the family of podiatric physicians.

Kathleen Stone, DPMGlendale, AZ

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Practical Marketing Tips for Practice As a private practitioner marketing is an integral aspect to your practice’s success. Group and multi-specialty practices should also market and advertise. Making a name requires effort and it needs to be lasting. Marketing can be an effective tool by which you can: l. Communicate your patient-oriented philosophy to public and referral sources. 2. Create a positive professional image in your community. 3. Help build a strong and growing patient base. As a starting point, think about your practice objectives. Who is your target patient base: diabetics, children, athletes, the elderly or all of these? Of course, you want to market in areas that you are proficient, so now you need to link your objectives with those in your base. How does the quality of the service given to your patients match their expectations and needs? Marketing can help you identify and match your professional objectives, your patients' objectives, and your referral marketing. Over time, you should gauge your marketing success. Two strong measures are the number of loyal repeat patients and the number of satisfied patients and referral physicians who refer their family, friends, and patients to you. Most practice management consultants suggest that the individual practitioner begin with a general marketing plan. 1. Where have I been? 2. Where am I? 3. Where do I want to go? 4. How can I get there? Answer #1: Will help you review not only the history of your practice but also your professional accomplishments, your education, training, and experience. Answer #2: Will give you a concrete description of your current patient population, referral network, and financial health. A patient profile helps identify your patients. The profile reveals dominant patient characteristics, e.g., age, sex, race, employment/income status, geographic distribution, referral source, reimbursement source, common diagnoses, and common surgical/therapeutic procedures. A practice profile can show the worth of your practice. One method of determining the financial status of your practice is to list your practice figures for the last two years, i.e., total charges, total receipts, collection ratio, accounts receivable, overhead costs, total adjustments, and your personal income. The answers may give you ideas on how you can strengthen and improve your practice. Answer #3: Will help you develop quantifiable objectives, action plans, timetable, and budget. A practical objective is specific and measurable, e.g., to increase the number of new patients seen by one patient per day. Tied to the objective are specific action plans, e.g., exhibit at a local health fair, perform foot screenings at a hospital's open house, lecture at a public health forum, write a foot health column or newsletter, and place an advertisement in the local paper. Before executing any action plan, it is best to outline a timetable and budget for each plan. You will want to monitor the success of each action plan. How can you measure the effectiveness of any action plan? You will want to ask a new patient about a referral source by including a question on the patient's initial registration form.

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For some action plans, you may wish to create a response action, e.g., offer a complimentary foot health brochure or newsletter. By creating a response action, you can track the success of your plan by the numbers of patient responses. A total commitment to "service excellence" is the key ingredient for a healthy practice. Joe Casurella, 3M Health Care Manager of Professional Relations said, "We [3M) realized that we don't define quality -- our customers do, and second, in a truly competitive market, quality is the most important competitive strategy an organization can adopt." Studies show that satisfied patients are your best sources of new patients; unsatisfied patients are three times as likely to express poor experiences. Promoting your practice involves both internal and external positive public relations. Tom Peters, a management consultant, urges the practice of service excellence in all businesses. Service excellence means a commitment to businesses. Service excellence means a commitment to delivering the best possible service to the customer. It is a practical commitment of everyone in the business to "do the best I can, and to strive for excellence in my work." This should be true of all employees; everyone has a role to play in the entire patient experience, whether they are at the front desk, or behind the scenes. How has this concept of service excellence been implemented in American businesses? One example is the "Managing Total Quality" (MTQ) program of the 3M Company. The MTQ approach signals the company's commitment to its customers' expectations. A customer is anyone who receives a service or product from the company's staff. Joe Casurella describes 3M's MTQ as a principled process: The MTQ approach is based on a number of fundamental beliefs: 1. Quality is a positive strategy for growth. It should be integrated into the

strategic business plan. 2. The commitment to quality must start at the top. 3. Quality must permeate the organizational efforts. Everybody must

participate. 4. Quality is a process, not a program. It is a journey, not a destination. 5. Quality benefits everybody -- customers, employees, community, and

organizations. How can service excellence be measured? For a practitioner, it can start with the initial contact. Internal operations play an important role in your public's perception of your practice. Often it is the intangibles, the personal attention given to the patient, which make or break a practice. Other ways by which your service excellence can be measured include: 1. The way in which you and your staff communicate with your patients. 2. The ease by which your patients can schedule an appointment. 3. The time that your patients wait to see you. 4. A convenient office location. 5. The appearance of your reception area and office suite. 6. Convenient office hours. 7. The ease of your billing procedures. You may wish to develop a "Managing Total Quality" program for your practice by involving your staff in the planning and implementation process. Your patient's description of

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services you render often rest on their perception of you and your staff's availability and willingness to respond to their needs. Key items to discuss with your staff include:

1. The kinds of services that your patients generally seek. Provide your staff with a “cheat sheet” of common procedures, surgeries, treatment protocols, etc., so they are equipped to answer basic patient questions.

2. The kinds of services you want to provide to your patients. Staff should keenly be aware of expertise, and be able to honestly communicate practice objectives. If a patient request is not consistent with your practice supply, educate your staff of other podiatrists or specialists that can handle their needs. Staff should maintain patient relationships with your office, by encouraging them to follow-up with you for other podiatric needs, if warranted.

3. How to communicate your commitment to total quality to your patients and public. Having “canned” response to the fundamentals of your practice helps maintain consistency in your practice’s message and public perception.

4. How to relate the needs of your patients with your staff's responsibilities and tasks. To make patient care more efficient, staff should know what conditions constitute podiatric emergencies. If a patient needs to be seen immediately, admitted, or needs a referral, staff should be able to make certain judgment decisions.

5. How to create positive patient responses. 6. Office appearance. As your discussions evolve, you may wish to discuss specific areas for improvement. These may include: 1. Telephone etiquette. 2. Sensitivity to patient relations. 3. Patient scheduling and waiting times. 4. Sensitivity to billing procedures and insurance issues. 5. Staff personal appearance and manner. 6. Office appearance. The telephone is a critical marketing tool. Warmth and interest in the patient's well-being can be conveyed over the telephone. Many practice management consultants suggest that all staff be trained to answer the phone with a smile, a pleasant "good morning or good afternoon," the practice name, his/her name, and "May I help you?" Another good way to convey patient interest is the continued use of the patient's name throughout the conversation. All of us like to be called by name. It is important that the patient is called by his/her surname unless the patient asks to be called by his/her first name. Patients cannot always evaluate the clinical care that is given to them, but they can and do evaluate the personal attention and "common courtesy" shown to them. Discuss the importance of welcoming and listening to patients. Also, discuss ways in which your staff can communicate better with your patients. Examples may include: 1. Courteous and respectful language. 2. Telephone reminders of the patient's appointment hour. 3. Written appointment reminders. 4. Attention to appointment scheduling system.

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5. Monitoring of delays in the schedule. 6. Encouragement of patient questioning. The personal appearance of a staff member can inspire confidence or it can convey a poor attention to detail. This is also true of the physical appearance of your office suite. Some practical things to consider are: cleanliness, interior decoration, comfortable furniture, lighting, and foot health related reading materials. The APMA produces a wide variety of foot health literature, including numerous patient-oriented foot health brochures. The APMA brochures can be helpful to your patients in understanding many foot health issues, including proper foot care, foot and ankle injuries, bunions, corns and calluses, fungus infections, the diabetic foot, the arthritic foot, and the reimbursement of foot services under Medicare to name but a few. FOR APMA BROCHURES CONTACT: The American Podiatric Medical Association (APMA) (800) ASK-APMA; Attn: Audio/Visual Membership Services The best way of finding out how patients feel about your services is to ask them. You may wish to periodically survey your patients concerning their satisfaction with your services. Practice management consultants often recommend a single sheet questionnaire. A good questionnaire opens with a statement of purpose. You may wish to state your goal of service excellence, e.g., "My goal is to deliver the best care possible..." Included in your statement of purpose would be a direct request for their comments and suggestions. A good questionnaire asks specific questions about a practice, e.g., telephone and office hour availability, the appointment scheduling system, the courtesy of the staff, the office appearance, the office wait, the care given, the specific patient instructions, and the fees and billing system. How do you write the questionnaire? Some consultants recommend the use of direct statements, alternating between positive and negative statements. All suggest that the statements be phrased in the third person, e.g., "the staff answers my calls courteously and promptly"; "the nurse or physician gives me instructions that I understand." Identifying staff may discourage honest answers. If you use the statement method, you will want to ask your patients to agree or disagree with the statements by using a rating scale. One method is a 7 point scale ranging from +3 for those who strongly agree or disagree to -3 for those who strongly disagree. Other consultants suggest open-ended questions, leaving blank spaces for the patient to state his/her opinions. Many consultants recommend that the questionnaire conclude with an opportunity for the patient to briefly state his/her general recommendations, e.g., "What I'd recommend to improve...or what I'd like to see changed...." Ask your patients to mail the questionnaire back to you directly by a specific date. For your patients' convenience, include a pre-addressed and stamped envelope. You may wish to close the questionnaire with a note of thanks and your signature. Confidentiality can be emphasized by avoiding patient identifiers. After you review the results, it is good to send your patients a letter expressing your appreciation for their help. This letter also can emphasize your commitment to service excellence by outlining any changes which you are implementing as a result of their completed surveys.

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In addition, consider placing a sign in your reception area, stating your commitment to giving the best possible care. For example, you may wish to state: "Welcome to my practice. As a podiatrist, I specialize in the diagnosis and treatment of diseases as well as surgery of the foot and its related structures. My services include routine foot examinations as well as diagnosis and treatment of [complete as appropriate]. I also have a subspecialty or special interest area in [complete as appropriate]. My goal is to deliver the best foot care possible. However, quality care depends upon patient participation. Please feel free to ask questions or make suggestions. Your comments are appreciated." Conclude your statement with your signature. This statement could also be used in a patient information brochure, practice newsletters, and print advertisements. Communicate the benefits of your services to your public begins with selling yourself to your public. You are your best public relations agent. The following ideas and approaches may help you to promote your practice to your public: Volunteer to speak to community groups, hospital groups, professional

societies, and neighborhood associations. Become active in professional societies, community groups, and health care

organizations. Volunteer to serve on committees; an especially good one is a membership committee. Introduce yourself to local community leaders and local hospital medical and nursing staffs, local health care practitioners, including dentists, optometrists, pharmacists, and public health nurses. These are the people who often refer patients.

Get your name and practice in print as much as possible. Write pieces for

patient newsletters, columns or articles in local papers, journal articles. Create "Helpful Foot Health Hints" pieces. Submit press releases (informational pieces) to professional society newsletters, local newspapers, and hospital newsletters. Submit letters to the editor addressing timely subjects.

Advertise, use paid space to promote your practice. Announce new

developments, e.g., new location, new associate, new services, expanded hours. Place ads in local newspapers, shoppers' papers, and/or telephone directories. Develop direct mailers to potential patients in your service area. The APMA's "Guidelines for Ethical Professional Advertising" is a useful resource.

Communicate with your patients and referral sources. Send birthday

greetings, holiday greetings, and thank you notes. Many supply companies offer a variety of contemporary greeting cards, including, birthday greetings, holiday greetings, get well cards, sympathy cards, and thank you cards. Of special interest are the appointment reminder post cards, referral thank you cards, and welcome to our practice cards. Any opportunity you have to get your name recognized and remembered will be effective.

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Promote your practice through the use of giveaways, including, foot health brochures, calendars, foot newsletters, or key chains. The APMA's Department of Public Affairs offers a wide variety of foot health brochures, including ones on common foot problems, children's foot health, arthritis, diabetes, foot and ankle injuries, foot health and aging, foot orthoses, running, walking, jogging, high blood pressure.

Participate in and/or be a sponsor of community health fairs, charitable

events, sports events or school teams, and other programs. Create a welcome card packet for the local welcome wagon.

Entertain. Sponsor practice "open houses" for potential patients, referral

sources, community leaders, and other health care professionals. Create a patient information brochure. Use this brochure to introduce

yourself to potential patients. The brochure can answer the common non-medical questions that patients often ask concerning issues like office hours, location, billing, and insurance participation. Consider mailing the brochure to the public in your service area.

Marketing can be challenging, fun, and rewarding. A good marketing plan can help you communicate your commitment to your patients, create a positive professional image, and build a growing patient base. Florida Podiatric Med Assn ¼ page ad email

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Enhancing Your Patient Relations The Many Uses of a Practice Management Brochure

What are the advantages of designing a brochure for your practice? A brochure can be an effective marketing tool, promoting your services, professional credentials, medical philosophy, location, and payment procedure. The central message of the brochure is to convey the value of your services to your target audience, e.g., your patients, referral physicians, and other health care professionals. The brochure must address the unique needs of the target audience, answering their most common questions and concerns. It must generate an awareness and appreciation of your services. Thus, the successful brochure's design and copy expresses the benefits of your services in clear and concise language. In developing a practice brochure or with a consultant, the first consideration should center on the "why" and the "who." Many practitioners choose to design a patient-oriented brochure first. After evaluating its usefulness, they may design "spin-off" brochures for other target groups. In designing a patient brochure, consider your patients' first visit to your office. They may be nervous and uncertain. They probably have many questions (often unspoken) concerning your hours of appointment, your billing, even your education and training. A well-designed and clearly written brochure can introduce you to your patients, state your commitment and express your expectations of them. Patients rarely evaluate a practitioner's medical treatment, but they can and do evaluate how the practitioner treats them as individuals. Patients will consider the manner in which they are greeted by the practitioner and his staff (i.e., whether they are treated courteously, respectfully, even compassionately). The way in which you and your staff communicate to your patients often can prevent patient misunderstanding or dissatisfaction. A patient brochure can create a good start. A patient brochure may reinforce your patient-oriented philosophy and serve as a personal Guide to your practice. A prime goal is to create your image as a competent, committed practitioner available to his or her patients as a specialist in the proper care of the foot and its related structures. By addressing patients' most common non-medical questions, your brochure can be an effective educational tool. Design and write a brochure with the help of all existing resources: your staff, your colleagues, and other health care professionals. Also give consideration to the format for distribution. It is best to design a brochure that will limit postage and can slip into correspondence and patient literature racks for your waiting room or for us with outreach activities. Write an introduction and welcome patients to your practice. State your commitment to your patients and cite the services you offer, including any area of special interest (i.e., sports medicine, geriatrics, diabetic foot care). A patient's selection of a doctor is a personal decision based on various factors. Patients often consider the following factors in selecting a doctor: the doctor's hospital affiliation, "medical philosophy," professional credentials, practice structure, and practice location. Include your education and training, board certification/ eligibility, and hospital or other health care system affiliation if appropriate.

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The patient brochure should state your policies concerning office days/hours, scheduling of procedures, practice coverage, insurance, and billing practices. Put yourself in your patient’s shoes and anticipate any questions they may have concerning these topics. The concluding statement should encourage the reader to take an action, i.e., call for more information or an appointment. The brochure's copy should be written in simple sentences. It may help if the writer assumes that the reader has little or no knowledge of the practice. The brochure's statements must be truthful; hyperbole and exaggeration should be avoided. Many professional consultants strongly advise against the use of humor. Humor, being distinctively individualistic, may "turn-off" the target audience. The tone and style of the brochure should convey the practitioner's commitment and dedication to his/her patients. When the initial draft is ready, seek the advice of your staff and close advisors. It is especially important to have someone outside the office (and unfamiliar with your office procedures and policies), review your copy for clarity. Ask your reviewers if your brochure conveys your commitment to your patients' well-being and the benefits you provide to your patients. Does the brochure create a positive response and prompt action? A well-written and designed patient brochure which addresses your patients' most common non-medical questions will help to reinforce your commitment to your patients. It will establish a personal rapport with new patients and strengthen your relationship with existing patients. It will also promote your practice by creating an awareness of your services and by clearly identifying the benefits of your services to patients. You may also use the brochure to serve as the framework for "spin-off" brochures targeted to special patient groups, health plans, or other professional groups.

®

Dr. William M. Scholl College of Podiatric Medicine at Rosalind Franklin University

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Scholl College leads now for the same reason it will lead

in the future — the timeless quality of its

forward-looking education.

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North Chicago, IL 60064 800.843.3059

RosalindFranklin.edu/WhyPodiatry

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Establishing a Broad Patient Referral Base

Many say that in today’s healthcare environment that if you don’t grow, you shrink. The practitioners who are most proactive continue to achieve the highest level of success and satisfaction. Referrals of patients to an office are the lifeblood of practice prosperity; they have become all the more important with the advent of managed care. There is not one model that fits all; however, here are a few ideas for building a referral base and increasing one’s growth potential. Building a Referral Base for Therapeutic Footwear Adding a diabetic footwear program to your practice can be one of the most clinically significant and financially rewarding strategies available to a podiatrist today. More than 20% of podiatrists are currently not dispensing these critically important products to their patients. A properly facilitated and administered education program in conjunction with diabetic footwear will result in a significant source of new referral sources, both professional and patient. Consider these facts. The diabetic population is rising by 30% per decade. This is troubling, considering that over 50% of non-traumatic amputations are performed on people with diabetes. Even more troubling is that over half of these could have been prevented with timely, conservative intervention, such as footwear and protective inserts. So why is it that only 3% of diabetic patients are receiving the Medicare benefits for which they are eligible? The fact that only 3% of eligible patients are receiving this important benefit is primarily due to a lack of knowledge, on the part of both the patient and the physician. This represents an enormous opportunity for podiatrists. By adopting an information-based strategy, you can easily go into your community and let interested parties know about the importance of foot health in the diabetic population and about Medicare’s desire to protect these “at risk” patients. Many practitioners adopt a proactive strategy regarding physician referrals. An informative letter outlining the danger that diabetic patient’s face and the role of the Therapeutic Footwear Program in mitigating these risks should be sent to the entire diabetic medical team in your community. A necessary step in supplying these patients with their footwear is a signed certifying statement from their physician. Properly handled, this too can be another element in your information campaign, while providing you with the opportunity to establish a working relationship with new referral sources. Proper advertisement about this service in your office will result in new patient referrals to your practice. Every one of your patients knows someone with diabetes. By letting them know that they may be eligible for this important benefit, your existing patients are turned into community advocates for your practice. Make certain that you have informative materials available to your patients to take and distribute within their social circles.

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PROMOTE YOUR PRACTICE P = Patients R = Radio O = Other Podiatrists M = Magazines/Newspapers/Newsletters O = Organizations T = Trainers E = Educational Institutions Y = Yellow Pages Ad O = Outside Sign U = Unique Events R = Representative from Pharmaceutical Companies P = Physicians R = Races A = All Shoe Stores C = Celebrate Foot Health Month T = The Drug Stores I = Industry C = Clinics/Hospitals E = Employees P = PATIENTS Past patients are the #1 source of referrals every year. Thank them for sending a card to all first time patients. You can also send magnets that promote your practice. End of the year rewards, such as holiday cards, or restaurant vouchers are also a great way to show patients your appreciation for their continued business, while increasing the potential for new, word-of-mouth referrals. It is also good practice to have easy access to small facts about your patients’ i.e. marital status, recreational activities, local groups/interests, and children. This information can be used for foster communication and convey your interest in your patient. Further, when people talk about themselves they think of a friend/family members who have expressed a podiatric need. R = RADIO Radio is a great means of advertising your practice. Volunteer to speak on talk shows, and/or tape public service announcements. You can even appear on local television shows. With any media advertising, it is wise to have a catch phrase that you can easily repeat throughout your segment- your office name, location, website, and slogan are all important pieces to reiterate. O = OTHER PODIATRISTS This may seem odd, but other podiatrists are a great source of referrals. Establish friendly terms with other podiatrists in your area, especially ones that specialize in triples, arthroscopy, pediatrics, wound care and diabetic care. Testify to their specific skill, and they will do the same for you! M = MAGAZINES/NEWSPAPERS/NEWSLETTERS These media are another great method of advertising your practice in your community. You can spotlight shoe sales, feature special health issues, or even feature your practice’s brochure.

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O = ORGANIZATIONS Promote yourself to your fellow community members by getting involved in local organizations like Kiwanis, Rotary Club and Lion’s Club. Remember that most of the patients that are making appointments are females. T = TRAINERS Trainers are a great source of referrals for sports-related injuries. Speak to trainers and coaches at local high schools and colleges. If you have children, young relatives, get involved in their extracurricular activities – there is always a wealth of potential referrals in this activities. E = EDUCATIONAL INSTITUTIONS Start educating tomorrow’s patient base today! Target young children and explain things like bee stings, athlete's foot, and warts on slide show presentations. Set up booths that offer free shoe laces, foot pins and foot-shaped candy. Y = YELLOW PAGES AD Place an ad in the yellow pages, mentioning insurance plans, hours and location. Consider using colored ink or bold black print in the white pages, and advertise to surrounding areas. Be careful, don’t overdo it. Sometimes less is more. O = OUTSIDE SIGN Place your logo on a sign outside your practice. Use bright colors, and print in large letters that are easy to read from the street. Be sure to define yourself as a foot or foot and ankle specialist. U = UNIQUE EVENTS Take part in events that target a smaller population like job fairs, senior health fairs, diabetes month. Offer screenings for diabetics or set up a booth at the county fair promotional activity. R = REPS FROM RX COMPANY Drug representatives are a great resource for referrals. Some may sponsor advertisements featuring a drug and your practice or sponsor talks with other podiatrists. If possible, get involved with their events where you can display your expertise. Most settings are geared toward other health caregivers – nurses, doctors, and medical assistants. P = PHYSICIANS Send letters for referrals, even to HMO’s. Also, put letters in the hospital mailbox for all staff members. Attend social events at the hospital, such as holiday parties or staff meetings to gain physician referrals or host an open house for physicians and their staff. R = RACES Volunteer to provide first aid services at races and marathons in your area. A = ALL SHOE STORES Promote yourself at local shoe stores. Some retailers take business cards and post them for customers. Offer coupons to your patients, as well as maps to the stores. Host free foot screenings and orthotic fittings at the shoe stores, and offer business cards and magnets to customers.

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C = CELEBRATE FOOT HEALTH MONTH Advertise free screenings in your office and give patients educational materials. You can get these materials from your state association or the APMA. T = THE DRUG STORES Become friendly with the local pharmacists and give them your business card. Also, be familiar with the foot-related health products that are available at the pharmacy. I = INDUSTRY Offer screenings at your largest local company. Ask if you can leave literature in the break room or on employee bulletin boards. C = CLINICS/HOSPITALS Offer to be on their speaker’s panel, or to speak at support groups for conditions such as diabetes, fibromyalgia or Charcot deformity. Place exhibit boards near the elevators in the hospital, which feature all of the podiatry staff in pictures; also consider volunteering on hospital committees. E = EMPLOYEES Equip your employees with business cards to distribute among their friends and associates. Fit your staff with jackets, tee shirts and polo shirts that feature the company logo. Also, consider offering revenue bonuses to promote team spirit! Don’t Forget Opportunities with Local Businesses Most local businesses and companies are a land of opportunity in which to build a referral base. Their employees typically have good insurance coverage, and promptly take care of any medical problems that keep them from working. The word about good doctors spreads quickly throughout their working environment due to the amount of time they spend interacting with each other. A good way to introduce yourself is by sending a letter to the personal director, occupational health nurse and/or medical director, with your resume or practice brochure attached. Emphasize that, as podiatrists, we can deliver cost containment. Focus on our ability to treat sprains, fractures or any injury of the foot and ankle in an effort to return an injured employee to work as soon as possible. Offer to speak or provide an in-service on topics appropriate to the industry, such as how to prevent lower extremity injuries and the importance of proper shoe gear. There can be a focus on preventative measures for their diabetic employees, as well. If a company has a newsletter, printed or on-line, offer to write/author articles to contribute to the column. Most companies host annual health fairs or wellness screenings. These are an excellent opportunity to gain referrals. If a company does not have a health fair, offer to organize one. Include blood pressure, glucose and cholesterol checks, hearing screenings, oral cancer screenings by a dentist and foot and ankle screenings. This is a great way to introduce yourself and your services to a large population in the community. Reach Out to Local Physicians In order to solicit comments and concerns from other podiatrists and their staff, consider surveying referring physicians on a yearly basis. This shows that you recognize the importance of your relationship with them and respect their input. If there is an internal

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medicine or family practice residency program at your local hospital, offer to give a lecture on podiatric medicine and surgery. Offer rotations in your office for the medical residents, in an effort to further educate them on the role of a podiatrist in the medical community. Grand Rounds is an opportunity to address an audience of physicians of all specialties at your hospital. Send a letter to physicians in your area offering an assortment of pamphlets on podiatric conditions to help educate their office. Offer to provide copies for patient distribution. Pamphlets should have a label attached with your name, address, phone number and web site. A web site is an excellent tool for physicians, their staff and referred patients to learn about your practice and conditions you commonly treat. Encourage referring physicians to give the web site to all patients referred to your office. A pad of podiatric referral forms should be printed and distributed to local physicians. These should include your name, address, phone and fax number and web site in large letters, the referred patient’s name, the referring doctor, the chief complaint (list the ten most common podiatric condition with a line for “other”), a map to your office and a line for the referring physician’s office to add a referral number if a written referral is needed. Marketing Your Practice Base Have you ever received a post-card in the mail from your dentist letting you know about the latest dental techniques being used for TMJ? There is a very good reason that you receive this postcard. It gets patients into the dentist office in an effective and inexpensive way. Why don’t podiatrists use this method of marketing more frequently? Statistics show that the past patient base is one of your best means of increasing your office volume. Your old patients know and trust you. They do not represent a “cold market”. In fact, they are pleased to hear from you. Here are a few ways to engage in the process of marketing your practice base:

� Write a letter (usually in October) informing patients that they should make an appointment to see you before January 1 to avoid paying a deductible.

� Pick a year (i.e. – 1999) and call those patients who have not been in your office recently and ask how their feet are doing. You will be surprised at the number of people that will make an appointment.

� Send out an office newsletter. � Send a postcard with a brief description of new treatment methods to all patients

with a relevant diagnosis. The list is endless, so be creative. Have your staff place follow up calls to your patients that have received letters. Patients will appreciate your concern. How to be Your Own Best Referral Source Your best referral source is a better you. I don’t think it’s a coincidence that when I attend a podiatry reunion, it is the friendliest and most well respected students that are succeeding in practice. They had found true enjoyment in giving themselves to the profession, and it had provided them with more than adequate income in return. To attract more patients to your practice, you must consider what you have to offer your family, your community, your place of worship, your staff, and your patients. Don’t do this

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in an effort to increase your wealth or bolster your number of surgery patients, but out of generosity of spirit. If you have little experience in giving service, then this might be a bit more difficult. Start small; sit in your waiting room and look around. What could you do to make your patients and their families more comfortable? Are the chairs padded and easy rising? Is the music pleasant? Is the reading material current and interesting? Next, sit in your treatment room chair and look around. Think about what your patients see, hear, and feel. Are there shiny or sharp instruments lying on the counter, creating anxiety? Is your burr in a prominent location, making the patient think of dental work? Do you draw up injections in front of the patient, causing them to become fearful even before the needle stick? Spend time listening to what your staff members are telling your patients – both in person and on the telephone. Recently, a senior citizen was scheduled for knee surgery at the hospital and was told she must schedule her own pre-operative testing. Not only was this confusing to her, but many of our patients would not be capable of doing this. More importantly, this patient was not being provided with good service. The same is true of tedious insurance claims. Long before legislation made it mandatory for a doctor’s office to bill Medicare for elderly patients, our office provided this service. We had learned how confusing and difficult it was for many people to send in their own claims, especially to the secondary insurance company.

Once you’ve looked closely at developing a “patient-oriented” practice, then you can look outside the doors of your office. Do you volunteer for any charitable organizations? It isn’t enough to spend five minutes writing a check that will be deducted from your taxes. Donations are nice, but to volunteer your valuable time is an even more charitable effort.

One example would be to get involved with local scouting programs. These activities consume a great deal of time but they create many good memories for us. The experience also taught my children that service is an important aspect of living in this world. Some of our service activities included cleaning up parks, working at the recycling center, collecting canned goods for our local food pantry, playing with children with disabilities at a local preschool, and holiday carols at nursing homes in the area. There are many ways in which to service the profession, as well. Numerous podiatrists give freely of their time to help improve podiatry through such organizations as the APMA and state associations. Others volunteer their medical services nationally and internationally. These podiatrists are giving back to the profession, while actively working to make the world a better place. I feel certain that if you meet some of these individuals, you will find an interesting pattern. Each of these doctors is likely to have a full schedule of patients and more wealth than they need. The generous nature of these men and women simply attract patients to their practices.

When faced with a new patient, I encourage students to refrain from asking themselves question like, “How many x-rays, surgeries or other services can I provide to help pay off my student loans?” Instead ask, “How can I make this patient so satisfied with my care that they will tell all their friends and relatives?”

If you concentrate on money, you will likely never earn enough. But if you focus on the people you treat and not their insurance carrier, you will find yourself with a steady, growing income that will never falter – even when Medicare decides to drop reimbursements

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by 5.4%. Furthermore, you will have attained the respect, love, and admiration of your family, your community, and your staff. But most importantly, you’ll look in the mirror at the end of the day and feel truly satisfied with the podiatrist that you have become. A Cup of Honey Recently, I have taken on the responsibility of verifying patient benefits and obtaining referrals. I have discovered that this procedure does involve numerous phone calls to PCP offices, insurance companies and patients (sometimes all three) in order to finally get results. I quickly got caught up in the monotonous daily routine of making calls, battling the automated telephone systems, being put on hold, asking the questions prompted on the prepared form in front of me and practically begging for a decent response. Before long, I was sounding as painfully mundane as the person on the other end of the phone. That’s when I turned to an old cliché - “You catch more flies with honey than you do with vinegar”. I decided to try and turn this problem into an opportunity. I started using the operator’s name more often, smiling more during my conversation, and asking them how they were. I shared my unfamiliarity of the referral system with them, and basically made the call more personable. Before I knew it, I was getting far more cooperation than I expected and far more information than I asked for. Tasks that had once required several initial and follow up phone calls now only took one. The insurance operators and the referral coordinators in the PCP offices began bending over backwards to make sure that the data I received was sufficient. Many even provided me with their extension numbers for future personalized service, bypassing all automation. Besides receiving more comprehensive information with less effort, I’ve literally cut my telephone time in half and opened the door to developing valuable relationships with PCP offices. The ideas presented should be shared with any podiatrists in your office especially the staff members. Discuss the concepts which can be integrated into your practice and how they can be implemented. Two months later evaluate the return on investment, fiscally and time spent putting the idea into practice. Complacency has hurt many good practices and your best defense is offense. Take every opportunity to spread the word that podiatrists are the best at treating the lower extremity and your practice is the place to visit.

APMA Sports Literature

Unit Quan. Price Total

Exercise Walking & Your Feet (3003) ______ .30 ______

Fitness & Your Feet (3001) ______ .30 ______

“Your Podiatric Physician Talks About”Aging (Code 2001) ______ .37 ______Arthritis (2002) ______ .37 ______Athlete’s Foot (2003) ______ .37 ______Bunions (2030) ______ .37 ______Children’s Feet (2004) ______ .37 ______Diabetes (2005) ______ .37 ______Diabetes — Spanish Translation (2029) ______ .37 ______Diabetic Wound Care (2034) ______ .37 ______Diabetic Wound Care —

Spanish Translation (2035) ______ .37 ______Foot and Ankle Injuries (2006) ______ .37 ______Foot Health (2007) ______ .37 ______Footwear (2009) ______ .37 ______Forefoot Surgery (2008) ______ .37 ______Hammertoes (2032) ______ .37 ______Heel Pain (2010) ______ .37 ______Peripheral Arterial Disease (PAD) (2036) ______ .37 ______Nail Problems (2013) ______ .37 ______Neuromas (2033) ______ .37 ______On-the-Job Foot Health (2014) ______ .37 ______Orthotics (2015) ______ .37 ______Podiatric Medicine (2037) ______ .37 ______Rearfoot Surgery (2027) ______ .37 ______Walking (2016) ______ .37 ______Warts (2017) ______ .37 ______Plastic Rack with precounted

assortment of 300 pamphlets (2023) ______ $145 ______Plastic Rack Only (4010) ______ $45 ______Assortment Only (refill) (2021) ______ $100 ______

All prices are APMA member prices; nonmembers add 100%.

Subtotal______________

Shipping $5.00

TOTAL________________

� My check, payable to the American Podiatric Medical Association, is enclosed.

Credit card ($10 minimum) � Mastercard � Visa

Number_________________________________________Expires________

Signature ___________________________________________________

Ship to: Name ________________________________________________

Street Address ________________________________________________

City _______________________________________________________

State ____________________________________ Zip _______________

Mail to: Literature Section, American Podiatric Medical Association, 9312 Old Georgetown Road, Bethesda, Maryland 20814-1621

Or Call: 1-800-ASK-APMA, extension 277.

Inform YourPatients . . .Inform YourPatients . . .Inform Your CommunityWith APMA Patient-Education Brochures

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Winning the Physician Referral Game

With the increased saturation of managed care, the survival of a practice is often dependent upon physician referrals. These referrals have become the livelihood of many podiatric practices under various managed care models. Primary care physicians serve as the colloquial ‘gatekeeper’, necessitating the partial redirection of our marketing efforts from the patient to their primary care physician. Though most podiatric physicians feel beaten up by the current healthcare environment, managed care has opened the door for savvy specialists to significantly increase physician referrals. Surveys conducted amongst the medical community indicate that the most important considerations for a primary care physician when sending patients to a specialist are the nature of the relationship between the physician and the specialist, timeliness of feedback regarding the patient visit, and physician competence. To win the physician referral game you must impress upon them that you are cost effective and user friendly. But first you must get your foot in the door. We often become complacent in our relationships with the physicians who refer to our office. To further strengthen these relationships and make your presence known, have your staff contact the office managers of the primary care physicians and specialists in your area. Ask for an appointment, just five to ten minutes during lunch for a formal introduction or to say hello. This brief meeting is an opportunity to assert your commitment to providing quality care to their patients and should be followed up with a thank-you letter (Sample A). It’s important to bring the staff some token of your appreciation, such as gourmet cookies or desserts. You should also ask to leave some business cards. What has been proven to be very effective is a small pad of referral forms that physicians can use when sending a patient to your office. This should include your address, phone number, web site address and a map, as well as a line for the patients name and diagnosis. Another option is to include a checklist of the ten most common conditions treated by a podiatrist in addition to a space for other diagnoses. Another valuable tool is the “Lunch and Learn”. This is a program presented to the staff of a physician’s office in your community. Select a knowledgeable assistant with first-rate communication skills to contact the manager of the physician’s office. Your assistant should offer to bring lunch for the office staff to enjoy while listening to a short presentation. Lunch can be followed by dessert and a question and answer session about conditions that podiatrists commonly treat. Present the office staff with a professional packet that includes a laminated list of contracted insurance plans and physician ID numbers, a pad of referral forms, brochures on the training of a podiatrist and the conditions we treat (available from the APMA), a comprehensive booklet on foot injuries and surgery rolodex cards with foot and ankle care on the tabs and a brochure specific to your podiatric practice. Though the podiatrist can also attend these lunches, the office assistants might better relate to a member of your staff. The physicians can also be invited; they may prove to be interested and attentive. Limit the lunch to 30 to 45 minutes, after which your assistant thanks the office for their time. Have your assistant leave the staff with his or her own business card so that he or she may serve as a point of contact in your office. Consider giving that particular staff person the title of “Physician Liaison”. A handwritten card should be written to the office manager thanking them for the opportunity to meet with their staff. During the holidays, gifts to physicians and their assistants are a nice way to send a holiday greeting. Though chocolate and treats are appreciated, a gift that can be used year round serves as a marketing opportunity. A good option is to distribute tee shirts. Choose a

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catchy phrase, such as “We are the Sole Authority”, to be displayed on the front of the shirt. Make sure to include your name or that of your practice in small print. Contact nearby physicians offices and inquire as to the total number of doctors and assistants in the office. A box of gummy or chocolate feet in conjunction with the shirts will make a nice holiday basket. Have a member of your staff personally delivery the baskets to individual physicians offices so that additional introductions can be made. When a physician or a skilled medical professional of any specialty opens or joins a practice in your area, send an introduction letter along with one of your cards. Two referral sources that are often overlooked are chiropractors and physical therapists. Welcome them to the community and inform them of your office protocol. Indicate that a brief report will be sent to them when one of their patients consults you. Relate that a complete history and physical is taken at the initial visit and that they will be contacted if medical complaints have developed. Mention that you welcome an opportunity to meet with them in their office or for lunch. Offer to provide an in-service lunch for their office. Focus on biomechanics and its relationship to the entire lower extremity and spine as well as its relationship to the development of the most common foot and ankle complaints and deformities we treat. There is a significant opportunity for referral to your office, especially for biomechanical abnormalities and leg-length discrepancies. Once you have introduced your practice to medical community, you must maintain your relationship with its members. Communicating with referring physicians about the treatment of their patients is the most critical factor in building and maintaining a winning relationship. If patient reports are sent to physicians in a diligent manner, the bottom line of your practice will be positively affected. Referral plans mandate that a report be given to the referring physician before subsequent referrals are made. When a patient is referred and there’s no communication with the referring physician, or when a referred patient is treated without the knowledge of their physician, your relationship with the primary care physician can be adversely affected.

If podiatric referrals were not a part of their training, then it would be your responsibility to create a link between their office and yours. The timely receipt of patient report letters will help to acquaint primary care physicians, specialists and medical assistants with the scope of our profession and the professional way in which we conduct our practices. Most physicians prefer a concise report, whether it be dictated or in reporting form (see Sample B). Physicians are inundated with paperwork, and therefore not impressed with a three-page report that they do not have time to read. There are vital pieces of information that concern the referring physician, such as the chief complaint, diagnosis and treatment, including medications prescribed (see Sample C). Avoid podiatric jargon that is likely to be meaningless to the physician. If an established patient comes in with a new condition, another report should be generated. A report should be generated for every new patient, not just referred patients, with a modification to the letter as noted at the end of Sample C. An additional benefit of sending letters to physicians is that they will know the patient has been to your office. The physician will often ask the patient how their foot or ankle is feeling. The patient acts as a goodwill ambassador, as they express their satisfaction with your office. When surgery is performed, send the primary care physician a copy of the operative report along with a brief cover letter (see Sample D). The operative report is a valuable educational tool for several reasons. It informs the physician as to the nature of the treatment administered. If the report is well detailed, it informs physicians as to the

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surgical techniques and precautions that are employed by podiatric surgeons and puts you in concert with other surgeons. It is also important to forward a copy of any blood work and radiology tests performed outside the office to the referring and primary care physician. If there is a significant abnormality, call the physician personally to discuss the results. Do not have your assistant call and place the physician on hold, as it implies that you think your time more valuable. Making the call yourself shows your respect for the physician and your genuine concern for the patient’s well being. It also gives you the opportunity to develop a positive relationship with their receptionist, which further aids in referrals. Try to ensure that the referring physician receives all reports within 72 hours. Faxing your report is an efficient, cost-effective method of realizing this goal. Faxing reports is a more timely approach than sending mail. The letter can be faxed directly from the transcriptions’ office to avoid postal delays and charges. Furthermore, a fax is much easier to handle than a mailed letter. Faxing a report results in less effort on the part of the referring physician and a cost savings for your office. Tell your patient that a report concerning their progress is being sent to their physician to keep their medical file up to date. Most patients are appreciative and impressed that this is being done once they are made aware of it. On your new patient form include the statement, “As a service to you, we will send a report to your physician(s) about your foot problem and our treatment plan”. This is part of ensuring that your group’s patients and other customers are satisfied, and a satisfied patient will mean more referrals. Remember the 80/20 rule: 80 percent of patients come from 20 percent of referral sources. Let’s also not forget that gatekeepers must often choose one podiatrist for capitated plans, and they typically will select one with a good track record. Patience is a virtue when playing the referring physician game. When you begin to focus on physician referrals do not expect an immediate flood to ensue. Conduct an annual survey of physicians’ offices in order to solicit their comments and concerns. This shows that you recognize the importance of your relationship with them and respect their input. If there is an internal medicine or family practice residency program at your local hospital, offer to give a lecture on podiatric medicine and surgery. You might even suggest rotations in your office for medical residents to further understand the role of a podiatrist in the medical community. Credibility takes times to develop, but the repetitive nature of your efforts will score the goal.

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Sample A

Sample of Follow-up Thank You Letter

Date: Madison Tralka, MD 123 Main Street Garfield, Kansas 08817 Dear Dr. Tralka: Thank you for the opportunity to meet with you last week. Our office has been located on Route 9 in Howell for 12 years and my partner, Dr. Nancy Sullivan, and I are available to treat patients six days a week including three evenings. We participate in most managed care plans which are detailed in a list given to your staff. I am Board Certified in foot surgery and affiliated with Jersey Shore Medical Center, Brick Hospital, Kimball Medical Center and the Center for Special Surgery. We provide a wide range of services including general podiatric care, x-rays, custom made orthotic devices, hospital consultations and minor and reconstructive surgery performed in the office and hospital. I have a particular interest in diabetic and wound care. It is our policy to provide timely reports and updates for patients referred and when requested by your office, the patient will be seen the same day. Please let us know if we can provide you or your staff with any educational materials about the conditions we treat. I hope we have the opportunity to provide quality podiatric care to your patients. Professionally yours, Rosemary Drake-Brockman, DPM Note: For Pediatricians the second paragraph is modified to read: I am Board Certified in foot surgery and affiliated with Jersey Shore Medical Center, Brick Hospital, Kimball Medical Center and The Center for Special Surgery. We provide a wide range of Podopediatric services including treatment of orthopedic structural deformities, custom made functional orthotic devices, prescriptions for corrective shoe gear, splints such as Denis–Browne bars and general podiatric conditions including warts and ingrown nails. An area in our reception area is decorated and supplied with toys for children to feel welcome and comfortable.

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Sample B

Sample of Standard Reporting Form to Referring Physician

Date: Patient: Dear (referring physician): Thank you for referring the above reference patient to my office for podiatric care. Chief Complaint: _______________________________________________ Diagnosis: ____________________________________________________ ____________________________________________________ Medications Given: ____________________________________________ ____________________________________________ Treatment: ___________________________________________________ ___________________________________________________ I will be sure to keep you informed of the treatment of this patient. Professionally yours, Rosemary Drake-Brockman, DPM

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Sample C

Sample of Letter to Physician for Referred Patient

Date: Madison Tralka, MD 123 Main Street Garfield, Kansas 08817 RE: Jackson Cahill Dear Dr. Tralka: Thank you for referring Ms. Anna Love to my office for podiatric care. She was seen for an initial consultation on (date) with a chief complaint of right heel pain for five months. Diagnosis: Plantar calcaneal spur, bursitis and plantar fasciitis, right foot Medications given: Celebrex 200 mg, #30, one QD with no refills Treatment: Corticosteroid injection and strapping. Use of proper shoe gear discussed as well as use of custom made functional orthotic devices. RTO two weeks. Thank you once again for this most thoughtful referral and I will be sure to keep you advised of significant developments in this case. Professionally yours, Rosemary Drake-Brockman, DPM Note: For a non-referred patient the first paragraph is modified to read: I had the pleasure of treating a mutual patient, Mr. Jackson Cahill who was seen for an initial consultation on (date) with a chief complaint of right heel pain for five months.

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Sample D

Attached Sample of Letter of Operative Report to Primary Care Physician with

Operative Report Date: Madison Tralka, MD 123 Main Street Garfield, Kansas 08817 RE: Jackson Cahill Dear Dr. Tralka: Mr. Jackson Cahill had foot surgery performed at the Center for Special Surgery on (date). The procedure was performed utilizing local anesthesia with IV sedation and she tolerated the procedure well. I have enclosed a copy of the operative report for your records. I will be sure to keep you advised of any significant developments in this case Professionally yours, Rosemary Drake-Brockman, DPM enclosure

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Strategies for Internal Marketing of Your Practice Large corporations have directed their marketing efforts from customer retention to new customer development. As physicians, we often concentrate too much on marketing outside the office. As a result, we lose focus of our most powerful marketing opportunity: your patient’s overall experience in your office. When we consider marketing strategies for a medical practice it is important to distinguish between internal and external marketing. External marketing involves activities that are usually either print (newspaper, flyers, etc.) or electronic (radio, television and web site) that are disseminated to the community at-large. Internal marketing involves those processes that promote your practice through behavioral activities within the office. When the current managed care environment evolved, most practitioners recognized that the most effective means of marketing shifted from external to internal. Patients were no longer motivated towards a particular office due to visual advertisements, but rather other attributes, and mostly driven by primary care physicians. A great deal of goodwill may be acquired through meticulous attention to these activities. Ten examples of effective internal marketing: 1. Strengthening and exercising personal charisma (communication skills) 2. Professional and social interaction with primary care physicians 3. Timely follow-up phone calls to patients 4. Timely reports to primary care physicians 5. Written literature explaining the patient’s diagnosis 6. A practice brochure/business cards detailing your expertise and conditions treated 7. Maintaining availability 8. A recorded message for callers “on hold” 9. Maintaining a bright, cheerful attractive setting 10. And lastly, never feel intimidated to ask for referrals from very satisfied patients Internal marketing is a strong practice enhancement tool. It delivers a far more powerful punch than external marketing in our quest for highly motivated loyal patients. Its cost/benefit ratio is one that simply can’t be beat.

Some Time-Tested Internal Marketing Ideas Some of the earliest experiences I had with internal marketing were some of the simplest ideas. So simple, in fact, that we didn’t even use that term. The doctors I worked with at that time sent birthday cards to patients, especially to long-time patients and to those with “special” birthdays. Patients loved that remembrance, and we were amazed to hear that sometimes ours was the only card that they received. Suppliers have a variety of foot-themed cards or design your own using computer software. Holiday greeting cards are also very well-received. Of course we all receive greeting cards from the radiology groups and the DME suppliers who appreciate and want our continued referrals, but the ones we really appreciate are from those special patients who include us in their greeting card lists. Patients also put special value on the cards they receive from the doctor who cares enough to remember them.

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A dentist I went to for many years sent Thanksgiving greetings instead. He was also a poet and usually wrote his message in verse, printing it on paper with autumn images. He theorized that everyone celebrates Thanksgiving, and so everyone could appreciate his greeting. We always enjoyed his writings and looked forward to them. Postage is certainly a much greater consideration these days, but perhaps you could make up the difference by printing your own message on paper you have purchased in bulk. Or even by designing your own electronic cards and sending them by email to those patients whose email addresses you have. A small remembrance on a special occasion will assure that you are also remembered.

Be a Friend to Your Patients Isn’t it nice to get a phone call from a friend who just wants to catch up with you and see how you are doing? Most people will tell everyone they know about the special phone call they received for days to come. It will be no surprise to discover that this phenomenon can work with your patients and can become the cornerstone of a successful internal marketing effort. Your practice has a treasure trove of old patients who have been satisfied with the care that you have given. By simply inspecting your files it is obvious that many patients have been discharged with a good result and have received no further contact from your practice. The further back you go, the more patients will be part of this group. Why not get those records and call the patients? You do not need a particular reason to do so because you are just calling to say, “How are you?” What you can expect is that the patient will be surprised if not shocked that their podiatrist’s office is calling. This is perfectly normal. Continue the conversation for a minute. Let them know you haven’t seen them in a while and it is a courtesy call. By now the patient is impressed. The conversation may not even touch on a podiatric complaint, which is generally the case. Train your staff to make these calls and do it consistently by year the patients were seen. You will see a return of many of these “woodwork” patients in about 6 weeks.

Educate Your Patients About Your Practice

A brag book is another way to internally market a practice. This book will not only show your patients your accolades and accomplishments but it will show them your community involvement. Surprisingly, patients will ask the physician to volunteer at certain events. In our office, our many accolades are exhibited on our walls in the waiting area. We have many newspaper articles and journals of our involvement and contributions to our profession. For instance, one of our partners was honored by our hometown newspaper for his contribution of medical services at the World Trade Center site. Also, our brag book has many of the groups’ accomplishments such as board certifications and appointments in the community. Another associate in our group was a faculty member at a medical school and we tend to promote that appointment. This appointment gives the patient a feeling that she is with a specialist and that patient will tell other potential patients about the scholarly attainments of our group.

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As patients read these achievements, our group has been asked to participate in lectures and health fairs. We have many certificates of appreciation and many patients can relate to your community involvement because they contribute or belong to the same organization. Moreover, this generated a new patient base and revenue. This newly generated patient base also leads to many patient referrals. A brag book is one of the best ways to internally market the practice. In conclusion, this “special book” can be an invaluable tool for the new practitioner.

There’s No Place Like Home A home-like atmosphere is another aspect of internally marketing your practice. It will take me a book to explain how many patients say our office is “so comfortable” or “your office is a great place to hang out.” However, it must be professional. Lighting is critical in our office and we have plenty of windows to allow natural light and fluorescent light in the office. Lighting changes the mood of most people and we feel that this factor exemplifies happiness. Our group is constantly checking lighting for our staffs’ area and patients’ area and we take pride in our lighting. It is nothing more satisfying than seeing a patient worried and leaving our office commenting on our bright and cheery treatment rooms. We use fresh flowers in our treatment rooms and this reveals freshness in our office. Patients enjoy this and they feel we are compassionate and we pay attention to detail. They realize that we not only care about them but we care about other things other than medicine and this gives the patient a “homey” feeling about our office. Again, this is a conversation piece and can lead to patient referrals. Patients always comment on our office environment and we get many referrals from patients who say how home-like our setting is in our office. Comfortable, home-like environment will always bring patients to your office. This aspect will keep patients coming to your office and generate new patients.

In-Office Dispensing for Patient and Profit Building

In-office dispensing is an effective way to increase your bottom line with a variety of fee-for-service and insurance-reimbursed products. The number of podiatric physicians who dispense is growing rapidly and this is true in allopathic/osteopathic medicine as well. The benefits of dispensing are financially obvious but are eclipsed by improved patient compliance, time savings and overall satisfaction. For more information read the APMSA New Practitioner’s Guide section “Durable Medical Equipment and Orthotics”.

We Have Two Ears and One Mouth for a Reason Listening is one of the most important skills necessary to help us hit a home run with patient satisfaction. That is why we have two ears and one mouth. There is a significant cost for correcting errors resulting from poor listening skills. There are several benefits of listening for your practice:

� Listen to others and they will listen to you � Learn more and with greater accuracy � Gain each other’s trust � Improved employee retention and satisfaction � Reduce mistakes

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Patients have come to expect that doctors and staff are poor listeners. Focus on listening skills throughout your office is an excellent opportunity to provide exceptional customer service. Listen with your ears, eyes and heart. Information can easily be dispensed through literature, however, it is the complex and multi-sensory human quality, once again, that allows people the unique ability to “communicate.” How can we communicate to the patient the information they need to know in a way they are assured of understanding? Ask yourself how you would feel in their situation. It is important to always put yourself in their shoes and help them understand what it is that you are trying to relate in the clearest, most sensible way. Start by taking your most frequent discussions (the overly explained referral process, an explanation of benefits, various office policies, etiology of common disorders, reasons for appointment schedule delays, etc.) and dissect them to determine if they can be misinterpreted in any way and then “can” them in such a way that every response is clear and concise.

Do You See Enough Kids? Pediatricians are busy and looking for ways to serve their patients more efficiently. Their schedules are full of croup, fever, flu and yes, foot pathology. The opportunity to cultivate podiatric pediatric referrals is present in every pediatric practice nationwide. Here are some simple techniques you can employ to have a thriving pediatric referral network. First, decide exactly what it is that you can treat well that is commonly seen in a pediatric practice. Almost every podiatrist can treat verruca, ingrown nails and pronation. Many pediatricians have neither the time nor the desire to treat these problems. You can expand into pediatric heel pain, apophysitis, in-toeing and sports injuries. The key is to market your skills effectively to the pediatric gatekeeper. Start your marketing effort with a visit to a local pediatric practice or a pediatrician that you may know. Go just before lunch at the end of the first session of patients, as it is likely that you will catch the doctors and nurses available. Physicians are almost always brought back to the doctor’s office and promptly seen unlike sales people. We always offer an in-service to the staff on children’s foot pathology. Focus on the pre-determined pathology that you will be treating. Ask for referrals. Before leaving, an in-service is scheduled and we leave our office info card (a business envelope sized card with a picture of the doctors, what conditions we treat, our location and directional maps) Tell the pediatrician that you will see their patients promptly and handle any emergencies immediately. When the pediatrician calls for you to see one of his/her patients right away, offer to immediately do so before being asked. I assure you it will not go unnoticed. You will see more patients and soon you will see their partner’s patients. Keep in mind that when a child is sick or in pain that the parents become worried and apprehensive. Prompt appointments help the patient, the parents, the referring doctor and ultimately your practice. Communication with the patient must be in their terms and age appropriate. I always explain what is going to happen to the parents and then to the child and ask if everyone understands. If the treatment will hurt, be honest with the child without creating fear. At the end of the visit all appreciate a reward (sticker, trinket or Gummy Feet). Quick Tip – When your patient is being treated for verucca, discuss the contagious nature of warts with anyone else in the treatment room. Give them a free screening on the spot and encourage the rest of the family to come in for the same on future visits. You will find more warts and schedule them as patients as a result of your diligence!

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Reducing Waiting Time Through Efficiency

Here are some ideas on how to “open” your schedule just enough to see a few more patients daily. First and foremost, start on time. Have your assistant bring back your first patient five to seven minutes before the first scheduled appointment so the assistant can help the patient remove their shoes and converse appropriately and then get the chart back to you. Another time saver is for you to go through your charts before the day begins. Write a daily schedule which takes about an hour. Next to each patient’s name include a treatment plan along with any instructions for x-rays, taping, injection, orthotic casting, surgical redressing, etc. By familiarizing yourself with patient’s charts and setting a daily plans for the day you may actually see three to six more patients. Pre-fill all injections at the beginning of the day. Pre-make “orthotic casting kits” with a pair of gloves, six strips of plaster, a splatter sheet and the orthotic order form. Doing this step will allow you to see another patient or two. Also, pre-cut or order ready-made padding. These few ideas allow you to see seven to 11 more patients a day. You do the money math.

Barry University ½ page b/w Via email

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The Essentials of Web Site Marketing Contributed by: Officite

With over 100,000 internet searches for podiatrists being conducted every month, having a customized web site is now an essential element of your marketing campaign. However, before you or a friend try to tackle this task, it is important to understand the critical elements of a strong web presence and why you should integrate your new web site into all of your marketing vehicles. You should also strongly consider hiring a firm that specializes in developing and hosting customized medical web sites, so you can focus your time and energy on your new patients and practice. Your web site is more than an electronic phone book ad Designed correctly, your web site can attract new patients, educate your existing patients, improve office efficiency, and differentiate your practice from other podiatrists in your area. However, in order for your web site to attract new patients, it must be optimized for the search engines, especially with the latest changes in Google’s local search algorithms. This allows Google, Yahoo and the other major search engines to find your site and list it high in the search engine results for local search queries. Once potential new patients find your site, it needs to contain the necessary information to persuade them to schedule an appointment. To accomplish this, your web site should include: a welcome statement, credentials and pictures of the doctor(s), facts and pictures of the staff and office, dynamic directions with a map of the office location, ability to e-mail the office with questions, online forms, newsletters, hundreds of pages of podiatry-specific content (so your patients can learn about new procedures, treatments, understand terminology and read up on relevant medical issues), and case studies so you can promote services and products offered by the practice and most importantly the ability to request (or book) an appointment online. Your web site is the core of your marketing campaign Leveraged properly your web site can work much harder than any other marketing vehicle. At the same time, it can make all of your other marketing vehicles work that much harder. Once your web site is operational, make sure you incorporate your www.practicename.com (called URL) into all of your other marketing vehicles, including brochures for health fairs and referrals, phone book ad, local newspaper and magazine ads, newsletters, on-hold message, signage, radio, TV and especially HMO/insurance listings. This will set your practice apart from others and encourage new and existing patients to visit your site for additional information. What to look for in a web site and online marketing partner Just as choosing the right location for your practice is vital to your success, choosing the right web site and Internet marketing company is critical to the ease and effectiveness of your web site and online presence. As you look for a partner, you should consider a firm who in addition to the above will provide:

� A turn key program � A quick turn around � Flexibility to customize the site � Inclusion of images, email addresses and on-line forms � Hosting, email, and ongoing site maintenance at a reasonable cost

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The New Patient Website People

A New WEBSITE Equals NEW PATIENTS

“3,053 new patients!”Greg Renton, Orlando, FL

“1,278 new patients!”Robert J. Abrams, DPM, FACFAS, Newhall, CA

“962 new patients!”Mitchell Waskin, DPM, FACFAS, Richmond, VA

877.484.7185www.dpmwebsites.com Websites starting at

$995

We Can Manage Your Entire Digital

Presence� Customizable Websites� Advanced SEO� Pay Per Click Advertising� Social Networking� Blog Management� Google Place Search Optimization� Patient Reviews Management

Reviews

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� Exclusive look and feel that reflects your style and philosophies The firm should also have a team of search specialists who understand search engines, keep abreast of industry changes, and have a fully staffed organization which promptly answers the phone and your questions. In addition, the firm should have a proven track record designing podiatry web sites. In summary, a comprehensive, fully functioning, integrated web site and comprehensive search marketing strategy will help propel your practice and set your office apart from other podiatrists. Choosing the right design partner is the first step in the process. Once your site is up and running, your patients (current and new) and staff will thank you. Officite ½ page B/W Email

VI.Establishingand Buyinga Practice

Congratulations on your accomplishments!

Columbia Foot and Ankle Associates

Stephen D. Palmer, DPMRoss E. Taubman, DPM

Congratulations!�e best is yet to come!

Phillip E. Ward, DPMPinehurst, NC

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Financing a Podiatric Practice Upon completion of your postgraduate training, the first thing on your mind will be beginning your practice. You’ve worked through the possible practice options. If you’ve chosen to open your own office, the next obstacle will be financing your practice. Banks will lend you money to handle your practice option choice and to cover your other associated costs and living expenses. Assess your needs and borrow only what is necessary and consider consolidating your debt. How do I get into a situation where I don’t bear the entire financial and managerial role myself? There are several options. First, you find a trusted partner, establish a sound business plan, and apply for a loan to start a practice. This way, you share the financial and managerial burdens while having the option to practice as a group. Another option involves pursuing an associate position offered by a practicing doctor. This has several advantages. You will enter an established practice with an instant patient base. Generally you do not have to be concerned with practice management decisions and you leave the office without the added responsibilities. However, your boss has an expectation that you will generate substantial income for the practice. The money that you generate goes to the practice and your salary is predetermined, usually regardless of what you generate for the practice. If you are not prepared for this disparity in earning potential and actual income, it can be a disquieting realization that you are making 50% of what you could be were you working for yourself. Fortunately, if the boss determines that the associate is beneficial to the practice, most associates are offered the opportunity to become a partner. Partners share the financial and managerial burdens of the practice, but they also share the financial rewards. Becoming a partner is similar to making a business investment or buying your own business. Your willingness to pay a percentage of the practice value ensures the owner that your are committed to your new role as co-owner. Both of you will benefit from this new relationship. The owner will receive a lump sum payment from your lender and also enjoys more time away from the practice for which he/she surrenders part ownership of the practice. Immediately you share in the profits but also gain a bank loan and managerial responsibilities. Another practice option which necessitates financing is the purchase of an established practice. This scenario involves a considerably larger amount of money to take full ownership rather than buying only a percentage of the practice. However, you will have a fair assessment value of the practice, immediate cash flow since the accounts receivables are yours and a “guaranteed” patient base. The practice buyout route has relatively flexible financing options and seller participation. Now that we have discussed some of the options for financing a practice, let’s consider the actual task of financing. Most banks are willing to lend money but you will need more than a smile and a clean suit. Banks want to know that they have a sound investment in you and your practice. Most banks have their own loan application process, but they are generally looking for the same things. They want to get to know you, your profession, and your potential for success. After reading this section, you will have the necessary tools to succeed.

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Five Common Myths of New Practitioners

Along the course of our podiatric education and post-graduate training we experience information overload. It is difficult to sort out the truths, fallacies and myths. Our forged beliefs which develop over this period of time are what builds the foundation of our professional life in practice. The myths we believe as a new practitioner can limit our potential and create much frustration as we begin our careers. Myth #1 – There is little potential to make significant money in podiatry with the current healthcare environment. The days of hanging a sign outside your office and having patients walk through your door are over. Darwinism now rules in medicine especially with podiatry because of the public’s general lack of knowledge of what we do. The concept of survival of the fittest now applies and has resulted in more high and low income practices with less in the middle. As new practitioners you each have the opportunity to “be fit” and end up with a thriving practice. You are the best medically and surgically trained group of podiatrists our profession has seen. This is an important piece of the puzzle but many more pieces must be coupled to achieve success. The students and residents who spend the time to learn as much as possible about practice and people management have consistently been the colleagues with the largest, most profitable practices who articulate how much they enjoy the practice of podiatry. Some tips to gain practice and people management skills while a student and resident include:

� Spend as much time as possible in multiple podiatrists’ offices. Don’t just spend time with the doctor but also a significant amount of time at the front desk and billing office if the doctor allows.

� Take a training class on sales at local college or business school training. � Read all articles on practice management and coding. � Attend any practice management track or lectures at meetings. � Attend assistant’s tracks at meetings you attend. There is a wealth of information

here and will be an eye opener. � Read books and articles on customer service as well as leadership. Many of these

are also available on tape and CD so you can listen in the car.

Myth #2 – You can no longer succeed by starting a new practice just out of residency. Years ago opening your own practice just out of your post-graduate training program was more realistic for many. But by no means are the days of starting a solo practice over. We continue to mentor many new practitioners who open practices in as we hear “saturated areas” and quickly thrive. Some have returned to open an office near their families and others to researched growing areas with high potential for growth. But the common trait among these new practitioners was the core desire to succeed. These individuals have a sense of what it will take to realize those desires, and are willing to pay the price and prepare themselves for achievement.

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These individuals have positioned themselves for success by being proactive during podiatry school and in their residency and understanding that “knowledge is power.” Myth #1 above discusses several ways to gain the knowledge that is critical for “starting from scratch.” They spent the time to learn such things as coding and billing, internal and external marketing, staff relations, office technology, designing an office and patient relations. There are several forces which make starting a new practice more challenging. Managed care plans have limited access to patients through restricting the number of specialists in an area. It is the savvy practitioner who prospers by aggressively and continually working to be included in insurance plans but even more importantly markets themselves to the population which has open access to anyone they choose such as patients with Medicare. A simple way to learn about the insurance plans in your area is to ask your local hospital and physical therapy and radiology groups for their lists and contacts. The frustrations relating to financing can be minimized by forging relationships with the small community banks in you locale. Your strength is in the loan proposal you present. Starting a new solo practice is not for everyone. Working as an associate will be the most practical approach for many. The overriding fear of risk many envision to enter a solo practice places them in a more comfortable position as an associate. This security is necessary for many practitioners where they can benefit from the strength of a group practice. Consider the first couple years as an associate in private practice as a “fellowship in practice management” to learn patient and office management. This may be the stepping stone to best prepare for solo practice and by learning the necessary skills to build a strong, healthy practice. Myth #3 – The patient is #1. The adage that “the customer is #1” is one of the service rules we have learned about customer service. But the wisest in business will soon realize that the most valuable asset and key to success and sanity is our staff. Measure success not only by rapport with patients, but also through the doctor-assistant relationship. Your success, both financially and professionally, is exponentially related to your assistants. A common quandary we see with new practitioners is putting themselves above their staff. In most cases the staff has been there several years and directly responsible for building and increasing efficiency in the office. The new doctor joins the group and attempts to define their territory by alienating themselves from the staff instead of bridging the relationship. Several seasoned practitioners have the scars we acquired from not knowing early on the utter respect and appreciation we must show for our employees. Even more important than your staff’s salary is your appreciation articulated daily with a simple “thank you” and finding them doing something “right”. The primary goal in our practices is to meet and then exceed patient expectations. With the focus being directed on the needs of the patient, office titles have become unimportant. Doctors and staff alike have discovered unimaginable satisfaction by helping patients feel better. We would speak regularly at office meetings about turning the attention away from ourselves and thinking only about how our actions can improve the overall care that each patient was receiving in the office. At the end of each day, we all feel more fulfilled and return the next morning refreshed and excited to face new challenges. The greatest lesson in working with assistants is that, in working toward a winning team is that the momentum must start at the top. Our role as the doctor is to coach our team and

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lead by example. In coaching our team we have learned that our attitudes are contagious and set the tone of the workplace. Through open communication and especially listening to one another, the office continues to learn from each other and grow together. Myth #4 – I’m just getting started and still paying off my debts. I couldn’t possibly afford to hire staff NOW! On the contrary, you can’t afford NOT to! Patients do not care about your debt. Perhaps your financial situation may have you “strapped” right now (and for what it’s worth, some patients may even recognize that), but when weighed against the amount of money you will conceivably make as a doctor they feel justified withholding any sympathy for your current situation. Realize, of course, that to most of your patients (and the general public) everything is relative and by comparison, your debt is insignificant to their own financial woes. Add that to the reality that physically sitting in your office 24/7 (so you don’t miss a call) and doing everything yourself is not only a waste of your time but it actually sends out negative inferences, such as:

� You are desperate for patients and will “hook” anyone that comes through the door. � You are too cheap to hire someone and diminish your efficiency for perceived

increased revenue. � You must be impossible because apparently no one wants to work for you. � Your practice is unprofessional.

Your professional image is important, and throughout your entire career protecting this should always be one of your top priorities. Right now, in the early stages of your practice, you have the opportunity to mold this image which, in turn, will generate not only referrals but also integrity and respect. Always, think and do what’s in the best interest your practice. This is a very impressionable time for your patients. They literally observe (and judge) everything you do, so while you are in a position to make a powerful impression. Train staff to answer the phone, greet patients with a friendly “hello,” make their appointment, address their questions and have a strong presence in your office. If it’s the right staff person, expect both your credibility (and your pocketbook) to benefit. But remember to keep things in perspective. You won’t need to hire a full-time (or high-salaried) employee right at the start; however, you may want to consider a personable relative or friend who is motivated to help you get the practice up and running. Or consider a part-time student who is looking to initiate a new career. Later, when you get busier, you will want to get a full-time employee (or move your part timer into a full time position) and have her/him contribute more to the growth and efficiency of the practice. So, don’t make a habit of answering your own phones, save that “typical” recorded message for after hours and put the “hook” away (try not to appear so eager). Personalize your practice and hire someone you can trust to manage your practice. Feel confident that in doing this, you will be taking a positive step towards setting a positive professional image for your new and exciting practice. Myth #5 – I'll never find the time to market my practice! I'll need to spend every minute at my office so I don’t miss any potential patients. “If you build it, they will come.” That is one of my favorite lines from a movie entitled ‘Field of Dreams’ and it was the incentive that encouraged the main character to follow through with his far-fetched “plan” to build a ballpark. It may have seemed a bit overwhelming when he started, but he believed in it and worked hard to make it a reality.

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That formula can be as worthwhile for you as it was for him with one slight difference, he was building a ballpark and you’re building a practice. The similarity however, lies in the fact that he didn’t accomplish what he did by sitting at home, waiting for it to build itself. Neither does building your practice mean staying glued to your office waiting for patients to knock your door down. If handled correctly, the notion that patients will go elsewhere is a huge misconception. Do what you can to schedule your time wisely at the office and understand that waiting for the phone to ring is a waste of time. From a scheduling standpoint, try to position appointments as close to each other as possible. This serves two purposes. First, it is likely your patients may run into each other and will give the impression that your office is crowded….or at least seemingly busy! Second, with all your patients scheduled back to back, you now have very shrewdly made some quality “marketing” time for yourself. Set a realistic goal that you will spend at least one hour a day visiting one new place. Get out and meet as many new people as you can in the neighborhood. Now is not the time to be shy. Schedule visits to schools, AARP meetings, nursing homes, sports clubs and other doctor’s offices. Stop in at the hospital cafeterias and introduce yourself to staff, colleagues and other healthcare professionals. The more that people see you, the more they will start to recognize you as the “foot doctor.” If you are serious about building your practice and are willing to put that extra effort into effective, proven marketing tools, things will start to happen around you, whether you are physically there or not. Remember, “If you build it...they will come.”

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The How, When, Where and Why of Associates and Buy-Ins John V. Guiliana, DPM, MS

Mike Crosby, MBA Associate yourself with people of good quality if you esteem your own reputation, for 'tis better to be alone than in bad company. --George Washington Over the past decade, the changing economic environment has resulted in a shift in the podiatry labor market. As recently as the early 1990s, the majority of podiatric students aspired to develop and manage their own practice. The more recent challenges associated with obtaining managed care contracts, as well as the managerial burden involved therein, now have many students leaning toward an associateship. While more students are entering the workforce, eager to associate with an experienced practitioner, many senior practitioners are appropriately “reading the writing on the wall” and searching for an associate and future buyer. This synergistic environment has sparked an acute interest in the “how, when, where and why” regarding associateships and buy-ins. The Timing While the mechanism behind finding the right associate for your practice may be similar to any other employee interview, there are important fundamental differences that must be explored. Hiring an associate is a major investment. The objective as well as the timing of such an investment should be carefully analyzed. Are you hiring an associate with the aim of taking more time off, or are you interested in achieving some form of practice enhancement (improved volume, diverse procedural capabilities, etc.)? The following is a list of questions that should be addressed.

� What credentials should the associate have in order to obtain your goal? � If the associate is expected to raise the overall patient visit volume, what will this do

to the practice’s total expenses? � At what patient volume level is your practice’s profit margin optimal? � Is your office infrastructure efficient enough to handle additional patients? � Is the community in which you practice conducive to growth? � Are you prepared to manage another physician or perhaps even lose some

autonomy? The Search Finding a potential associate often demands the use of outside resources. Podiatry journals or the numerous on-line resources are a great place to start. There are also private management companies available that assist in finding a qualified candidate. Be sure that the prospective associate knows the intent of your hire. Frustrations associated with the frequently “disappearing” senior partner can easily be avoided if the associate expects this up-front. Goals and objectives for the associateship should be explored during the interview process. While the significance of medical training can not be overlooked, the candidate’s “people skills” should also be assessed. Creating mock situations during the interview is often helpful in evaluating this skill. Attempt to find a candidate who matches the corporate culture that your office provides. Corporate culture includes the personality and philosophy of your office. Assessing the

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candidate within a social environment may assist in this endeavor. Here are some questions that need attention during this process.

� Does the candidate share a similar philosophy regarding patient care? � Is the candidate willing and capable of carrying out your objectives? � Is the candidate comfortable living and working within your community?

The Investment Aside from your support staff, hiring an associate will likely be one of the largest investments that you will make in your practice. It should be treated as such. While the “get what you pay for” proverb may not be completely applicable in this regard, fair business policies and adequate compensation methods are critical for a productive relationship. Geographical variations of salary exist. That notwithstanding, there are three basic methods of associate compensation:

� Pure salary � Pure percentage of production (based on percentage of income)

*obtain legal advice to be certain that anti-kick back laws are not violated � Salary plus incentive

Solely providing an associate with a pre-determined salary is an employer-weighted risk. It is difficult to ascertain in advance if the associate will generate enough revenue to warrant this compensation. In the pure percentage of production model, the associate is taking more of the risk. He or she is not able to predict if the patient volume will shift or increase. In the salary-plus-incentive model, both the employer as well as the associate shares the risk. In this compensation package, the associate is paid a nominal base salary and is awarded a bonus after a preset threshold of income is generated. The threshold should be set at approximately three times the base salary. For example, if the base salary is $40,000 per year, the threshold at which the associate is rewarded a bonus begins at $120,000 of generated practice income. A percentage (usually 15-25%) of each dollar above $120,000 is provided as a bonus and may be calculated and paid monthly or quarterly. This is generally the compensation model of choice. It provides and necessitates continual feedback as well as an associate’s active participation in the financial state of the practice. Aside from salary and bonuses, there are other aspects of the compensation package that may be discussed and negotiated. Some of these are listed below.

� Vacations � Malpractice insurance � Health insurance � Disability insurance � CME allowances � Dues and subscriptions � Auto/gas allowances � Fees for Licenses and Boards, Managed Care Privileges and Hospital applications

The Contract Associates should be required to sign a contract of employment. By neglecting to draw up a written agreement, the employer places the arrangement in serious violation of state and federal regulations, and creates employment law conflicts for both parties. The contract

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should be designed to protect both parties, and should be prepared by a qualified legal consultant. The following is a list of sections that the contract should address.

� Employment duties and performance � Terms of employment � Compensation package (Base and incentive) � Issues regarding maintenance of working facilities � Death/Disability/Worker’s compensation � Malpractice Insurance � Issues pertaining to ownership of medical records � Covenant not to compete / not to solicit � Termination clauses

The contract should be as clear as possible. The expected duties and responsibilities of the associate must be detailed. Covenants should be reasonable if they will be expected to hold up in court. As an example, a reasonable restrictive covenant will preclude the associate from practicing podiatry during employment as well as after termination from employ, within a radius of 10 miles of all offices for a period of three years. A covenant will vary according to the population density. Liquidated damages may also be discussed in the contract, should the associate breech this covenant. (You should consult your legal counsel as to the specific parameters that are usual and customary in your state.) The Responsibility Once the associate is chosen and the contract is signed, both parties must assume some responsibilities. The senior practitioner should tirelessly introduce the associate to patients as well as physicians, expounding upon his/her credentials. Established practice protocols should be reviewed and mutually agreed upon in order to ensure that both practitioners essentially “practice as one”. The dialog and terms used in the presentation of pathologies and etiologies, as well as the actual delivery of care should be consistent. The office staff should be educated regarding the associate’s role. For a variety of reasons, staff members are often initially reluctant to schedule patients for a new associate. The precise verbiage to use with patients should be selected and discussed with the staff. The senior partner has an obligation to provide clear and consistent feedback to the new associate. Criticize constructively and privately, yet praise loudly and publicly. Allowing the associate to participate in management decisions gives him/her a sense of empowerment. Setting quarterly financial goals facilitates the associate’s “aim” and improves productivity. Since trust is a critical ingredient for a long-term relationship, an “open book” policy is the only effective way to manage the finances of the practice. The Buy-In Whether by an established or new associate, the foundation of a buy-in relies upon evaluation of the practice’s worth. Since many associates feel that they have substantially contributed to the growth of the practice, it is crucial to obtain a qualified appraisal of the practice as early as possible in the relationship. However, should this not occur, an alternative would be to agree upon a date of valuation, generally the date of hire. If this issue is neglected, an associate may feel as though they are buying into their own hard-earned achievements.

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A practice is generally worth the sum of its tangible and intangible assets. The tangible assets are those items that can be “touched” such as equipment, furniture, supplies, etc. The sole intangible asset of a medical practice is “goodwill”. In a medical practice, there are many components that contribute to this value. While the tangible assets are usually fairly easy to value using current market prices, the intangible assets can be difficult to quantify. Knowing a practice’s factors of production helps. The factors of production include such things as the net collection ratio, visit volume, payer mix, cash flow, effectiveness of the management, infrastructure, new patient flow, existing reputation of the practice, and the market share the practice commands. These statistics often help quantify what we often can only qualify. In summary, a podiatric practice is worth somewhere between one year’s gross and one year’s owner’s compensation. An experienced and qualified medical practice appraiser should be used for the valuation. The Information The seller is expected to disclose all clinical and financial information necessary for the buyer to evaluate his or her risk. The information that may be considered material to the transaction includes, but is not limited to:

� Financial statements � Tax records � Bank statements � Debts of the practice (Both recorded and unrecorded) � Patient payment records � Patient medical records � Information regarding any past, present or potential legal actions � Documentation of compliance with all regulatory agencies � Key managed care contracts � Any special employment arrangements (i.e. family members on the payroll) � Leases for real estate and/or business equipment

Prior to the disclosure of the above information, the buyer should sign a document of confidentiality. The purpose of this document is to ensure that the information obtained is protected from becoming public and exposing the owner to unnecessary public scrutiny. The Negotiation In any buy-in or practice merger, there are three issues that must be negotiated. They are:

� The price and the terms of the sale. � The terms of the employment of the physicians as well as how income will be

distributed. � Determining how decisions will be made (governance).

The price of the buy-in and its terms are usually inversely related. Do you want a better price or more favorable terms? Parties negotiating the statement of key issues at the beginning of the process can not only enhance the process by identifying key issues (price vs. terms); they also make the process significantly shorter. Associates must have an understanding for the emotional state of the proprietor, and likewise the owner must help the associate to appreciate the opportunity being offered and its long-term benefits. Further, the needs of all parties should be considered, from both a cash flow as well as tax position. Both parties must understand that the goal is to develop a long term working

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relationship - one that fosters practice growth and enhancement. Preferably, the buyer should be permitted to pay down at least some of the debt with pretax dollars. This may be accomplished by structuring a compensation plan with a compensation differential. A lower compensation is provided to the buyer and the differential is applied to the debt on a pre-tax basis. However, care should be taken to ensure that the employment documents and other agreements adequately reflect the intent of the plan, its timing and full implementation. Critical to the long-term success of a multi-physician practice is the concept of governance. Governance is all about balance in the daily operation and decision-making process of the practice. While the managing partner has the responsibility of prioritizing corporate goals and objectives, he/she must maintain a subtle balance between those goals and supporting the other physicians’ autonomy. Experience, fairness, a keen business insight and a rational decision making strategy are important characteristics of a successful managing partner. During negotiation, it is important that each party clearly states their needs and priorities. The seller’s needs may include:

� Income security � More free time � Improved procedural capabilities � Cash

The buyer’s needs may consist of:

� Participation in contracts � Cost containment (economy of scales) � Freedom from management � Increase market share

The rationale for listing as well as ranking these needs should be clear. Both parties should strive to meet the needs of the other, in order to facilitate the process. The Consequences Every transaction has its good and bad consequences. The good consequences are those that allow the arrangement to last indefinitely, and the bad consequences are those that prevent the arrangement from flourishing. These consequences should be anticipated in advance of the buy-in. Therefore, the documents should not only outline the coming together, but also the process for dissolution of the merger. In the event of a break-up, this will reduce the potential for chaos. Here are some factors to consider:

� Will all providers have a balanced incentive to perform? Senior practitioners, particularly those with a priority of more time off, are often accused of “retirement on the job”.

� What if reimbursement patterns should change or reduce? Are you banking on the current economy for long term success?

� How might a new partner affect referral patterns? � How might competitors respond? Will the transaction invite new competition? � What will happen if the relationship does not work? Are there provisions and break

up clauses to protect each party? � What are the possible consequences of not taking in a partner or an associate? Will

the competition move in this strategic direction in order to gain market share?

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� How will future growth be borne only by the associate? � Can we easily follow the cash? � Does the arrangement promote cooperation and trust? � Is risk clearly outlined?

The Legalities Practice transactions require a comprehensive review of the circumstances by a qualified healthcare attorney. Antitrust laws, federal anti-kickback laws, including the Stark Self-Referral Restrictions, are all beyond the comprehension of most buyers and sellers. A healthcare attorney will help to navigate the tumultuous waters, and his importance cannot be overemphasized. Aside from federal regulations, particular protective covenants should be discussed and agreed upon. The protective covenants for the buyer may include:

� Full disclosure of all financial information � Indemnification from prior acts. (“Tail Coverage”) � Maintenance of license, insurability and privileges of the seller (if the seller is to

remain an employee of the practice). � Full effort of selling physician (if remaining an employee) � Production standards designed to promote full effort. � Covenant not to compete or solicit patients. � Termination clause and notice required upon termination. � Assets transferred free and clear of any liabilities or full disclosure of any related

liens. The protective covenants for the seller may include:

� Timely payment � Certain amount of autonomy for patient care delivery. � Time-limited clause to back out of the sale should seller’s discretion change. � Termination clause and notice required upon termination. � Covenant not to compete or solicit patients. � Full disclosure and warranties as to performance.

The Process One of the most critical factors is for both parties to set realistic expectations regarding the process. The process of finding a partner takes significant time. The first try is often unsuccessful. Secondly, to find the right partner/ associate to negotiate takes patience. The associate may believe that he or she has the ability to negotiate a deal without professional assistance. While it may seem easy, the reality is that this process takes at least four to six months. Finally, both parties must evaluate the impact of the negotiations on their long-term relationship and their ability to work together. The process is complex, time consuming, and requires professional assistance. We recommend engaging professionals, developing a strategy, and following a plan in order to achieve a successful end result.

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Factors to Consider in Compensating a New Associate

How much should you pay an associate? The answer is almost always the same—“it depends.” The compensation of a new associate depends upon a number of economic, personal and geographic factors. Since the geographical location often affects salary issues, you should be aware of the variations that exist. This factor is usually well understood by most associates and employers. Starting with the economic factors that you need to consider, each practice is a unique entity, complete with its own set of financial data. Obviously, paying an associate 50% of their individual receipts may be acceptable for a practice with a 30% overhead, but it is not feasible for a practice with a 75% overhead. For this reason, it is necessary to become very familiar with the important financial data of your practice before trying to establish a fair salary for a new associate. It is important that you predict the profit (or loss) that a new associate will bring to your practice. This is accomplished through the examination of some important data. Start by determining your average revenue/patient ratio. Divide your collected receipts for a given period (i.e., 2008) by the total number of patients seen in that time period. You must also calculate your total costs/patient ratio by dividing your operating costs (minus your salary/perks), by the total number of patients seen in that time period. Once you have these figures, you must factor in your personal considerations with regards to your new hire. What are the duties and responsibilities of this associate according to the contract, and what purpose are they to serve in your employment? Are you hiring an associate to allow you more free time, or is their function to promote themselves and increase volume for your practice? If they will be increasing patient volume, you need to be able to estimate the cost per patient that you will incur as a result. To do this, you need to differentiate between your fixed expenses and your variable expenses for a given time period. Any additional patients will likely add to your variable expenses only, since your fixed expenses are most likely already paid for and independent of volume. Once you have determined your variable expenses per patient, you can begin to predict how many patients a new associate must see per day or per hour in order to break even. From there, it becomes a lot easier to establish and rationalize a fair compensation package for the associate. During the initial start up period, the associate will undoubtedly see some of your patients, thereby reducing your revenue pool. This may be part of your plan, according to your personal factors. If it's not, don't panic. This initial revenue loss should be viewed as an investment in the growth of your practice. If the associate is right for your office, then he or she will eventually begin working to increase the overall practice volume and revenue. Once a salary is agreed upon and the duties of the new associate are outlined, consult legal and accounting professionals in order to draw up a contract. With a solid agreement that is beneficial to both your associate and your practice, you can begin working together to achieve your common goals.

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Buying and Selling a Medical Practice Mike Crosby, President, Provider Resources, LLC

In this article, we will look at common deal structures and key elements that influence the structure/factors affecting your decisions, and evaluates factors such as economic and emotional value in the pricing of a practice, and includes information to complete the due diligence process when investigating a practice for purchase. Today’s marketplace is filled with innovative new arrangements. Therefore, when one considers a practice purchase the key element may be to look outside the “box” rather than solely on the price. Common Structure The type of business structure that a selling practice has (for tax reporting purposes) will determine the seller’s preference. (Remember, the seller wants to maximize cash regardless of price.) The table below highlights common selling structures: Operating Structure (Tax Form) Transaction Preference “C” Corporation (1120) Stock Sale “S” Corporation (1120 S) Asset or Stock Sale Partnership (1065) Asset Sale Sole Proprietor (Schedule C Form 1040) Asset Sale Key Elements Each transaction structure has key elements that are important to consider. They are outlined as follows: Structure Elements Asset Purchase Ability to include and exclude assets of

the practice, thereby, affecting purchase price

Goodwill is deductible (for tax purposes) by the buyer

Ability to carve-out accounts receivable Stock Purchase Seller recognizes capital gains – except

for “amounts assigned to non-compete” All assets and liabilities, both known and

unknown, go with buyer. Seller is able to recognize capital gains

on sale – except for “amounts assigned to non-compete”

Buyer loses goodwill deductibility for tax purposes

Loss of goodwill amortization and assumption of corporation’s liabilities affect purchase price

Factors to Consider There are many factors to consider when evaluating a potential practice purchase. First, is a structure that maximizes the cash-flow benefit to the purchaser. The purchase of stock versus assets may not appear significant when first evaluated on price solely; however, given the loss of the amortization of goodwill by the buyer, the impact becomes significant. On the same note, when stock is purchased the liabilit ies, both known and unknown, transfer to the purchaser. The key issue becomes: What acts have occurred in the past

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which could now be presented against the corporation that the new owner would have to defend? Second, how will the transaction structure support the lender’s ability to fund the transaction? Lenders look for a minimum cash flow coverage of monthly/annualized personal expenses of 1.25-1.5%. With an appropriate structure, cash-flow coverage is maximized, allowing the seller to achieve the goal of getting the maximum for the practice. Third, define exactly what is being purchased. In a podiatry practice, the fixed assets are generally not the major component of the purchase price. Generally, the cash-flow of the practice is the major component and ensuring its transfer is critical to future success. Therefore, the definition of items included and excluded is critically important. Economic Value versus Emotional Value While many are trying to determine their practice’s worth, others are trying to determine how much they can afford. Recognizing this buy/sell view, what is the emotional versus the economic value?

Emotional Value Most podiatrists have built their practices and early on it was a struggle just to make a living. However, with hard work and a commitment to deliver quality patient care, the practice flourished and provided a good income and a recognized place in the local medical community. Today, emotional value is a part of them; it is an extension of their professional reputation, and no amount of money is sufficient to meet his/her investment. Recognizing and respecting this, the podiatrist must be willing to evaluate the practice given the market dynamics of physical and economic value. Economic Value The economic value for a practice can be drastically different from the emotional value. Economic value is a price/value that an individual can sell a practice to a qualified buyer and is driven by the ability of the market to support the price through several factors: � Sustainable revenue stream � Recognized clinical quality � Transferable assets: equipment, patient list, managed care contracts, hospital

relationships and referral source satisfaction � Efficient operating systems/processes � Market position These factors affect value by the amount of risk each contributes to the overall success of the practice. In today’s environment many different methods are used to determine the economic value of a practice. The most widely used method for valuing a medical practice is the Capitalized Earnings Approach as outlined by the IRS in Revenue Ruling 59-60. While most of the methods have similar results, the key becomes what the buyer can finance. Therefore, economic value becomes defined as the amount a practice can be sold to and financed by a qualified buyer. To estimate your economic value, ask these questions: What was I able to finance when I started practice? What part of the practice is worth something to me that means nothing to someone else? Can anyone else replicate my practice? Then check the market, evaluate the difference, consider the options, and make your decision to sell, buy or hold your current position. Due Diligence Considerations When the decision to buy is made, the process of completing due diligence is a critical first step. Using the below outline will assist the buyer in evaluating the opportunity recognizing

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his/her ability to produce revenue/make payments for the practice debt. A key will be for each party to be thoroughly prepared and involved with a competent team of professionals to complete the purchase and/or sell process. Practice Background and History Summary of practice history Copy of physicians’ CV/resume Copies of physician employment contracts, if any Hours of operation Physician call schedule List of managed care plans in which each physician participates Samples of marketing information Samples of patient education materials Copies of stockholder or partnership agreements List of stockholders or partners, showing the amount of stock or percentage owned by

each person, if applicable Details of transactions in the company’s stock during the last 5 years Details of transactions with related parties

Personnel Assessment Listing of employees including job title, date of hire, compensation, and hours worked Copies of employment contracts, if applicable Copies of all job descriptions, if available Copy of personnel manual, if available Details of employee benefit plans, including pension plans and profit-sharing plans Copies of pension/profit sharing documents

Accounts Receivable Accounts receivable aging report at most recent end of month Annual charges, payments, and adjustments for most recently completed 3 years Charges, payments, and adjustments by month (and by payer, if available) for most

recently completed 12 months Charges by payer for most recent 12 months (year-to-date) or as of 12/31/XX Breakdown of accounts receivable by insurance and patient responsibility as of the most

recent month-end

Regulatory Reports of examination issued by government agencies such as EPA, OSHA, IRS and

EEOC or HCFA Copy of CLIA certificate, if applicable Copy of radiology inspections and registrations Copy of written evacuation plans Copy or evidence of HIPPA Compliance

Facility/Ancillary Services Assessment Copy of office lease(s), if applicable Charges by CPT code summary for the practice (for most recent month-end and

previous 12 months) access to them (if possible, charges by CPT code for all Medicare services)

Equipment Copy of most recent depreciation schedule listing equipment and furnishings owned by

the practice (from the tax return)

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� Description of phone system, including number of phones and locations � Description of computer system, including hardware, software, terminals, printers, and

their locations � Copies of significant equipment leases Financial Analysis � Financial statements for the most recent three fiscal years and the interim period since

the last fiscal year end � Copies of income tax returns for the last 3 years � Schedules showing computation of actual annual compensation of physicians for last 3

years Outstanding Liabilities � Copies of loan agreements or notes payable � Details of any litigation, including pending or threatened lawsuits � Details of contingent liabilities or off-balance sheet financing (such as letters of credit) � Insurance and liability coverage and claims history � Copies of managed care contracts (PPO, POS or HMO) please be sure to have a

comprehensive listing of the managed care contracts to ensure you capture all of the key contracts and their provisions

Financial Systems � Copy of any financial analyses already performed on the practice � List of future capital requirements Physician Productivity � Production report containing charges and volumes by CPT code, by physician for most

recent 12 months � Scheduled office hours to see patients for each physician by location Billing and Collection � Written policies and procedures for collections and billing (if available) � Encounter form or superbill � Samples of patient information form and hospital charges sheets � Sample of patient billing statement � Listing of all adjustment codes Patient Analysis � Actual or estimated active patient charts (patients seen within last 3 years) � Production report containing charges and volumes by CPT code, by physician for most

recent 12 months � Encounters by physician for most recent 12 months, year-to-date � Summary of active patients by residence zip code, if available, from computer system � Summary of active patients by age, if available, from computer system Medical Records � Complete a review (using selected charts) to determine the adequacy of documentation in the medical record supporting patient encounters.

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More Than Money Mike Crosby, President, Provider Resources, LLC

In today’s competitive job market employers are looking for ways to create loyalty and retention in the work force. One of the most compelling methods is by offering incentives and certain “non-cash” benefits to employees. Therefore, when considering job offers, consider more than just the “cash”. Let’s evaluate offers and determine if any of the offers present a superior offer versus another. Scenario #1 A new associate is offered a starting salary of $100,000 with no incentive clause. The contract is for a one year period. The benefits in include fully paid insurance, malpractice insurance, two weeks vacation, CME (up to $1,500) auto allowance (500/mo) and cell phone service. There are no production targets and the contract has a 60 day out clause for both parties. Scenario #2 A new associate is offered a starting salary of $60,000 with a bonus of 30% once collections, (in the year) based on his production, reaches $180,000. The contract is for three years and has an escalation clause for years 2 and 3 (in both salary and bonus). The benefits include fully paid health insurance, malpractice insurance, two weeks paid time-off, CME allowance (up to $1,500), cell phone service, and an auto allowance of $500.00 per month.

Scenario #3 A new associate is being offered a compensation plan of 55% of their production (collections). The practice will not pay for any benefits or time off (no work-no pay). In order to compare we are going to make the following assumptions:

� The practice is well positioned to grow and future opportunities for equity are similar.

� The practice is highly successful and there is significant “pent-up” demand for a new doctor and in the first year the doctor will collect $400,000.

Category Offer #1 Offer #2 Offer #3 Guaranteed Compensation $100,000 $60,000 Incentive 0 $66,000 $220,000 Total Cash $100,000 $126,000 $220,000 Benefits (Value) Health Insurance $5,500 $5,500 (5,550) Malpractice $3,000 $3,000 (3,000) Vacation CME $1,500 $1,500 (1,500) Cell Phone $ 750 $ 750 (750) Auto Allowance $6,000 $6,000 (6,000) Taxes (15%) _______ ______ $33,000) Net Deal $116,750 $142,750 $170,250 When evaluating offers be sure to consider all the components not just the cash. As noted above, lower risk yields lower rewards.

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Employment Agreement

This Agreement made this ___ day of April, 2011, by and between Bailey Hoffman, DPM P.A., a Texas corporation (the "Employer") and Timothy Tralka ("Employee"). W I T N E S S E T H:

WHEREAS, the Employer desires to employ Employee and Employee desires to be employed by the Employer upon the terms and conditions set forth herein.

NOW, THEREFORE, in consideration of the premises and mutual covenants herein contained, it is agreed as follows:

Employment. The Employer hereby employs Employee as a podiatrist and Employee hereby accepts employment by the Employer upon the terms and conditions herein set forth. The place of employment shall be at the Employer's principal office or at such other location as the Employer may designate.

Term and Annual Renewal. The term of this Agreement shall commence as of the effective date of this Agreement, and shall expire one (1) year from the date hereof, unless sooner terminated as herein set forth. This Agreement shall automatically renew for one (1) year periods following the Agreement's initial term unless either Employer or Employee gives written notice of the termination of the Agreement within the sixty (60) day period preceding any renewal date of the Agreement.

Duties. The Employee will, during the initial and any subsequent term of this Agreement:

A. faithfully and diligently do and perform all such acts and duties and furnish such services as the Employer shall direct, and do and perform all acts in the ordinary course of the Employer's business (with such limits as the Employer may prescribe) which are necessary and conducive to the Employer's best interests;

B. devote his full time, energy, and skill to the business of the Employer and to the promotion of the Employer's best interests, except for vacations and absences made necessary because of illness;

C. complete medical education courses and annually complete training in patient relations/relationship management and interpersonal skills development.

Compensation. Subject to the provisions hereof, the Employer shall pay to Employee the following for all services to be performed by Employee during the initial and any subsequent term of this Agreement.

A. Salary. A fixed salary shall be paid to the Employee at the rate of 35% of collected charges for services rendered per annum (which may be increased at the Employer's discretion), payable in equal monthly installments. All such payments will be subject to such deductions as

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from time to time may be required to be made pursuant to law, government regulation or orders, or by agreement with, or consent of, Employee.

B. Benefits.

[i] Employee shall be entitled to participate in such life insurance, disability, medical, dental, auto reimbursement/leasing, pension and retirement plans and other programs as may be approved from time to time by the Employer for the benefit of its employees.

[ii] Employer shall maintain a life insurance policy (the "Life Insurance") on the life of Employee for $300,000 In the event of Employee's death, the proceeds of the Life Insurance shall [i] first, be used to pay off any remaining debt evidenced by the Promissory Note executed of even date herewith by Employee payable to the order of Bailey Hoffman and [ii] second, any remaining amount shall be paid to Employee's estate.

[iii] Employee shall provide at his own expense benefits listed on Exhibit A.

C. Disability. In the event that Employee is permanently disabled, as herein defined, for a continuous period of three (3) months, the Employer may terminate this Agreement upon written notice to Employee. In the event of such termination, Employee's compensation set forth herein shall continue for the lesser of: (i) any waiting period set forth in any disability insurance policy maintained by the Employer and covering Employee, if any, or (ii) three (3) months after termination of this Agreement.

For purposes of this Paragraph, "permanently disabled" shall mean a condition resulting from bodily injury or diseases or mental disorders such that Employee is prevented from performing the principal duties of his employment. The Employer, in its discretion, based on competent medical advice, shall determine whether Employee is and continues to be, permanently disabled for purposes of this Paragraph.

D. Within 30 days following the end of each fiscal year of the Employer,

Employee will receive a share of the Profits equal to his ownership of common stock of the Employer. Profits shall be defined as the remainder of collected revenues after business expenses and physician employment agreement payments have been satisfied.

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Termination. This Agreement shall terminate upon the occurrence of any of the following:

A. Death. On the date of the death of Employee;

B. Disability. On the date that the Employer gives written notice to Employee that the Employer is terminating the Agreement;

C. End of Term. On the expiration of the then existing term following the date either the Employee or the Employer gives written notice to the other party of his or its election to terminate the Agreement pursuant to Section 2 of the Agreement; or

D. Termination For Cause. On the tenth (10th) day after the Employer gives Employee written notice of a Termination For Cause hereunder.

In the event of termination under Subsections (A), (B) and (C) of this Section 5, the Employee (or his estate) will be entitled to the Annual Salary, to the extent unpaid, set forth herein, prorated from January 1 of the year of termination to the date of termination. In the event of termination under Subsection (D) of this Section 7, the Employee will forfeit all benefits payable under this Agreement.

Termination for Cause. Notwithstanding any other provision of this Agreement, if the Employee is discharged for cause, or violates Article 7 ("Confidentiality") or Article 8 "Non-Competition") of this Agreement, then Employee, shall immediately forfeit any and all rights and benefits under the terms of the Agreement. For purposes of the Agreement, a discharge for cause shall consist of a termination of Employee's employment with the Employer for any of the following reasons: (i) Employee's conviction of any criminal violation involving dishonesty, fraud

or breach of trust;

(ii) Employee's willful engagement in any misconduct in the performance of his duties which materially injures the Employer;

(iii) Participant's breach of fiduciary duty involving personal profit, willful

violation of any law, rule or regulation (other than traffic violations or similar offenses) or final cease-and-desist order;

(iv) Employee's performance of any act which, if known to the customers or

clients of Employer, will have a material and adverse impact of the business of Employer; or

(v) Employee's willful and substantial nonperformance of assigned duties,

provided that such nonperformance has continued for more than ten (10) days after Employer has given written notice of such nonperformance and of its intention to terminate Employee's right to benefits under the Agreement because of such nonperformance.

Any denial of rights or benefits pursuant to this Article 6 shall be made by Employer's Board of Directors in their sole discretion, applied in a reasonable, good faith manner.

7. Confidentiality. The Employee recognizes and acknowledges that he will have access to confidential information of the Employer and of entities affiliated with the Employer, and that such information constitutes valuable, special and unique property of the

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Employer and such other entities. The Employee will not, during or after the term of this Agreement and for a period of two (2) years thereafter, disclose any such confidential information to any person or firm, corporation, association or other entity for any reason or purpose whatsoever, except to authorized representatives of the Employer or if ordered to do so by a court or governmental agency of competent jurisdiction. In the event of a breach or threatened breach by the Employee of the provisions of this Article, the Employer shall be entitled: (i) to an injunction restraining the Employee from disclosing, in whole or in part, such confidential information, and (ii) to terminate this Agreement and re-collect any and all payments made to the Employee pursuant to this Agreement. Nothing herein shall be construed as prohibiting the Employer from pursuing any other remedies available to it upon such breach or threatened breach including the recovery of damages from the Employee.

8. Noncompetition During Employment. The Employee agrees to the following during and after his term of employment under this Agreement.

A. Noncompetition During Employment. The Employee agrees that at all times during the term of his employment he will not, either directly or through the agency of any corporation, partnership, association or agent or agency, engage in any similar business conducted by the Employer.

B. Violation of Covenant. If any of the covenants set forth herein at this Article 8 are violated, the Employer, at its option, shall be entitled to: (i) notify the Employee that this Agreement is terminated, in which case this Agreement shall be rescinded (and thus terminated retroactively to the date of its inception); and (ii) demand repayment from the Employee of all payments made to the Employee pursuant to this Agreement.

9. Non-assignment. This Agreement is personal to Employee and shall not be assigned. Employee shall not hypothecate, delegate, encumber, alienate, transfer or otherwise dispose of his rights and duties hereunder.

10. Waiver. The waiver by the Employer of a breach of Employee of any provision of this Agreement shall not be construed as a waiver of any subsequent breach by Employee.

11. Severability. If any clause, phrase, provision or portion of this Agreement or the application thereof to any person or circumstance shall be invalid or unenforceable under any applicable law, such event shall not affect or render invalid or unenforceable the remainder of this Agreement and shall not affect the application of any clause, provision, or portion hereof to other persons or circumstances.

12. Benefit. The provisions of this Agreement shall inure to the benefit of the Employer, its successors, assigns, and shall be binding upon Employee, his heirs, personal representatives and successors, including without limitation, Employee's estate and the executors, administrators, or trustees of such estate.

13. Relevant Law. This Agreement shall be construed and enforced in accordance with the laws of the State of Texas.

14. Notices. All notices, requests, demands and other communications in connection with this Agreement shall be made in writing and shall be deemed to have been given when delivered by hand or 48 hours after mailing at any general or branch United States Post Office, by registered or certified mail, postage prepaid, addressed as follows, or to such other address as shall have been designated in writing by the addressee:

If to the Employer: Bailey Hoffman, DPM P.A. Attn: Bailey Hoffman

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99 My House Way Wayback, Texas 51515

If to the Employee: Timothy Tralka, DPM 33 Your Apartment In the City, Texas 51515

15. Entire Agreement. This Agreement sets forth the entire understanding of the parties and supersedes all prior agreements, arrangements, and communications, whether oral or written, pertaining to the subject matter hereof; and this Agreement shall not be modified or amended except by written agreement of the Employer and Employee.

IN WITNESS WHEREOF, the parties hereto have executed this Agreement on the date first set forth above.

EMPLOYER: BAILEY HOFFMAN, DPM, P.A. By: __________________________ Title: _________________________ EMPLOYEE: ______________________________ Timothy Tralka, DPM

EXHIBIT A Benefits Provided by Employee

VII.Insurance

Congratulations and best of luck to the class of 2011!


Congratulations and welcome to the profession. Be involved, be active, and give back!


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Insurance for the New Practitioner The term insurance can produce a feeling of anxiety in the minds of new practitioners. The following outline and checklist are designed to assist you in determining what your insurance needs are and how to meet them. Keep in mind that the primary purpose of insurance is to provide adequate protection for your personal, professional and financial security. For your convenience, the following is divided into sections to include personal, office and professional insurance. Determining the type and amount of coverage to obtain can be confusing. It is best to find an experienced agent, representative or business consultant to help determine your needs and locate a reputable company. A personal recommendation or referral from a respected colleague is a good way to choose such a person. The APMA sponsors a variety of life and health insurance programs for podiatrists and their families. These plans are offered through a professional third party administrator appointed by the APMA. Remember though, it is ultimately your responsibility to educate yourself on insurance matters and monitor your coverage. Health Insurance: This is a necessity for everyone. It is less expensive and easier to obtain when one is young and healthy. Plans are available with varying deductibles and co-payments. Plans are available through preferred provider organizations such as HMOs and PPOs and may be purchased as an individual program covering a physician and his/her family or as a small group, where rates are normally lower and coverage is more comprehensive. Remember that health insurance is also an attractive benefit for your employees. You may decide to explore the benefits of a company group policy for yourself and your employees. You may also want to try to negotiate rates for your health insurance along with those for your employees to find the best rates available for everyone. Life Insurance: If you are young and single you may feel that you do not need life insurance and you may not if you plan to live the rest of your life single with no dependents. If you do have reasons to purchase life insurance, it is always easier to purchase coverage at a reasonable rate while still young and healthy. There are many reasons why you should consider life insurance now, some are as follows, but these are certainly not limited to the following: 1) You have a family or dependents now, or plan to in the future, who rely on your income to support a mortgage, schooling, day-to-day living expenses, etc. 2) There is ANY possibility that in your later years a spouse can become ill and require medical care that depletes your retirement fund. 3) You plan to eventually have a wealthy estate and you would like to offset the tax liabilities of passing that estate on to your posterity. Life insurance comes in two basic types; term insurance and whole-life or permanent insurance. As the name implies, term insurance covers only a period of time, normally one year. Coverage can be purchased for benefit periods ranging from one to thirty years of level term. A young person can buy a large amount of coverage at a low cost. Each year or bracket of years, the cost of this insurance increases and most term coverage ends when the insured reaches the age of 65 to 75. Some, however, continue as long as premiums are paid. At the end of a policy period, or when you leave the plan, you have no residual or investment interest. Term insurance is very price competitive since you are only paying for the "true" cost of the insurance. Non-smokers pay less than smokers and women pay less than men. A good way to compare plans is cost per $1000 of coverage per year. You will want to review the provision that deals with renewing your coverage at the end of each term. Look for a plan that offers a renewal period that most closely matches your current need for coverage.

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Whole-life or permanent life insurance differs in that the contract is long term. You agree to pay premiums over a long period of time, i.e. to age 65 or 99, for lifelong coverage. Your annual life is considerably more costly than term insurance when you are young because a portion must be invested to subsidize these low premiums when you are older. This investment piece is your "cash value" should you terminate the policy. This is a policy to consider if you are also concerned about estate planning. The “cash value” of the policy is usually tax-free as is the death benefit. However, you should look very closely at your situation and determine which of these products is right for you. Not all “WHOLE LIFE” policies are created equally and many critics cite the large fees and costs of whole life policies as reasons to avoid them. You should be able to sit down with your agent and perform a cost analysis regarding his or her product compared to other similar products as well as investing in other vehicles such as the stock market. For example: If a whole life policy had a cash value of $100,000.00 and was averaging a 7.5% annual return on that value; a stock market portfolio would need to provide an annual return of 11.5% to be equivalent assuming 35% tax bracket. This varies based on the tax bracket of the investor. Your financial advisor or agent should be able to walk you through this in more detail. Whole Life policies are not meant to be primary retirement vehicles however, with a good product and careful planning it can provide significant financial upside in your retirement years including a death benefit to your loved ones. To assess how much insurance you should purchase you must first figure out what your dollar contributions are towards you and your family’s long-term financial goals. The goal is to replace the insured person’s income, in the event of an untimely death, to an adequate level so that loved ones do not need to alter their future plans to make up for a lost provider. A general rule of thumb is that 5 to 10 times the insured person’s annual salary would be adequate coverage. Remember, your situation may be unique and should be accounted for accordingly. An example would be to add extra for large one time expenses such as college tuition and/or to pay down mortgage, car loan or credit debt should you have any of these. Regarding “Term Insurance”, it is not your responsibility to purchase enough coverage to make your loved ones “rich” in the event of your untimely death and you would likely do better putting the extra premiums towards another investment, especially since you would most likely outlive your “term” policy. All life insurance is expensive if purchased in later years. Some combinations of term life and whole-life will fit most situations, but each situation is unique. Employers frequently provide term insurance in amounts related to salary level. There are many hybrids on the market, which combine term insurance with investment programs, termed Universal Life or Variable Life. A final comment on life insurance--these products are very price competitive. Shop around, avoid the extra "bells and whistles", take your time and don't be pressured into making a quick decision. If you are a two-income family, be sure to insure your spouse. Diversity is usually in order when considering this tough decision so take the time to research your needs and research the products before buying. You can usually purchase a combined “term life” with some “whole life” and role the term into whole as you become more financially secure and need less early death coverage and more long term coverage. However, it does not usually make sense to purchase a whole policy later in life as many take between 4-6 years to show a significant positive “cash value”. Lastly, ask lots of questions to your agent. Have your agent provide you with more than one plan and more than one scenario with more than one underwriter (the company providing the insurance) and then play those scenarios out and evaluate the compatibility with your long term goals.

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Disability Income Insurance: A risk to your income could come from a disabling injury or illness. Regardless if you cannot practice your profession, either temporarily or permanently, bills still have to be paid. The answer to this unpleasant possibility is found in disability income insurance. This type of coverage begins replacing your normal income after some waiting period, normally thirty, ninety or 180 days for personal long-term disability coverage. It pays benefits for a specific period of time and frequently pays reduced benefits as you work yourself back into a full schedule after recovery. When looking at a disability insurance plan, the main feature to key in on is the definition of disability. You will want the benefits to be paid if you can't perform in "your own occupation" rather than some lesser definition such as "any occupation for which reasonably qualified." The maximum insurable benefit will be tied to your current income. The waiting period and number of years the benefits are paid to you are all options of varying disability insurance plans. Your choice should reflect your financial situation and ability to withstand loss of income. Many companies will sell “any occupation” which theoretically could deny paying your claim if for example; you could not be a podiatrist because you lost one arm in an accident, but were reasonably qualified to be a greeter at Wal-Mart or more realistically, teach at a podiatry college. Conventional wisdom has been to buy “true occupation” “own occupation” or “true own occupation” – all of which define disability as “being unable to perform the principal and unique duties of your occupation” or in other words for your case - unable to be a podiatrist as defined by your practice supporting your current income. Very few companies still offer own occupation to podiatry because of actuarial classifications that assign risk to the profession. The catch is that own occupation would pay full benefits even if you lost a finger and could not be a surgeon, but were gainfully employed as a foot and ankle radiologist or professor. “Modified own occupation” has the same definition of disability only it pays benefits based on your ability to produce your insured income level. For example; if you cannot perform surgery because you injured your dominant hand, you would receive full benefits for the term of the contract until you return to your full scope of practice. If you chose to continue to teach podiatry, you would receive a prorated benefit based on your new earned income below the level you previously insured. You may also elect to not return to podiatry and work in an office; again your benefit is prorated based on your post injury income. Of course you can stay totally disabled by definition and collect full benefits. You should not purchase expensive disability insurance with the intent to be able to become another type of doctor and still receive full benefits in the wake of a disabling (again by definition) event. It is not money well spent on the extra premium if you truly only want to protect your ability to live at you current income level and meet your financial demands. You must also consider the strength of the company underwriting your policy. If the company you purchase from goes bankrupt while fulfilling its obligations and paying claims; anyone, including you, who was relying on those benefits is generally out of luck. Some of the bigger and more established companies are: Guardian, Berkshire, and Northwestern Mutual. It cannot be stressed enough, the importance of researching these companies and their products. It is also important to read your policy. Understand what you are paying for; many policies will quote lower premiums, but often times they provide less coverage and include more loopholes to becoming officially designated as disabled. Again, get many quotes from many sources and approach two separate agents. Disclose to them that you are comparing their products and ask them to explain any discrepancies between their policies. It is also a good idea to have a personal attorney review these policies on your behalf.

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You have worked very hard for many years to attain the income you are going to earn. You should protect that like any other asset (car, house), at least until you are financially independent. Use this vehicle as peace of mind towards a secure financial future for you and your family. Hopefully, you will never need your disability insurance, but it is better to have it and never need it than need it and not have it. Lastly, do not approach this lightly or lazily. Do your homework, educate yourself, and force those who will gladly take you money to provide you with satisfactory answers to your questions. Check them against each other and verify what you are being told by independent sources. Disability insurance should be one of your life’s most tedious preparations that you never need to call on. Office Insurance: As you begin your practice, you may either open your own practice or share office space with another physician. Your insurance needs will vary based on the option you select. Opening an office will entail either buying a building or office condominium or leasing space from someone else who owns the building. If you own the building, your office insurance will include the physical property or building, the office contents, medical equipment and computer hardware and software programs. If you lease the premises, you will not need to purchase insurance on the building, but you will need insurance for your contents and equipment. Whether you lease or purchase your office space, you will also need Premises Liability coverage. This is a very broad contract that insures you if a patient or a member of the public slips and falls on your property. This section of coverage also protects you from personal injury, slander, and advertising lawsuits. The standard limit for liability coverage is $1,000,000. Insurance companies often package coverage, enabling you to obtain excellent coverage for a few hundred dollars. Your package insurance will also include employee theft and dishonesty, non-owned automobile, excess liability and workers compensation.

Optional coverage you should look for are building ordinance liabilities and fire legal liability. Building ordinance insures you if you need to rebuild after a loss and the fire codes have

changed insurance company to bear the burden of the extra expense to rebuild your building. Fire legal liability protects you against lawsuits from other tenants in the event a loss originates within your premises.

Business overhead insurance is another type of disability coverage and works with your

business interruption insurance to provide continuous income for your salary and other office expenses in the event of a loss. This coverage provides cash to meet overhead expenses such as salaries and utilities should a covered disability prevent you from earning an income. High amounts are usually available and payments can begin after a waiting period of either 15 or 30 days.

A final reminder, if you do share office space with another physician, you should be named as

an additional insurer on his/her office insurance policies. Insurance companies usually do not charge an additional premium to do this and it protects you while sharing space and expenses. You should obtain a copy of the endorsement and retain this information with your important documents. Professional Liability/Medical Malpractice Insurance: Imagine adding another $20,000 to $25,000 on top of the thousands of dollars you've already spent for your podiatric education. Without malpractice insurance, you could be held personally liable for court costs and for settlements and damages; essentially paying well over the cost of malpractice premiums if you are sued. And those are just the average figures. Some of the more serious suits--and there are plenty--could cost you much more. Purchasing malpractice insurance makes a lot of sense. But which insurance company should you choose? The company you

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choose should be well-established and financially sound. There are six factors to consider when choosing a malpractice insurance carrier:

1). Best report management rating - An A.M. Best Company rating of A (excellent) is considered acceptable. These ratings often gauge the financial stability of the insurance company.

2). Licensed or "admitted" status- The company should be licensed or admitted by the state department of insurance to do business in that state. In most states, admitted status means that if any insurance company goes out of business, the policy holders are protected by the state's guaranty fund.

3). Availability of claims and loss data- The company should routinely share program claims and loss information with the state podiatric association. Some companies publish annual reports, which include this type of data.

4). A sound risk reduction and loss prevention program- An insurance company that promotes risk management is interested in keeping the cost of claims down. These savings can then be passed on to the policyholders in the form of lower premiums. Some companies offer seminars and/or discounts for attending these programs. 5). Podiatric involvement in the program- A good malpractice insurance program responds to policy holder's needs. Using committees of podiatrists to review claims and underwriting procedures adds to the fairness of the program and ensures that the best interests of the profession are kept at the forefront.

6). Factors for setting premiums- Three main factors that should be considered when setting rates are the program's loss history, the legal climate in the location of the practice and the investment history. Programs that insure only low risk doctors are able to keep rates down, and are obviously more stable. Legal climate is important because awards vary depending upon the size of a city. The investment history will determine future rates.

Deciding on Malpractice Insurance Coverage: Malpractice insurance is available under two main types of policy forms: occurrence and claims made. Most professional liability insurance is written on a claims-made basis. Occurrence Coverage: An occurrence policy provides coverage for any incident that occurs during the policy period, regardless of when the claim arose or was reported. For example, a claim could be made many years after the initial incident occurred, and as long as occurrence insurance is current, the policyholder is covered. Occurrence policies take in to account future projections not on current experience. Occurrence policy rates are based upon the estimated cost of claims that may be reported in the future. It is sometimes difficult to predict these costs because of inflation and other factors. Premiums for occurrence coverage are generally higher than initial claims made premiums. One benefit of having occurrence insurance is that no tail coverage or retroactive insurance coverage is necessary if you cancel and occurrence policy. Claims-Made Coverage: A claims-made policy provides coverage for incidents that occur and are reported as claims during the policy period. If you terminate your claims-made policy, it is important that you consider additional coverage (called extended reporting period or tail coverage) to cover claims that are reported after your policy ended. Claims made rates are

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based on actual claims reporting trends, so rates are more in line with the actual cost of losses. First year premiums are lower and are often more affordable to the new practitioner. As exposure to claims increases, rates follow a step-rate scale to maturity. First year premiums for a claims-made policy could represent up to a 60% savings over the occurrence rate. Tail Coverage: Tail coverage policies, often referred to as extended reporting period, covers the insured for claims that are made after your claims-made policy is discontinued. It allows the insured to continue reporting claims for the year you were covered by your original claims-made policy. Tail coverage is typically purchased from the same company you selected for your claims-made policy. Prior Acts Coverage: Prior Acts coverage provides the insured coverage for claims, which arose during the time before the insured was covered under the current claims-made policy. Prior-acts coverage can be divided into two sub-types: full prior acts or retroactive date. Full prior-acts coverage covers the insured for acts occurring at any time prior to the current policy period where as retroactive date coverage selects a specific date where coverage for acts begins. Unlike tail-coverage, prior-acts coverage is purchased from the new company providing the new claims-made policy. Limits of Liability: You will also need to choose the limits of liability for your policy. Limits are generally stated in two figures. The first figure represents the monetary amount per claim that the insurance company will pay in one claim; the second is the maximum amount payable in total claims per policy year. Some common limits are $200,000/$600,000; $500,000/$1.5 million; $1 million/$1 million and $1 million/$3 million. One factor to keep in mind when selecting limits is whether you will be on staff at a hospital. It is current practice today for many hospitals to require $1 million/$3 million limits. Consider too, the value of your assets. Additionally, some insurance policies include legal court costs in the limits of the liability, while others are covered separately. Selecting the right policy limits will protect not only your practice, but also your personal assets. Calculation of Premiums: The calculation of your premium for the various liability policies are based on a multitude of factors including education, training, experience, American Board certifications, type of policy and coverage requested, your geographic location, your patient load, employment of nurses or other health care professionals in your practice, in office administration of anesthesia, sites where you perform surgery, past claims, your scope of practice, and your specialty to name a few. Every application for medical malpractice is slightly different, but expect to find questions relating to a majority of the items listed above. The Value of Service: Look for extra features and services from your insurance company. Some companies offer special rates for residents or preceptees. Other services might include premium financing and flexible payment arrangements. If you have a problem or questions about your coverage, you should be able to contact your insurance company easily. Look for accessibility in the form of toll-free telephone numbers and active web sites. If you have a claim, good communication with your insurance company is absolutely essential. Consider too, the overall philosophy and performance of your insurance carrier. Is the program exclusively for podiatrists? How large is the policy holder base? What is the company's level of commitment to podiatry? Do they support state associations and student programs?

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Does the company have access to professionals who vigorously defend claims? Is two-way communication encouraged through podiatric committees, participation in podiatric conferences and meetings, and through newsletters and other publications? It's Your Decision: Deciding on a malpractice insurance carrier is much more than shopping for the best bargain. The company's financial stability, reliability and level of service are all important factors. Understanding the scope and level of your own practice, however, will probably help you more than anything else. Consider the legal climate where you will be practicing. Will your patients be generally young or old? Will you be performing surgery? Lastly, make every attempt at ensuring an open and communicative relationship with your patients is often the best way to avoid the pitfalls of a malpractice suit. Answering these questions will help you choose the company and the coverage that best suit your needs. In closing, please remember that all types of insurance are designed to put you at ease first. Do not let an agent sell you more coverage than needed nor scale down your coverage to meet a fixed price. There are several books out on the market, which can help you in determining your insurance position. It is advisable to research your insurance options six months before you begin your practice. Group coverage, if available, will generally be less costly than an individual policy. Spending time to shop the insurance market will save you money.

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Insurance Action Plan Current Status Needs Okay or Action Not Applicable

_____ _____ Review all your insurance coverage annually. Your

insurance agent should orchestrate this review.

_____ _____ Prepare your own estimate of your life insurance needs. Don't rely on others to do it for you.

_____ _____ Be sure you or your agent gets quotes from several

companies prior to purchasing any life insurance. _____ _____ If you need term insurance be sure to check on any

coverage that may be available through your employer and professional groups and associations such as the APMA.

_____ _____ If you have an estate that is likely to be near or in excess

of $l million, check with an estate planning attorney to assure that you have designated appropriate life insurance policy owners and beneficiaries.

_____ _____ Be sure that all family members, including parents and

children, have adequate and continuous health insurance. _____ _____ Evaluate the sufficiency of the amount and the policy

provisions of all disability insurance policies currently owned or provided by your employer.

_____ _____ If necessary, obtain additional disability coverage. Look for

individually purchased policies with desirable features. _____ _____ Take an inventory of your household possessions. _____ _____ Evaluate the adequacy of your homeowner's or renter's

insurance and add to the coverage if you find any areas that are not fully insured.

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Needs Okay or Action Not Applicable _____ _____ If you don't have professional liability for all of your professional

endeavors, inquire as to your potential exposure. Take action to reduce this exposure if necessary.

_____ _____ If you are considering any action to shield your assets from any

potential medical lawsuits, seek legal counsel in advance.

_____ _____ Obtain an extended personal liability (umbrella) policy if you haven't already.

_____ _____ Consider increasing the amount of umbrella coverage if you now

have only $1M. _____ _____ Your insurance agent should be competent and responsive. If

not, make a change. Important Areas of Insurance Coverage Type of Insurance Description/Features Health Protects you from both the out-of-pocket costs of health care

and large cash outflows during major illness. Homeowner's Property (home),other structures, personal property, and general

contents of the dwelling are insured against theft/destruction; protects against the possibility of cash outflows for replacement of these assets.

Renter's Protects the personal possessions of the tenant. Automobile Protects you from large cash outflows for damages resulting

from automobile accident or theft.

Personal Liability Protects you from having personal assets or future earnings forfeited as a result of a personal liability suit. Provides additional protection on top of homeowner's and automobile liability coverage.

Professional Liability Protects you from claims arising out of professional acts or

omissions. Disability Replaces part or most of your wage income in the event of

disability. Life Replaces part or most of your wage income in the event of your

death and covers nonrecurring expenses If your dependents during a readjustment period after death.

To register, make hotel reservations, and get more information, visit

www.apma.org/thenational.

OPENING SESSIONFeaturing Ross Shafer, six-time EmmyAward-winning comedian, writer and TV host

SCHEDULE AT-A-GLANCE

WEDNESDAY, JULY 27, 2011

8:30 am – Noon Surgical Workshop 1 1:00 – 4:30 pm Surgical Workshop 2 2:00 – 6:00 pm APMA Registration

THURSDAY, JULY 28, 2011

7:00 am – 6:30 pm APMA Registration7:30 – 9:00 am Breakfast Symposium9:00 – 10:00 am Plenary Lecture 10:00 am – 3:00 pm Scientific Sessions12:00 – 1:00 pm Podiatry Management’s Hall of Fame Luncheon3:00 – 4:00 pm Opening Session Address4:00 – 6:30 pm Exhibit Hall Grand Opening

FRIDAY, JULY 29, 2011

7:00 am – 5:00 pm APMA Registration7:30 – 9:00 am Breakfast Symposium9:00 – 10:00 am Plenary Lecture9:00 am – 5:00 pm Exhibit Hall Open10:30 am – 5:00 pm Scientific Sessions5:00 – 6:00 pm Poster Abstracts Reception

SATURDAY, JULY 30, 2011

7:00 am – 5:00 pm APMA Registration7:30 – 9:00 am Breakfast Symposium (non-CME)9:00 – 10:00 am Plenary Lecture9:00 am – Noon Surgical Workshop 39:00 am – 1:30 pm Exhibit Hall Open10:30 am – 3:00 pm Scientific Sessions12:30 – 3:30 pm Surgical Workshop 43:30 – 5:30 pm PICA Risk Management Program6:00 – 7:30 pm APMA Final Night Reception

SUNDAY, JULY 31, 2011

7:00 – 10:00 am APMA Registration7:30 – 9:00 am Breakfast Symposium9:30 am – Noon Scientific Sessions

The National is a unique value, offering you more CME contact hours (up to 25*) for your dollar than any other meeting. At The National, you’ll receive:

management, podiatric medicine, radiology and more.

the same APMA member practice receives a 25% discount.

surviving the 21st century practice.

* Up to 25 continuing medical education contact hours. This number is based on attendance at all breakfast symposia, general session lectures, and the poster abstracts reception.

REGISTRATION Make your hotel reservation today; the APMA room blocks are limited. Once the blocks are full, rooms are subject to availability at prevailing rates.

Podiatric medical students and APMA postgraduate members receive complimentary registration.

APMA Grad Hdbk Ad_BW.indd 1 3/18/11 2:23 PM

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Malpractice Claims: What You Should Know Contributed by: PICA Group

Malpractice insurance companies realize that, despite everyone’s best efforts, professional liability claims do occur and that “bad things can happen to good people.” It is also recognized that the vast majority of negligence suits involve unexpected outcomes rather than malpractice. Nature of a Malpractice Claim Under our civil law system, an alleged victim (the plaintiff) can seek compensation from the alleged wrongdoer (the defendant) if the plaintiff can establish the following:

� a duty was owed by the defendant to the plaintiff; � a breach of that duty occurred; and � that breach proximately caused demonstrable damage to the plaintiff.

When applied to malpractice claims, the three elements to be established become the following:

� there must be a verifiable doctor-patient relationship (duty owed); � negligence, in the form of a departure from acceptable medical standards; � plaintiff must have suffered damage proximately caused by the doctor’s negligence.

It is the responsibility of the plaintiff, through his/her attorney, to prove that all three elements exist. Failure to convince a jury of any one of these elements results in a judgment in favor of the doctor/defendant. Lawsuits, Claims and Reportable Events The first notice of a claim can be in the form of a lawsuit or other legal document, such as a written notice of intent to sue. Formal legal notification of a lawsuit can be served in numerous ways and varies from state to state. In some states service may be made:

� by a process server who personally serves you with papers. You can be served anywhere. Service can also be made by leaving papers with a spouse or employee; and/or

� by the local sheriff’s department; and/or � by the plaintiff’s attorney or the attorney’s designated representative; and/or � via the U.S. mail (certified or regular); and/or � via fax

In addition to a formal legal notification of a lawsuit, there are several situations that should alert you to the possibility of future legal action. Prompt and thoughtful response to these situations can many times prevent or substantially mitigate subsequent formal legal action. What Should be Reported? Your malpractice insurance company should be notified immediately

� upon receipt of lawsuit papers; � of any claim (defined as a demand received by the insured for money or services,

including the service of suit or institution of arbitration proceedings against the insured);

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� upon receipt of a subpoena, a formal command from a court or other governmental body that requires the recipient to appear at a certain place and time in order to give testimony and sometimes to provide documents;

� of any event or incident which may result in a claim or lawsuit in the future.

When should a lawsuit, claim or reportable event be reported? You are encouraged to immediately notify your malpractice insurance company of any circumstance that you feel could result in a claim or lawsuit against you. Timely and proactive actions by you and claim professionals can often prevent formal legal action by your patient. Furthermore, prompt action enables your malpractice insurance company to evaluate the situation while the facts surrounding the event and your memory of the incident are still fresh. Failure to promptly notify your malpractice insurance company of any claim made against you could cause you to forfeit the coverage provided by your malpractice insurance policy. PICA realizes that the primary role of a doctor is that of a healer. We are committed to supporting you in your role of healer and will constantly strive to minimize the interruptions caused by malpractice claims. PICA’s ongoing risk management program is dedicated to the reduction of professional liability claim frequency and severity. We urge you to participate actively in our risk management educational programs. For more information or a free quote, visit www.picagroup.com or call us toll-free (866) 742-2477.

VIII.��

and Set-up

Best of luck in the greatest profession of all—podiatric medicine and surgery!

Joe Caporusso, DPMMcAllen, TX

Congratulations! APMA will always be there for you.

R. Dan Davis, DPMBridgeport, CT

800.321.9348 • www.gebauer.com/apmsa

Provide lesspainful podiatryGebauer’s Ethyl Chloride® topical anesthetic skin refrigerant is the suggested application

preference for topical anesthesia prior to podiatric blocks and minor surgical procedures

such as ingrown toenails. Only Gebauer’s non-drug, instant topical anesthetic skin

refrigerants are FDA approved to help control the pain of needle procedures and minor

surgical procedures. There is no waiting as with anesthetic creams. Just spray for a few

seconds. The anesthetic effect lasts up to one minute.

Gebauer’s Ethyl Chloride is available in the familiar brown glass bottle in Fine Pinpoint Spray

and Medium Stream Spray. The aerosol spray cans are available in Mist Spray and Medium

Stream Spray.

Important Risk and Safety Information Ethyl Chloride is FLAMMABLE and should never be used in the presence of an open

� ame or electrical cautery equipment

Inhalation should be avoided as it may produce narcotic and general anesthetic

e� ects, and may produce deep anesthesia or fatal coma or cardiac arrest

Do not spray in eyes

Over spraying may cause frostbite

Freezing may alter skin pigmentation

The thawing process may be painful and freezing may lower resistance to infection

and delay healing

Cutaneous sensitization may occur, but appears to be extremely rare

Long term exposure may cause liver or kidney damage

Rx Only

602.1 ©2010 Gebauer Company Rev. 01/10

The APMA EducationalFoundation StudentScholarship Fund is the onlynational scholarship programdedicated to helping studentsstudying podiatric medicine.

The Foundation strives toaward more students withscholarships each year, whichare instrumental in helping toease the financial burden ofpodiatric medical school.

Awards are made to third-and fourth-year studentsattending one of the nine colleges of podiatricmedicine. The criteria used to select scholarship recipients are GPA, communityservice, school leadership,and financial need.

Schools of Podiatric Medicine• Arizona School of

Podiatric Medicine at Midwestern University

• Barry University School ofPodiatric Medicine

• California School of Podiatric Medicine at Samuel Merritt University

• College of Podiatric Medicine at Western University of Health Sciences

• Des Moines University—College of Podiatric Medicine and Surgery

• New York College of Podiatric Medicine

• Ohio College of Podiatric Medicine

• Dr. William M. Scholl College of Podiatric Medicine at the Rosalind Franklin University of Medicine and Science

• Temple University School ofPodiatric Medicine

Congratulations to the Class of 2011!

www.apma.org/educationalfoundation

EDUCATIONAL FOUNDATIONEducational Initiative of the American Podiatric Medical Association

Contact Information:APMA Educational FoundationSandra F. ArezFoundation Coordinator9312 Old Georgetown Road Bethesda, Maryland 20814-1621 Tel: 301-581-9244 Fax: 301-530-2752

Established in 1959 as a tax-exempt organization,the program has awarded more than 2,000 graduates.

In 2010 the Foundation Student Scholarship Fund disbursed 161 scholarships totaling more than $195,000.

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Podiatric Supplies The idea of preparing to open a new practice is daunting, especially right after residency when you’ve already amassed a great deal of debt. In hopes of making this process easier and less confusing, the APMA has created a APMA Buyer’s Guide to have at your fingertips. The Guide is one of the easiest ways to find information about products for podiatrists is by using the "APMA Buyers' Guide-Commercial Reference to the Podiatric Office." This timely member benefit is easily accessible from the button on the APMA members' homepage. The APMA Buyers' Guide enables you to conveniently perform targeted searches for industry-related products and services. Unlike traditional Internet searches that can generate numerous irrelevant results and slow down your procurement process, the Guide is filled with APMA-friendly suppliers and service providers, many of whom are also valued APMSA CAB members. The Guide is a valuable tool for researching, selecting, and purchasing the industry resources. You also can search the supplier network directly from your desktop by downloading the search tool! Visit http://members.apma.org and click the APMA Buyers' Guide logo. Remember: Please consider APMSA CAB members when possible. In addition, here’s some other useful advice: How do I decide which supplier to use?

- Prepare an equipment list and send the list to at least two separate supply houses to obtain the best estimate on equipment (see enclosed list).

- A good way to choose suppliers is to go to a podiatry conference with exhibits where they have items on display. Look for companies that are willing to go out of their way to help you. Some companies are willing, at no extra cost, to personally deliver the equipment and set everything up. Used equipment is also always an option but be selective.

- It is also important to know how long it will take a supplier to deliver supplies and how they handle billing. Will the supplier handle the shipping costs? Some suppliers will if you order large amounts of material. Also, how will the items be shipped? Do they have next day delivery options? If the supplier has a large stock of items they can usually ship quickly but if they do not usually carry some items (especially if you are not using a supplier that caters to podiatry) it can take several weeks. Some suppliers have various payment methods. Consider which one is right for you.

One must assess many variables when choosing suppliers. To better help you choose, ask yourself some of these questions. Is the supplier able to handle all the durable equipment and the sundry supplies needed? Is the supplier you are considering located relatively close to your office? Will they be able to respond to the unexpected short-term supply needs of your office? Does the supplier have a long standing and positive relationship with its buyers? What supplies and equipment should I buy and how much will it cost?

- To save money practitioners can obtain one power podiatry chair and one non-powered examination table, the latter costs approximately $300 to $400 versus $5,000 to $6,000 for a power examination chair. Consider purchasing used powered chairs over buying one power and one non-powered. You might need that second chair faster than

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you think so why buy something that needs replacing so quickly. Used chairs can be reupholstered easily and cheaply and often come with warranties.

- Buy stainless steel instruments versus chrome plated. Stainless steel will survive better when autoclaved on a repetitive basis. Quality instrumentation will obviously last longer and should be sought out when ordering. Also consider obtaining instrumentation for a surgical pack. When starting one’s practice, only two or three packs would be necessary.

- Depending on finances, dip tanks can be used in lieu of an automatic processor for developing radiographs. However an automatic processor is preferable despite its probable cost of around $15,000 (this includes other important instrumentation such as a Hyfrecator, routine supplies, etc.). Consider digital radiology and digital processing, this is a more expensive option, however, the technology of the office is moving to paperless and this may be an expense that is worth it. Not to mention the savings associated with saving square footage in the office, no dark room, no film storage!

- Buy the bare minimum of office supplies because it is very expensive in the beginning to keep a lot of inventory that you don’t use. Most supplies can be delivered in two to three days.

What about discounts on supplies and equipment?

- Discounts are available. A 10% discount or more may be negotiated on routine supplies.

- Prices in catalogs, or the “list prices” can be anywhere from 40-60% higher than the actual cost. Send a ‘Pro Forma’ (which is a list of equipment you are thinking of purchasing) to the different companies and they will then list the real prices of everything, so you can get an idea what you will really be paying. Allow competing companies bid for your business.

Here are some other money saving tips:

- If you move into a community with a large number of podiatrists, investigate group discounts on certain office supplies/equipment.

- At first, unless you are buying an existing practice, you could easily lower expenses by using just one exam room.

- Don’t buy things such as specimen containers, culture swabs, biopsy kits, etc. that you can get from the hospital or lab. They often give you these just for using their services. Consider using pathology labs that are podiatry friendly, most if not all will give you supplies for free.

Should I lease or purchase equipment? Depending on how your accountant has set up your practice, there may be advantages to both leasing and buying, for example, deducting the lease from your taxes verses writing off the depreciation after buying the equipment. These types of situations are best discussed with your accountant on an individual basis. It’s important to keep abreast on matters regarding your business. The new practitioner should read business journals, join the local small business bureau and take business courses. Please remember to support the APMSA 2011-2012 Corporate Advisory Board listed on page 10.

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you think so why buy something that needs replacing so quickly. Used chairs can be reupholstered easily and cheaply and often come with warranties.

- Buy stainless steel instruments versus chrome plated. Stainless steel will survive better when autoclaved on a repetitive basis. Quality instrumentation will obviously last longer and should be sought out when ordering. Also consider obtaining instrumentation for a surgical pack. When starting one’s practice, only two or three packs would be necessary.

- Depending on finances, dip tanks can be used in lieu of an automatic processor for developing radiographs. However an automatic processor is preferable despite its probable cost of around $15,000 (this includes other important instrumentation such as a Hyfrecator, routine supplies, etc.). Consider digital radiology and digital processing, this is a more expensive option, however, the technology of the office is moving to paperless and this may be an expense that is worth it. Not to mention the savings associated with saving square footage in the office, no dark room, no film storage!

- Buy the bare minimum of office supplies because it is very expensive in the beginning to keep a lot of inventory that you don’t use. Most supplies can be delivered in two to three days.

What about discounts on supplies and equipment?

- Discounts are available. A 10% discount or more may be negotiated on routine supplies.

- Prices in catalogs, or the “list prices” can be anywhere from 40-60% higher than the actual cost. Send a ‘Pro Forma’ (which is a list of equipment you are thinking of purchasing) to the different companies and they will then list the real prices of everything, so you can get an idea what you will really be paying. Allow competing companies bid for your business.

Here are some other money saving tips:

- If you move into a community with a large number of podiatrists, investigate group discounts on certain office supplies/equipment.

- At first, unless you are buying an existing practice, you could easily lower expenses by using just one exam room.

- Don’t buy things such as specimen containers, culture swabs, biopsy kits, etc. that you can get from the hospital or lab. They often give you these just for using their services. Consider using pathology labs that are podiatry friendly, most if not all will give you supplies for free.

Should I lease or purchase equipment? Depending on how your accountant has set up your practice, there may be advantages to both leasing and buying, for example, deducting the lease from your taxes verses writing off the depreciation after buying the equipment. These types of situations are best discussed with your accountant on an individual basis. It’s important to keep abreast on matters regarding your business. The new practitioner should read business journals, join the local small business bureau and take business courses. Please remember to support the APMSA 2011-2012 Corporate Advisory Board listed on page 10.

It’s In Our DNALanger Biomechanics, Inc. would like to congratulate the class of 2011; we wish you great success in your upcoming residencies and future endeavors. Langer has been developing, manufacturing and distributing the highest quality, most innovative lower extremity products for over 40 years. We are excited to form fruitful and meaningful partnerships with the promising future of the podiatric community.

InnovationQuality

Education

Placing your trust in Langer is good for your patients and good for your practice. Let us show you why.

Call 800-645-5520 today for more information or to have an Account Specialist contact you.

Biomechanics

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Top Ten Ways to Improve Exam Room Efficiency

1. Place a minimum of two chairs in the exam room for individuals accompanying the patient to create a consultative environment.

2. Reverse hinge the exam room entry door to create a visual barrier to hallway traffic for

patient privacy. 3. Replace box-style examination table with high efficiency, high-low power tables that are

patient accessible and staff friendly. 4. Place the examination table on an angle to maximize the visualization and lighting

between you and the patient. 5. In consideration of the Americans with Disabilities Act (ADA) Guidelines, exam rooms,

hallways, exits and bathrooms should accommodate wheelchairs. 6. Store diagnostic devices and hazardous waste receptacles to the left of the patient,

making them more accessible to the podiatrist and less accessible to patients. 7. Incorporate a “pull-out writing surface” into the casework/cabinetry and create an

“instant” desk when documenting patient records. When not in use, this preserves valuable floor space.

8. Place sinks in the corner of the room to minimize inadvertent splashes and maintain

cleanliness of countertops. 9. If EMR or computer access is involved, incorporate a desk workstation with a side chair.

This allows the podiatrist to maintain eye contact with their patient during the medical record taking process.

10. Replace wooden casework with seamless, non-porous casework designed for the

medical environment. Its durability and ease of cleanliness will last the life of your practice.

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Office Furnishings and Supply Costs

The items listed below are estimations and do not specify companies, brands, or exact prices. Waiting Room Chairs (6 seats at $200) $1200 Coat Rack 100 Table(s) 450 Plants 125 Mural/Prints 175 Waste Basket 25 Magazine Subscriptions 25 Private Office for Doctor Desk, Chair, Mat 700 Bookcase 275 Chairs (2) visitor 300 Waste can 25 Computer 500 Reception Area/Business Office/Nurses Station Computer and Basic Software $7500 File Cabinets (2) 500 Lateral File 600 Desk, Chair, Mat 700 Waste Can 25 Sound System with Ceiling Speakers 300 Stationary 450 Charts, Stationary 500 Refrigerator 100 Miscellaneous Supplies 250 Copier/Fax/Scanner/Printer (Consider separate Devices) 1500 Card Scanner 100 Consider EMR (Medicare Incentive) 15K -20K

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Medical Equipment for the New Practitioner The items listed below are suggestions and do not specify companies, brands, or prices. However, approximately $35,000 is estimated for initial medical equipment cost. Podiatry chair Casting table Instrument cabinet Doctor's stool (2) X-ray unit Exam light Light handle Autoclave Cast cutter, spreader Stainless steel basin Mayo stand Oxygen tank Tuning fork Percussion hammer Ultrasound unit Electric cautery Alcohol dispenser Waste cans (2) Sani-Grinder (optional) Heat-blo gun X-ray processor, film, cassettes (3), film bin, developer, fixer, marker and labels Darkroom light View box Lead apron Darkroom timer Lead film blocker Iodine solution and ointment Surgical masks and gowns Sterile surgical and non-sterile examination gloves Scrub brushes Autoclave sheets, tape and pouches Autoclave tape Sharps containers Syringes, syringe needles Surgical blades and handles Forceps Nail splitters Skin hooks Needle holders Bone rasps Hemostats Bone curettes Surgical, moleskin, felt, and bandage scissors Nail nippers and drill Burs Dust extractor

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Steri-strips Sterile drapes Phenol Antiseptics Tractograph Surgical shoes (post-op) Casting supplies (plaster, fiberglass) Cast shoes (Med-Surg Shoes, CAM walkers) Cast padding

Bandages (Kling, Coban, gauze, Adaptic, Kerlix rolls, 4x4’s etc.) Cotton tipped applicators Stockinette Alcohol preps and Skin Preps Tape (paper, nylon, elastoplast, athletic, etc.) Band-Aids Wound Care Supplies (consider 5 major dressing types) Hand mirrors for patients to observe their feet

Suture Plastizote Corex Cement Palliative care supplies (moleskin, felt/foam pads, sleeves, etc) Pre tape Unna boots Hemostatic agent Ammonia ampules Alcohol Local anesthetic Ethyl chloride Paper towels Educational board Utility jars

OTC Items for Resale (Orthotics, Creams, Lotions, Pads) Miscellaneous- (snacks for diabetic patients, thermometers, glucose measuring devices, blood pressure cuffs and scales) Consider going high tech! This route removes all dark room and dark room supplies, digital radiography saves time and supplies and will pay for itself quickly with efficiency. It removes all paper goods associated with a charting, EMR software is affordable and with the Medicare Incentive program over the next 5 years there is no reason not to go paperless.

IX.Durable

Medical Equipment and Orthotics

Congratulations to the Class of 2011!

Best wishes and continued successas you enter the podiatric profession.

On behalf of these generous supporters,congratulations to the class of 2011.

Advanced Foot CareIra Kraus, DPMFort Oglethrope, GA

A liated Foot and Ankle CenterAlison DeWaters, DPMHal Ornstein, DPMHowell, NJ

A liates in Foot CarePeter Paicos, DPMLieke Lee, DPMStoneham, MA

Terence B. Albright, DPMNorth Chicago, IL

Joe Caporusso, DPMMcAllen, TX

Columbia Foot and Ankle AssociatesStephen D. Palmer, DPMRoss E. Taubman, DPMClarksville, MD

R. Dan Davis, DPMBridgeport, CT


Joy and Glenn Gastwirth, DPMPotomac, MD


� omas S. Godfryd, DPMBirmingham, AL

Eric R. Hubbard, DPM, MS.ed.Long Beach, CA

Mike King, DPMFall River, MA

Jay D. Lifshen, DPMIrving, TX

Nancy L. Parsley, DPMNorth Chicago, IL

Marlene Reid, DPMWestmont, IL

Christian A. Robertozzi, DPMNewton, NJ

Seth Rubenstein, DPMReston, VA

Brian P. Spencer, DPMGrove City, PA

Frank Spinosa, DPMShelter Island, NY

Kathleen Stone, DPMGlendale, AZ

Phillip E. Ward, DPMPinehurst, NC

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Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS)

Durable medical equipment has become an integral part of podiatric practice. Orthotic devices lead the way in podiatric DME usage due to our extensive training in biomechanics and diabetic foot complications. Other DME devices serve in our many treatment protocols to improve care and increase practice revenue. DMEs are considered an item of medical equipment owned or rented that is placed in the home to facilitate treatment and/or rehabilitation. DME generally consists of items that can withstand repeated use and are primarily used to serve a medical purpose, and are usually not useful to a person in the absence of illness or injury. Below is a list of DME common to podiatric medicine:

� Ankle Braces � Walking Boots � Night Splints � Extra Depth Shoes/ Therapeutic Shoes � Heat molded, non custom orthotics � Custom orthotics � AFOs � Some wound dressings

When submitting claims to Medicare for DMEs, be sure you are using your “National Provider Identifier” (NPI) number and your name (or the NPI/name of a provider in your group practice) as the referring/ordering physician for your claim. As new practitioners, you should already be listed in the “Provider Enrollment, Chain, and Ownership System” (PECOS) database because you were enrolled in Medicare after 2003. However, it is still a good idea to verify you are in the database: https://pecos.cms.hhs.gov/pecos/login.do. You may also receive warnings/notifications on DME claims if your NPI is not correctly linked to your Medicare profile or if the spelling of your name (must be in all UPPER case letters) in Box 17 of the CMS form does not match that of your NPI file. If you use an outside practitioner’s NPI number on your claim forms, you are implying that you are not providing DME for your patients and are serving as a commercial supplier. Due to very hard work on the part of the APMA, you, as podiatric physicians, are exempt from obtaining a surety bond or accreditation in order to supply DMEPOS. However, if you use an outside provider’s NPI/name you lose this benefit. In the event that you are unsure whether a DME is covered by a patient’s particular insurance, be sure to verify coverage by calling the patient’s insurance company or advising the patient to do so. Additionally, a patient’s insurance may cover a particular DME, but they may owe co-insurance, a co-pay, or they may not have met their deductible. Knowing this ahead of time can save you many headaches. Keep in mind that many HMOs will not reimburse you for DMEs and the patient may need to be sent to an outside supplier. Additionally, you will probably not be reimbursed for DMEs dispensed to skilled nursing facility patients and such patients should be given a prescription for an outside distributer as well. Medicare does not reimburse for all DMEs. In order to bill the patient for DMEs that are not covered by Medicare, your patient needs to fill out and sign an “Advanced Beneficiary Notice of Non-coverage” form (ABN). The latest ABN form can be found on the CMS website. When an ABN form is used, a “GA” modifier needs to be included

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with the DME code. Medicaid/Public Aid will not reimburse you for DMEs either, and such patients should be sent to an outside supplier. However, do not be discouraged! Many insurers do reimburse for DME and this can be a profitable part of your practice. As a prescribing practitioner, you should contact your local insurance carriers, www.cms.gov (Centers for Medicare & Medicaid Services), or www.APMA.org to verify billing codes, regulations, guidelines and fees relevant to your geographic area.

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In-Office Dispensing

In-office dispensing is selling products within your office to patients. There are significant benefits for your patients to have products available in your office. Primarily, that your patient is saving a considerable amount of time not having to make trips to one or more stores, with the possibility of the product being out of stock or backordered. This is a value-added service patients appreciate and compliance is also significantly improved. Patients should read printed instructions before you dispense and have the product in hand when possible. A professional can answer questions and explain its use. Patient satisfaction is improved when consumers perceive your office as one that focuses on the needs of patients and provides the additional service of in-office dispensing. It is important in the presentation of these products to make it clear that your patients deserve the best and that is what you are providing. That being said, make sure you truly believe in the product that you are selling. This is also a very profitable source of income. Patients return to your office to re-purchase a product, keeping your patient population in frequent contact. If a patient is very satisfied with a product, he/she may refer patients to your office. Not only does your profit margin increase in this manner, but the constant stream of people in and out of your office can very well lead to an increased patient population. How do you begin? Many practices with very successful in-office dispensing programs employ a technique known as “passive marketing”. Patients are never told that they have to purchase a product. Instead a statement is made such as, “Mrs. Smith, you really need to use a skin moisturizer on your feet twice a day”. Her response is usually, “Can you recommend one for me?” With this response, your door of product opportunity flies wide open. The idea is to have your patients exposed to various products in several ways throughout your office. Some offices will have binders available for patients to review information on the doctors, the staff, the services offered, and a section on foot care products. The section on products shows what is available and outlines common uses. You can hang a sign in your waiting room as an added reinforcement stating, “We carry several products such as pads, arch supports, skin moisturizers, ankle supports and healing products in our office for your convenience.” Many offices have had success with a small display in the reception area showcasing available products. Try negotiating complimentary display cases from vendors. Patients often ask at the front desk about which product they should use. Your staff should be trained in “non-selling” and instructed not to push a product. Inform the patient that similar products can be found in the pharmacy, but these are available for purchase in your office if they prefer. With the advent of digital photography, it is easy to create a collage of your products and have them enlarged and framed for each treatment room. Patients’ curiosity as to the use of the products will lead to increased sales. This also increases patient satisfaction through providing solutions to their problems. Be sure to let your patients know that they can stop in at anytime to purchase products. During follow-up visits, be sure to ask if the products are being used and with the prescribed frequency. Discuss any improvements noted with use of the product. Offer additional product if the patient is running low. The key is the soft sell. Convey to your patients that this is not the focus of their visits, but simply a component of the treatment plan.

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Acceptance of a product is greatly enhanced by relating to a patient how popular the particular product is among your other patients with similar or identical conditions. Make it clear that if they want to return the product for any reason, they will be given a full refund without question. It is rare that a patient will ask for a refund or request a replacement. You should consider not assigning any time-frame for this offer. If patients come back six months after obtaining a product, gladly refund their money. Many vendors will issue a replacement product as well. When visiting the offices of referring physicians, bring some products that would be appealing to their staff. Simply let their staff know that you have found these products to be of great benefit to patients and you would like to provide these gifts for them to try. Again, present the products simply as part of your treatment plan for the particular condition you are discussing. The Holidays also provide a prime opportunity for you to assemble a basket of products for the referring doctor and staff to try. As mentioned above, do not be fooled by misconceptions regarding patients. They are willing to spend any money necessary to improve their health. It is your job as the specialist to inform them of the products that are necessary for their well being. In order to convince your patients that you know what is in their best interest, you must speak in a manner that is confident. Your job as a physician is to gain this trust by giving the patient what they need to feel better and reinforcing the importance of your treatment plan. Therefore, if you find yourself in a practice rut, consider expanding the service base of your business. Start by evaluating where you are today. Keep a running list for one month of all of the patients that you send out of your practice to buy products from others. Go through that list and decide which of those products you think you could effectively bring into the practice. Approach it slowly, building one product or service expansion on top another. Each success will lead to greater confidence and patient satisfaction. If you decide to dispense, take time examining and using the products available. Ask a few patients to test them as they are generally willing to provide “market research” such as skin moisturizers, keratolytics, antifungal preparations, pain relieving creams/gels, wart therapies or pre-fabricated orthotics. Visit local pharmacies and supermarkets and explore their foot care areas to see what is readily available to patients. Pay close attention to podiatric product advertisements, so you can offer a full array of foot care products. Pricing is completely up to you. Products can be sold at cost or for profit. If you are selling products at cost, be sure to factor in your shipping expenses. Non-covered services such as in-office dispensing should be looked upon as a positive aspect of the practice. Confidence makes all the difference! Oftentimes, practitioners are non-definitive with respect to their treatment recommendations. Do not hesitate to offer your patients a product that will help.

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Orthotics in Your Practice

As the health insurance industry in this country continues to change and challenge every practicing physician, it is important to solidify those services that are unique to podiatry. Many of our patients who need orthotic therapy must choose to pay out of pocket or go without the device all together. It is up to each practitioner to provide the necessary information for the patient to make an educated decision about the proposed orthotic therapy. 100% Satisfaction Guarantee: As a practitioner, you may consider providing this guarantee to your orthotic therapy patients. This is especially beneficial for patients for whom insurance does not cover orthotic therapy. Such a guarantee immediately relieves apprehension about parting with large sum of money. Rarely will a patient request a refund. More than likely, patients will be more inclined to purchase the device because there is no financial risk. Follow Up Visits: It is important to stress to patients that the orthotics alone cannot treat all their future foot maladies and they require periodic follow-up exams to assure optimum function of their orthotic devices. Using the analogy of prescription eyewear that requires eye examination at regular intervals to disclose any changes in vision can help a patient understand the need for regular follow up foot examinations to detect any biomechanical changes. Establish a follow up protocol for your patients. This may include a 3-6 week, 3 month, 6 month, and 1 year follow up. Consider sending out a letter to all patients 2 years after receiving orthotics to make an appointment for top cover replacement or orthotic adjustments. Many will respond to this letter and schedule an appointment. Second Pair Discount: Patients often need a second pair of orthotic inserts for their work shoes (heels, boots, dress shoe, etc). Most orthotic labs offer a discount for additional pairs of orthotics and passing the savings on to your patients is a great way to provide your patients with biomechanics care throughout each and every day along with building revenue. Logo: Many labs offer the ability to print a customized logo (your office name and number) on the top covers of the orthotics that you order. This is a marketing strategy that works well when patients are satisfied with their orthotic devices. Many patients will show their friends their inserts and those friends will see the logo. This may generate a new patient visit for your practice.

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Getting Started With Orthotics As an expert in biomechanics, it is essential to provide your patients with quality orthotics that suitably address pathomechanics and alleviate symptoms. Podiatric physicians are no longer the only practitioners prescribing orthotics. Generating a superior orthotic protocol will establish you as the biomechanics/orthotics specialist. SELECTING AN ORTHOTIC LAB Quality: There are many commercial laboratories that produce custom-made orthotics. Competition is fierce between these labs because they are all bidding for your business. As a new practitioner, you must make a wise choice in your selection of an orthotic laboratory. The product that you dispense to your patient is a direct reflection of you. Recognize orthotics as an investment made by patients to improve their health. Because they are often costly, the patient, and rightfully so, expects a high quality product. Some orthotic labs excel at producing certain types of orthotics over others. For example, Lab ABC might produce superior pediatric devices while Lab XYZ fabricates excellent cork-and-leather devices. Large vs. Small: Regardless of the size of the lab, you should receive excellent service. A smaller lab may offer a limited scope of materials and less orthotic options while a larger lab may offer a larger scope of therapies and more materials, but this is not always the case. Request catalogues to view material and device options. As a consumer, you should expect timely turnaround, prompt return of phone calls, and most importantly, a quality product. This can be achieved in either a small or large laboratory, as long as the lab is right for you and ultimately right for your patients Precision and Specificity: Any lab not compliant with the physician’s prescription should be avoided. When a device is not fabricated to your specifications, it does not reflect poorly on the lab, it reflects poorly on you, the practitioner, as you dispense the product. Making corrections to orthotics costs you time and money. Versatility and Spectrum: There is no such thing as a standard foot orthotic. Different pathologies require different foot orthoses. Be sure that your lab can handle several different types of orthoses. If one lab seems to excel at a certain type of device over others, it might be in your best interest to utilize a few different labs for your various orthotic needs. Make sure your lab is keeping up with advances in materials as this may lead to increased efficiency that can be passed on to you and it may improve the performance and longevity of the device. Prescription Forms: You should be comfortable with the components of your lab’s prescription form. If anything is not clear to you as to the jargon used, call the lab and ask for an explanation. It is better to measure twice and cut once! If the lab does not use carbon copies for its prescription forms,

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make a copy of the form to keep in the patient’s chart. Thus, if there is a discrepancy between what device you received and what was ordered, you have proof as to what you delineated on the form. Pricing: When choosing an orthotic laboratory, you must consider price and the determination of that price. Many factors are figured in when a product is priced such as, warranties, adjustments, delivery time, materials and labor charges. Do not assume that the most expensive or the least expensive company is going to be the best possible choice. Be sure to do "comparative shopping." Various accommodations, material changes, top cover lengths and postings are not always included in the set price of the orthotic and these can add up. Additionally, “pre-paid” shipping boxes are not always what they seem and you may be absorbing the shipping cost elsewhere. Rush deliveries will certainly affect pricing and if you are not happy with the lab’s typical turn-around and have to resort to “rush” services, you should probably select a different lab. Warranties: The lab that you choose should have some form of a warranty policy. Coverage should include craftsmanship and quality of the material used in the shell, accommodations, posts and top covers. You as the consumer and prescribing physician should demand that the quality of craftsmanship and materials last a reasonable amount of time under normal conditions of wear and tear. If they do not, they should be replaced free of charge or at minimal charge. Adjustments: When looking for the proper laboratory, you should try to find one that has a podiatrist on staff or at least available for consultation. This way you can maximize the use of this lab by making sure you order the proper orthotic for the pathology you are treating. Many labs will keep positive casts for a specified period of time in the event that a second orthotic is needed or if the existing orthotic needs to be sent back for adjustments. Thus, if you need adjustments or a second orthotic, you do not need to recast the patient. Alternatively, you can request that the positive cast be sent with the orthotics. A Good Orthotic Starts With You! To ensure that your lab receives a good representation of your patients’ foot in order to start the fabrication process:

1. Use two splints of plaster of Paris to cast the normal size adult foot and three splints to cast men's feet over size 12. Do not attempt to save money by skimping on splints as these casts may not survive the shipping process and can arrive deformed.

2. Allow casts to dry overnight prior to shipping. 3. Ship negative casts in a box with minimal packing material around them and do not ship

negative casts wrapped in plastic lined drapes. Over packing can prevent sufficient drying needed for the plaster in transit.

4. Do not forget to record the patient’s name on the cast! As you begin incorporating orthotics into your budding practice, be sure to make an effort to find a lab that is best suited to your needs and your patients’ needs. In conjunction with your own orthotic protocol, your care in choosing a laboratory with a quality product will ultimately aid in making your practice flourish.

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Orthotic Tips

1. Communicate with your patient in layman’s terms as to how orthotics can help them function and can alleviate pain. Be specific, but do not confuse your patient with biomechanics jargon.

2. Use illustrations or anatomical models demonstrating how the foot functions with and without

orthotics. Earn your patients’ trust by taking the time to attempt to educate them about their gait and mechanics and why orthotics are necessary.

3. Do not promise what you cannot deliver. Be positive about the outcome, but not unrealistic.

Do not place orthotics in a realm of a cure-all treatment. Educate your patient about what orthotics can and cannot do.

4. Realize that orthoses are not for everyone. Remind your patient (and yourself!) that in

medicine, solutions do not always exist. 5. Treat the patient’s chief complaint. If another abnormality is not related to his/her chief

complaint, do not treat it. You may create additional problems. 6. Make sure your patients know all of the possible negatives involved in getting into a new pair

of orthotics, such as difficulty in certain shoe gear, possible change in shoe size, the break-in process, etc. Most patients will be accepting of the downside to many treatments as long as they have been forewarned.

7. Do not have untrained staff cast your patients for orthotics. 8. Introduce your patient to orthoses slowly. Begin with padding and strapping in order to see

how they respond. 9. Make sure your patients know that orthotics, like eye glasses, only control their problem, and

do not cure it. 10. Be open and honest about the costs involved with orthoses. When it comes to children, take

the time to sit down and discuss future costs with the child’s parents. Many physicians offer replacement orthoses at cost for their pediatric patients.

11. Make sure that the patient is well educated to the use of orthotics. The patient should be

given a set of guidelines for the break-in process, maintenance, and appropriate shoe gear. This will help ensure the best possible outcome.

275

275

Making the Most of the Medicare Therapeutic Shoe Program

The Medicare Therapeutic Shoe Program represents a WIN – WIN – WIN opportunity for patients, podiatrists as well as Medicare. If qualified patients are correctly fitted with shoes and inserts, they stand a reduced chance of amputation and infection. Podiatric physicians can significantly add to their practice because qualified patients are covered for a new pair of shoes with inserts each year. Follow current Medicare guidelines for application to dispense therapeutic shoes. Visit www.cms.gov. The following are suggestions on how to streamline shoe fitting in your office: One person in charge of orders from start to finish It works best when one person sees orders through from start to finish. There are many steps in ordering and dispensing shoes including, the fitting of the shoes, ordering the shoes, obtaining documentation from the PCP, logging in shoes, contacting patients for pick-ups, billing Medicare, and returns. If several people are involved, make sure you establish a check-off system for the process. Use a “fitting set” of try-on shoes Stocking a small number of shoes in select sizes will decrease the guesswork in fittings associated with using a measuring stick or Brannock device. We all know there can be discrepancies between sizes among styles and brands. Utilizing a small sizing inventory will improve fit rates. Establish an annual system Medicare covers new shoes and inserts for qualified patients each calendar year. Send patients reminder letters about the importance of replacing well worn shoes and inserts. Verbiage should not direct patients to simply come in for a new free pair of shoes. Establish a reminder system for those patients who return regularly for routine care so as to remind you and the patient that they are eligible for a new pair of shoes and inserts. Shoe samples Nothing works as wells as “what you see is what you get.” Shoe manufacturers are doing a better job of creating aesthetically pleasing shoes. Display shoe samples in your waiting room and be sure to show patients exactly what you are ordering. Some patients who do not qualify for the Medicare program may be inclined to pay out-of-pocket for shoes. Advertise Therapeutic shoe companies can provide you with well designed advertisement layouts that can be customized to your office. Remember that you should not describe the shoes as “free” and you must verify eligibility before guaranteeing Medicare coverage. Present appropriate shoes Limit the number of styles you offer to your patients. Choose styles that are appropriate for that particular patient so as not to overwhelm them with several options, some of which may not be suitable for their particular pathology. Again, show actual shoe samples to avoid any surprises when the patient receives her new shoes.

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276

Know when to use custom shoes Approximately 10 percent of patients have therapeutic needs that exceed what is possible with extra depth shoes and are most appropriately addressed with custom molded shoes. Such conditions include Charcot deformity and partial foot amputations. Either cast these patients for molded shoes or refer to another podiatrist, pedorthist or orthotist/prosthetist. Confirm received orders are correct Your designated shoe staff member should check in all received orders and verify the style, size, and color. This allows you to send incorrect orders back rather than making this discovery when the patient is in your office during the fitting. Return improperly fitted shoes immediately The whole reason we order shoes for our patients is to ensure a good, proper fit. If the shoe does not fit the patient, send them back immediately and reorder the proper shoe. Do not allow the patient to return home with an ill-fitting shoe as this may lead to foot problems and the manufacturer will likely not take back a used shoe. Patient education handouts Go over the shoe break-in process and give the patient written information regarding same. Have your patients sign an acknowledgement that they received and understood the break-in process. Dispense the Medicare Supplier Standards for the shoes and document that you have reviewed these with the patient. Documentation PCP Statement, DPM note or prescription, invoice from vendor, copy of signed certificate of delivery, and acknowledgment of break-in instructions and patient satisfaction. Make sure the shoes fit before heat molding inserts Prefabricated inserts can be returned to most shoe companies for a full refund as long as they are sent back in the condition that they can be dispensed to someone else. Ensure that the shoe fits before heat-molding the inserts because heat-molded inserts cannot be returned. Do not write the patient’s name on the shoe box Use an adhesive, removable note to record the patient’s name and stick it to the shoe box. If the shoes need to be returned, a shoe box with writing on it will have to be replaced and this cost may be passed on to you. These suggestions will improve your ability to accurately fit patients and make valuable and easy use of the Medicare Therapeutic Shoe Program. For additional information visit www.apma.org or www.cms.hhs.gov/medlearn.

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APMSA 2011 New Practitioner’s Guide

Index of Advertisers

The APMSA extends its appreciation to its advertisers: corporate, organizational, and alumnus for their generous support. The APMSA encourages you to support our advertisers and to utilize the enclosed valuable coupons. Blue companies denote APMSA CAB members.

280

APMSA 2011 New Practitioner’s Guide Index of Advertisers

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Gordon Labs 14 Histology Associates 57 Hygenic Corporation/Performance Health 26 Langer Biomechanics 259 Merz Pharmaceuticals, Inc. Cover Moore Medical Corporation 278 New Balance 5 New Jersey Podiatric Medical Association 45 New York College of Podiatric Medicine 225 Officite, LLC 210 Ohio College of Podiatric Medicine 260 Pedinol 117 PICA Group Cover Present eLearning Systems 52 ProLab Custom Orthotics USA 2 Promet Custom Labs 170 Rockwood Programs, Inc. 118 RX Sorbo Performance Insoles 129 SAS Shoemakers 6 Scholl College of Podiatric Medicine 186 Spenco Medical Corporation 8 Stable Step/Power Step, LLC 185 Straight Arrow Products 207 Swede-O, Inc. 107 Temple University 80 Upsher-Smith Laboratories 157 Western University of Health Sciences 174

Now that you have completed your residency, you are responsible for .

A.) Taking a long, leisurely vacation.

B.) Having a life again.

C.) Making sure you have the proper malpractice insurance coverage before you see a patient.

Podiatry Insurance Company of America (PICA) was founded by podiatrists, for podiatrists over 30 years ago. PICA is podiatry-focused and the nation’s top podiatric malpractice insurance provider. We are endorsed by APMA and offer generous new practitioner discounts. PICA, however, cannot provide accommodations for a long vacation or assist you with your social calendar.

One Last Quiz

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Please see adjacent page for Full Prescribing Information1 RITA. Research and Innovative Technology Administration, Bureau of Transportation Statistics.http://

www.transtats.bts.gov/Oneway.asp? Display_Flag=0&Percent_Flag=0. Accessed Aug 24, 2010.


IndicationNaftin® (naftifine HCl 1%) Cream and Gel are indicated for the topical treatment of tinea pedis, tinea cruris and tinea corporis caused by Trichophyton rubrum, Trichophyton mentagro phytes, Epidermophyton floccosum and Trichophy ton tonsurans (Gel only).








Rx ONLY

INDICATIONS AND USAGE: Naftin® Cream, 1% is indicated for the topical treatment of tinea pedis, tinea cruris, and tinea corporis caused by the organisms Trichophyton rubrum, Trichophyton mentagrophytes, and Epidermophyton floccosum. Naftin® Gel, 1% is indicated for the topical treatment of tinea pedis, tinea cruris, and tinea corporis caused by the organisms Trichophyton rubrum, Trichophyton mentagrophytes, Trichophyton tonsurans*, Epidermophyton floccosum*.

* Efficacy for this organism in this organ system was studied in fewer than 10 infections.

CONTRAINDICATIONS: Naftin® Cream and Gel, 1% are contraindicated in individuals who have shown hypersensitivity to any of their components.

WARNINGS: Naftin® Cream and Gel, 1% are for topical use only and not for ophthalmic use.

PRECAUTIONS: General: Naftin® Cream and Gel, 1%, are for external use only. If irritation or sensitivity develops with the use of Naftin® Cream or Gel, 1%, treatment should be discontinued and appropriate therapy instituted. Diagnosis of the disease should be confirmed either by direct microscopic examination of a mounting of infected tissue in a solution of potassium hydroxide or by culture on an appropriate medium.

Information for patients: The patient should be told to:1. Avoid the use of occlusive dressings or wrappings unless otherwise directed by

the physician.2. Keep Naftin® Cream and Gel, 1% away from the eyes, nose, mouth and other

mucous membranes.

Carcinogenesis, mutagenesis, impairment of fertility: Long-term studies to evaluate the carcinogenic potential of Naftin® Cream and Gel, 1% have not been performed. In vitro and animal studies have not demonstrated any mutagenic effect or effect on fertility.

Pregnancy: Teratogenic Effects: Pregnancy Category B: Reproduction studies have been performed in rats and rabbits (via oral administration) at doses 150 times or more than the topical human dose and have revealed no evidence of impaired fertility or harm to the fetus due to naftifine. There are, however, no adequate and well-controlled studies in pregnant women. Because animal reproduction studies are not always predictive of human response, this drug should be used during pregnancy only if clearly needed.

Nursing mothers: It is not known whether this drug is excreted in human milk. Because many drugs are excreted in human milk, caution should be exercised when Naftin® Cream or Gel,1% are administered to a nursing woman.

Pediatric use: Safety and effectiveness in pediatric patients have not been established.

ADVERSE REACTIONS: During clinical trials with Naftin® Cream, 1%, the incidence of adverse reactions was as follows: burning/stinging (6%), dryness (3%), erythema (2%), itching (2%), local irritation (2%). During clinical trials with Naftin® Gel, 1%, the incidence of adverse reactions was as follows: burning /stinging (5.0%), itching (1.0%), erythema (0.5%), rash (0.5%), skin tenderness (0.5%).

G E L C R E A M

Manufactured for Merz Pharmaceuticals, Greensboro, NC 27410© 2010 Merz Pharmaceuticals Rev 3/10

BRIEF SUMMARY

2 0 1 1APMSA

NEWPRACTITIONER’S

GUIDE


1 RITA. Research and Innovative Technology Administration, Bureau of Transportation Statistics.http://www.transtats.bts.gov/Oneway.asp? Display_Flag=0&Percent_Flag=0. Accessed Aug 24, 2010.


IndicationNaftin® (naftifine HCl 1%) Cream and Gel are indicated for the topical treatment of tinea pedis, tinea cruris and tinea corporis caused by Tricho-phyton rubrum, Trichophyton mentagro phytes, Epidermophyton floccosum and Trichophy ton tonsurans (Gel only).



Please see adjacent page for Full Prescribing Information





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Com

plet

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lad

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ses.

Plea

se ty

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prin

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Podi

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PMA

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ill fo

rwar

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copy

of

you

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licat

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to th

e ap

prop

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st

ate

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pone

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Am

erican Podiatric Medical A

ssociation9312 O

LD

GE

OR

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TO

WN

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AD

BE

TH

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A, M

D 20814-1621

POSTA

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BY AD

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IF MA

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IN TH

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BU

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