Technology Terror: It Never “Just Works”

By Byron Harrison of Jackson Thornton Technologies

I hate technology!   Why do we have to use this!?   I want to go back to the old way!

I have heard these comments time and time again in my position as an IT Consultant.  Individuals and businesses as a whole have historically seen technology as a necessary evil; something that cuts into their profits and does not help their business perform any better.  Further, and especially in the accounting, legal, and medical industries, the government is pushing technology down the throat of companies whether they want it or not.  Needless to say, perception of technology is oftentimes poor.

And who can really argue this point?  For such a long time information technology was limited to either that which was forced on you in your workplace or that expensive new home theater system with a 200 button remote that no one seemed to know how to use.  But the good news is that it was just that, perception, and not necessarily the technology itself.  In fact the technologies were and are quite remarkable but the negative connotations including cost, poor implementation, lack of training and complexity all led to negative perceptions.

All that said, over the past 2-3 years there has been an active shift in the perceptions of technology.  It is my opinion that this is a result of extreme popularization of consumer technologies that are actively making peoples’ lives better.  Technologies like Skype, iPads, Netflix, GPS, and SmartPhones, just to name a few, are changing perceptions.  It’s no secret that these technologies are older than 2-3 years, but what has changed during this recent period is the simplicity of these technologies and the fact that “they just work.”   As proof in point, my grandmother of 87 years asked me what my “Skype name” was last week.  That hit home.

As a result of consumer grade technology drastically improving in capability and simplicity, and people actively seeing it as a way to improve their lives, positive perceptions are spilling over into the workplace.  Instead of me, the IT consultant, showing a doctor how an EMR feature can improve their patient flow, I have doctors coming to me with ideas on how a tablet device they saw on the news last night might fit into their practice.  This is great news and has positively impacted countless businesses as they begin to embrace technology.

And while this effect has also improved my quality of life as an IT consultant, it does present an unwanted spillover.  The “it just works” factor does not simply apply to business class technologies like it does for consumer grade devices.  While consumer grade technologies are largely self-contained, the business class technologies have an incredible number if pieces that must perform flawlessly for the “it just works” factor.  For example, video chatting with Skype really just needs some battery life, a working iPad and a connection to the internet.  Not too much can go wrong.  However take that iPad to your medical practice for use with an EMR and it needs an application to connect to the EMR, a strong and secure wireless infrastructure, high performing EMR server(s) that are redundant and backed up regularly and the list goes on and on.  If any of these pieces are missing then failure results and perceptions are ruined once again.

So while there is a significant improvement in the perception of technology, there is a disconnect with respect to the perception of the management, planning, and implementation of that technology in the workplace.  Navigation of this terrain gets difficult.  The “Nerd Herd” can rarely solve business infrastructure needs or achieve the “it just works” factor as they can with consumer grade technologies.

In summary, as you continue to improve your business and make those critical decisions, ask yourself if you have used the following comments in the past 12 months:  I hate technology!   Why do we have to use this!?   I want to go back to the old way!   If you have, then an opportunity exists to leverage technology in a more cost effective, efficient, and “it just works” way.  Just remember, in order for technology to be an enabler in your business, managing that technology and the accompanying perception is key. 

New Options for Surgery in Women’s Health Available at Trinity Medical Center: da Vinci® Robotic Surgery Reduces Pain, Recovery Time

By Robert A. DeSantis, MD, FACOG

a da Vinci surgeon and Board Certified OB/GYN at Trinity Medical Center

Hysterectomy remains one of the most common surgeries performed in the United States today, second only to cesarean sections.  This procedure is performed for numerous conditions including endometriosis, uterine prolapsed, fibroids and cancer. 

While the majority of hysterectomies are still being performed by making a large incision in the abdomen - resulting in a large scar, increased pain, and extended time away from work while recovering - there is another option. 

New advancements with the da Vinci® surgical system provides patients and physicians with a minimally invasive approach that shortens hospital stays (less than 24 hours in most cases), recovery time, and time away from work.  Other potential benefits over traditional surgery include less pain, less blood loss, lower risk of wound infection, less scarring and fewer complications.

Compared to traditional laparoscopy, the da Vinci Robotic Surgical System provides us with enhanced capabilities and offers high definition 3D views with 12 times the magnification.  Any procedure that I would have normally performed through a traditional large incision on the belly can now be done with the da Vinci® using a one to two centimeter incision.

Don’t let the term “robot” scare you.  The system cannot act on its own; the surgeon is always in control of every move.  The robotic technology allows the surgeon to sit at a console viewing the procedure through a 3D image.  The surgeon’s fingers grasp the master controls below the display and the system translates the surgeon’s hand, wrist and finger movements into precise, real-time movements inside the patient.

Regarding gynecologic conditions, hysterectomy is the most common procedure I perform using the da Vinci® system. And I, along with other experienced surgeons, have taken the procedure beyond the basics.  I have also used the da Vinci® for endometriosis surgery, pelvic organ prolapse, ovarian cystectomy (cyst removal), tubal reversal in women who have undergone sterilization and desire reversal, myomectomy (removal of fibroid tumors from the uterus with preservation of the womb), and trachelectomy (removal of the cervix in women who have previously undergone a supracervical hysterectomy).

I trained on the da Vinci® system in 2007 and have now done over 300 cases.  Prior to becoming a da Vinci surgeon, I was performing approximately 50 percent of my hysterectomy cases open.  Over the past 36 months, my open rate is <1% for hysterectomy and <5% for all gynecologic surgery.  A recent study comparing da Vinci®, traditional laparoscopy and open abdominal hysterectomies was released and the operating time in the hands of an experienced da Vinci surgeon was shorter, blood loss was 50 percent less than traditional laparoscopy and 75 percent less than open, and the average hospital stay was 1.1 days compared to 1.6 for traditional laparoscopy and 5 days for open.

Although individual results may vary, I have had patients return to work within one week after hysterectomy, and I even had one patient return after one day.  Interestingly, 20 percent of patients who underwent an attempted hysterectomy with traditional 2D laparoscopy required open surgery to complete the case compared to 4 percent of those who underwent da Vinci surgery.  The system allows me to treat patients with more advanced benign disease including significantly enlarged uteri (due to fibroid tumors) and pelvic adhesive disease and scarring (due to severe endometriosis and/or prior pelvic surgery). 

I, along with my partners J.C. Brock, MD and Andrew Lemons, MD, now provide this state-of-the-art surgery at the Alabama Robotic Institute at Trinity Medical Center.  For more information about the da Vinci Surgical System® at Trinity Medical Center please call 592-5499 or visit www.trinitymedicalonline.com.

Chronic Sinusitis

By Sheldon Black, MD of ENT Associates of Alabama

What does it mean when someone says they have “sinus”? Most of the time, these patients have chronic sinusitis. This is often not a bacterial infection, but instead an inflammation or swelling of the lining of the sinus cavities. Treatment usually starts with steroid nasal sprays and nasal irrigations, but can include surgical intervention. Your doctor can diagnose this with good examination and CT scans of the sinuses. Do not just live with your “sinus”. It can be helped.

Judge Poole Rules Against Trinity Digital Hospital

By Steve Spencer

Montgomery County Judge Jimmy Pool has ruled against allowing Trinity Medical Center to move its operations to the Digital Hospital campus on Highway 280.

This decision is a big surprise, given that there have been five rulings by Alabama judges and the Alabama Certificate of Need Board that approved the move.

Trinity issued a statement saying they will appeal the decision to the Alabama Court of Civil Appeals and will seek their expedited review.

Practice-Based Research Affords Patients Additional Treatment

By Diane Paige, RN with Clinical Research Center of Alabama

Mr. Smith’s worsening COPD has left him unable to work or enjoy activities with his grandchildren. His doctor has prescribed multiple medicines, often expensive, rarely effective. Mrs. Jones has been to several doctors, and no one can find an effective treatment for her chronic hives. She’s tried this pill and that cream, enduring side effects with little or no relief. Little Johnny’s asthma keeps getting worse. His single mom struggles to afford the medicines he needs, and nothing currently available has worked. What do these tree patients have in common? They have all benefited from community practice-based clinical research.

The NIH Roadmap for Medical Research has prioritized the expansion of the community-based physicians’ role in facilitating the dissemination of evidence-based medicine. Practice-based research occurs in the office, where most patients receive the majority of their care and may be the essential link between bench discoveries, bedside efficacy, and everyday clinical effectiveness.

 A clinical trial may afford patients additional treatment options-beyond standard care-that are on the cutting edge, and at no cost. While delivering improved patient care, doctors, nurses, and research coordinators have the opportunity for professional development, acquiring expertise in therapeutic areas of interest as well as continuing medical education, training, and additional credentialing. Offices that incorporate research into their practice report higher levels of personal satisfaction amongst their staff. Conducting trials is also an excellent vehicle for practice growth while providing a new revenue stream.

Ultimately, office based clinical research is universally beneficial for patients and providers alike, and the future for translating research in to practice.

How to make Real Estate a Valuable Part of any Medical Practice

By William Ledbetter of Harris Tynes Realty Group

In today’s uncertain medical environment, physicians and practices are looking at many approaches to maximize efficiency and performance while providing the best care possible to their patients.  While most of the practice’s efforts are reviewed and critiqued, many physicians don’t realize they have another partner involved in the daily operations of their practice.  Real estate is a contributor to each and every medical practice and can produce very positive, minimal, or sometimes negative results which have a direct correlation to the practice’s overall performance.  Thus each practice should examine their “silent” partner and ensure the real estate is producing maximum benefits for the practice and its patients.

Real estate can take on several different roles and affect practices in many different ways.  The two basic roles of real estate for a practice are to become either an owner (landlord) or to become a tenant.  The concept of both roles is simple, but the characteristics and details can be complex and confusing and should be analyzed and approached on a case by case basis.

When a practice purchases real estate to house their operation, the practice has made a fundamental choice to become a landlord.  This can affect the practice both positively and negatively.  A positive example could be that the practice has decided to start seeing patients outside of routine business hours.  The practice, as its own landlord, will sacrifice and absorb increased costs or resources used to operate the building to help the practice benefit from seeing patients at odd hours.  On the contrary, a negative could be derived from the same example above.  If the practice began seeing patients after hours, the landlord will have to sacrifice and absorb increased costs and resources spent to achieve the extended hours which could include security, maintenance, and personnel costs outside the costs associated with the normal operation of the practice.

Another aspect to consider when becoming an owner of real estate is from an investment standpoint.  Purchasing real estate can be expensive, especially in desirable locations within the market. Further, once a practice enters the market, they become a market participant and the asset is subject to supply and demand factors which cause increases or decreases in the price of the real estate.  Many owners have benefited from participating in the market over a long period of time. Purchasing real estate should be a long term investment with its performance measured over at least a 7-10 year timeline.  Typically, investment parameters outweigh operational concerns when dealing with real estate, and this could negatively impact a practice’s performance.

If a practice has concerns becoming a Landlord, leasing is a viable option to secure the real estate.  Some of the concerns could be the practice has a complex ownership structure and disagreement could exist or concerns of the risks faced from being an investor and market participant.  Real estate leases can take on a variety of identities, but for our purpose, we’ll consider two basic types: 1) a “Full Service Lease” & 2) a “Net Lease” or a “Triple Net Lease.”  A “Full Service Lease” is a lease agreement between a Landlord and a Tenant where the Tenant pays a premium rent, but the landlord is required to perform more services to accommodate the tenant.  These leases are typically found in larger, multi-tenant medical office buildings and office buildings.  A “Net Lease” is an agreement that defines the base rent required by the landlord and also defines and transfers the operational costs associated with the real estate to the tenant.  These leases are typically found in buildings where each tenant’s consumption of the operational costs can be easily defined.  For example, a tenant in a “Full Service Lease” agreement would not have to pay for its monthly power service in addition to the monthly rent, the service would be included.  On the contrary, a tenant with a “Net Lease” would have to pay for its monthly power service in addition to the base rent paid to the landlord.

While becoming a tenant can be construed with a negative reflection from an investment standpoint, it certainly has positives from the operational side of the practice.  Some of the costs and burdens faced with practices are passed along to the landlords and this allows practices to focus more resources to providing the best patient care possible.  Certainly, becoming an owner has its advantages as well.  Practices have more operational freedoms that allow for more customized patient care which could positively impact performance.

Each practice and physician should asses its own needs, requirements, and the objectives they would like to see their partner contribute.  For further information or help in analyzing your current position as it relates to Real Estate, please contact William Ledbetter at Harris Tynes Realty Group.

William Ledbetter

Associate Broker

Harris Tynes Realty Group Inc.

2001 Park Place North

Suite 580

Birmingham, Alabama 35203

(205)879-6366

wledbetter@harristynesrealty.com

www.harristynesrealty.com

Mid-Year Reality Check: Covering Your Bases in Uncertain Times

BY Patrick Cummings, CFP®, CRPC®, CLU®, ChFC®

Ameriprise Financial 

Imagine playing a complicated game, but the rules of the game are changing, and the new rules have yet to be announced. That's what income tax planning is like this year. In fact, if there was ever a year to spend some quality time with your financial professional, this is it. Here are a few items to discuss.

How will higher rates next year affect you?

Federal income tax rates are scheduled to jump in 2013, with the bottom (10%) rate disappearing, and the top rate increasing from 35% to 39.6%. Starting in 2013, high wage earners--those with wages exceeding $200,000 ($250,000 for married couples filing jointly and $125,000 for married individuals filing separately)--will also have to pay an additional 0.9% in the hospital insurance (HI) portion of their payroll tax, commonly referred to as the Medicare portion.

Could the current federal income tax rates be extended again? Of course, but it's far from a certain bet, and the odds are that any action would not take place until after the presidential election. That means any financial plan you put in place has to account for this uncertainty. And the uncertainty extends beyond just tax rates, because a number of popular tax breaks are also scheduled to expire at the end of the year, while others have already expired. So, any potential moves have to be considered in the context of several "what if" scenarios. For example, if you have the opportunity to defer compensation to next year, you have to really think about whether that makes sense, or if you would be better off paying tax on the income at this year's rates.

Potential investment moves

In addition to increased tax rates on earnings, the rates that apply to long-term capital gain and qualifying dividends are scheduled to increase in 2013. The maximum rate on long-term capital gain will jump from 15% to 20%. And while qualifying dividends currently benefit from being taxed at the rates that apply to long-term capital gain, in 2013 they'll be taxed at ordinary income tax rates. Also beginning in 2013, a new 3.8% Medicare contribution tax will be imposed on the net investment income of individuals with modified adjusted gross income that exceeds $200,000 ($250,000 for married couples filing jointly and $125,000 for married individuals filing separately). That means someone in the top tax bracket could potentially end up paying tax on some investment income at a total rate of 43.4%.

Potentially higher rates in 2013 could be a motivating factor in your investment strategy. For example, you might want to consider selling investments that have appreciated in value to recognize long-term capital gain in 2012, before the maximum rate is scheduled to increase. Alternatively, you might consider timing the sale of an investment to postpone the recognition of a capital loss until 2013, when it could be more valuable.

Roth conversions--is this the year?

If you've been on the fence about converting traditional IRA funds or pretax 401(k) contributions to a Roth account, you ought to give the matter one last hard look before the year ends. That's because when you convert a traditional IRA to a Roth IRA, or pretax dollars in a 401(k) plan to a Roth account, the converted funds are subject to federal income tax (to the extent the funds represent investment earnings, tax-deductible IRA contributions, or pretax 401(k) contributions) in the year that you make the conversion.

If tax rates go up next year, so will the effective cost of doing a Roth conversion. Additionally, qualified distributions from Roth IRAs and Roth 401(k)s are free from federal income tax. That could make a big difference in retirement if you're paying tax at a higher rate at the time. Whether a Roth conversion is right for you depends on a number of factors. If it makes sense for you, though, it might pay to think about acting now, rather than later.

Patrick Cummings, CFP®, CRPC®, CLU®, ChFC®

Financial Advisor | Vice President

CERTIFIED FINANCIAL PLANNER^™ practitioner

 "An Ameriprise Platinum Financial Services^® practice"

Ameriprise Financial

Ameriprise Financial Services, Inc.

1500 Urban Center Drive Suite 200 | Birmingham, AL 35242

Office: 205.967.2627 | Fax: 205.967.8021

Direct: 205.909.3119 | patrick.2.cummings@ampf.com

 www.ameripriseadvisors.com/patrick.2.cummings |  ameriprise.com

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We shape financial solutions for a lifetime^®

Ameriprise Financial Services, Inc. offers financial advisory services, investments, insurance and annuity products.  RiverSource^® and Columbia Management^SM products are offered by affiliates of Ameriprise Financial Services, Inc., Member FINRA and SIPC.

References & Resources:

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Supreme Court Upholds Federal Health Care Reform

By Lenora W. Pate,  Cynthia Ransburg-Brown, and Kelli F. Robinson of Sirote & Permutt

Supreme Court Upholds Federal Health Care Reform

On June 28, 2012, the U.S. Supreme Court issued its highly-anticipated opinion in National Federation of Independent Business v. Sebelius deciding the constitutionality of the Act.  By a 5-4 margin – with Chief Justice Roberts casting the deciding vote - the Court ruled that the Act’s highly-debated “individual mandate,” which requires most Americans to maintain “minimum essential” health care coverage or pay a “shared responsibility payment” (penalty) to the IRS, was not constitutional under Congress’ Commerce Clause power. 

Writing for the majority, however, Chief Justice Roberts creatively upheld the Act under Congress’ Taxing power, stating that “it is reasonable to construe what Congress has done as increasing taxes on those who have a certain amount of income, but choose to go without health insurance.”  Hence, what was written by Congress as an individual “mandate,” with a penalty, was converted by the Chief Justice’s creative construction to an individual “option,” with a tax on certain individuals who choose to go without health insurance.  The Chief Justice concluded that the financial “penalty” could be reasonably characterized as a “tax,” in part because “for most Americans the amount due will be far less than the price of insurance and by statute can never be more,” and “may often be a reasonable financial decision to make the payment rather than purchase insurance.” If, instead, the “tax” had been coercive, or so great that it would have compelled action, Chief Justice Roberts noted that it would have been an actual “penalty” and could not have been upheld under the Congress’ Taxing power.

The majority of the Court also ruled that the Medicaid expansion provisions of the Act, while constitutional, could not be forced upon the States by coercively threatening the loss of existing federal Medicaid funding if a State chose not to expand its Medicaid program to cover all adults at or below 133% of the poverty level.  While Congress may offer the States certain funding under its Spending power and require certain conditions relating specifically to such offer of funds, the States must, however, have a “genuine choice” whether to accept the offer.  Finding that the Medicaid expansion provisions could be severed without affecting the remainder of the Act, the Court, in its opinion, removed the coercive threat by prohibiting the Federal Government from withdrawing existing Medicaid funds from any State which chooses not to expand its Medicaid program.

While upholding the constitutionality of the Act, the Court, in essence, converted an individual “mandate” to purchase health insurance to an individual “option” with a tax on certain individuals if not purchased, and converted what was, in effect, a coercive mandatory Medicaid expansion on the States to an option by the States.  It is not clear what impact these two judicially created “options” will have on the overall goal of the Act of insuring all Americans, considering that the individual mandate and the Medicaid expansion provisions were considered key to achieving near universal health insurance coverage under the Act.  We can expect much cost benefit analysis, assessing the cost of coverage versus the limited tax, and the potential cost of expansion of Medicaid by the States, before the verdict is in on such impact!

What we do know, however, is that all of the other provisions of the Act are on track to move forward on what has now become an aggressive timetable, with numerous penalties, taxes and other incentives and disincentives embedded throughout the Act.   To learn more about the Act and its implications for individuals and employers, see Sirote & Permutt’s library of Health Care Alerts HERE. 

Background.  The suit challenging the Act was originally brought by two individuals, twenty-six (26) States, and the National Federation of Independent Business.  Two additional individual plaintiffs were added when questions arose as to whether the two original private plaintiffs had standing to challenge the Act.  In October 2010, the U.S. District Court for the Northern District of Florida invalidated the entire Act.  In August 2011, the U.S. Court of Appeals for the Eleventh Circuit agreed that the individual mandate was unconstitutional, but reversed and upheld the rest of the Act.  The U.S. Supreme Court agreed to review the case, and heard extensive oral arguments in late March 2012. 

The Court considered four central issues in its opinion:

1. Anti-Injunction Act.  The Court first considered whether the case was premature under the Anti-Injunction Act, a federal law requiring a taxpayer to first pay the tax assessment before he can challenge a tax’s legality.  The challenge before the Court involved collection of the “shared responsibility payment” from those who do not comply with the individual mandate, which will not be payable by anyone until 2014.  The Court decided that Congress did not intend the payment to be treated as a “tax” for purposes of the Anti-Injunction Act and noted that the Act describes the payment as a “penalty,” not a “tax.”  While the “penalty” label did not control whether the payment is a tax for purposes of the Court’s Constitutional analysis, it did determine application of the Anti-Injunction Act.  Therefore, the Court held that the Anti-Injunction Act did not bar this suit.

2. Individual Mandate.  The Court held that the individual mandate exceeded Congress’ power under the Commerce Clause and the Necessary and Proper Clause of the U.S. Constitution.  The individual mandate’s imposition of a penalty for failing to purchase health insurance was not commerce that could be regulated by Congress.  Although Congress has the power to regulate an existing business or activity, it does not have the power to regulate inactivity or compel the creation of a new business or activity or commerce.  Thus, the Court found the individual mandate to be impermissible and unconstitutional under the Commerce Clause, as well as the Necessary and Proper Clause of the U.S Constitution.

Five justices, however, agreed that the individual mandate “penalty” may reasonably be characterized as a “tax,” and held that Congress has power under the U.S. Constitution’s Taxing and Spending Clause to order individuals to pay a tax for failure to have health insurance.  According to the Court’s opinion, “the shared responsibility payment merely imposes a tax citizens may lawfully choose to pay in lieu of buying health insurance.”  Consequently, the Court upheld the penalty as a constitutional exercise of Congress’ power to tax.

3. Severability.  Because the individual mandate was in effect converted to an option with a tax and held to be constitutional, the issue of whether it could be severed from the rest of the Act was declared moot.

4. Expansion of Medicaid Program.  The Court ruled that Congress could not threaten to withhold all existing Medicaid funding from a State for failure to expand its Medicaid coverage under the Act, but noted that this threatened withholding could be severed from the Medicaid expansion provisions without otherwise invalidating the rest of the Act.  In essence, the Court determined that Congress cannot penalize States that choose not to participate in the expansion of Medicaid coverage under the Act by taking away their existing Medicaid funding. 

We will continue to monitor the effects of this important Supreme Court decision.

Sirote & Permutt’s Health Care Practice Group stands ready to assist you with any questions that you may have concerning PPACA.  For additional information, please contact Lenora W. Pate at 205-930-5162 (lpate@sirote.com), Cynthia Ransburg-Brown at 205-930-5389 (cransburgbrown@sirote.com), or Kelli F. Robinson (krobinson@sirote.com) at 205-930-5158.