January 17, 2020

William L. Coker, Jr, MD, Leslie R. Coker, MD

Associates in Dermatology, Inc.

Forty-six years ago, a dermatology practice was established on the Virginia Peninsula by Dr. William L. Coker, Jr.  He hadn’t planned to be a dermatologist, nor even a physician – he just wanted a career that would take him far away from the South Carolina tobacco farm on which he grew up.  “My dad was also a school teacher, but I didn’t want to do that either,” Dr. Coker says.  “I knew doctors were held in high esteem, so I thought I’d become a dentist.”  When his father developed rheumatoid arthritis, he reckoned that inheriting the condition would bode badly for a dentist, so he went to medical school.  His plan was to become a family doctor in a small town in South Carolina.  But, as he says today, “Plans go astray.”

‘Astray’ for Dr. Coker meant being drafted during his internship and deferred under the Berry Plan.  “I joined the Navy, and they asked me if I was interested in submarines,” he remembers, “so I said yes, thinking they’d send me information.  Instead, they sent me a notice to report to sub school.”

Two important things happened to Dr. Coker during this time: he met his future wife, the renowned artist Gloria Coker, and he worked in a dermatology clinic.  “I’d had no dermatology rotation in med school,” he says, “and figured I’d need it to be a good family doctor.  The dermatologist I worked with on the Base made it interesting and fun, and I knew that’s what I wanted to do.”   After two years in dermatology at Baylor and one at Duke, he and his wife settled on Hampton Roads as their home.  “It was a compromise,” Dr. Coker explains:  “She was from Connecticut and I didn’t want to live there; and I was from South Carolina, and she didn’t want to live there.  Hampton Roads was our happy medium.”

Dr. William Coker opened his first practice in 1970.

Coker2That same year, Leslie Robin Coker was born.  Growing up, she watched her father with his patients, sometimes accompanying him on after-hours calls.  “He never grumbled about long days, or even about taking calls for other dermatologists,” she remembers.  “It was always obvious that he loved his work, and even more obvious that he cared about his patients.”

She thought off and on about becoming a physician, but that decision was confirmed when she was 16. “I got a speeding ticket,” she says.  “My court appointed community service was working in the emergency department at Riverside Hospital.  I was struck by the compassion of the doctors working there, and even more drawn to medicine.  I didn’t know what specialty I wanted to pursue, but I knew I wanted to become a doctor.”

It wasn’t until medical school that Dr. Leslie Coker – Lee to her friends and family – chose dermatology as her specialty.  “I considered general surgery and even OB, but I wanted to be able to balance my career with family,” she recalls.  “It was in my third year, after rotations in many other specialties, that I came to the realization that dermatology was where I belonged. I’m very visually oriented (a gift from her mother) and dexterous.  It was a good fit from the start, and it allowed me to have a family as well as a career.”

When Dr. Lee Coker went into practice with her father, she discovered what he had known along: in dermatology, your patients become like family.  “It sounds corny,” Dr. Luke Coker says, “but after 46 years, it still doesn’t feel like going to work.  My patients have become my dear friends.  And I’ve had some of them for all of my 46 years.  We’ve matured together.”

Dr. Lee Coker is already experiencing that sense of family, both with some of her father’s long-standing patients as well as her own.

Both Drs. Coker are enthusiastic about the advances they’ve seen in dermatology over the years – 46 for him and 13 for her.  Dr. Luke Coker still recalls the excitement that accompanied the discovery of Accutane, which made such a huge difference in managing patients with severe acne.  “There are so many better ways to treat skin problems today – things like biologics and the medications to treat psoriasis,” he says.  “The technology is expensive, but it has helped our patients so much.”

They’re both concerned about the prevalence of melanoma, which has been rising for the last 30 years.  The American Cancer Society estimates that about 76,380 new melanomas will be diagnosed in 2016 in the US, and about 10,130 will die of the disease this year.  “It’s not just the sun worshipers who flock to our beaches,” Dr. Lee Coker says.  “Melanoma sufferers include farmers, golfers, boaters, commercial fishermen – anyone who spends time in the sun without adequate protection.”  She is hopeful that some of the advances being made in immunologic drugs to treat melanoma can be built upon to develop even more effective treatments – including vaccines to treat melanoma, which are currently being studied in clinical trials.

“I can’t say enough good things about my dad, both as a father and as a physician,” Dr. Lee Coker emphasizes.  “The reason I’m as good as I am is because of him.  He taught me what they don’t teach in medical school: how to treat the staff, how to deal with colleagues and especially, how to not just treat patients, but how to care for them.  I try to emulate what I see in him.”

Brian L. Johnson, MD

Virginia Dermatology & Skin Cancer Center

JohnsonDr. Brian L. Johnson began his medical training at the Uniformed Services University of the Health Sciences in Bethesda, Maryland.  His Navy medical career included service aboard the USS Yellowstone, the Kearsarge and the Iwo Jima.  He participated in major deployments and field assignments with the Seabees and Special Forces.

He studied dermatology at Johns Hopkins, and completed a Mohs Surgery Fellowship at Northwestern Skin Cancer Institute in Chicago.  He’s a Fellow of the American Academy of Dermatology, the American College of Mohs Surgery, and the American Society of Dermatologic Surgery.

Dr. Johnson wanted to really make a difference in his patients’ lives.  He soon realized that was dermatology: “I grew up with it,” he says.  “My father, Dr. Bernett L. Johnson, was a renowned master dermatologist who subspecialized in dermatopathology, and I knew that there were cases – like melanoma – where I could literally save lives.”

He also realized that dermatology was very diverse: his father’s specialty, dermatopathology, focuses on the study of cutaneous diseases and their causes at the microscopic level.  Where Dr. Bernett Johnson enjoyed looking at samples under the microscope, his son preferred the hands-on approach of treating patients in the surgical setting.

During his Mohs fellowship, Dr. Johnson knew he had found a niche.  The ground-breaking surgical procedure for treating skin cancer lesions was developed by Frederic Mohs in the late 1930s.  “He developed the technique of removing skin cancers and looking at the margins immediately,” Dr. Johnson explains, but relates that the procedure wasn’t adopted by general surgeons at the time because during those years, “skin was considered a non-issue.  If you weren’t an internist or a general surgeon, you weren’t considered a real doctor,” he says.  Dr. Mohs tried to publish his findings, but surgeons then weren’t comfortable learning skin pathology and laboratory techniques, while dermatologists, who are well versed in dermatopathology, and who routinely treated skin cancers, embraced the procedure.

Johnson2“Dermatologists picked up the technique and ran with it,” Dr. Johnson says, “and over the years, we’ve refined it to the point where we can use local anesthesia, remove the cancers and evaluate the margins under the microscope while the patient is waiting. It’s easier on the patient in many ways – notably, it completely eliminates the anxiety of having to wait days or even weeks for a biopsy report, or to have the wound repaired.”

Dr. Johnson can perform as many as 10-15 surgeries in a typical day.  When his patients arrive for their Mohs surgery, they expect to stay a while, because the entire process can take several hours.  Some are there all day – which leads to one of the most fascinating non-medical aspects of Dr. Johnson’s practice: after their initial incision, patients are bandaged and sent to Dr. Johnson’s waiting room.  While they wait for their tissue to be processed and read – a process that can take up to 90 minutes – they become part of a small fraternity. “Some patients are self-conscious about going into the waiting room with bandages on their face,” Dr. Johnson says, but adds their embarrassment is short-lived, because in his waiting room, everyone has bandages – on their ears, noses, cheeks: anywhere on their face or neck.  “They don’t even think about it, because everybody is bandaged,” he says.  “They may start out watching TV or reading – but they always wind up talking to each other.  They trade stories about how they got their cancers, and conversation grows from there.  It lessens the anxiety.”

Some of his patients have been coming to him for years, and he sees them calming down some of the newer patients.   “It’s incredible,” he says.  “The waiting room evolves into a big support group.”

“Mohs surgeons are really three doctors in one,” Dr. Johnson says.  “We’re oncologists, cutting out cancers.  We’re pathologists, reading the slides to make sure all the margins are clear.  And we’re reconstructive surgeons.  We perform all three functions.”

From the patients’ standpoint, that efficiency means everything is dealt with on the same day, so they’re spared the ordeal of waiting for pathology and follow-up appointments.  The cost savings can be substantial, but many think the convenience and lessened anxiety are even more important.

Dr. Johnson’s passion for surgery and providing a family-friendly environment was an integral part of his motivation to build a 16,000 square foot, state-of-the art medical facility in Norfolk.  The building was designed to provide patients with unparalleled convenience for general, surgical, and cosmetic dermatology services under one roof.  The building is equipped with the latest technology to treat the diseases of the skin, hair, and nails.  In addition, the facility offers an exclusive cosmetic dermatological suite with the most innovative technology for aesthetic and body contouring procedures.

Dr. Johnson says, “We found it necessary to become a larger organization to help counteract the many negative changes in healthcare that inhibit a provider’s ability to adequately care for and treat patients – notably, insurance companie’s control of what procedures we can perform or what medications we can prescribe and pharmaceutical companie’s exorbitant pricing of prescriptions. “Many of my patients can’t afford to get the medications we feel are best to treat their condition,” he says. “I was absolutely horrified when a patient told me that she spent $800 out-of-pocket for a small tube of ointment because I recommended it. Things won’t change until physicians come together as a group and demand a change. The system does not run without us.”

Dr. Johnson’s top priority remains to promote outstanding quality healthcare through education, and providing patients with the highest level of personalized care in a family-friendly environment.

Abby S. Van Voorhees, MD

Chair, Department of Dermatology
Eastern Virginia Medical School

Abby1Physicians go into medicine for as many diverse reasons as there are specialties to choose from.  In the case of Dr. Abby Van Voorhees, Chair of the Department of Dermatology at EVMS, it was because her mother was diagnosed with breast cancer while she was in college.  She wasn’t planning to go into medicine, but rather to pursue her love of the sciences.  But when she saw the treatment her mother was receiving, she had an epiphany: “I knew I could do a lot better than what I was seeing happen.”

She earned her medical degree at Yale, where she met Dr. Irwin Braverman, a Professor of Dermatology who developed a now iconic course incorporating Victorian paintings to help students improve their diagnostic and observational skills.  “He became my mentor,” Dr. Van Voorhees says.  “We had very few treatments in those days to take care of patients with psoriasis.  It’s a terribly disabling disease, but even with such scarce resources, he was masterful.  I learned so much from him, and knew I wanted to make dermatology my focus.”

Abby2Her studies with Dr. Braverman were a contributing factor to her decision to specialize in treating patients with psoriasis, particularly those at the more severe end of the disease spectrum.  “I really liked caring for these patients,” she says, “and it’s been nothing short of revolutionary in terms of what we can do now for patients with the ever more precise biologics that are available today.”

She still remembers the standard of care for such patients during her years in and just out of medical school: a treatment she describes as left over from the 1920s, in which patients would submit to tar baths, coupled with tar applications to their skin for 23 hours daily in combination with ultraviolet light therapy.  “The truth is, it can be highly effective,” Dr. Van Voorhees notes, “but it requires patients to essentially devote a month of their life to their skin, and your average working person would have a hard time making that commitment.”  But as recently as a year ago, she successfully used the method for a patient who wasn’t an appropriate candidate for biologics.

Fortunately, for most patients – even the most severe – there are at least 10 therapies she can prescribe, individually or tailored to each patient’s case, and more are being developed.  “These drugs are getting increasingly more exact.  We now have IL17 inhibitors and soon we’ll have IL23 inhibitors, which means they’re getting more effective all the time, without suppressing the entire immune system.”

Not content merely to treat these patients, Dr. Van Voorhees has lectured and published extensively on various aspects of caring for them and the many sequelae of their disease, including an overlay of depression that can accompany it.  In addition, she says, “we’re discovering that patients with psoriasis have increased risk of heart disease, diabetes, stroke –  and they die younger than the average person.  We’re thinking it’s a result of the amount of systemic inflammation they have in their whole body, and we’re coming to view the skin as almost like a weather vane, a sign of all the inflammation that’s inside their body.”

Much of her own research has lately concentrated on education about the importance of knowing these patients are at risk, because “if physicians don’t know that, they can’t possibly think to screen for it.  Since psoriasis is a disease that affects people when they’re teenagers, in many ways, the dermatologist is in the best position to serve as that early warning detection system.”  She explains: “If I have patients I can identify as being at risk when they’re 18, think of the impact it could have if they’d start making changes to their lifestyle at that point, rather than at 60, when heart disease is discovered.  So a lot of my work has been in educating people about the associated co-morbid diseases that travel with psoriasis.”

As chair of the National Psoriasis Foundation’s Medical Board, she’s working with a team that is developing a treat-to-target – establishing guidelines to determine the point at which a patient’s psoriasis can be considered in good control.  “Along the way, we’ve created a lot of best practice standards for managing patients to minimize their risk of sequelae in the future,” Dr. Van Voorhees says. “We’re just working on that effort right now, so it’s very exciting.  This will be the first time that will be in the dermatology literature.”

Dr. Van Voorhees has held editorial positions on a number of national dermatology publications, including Practical Dermatology and The Journal of Psoriasis and Psoriatic Arthritis.  As editor of Dermatology World, the magazine of the American Academy of Dermatology, she has written a great deal about all of the different sides of dermatology – the surgical side of the house, the medical and cosmetic sides.

In medical school, she discovered “an overwhelming kind of inner compass that said what’s right for a patient will always be right.”  That’s still true, to this day, any time decisions are being made about a patient’s treatment.  “If it’s in the best interest of the patient, it’s always right,” Dr. Van Voorhees says.  “The idea of ‘patient first’ has been a very recharging and inspiring motivation.”

Thinking BIG

By Ken Morris, PT, DPT, CMTPT LSVT-Big and Sarah Zeisler, PT, DPT, LSVT-Big 
Tidewater Physical Therapy- Hidenwood

Big1Imagine what it would be like to go from being an active person to someone who now takes 10 slow, deliberate steps just to get out of the car, or five minutes to put a jacket on. And while navigating the aisles of the grocery store used to be easy, these days it feels more like climbing Mount Everest.

These are just a few of the scenarios patients living with Parkinson’s disease can face as the neurological illness takes its toll. Parkinson’s, which is a cluster of motor system disorders caused by a loss of dopamine in the brain, can create a debilitating tremor, rigidity in the limbs and trunk, a slowness of movement and a loss of balance or coordination. According to the National Parkinson Foundation, there is no cure for the disease and a doctor’s goal when treating Parkinson’s is to minimize symptoms through prescription medications.

Traditional physical therapy can play a part in assisting Parkinson’s patients who are suffering from a loss of balance or chronic falls, but that type of treatment isn’t geared toward tackling the neurological causes for those problems. However, in recent years, a new type of physical therapy has emerged that focuses less on remedying musculoskeletal impairments, and instead helps patients think about the art of moving.

The treatment, referred to as LSVT (Lee Silverman Voice Treatment) BIG, is based on another Parkinson’s related treatment that helps patients who have had a decline in speech due to a loss of vocal volume. While the voice treatment encourages patients to talk louder, LSVT BIG tasks patients with thinking big – big movements that is.

In addition to causing a slowing of movement, Parkinson’s can distort a patient’s sense of movement, making him or her feel like they’re moving at a regular pace, when in actuality they are making small, jerky motions. Training patients to make larger, more fluid movements can actually normalize their motions and make it safer for them to do things like exit a car or walk through a crowded hallway.

So how does it work? It really is as simple as teaching patients larger movements as a mechanism to complete daily tasks. And the technique can help with either gross motor function or fine motor skills. LSVT BIG treatment typically includes four sessions a week for four weeks. Exercises focus on creating big postures, big hand movements, big steps and big fluid motions, such as swinging or pivoting the arms or legs to exit a car or put on a jacket. The goal is to help patients feel more comfortable moving in a larger pattern and navigating different tasks using those techniques.

Success happens when a patient for whom it once took 10 steps to get out of the car can now do so in one fluid movement. For others, improvement may mean a general boost in confidence when they feel reassured they can easily stand up on their own and walk to the kitchen, bathroom or mailbox with ease.

Over time, those big movements will come naturally, and Parkinson’s patients can enjoy the art of moving comfortably through their day.

Big2Ken Morris, PT, DPT, CMTPT,LSVT-Big currently serves as the Clinical Director for Tidewater Physical Therapy’s Hidenwood Clinic.

Sarah Zeisler, PT, DPT, LSVT-Big came to Tidewater Physical Therapy as a physical therapy student, before joining the Hidenwood Clinic full time as a physical therapist. Tidewater LSVT-Big therapy is offered in Williamsburg and Franklin clinics as well.

Dominion Pathology





Dermatopathology is our Specialty


It can be an excruciatingly long wait: for anyone having undergone a biopsy, the time between the procedure and the results can seem like an eternity – whether it’s two days or two weeks.  It’s not unusual for patients to experience physical and emotional symptoms like lack of sleep, irritability or nervousness.  It’s also not unnatural: fear and anxiety over the results can set the body’s nervous system on overdrive – releasing adrenaline and other stress chemicals into the bloodstream.
Doctors understand that patients waiting for a biopsy result are in this apprehensive state, so they want to assure them a rapid and dependable diagnosis.  In Hampton Roads, for many physicians – particularly those who treat conditions of the skin – that means utilizing the diagnostic services of Dominion Pathology Laboratories.

1DominionFounded in 2002 by Robert Frazier, MD and Kevaghn Fair, DO, Dominion Pathology Laboratories was at that time the only independent surgical pathology laboratory based in the Tidewater area.   Both doctors had well-established careers in surgical pathology: Dr. Frazier at Virginia Beach General Hospital and Dr. Fair at Riverside Hospital in Newport News.  They were familiar with the myriad challenges faced by pathologists working in busy hospitals, who must not only be familiar with the diseases of each organ system, but also able to communicate about them effectively with clinicians.

Pathology – the crossroads of all specialties.  
“As hospital-based pathologists, on any given day we would converse with a pulmonologist about the results of his or her patient’s biopsy one minute; then discuss colon biopsies with a gastroenterologist next; then we’d talk to general surgeons about liver or pancreatic biopsies; or with gynecologists about their patients,” Dr. Frazier explains.  “In the hospital setting a pathologist has to be proficient with the variety of problems in each specialty because they come up on a day to day basis.”

DominionBecause of the ever expanding complexity and ongoing changes in every medical specialty, many pathologists choose to focus on and pursue additional training within the various subspecialties. Drs. Frazier and Fair, both fellowship trained in dermatopathology, opened Dominion Pathology Laboratories to allow them to put their specialized knowledge, training and experience to wider use.  Their decision to form an independent laboratory was based on a shared mission of individualized service to area physicians who perform biopsies in their offices.  These physicians are aggressively marketed by large-scale national laboratories for biopsy specimens but “because we are small and local we can provide accurate results quickly,” Dr. Frazier says, “and, more importantly, we can establish and maintain a more personal relationship with each physician and their office.”

It’s a mission that helped DPL grow over the last decade.  In 2008, Michael Ryan, DO, a fellowship trained dermatopathology,  joined the practice.

Such extensive training is important because of the nature of the work that dermatopathologists do.  “Malignant melanoma is what we all worry about the most,” Dr. Frazier says.  “It’s one of the most lethal of all the cancers, and survival depends almost entirely upon diagnosing and removing it early, before it can spread to other parts of the body – most commonly lymph nodes, lungs and the liver.”

But melanomas can be problematic to diagnose early since many of them are relatively slow growing.   While more common skin cancers grow rapidly and noticeably from the beginning, some forms of melanoma are different.  “Patients can literally have them for many years and hardly notice as they get almost imperceptibly larger,” Dr. Frazier notes.  “They’ll see a little blemish or mole from its inception and think it doesn’t look that bad, but over the years, more and more mutations happen, making that lesion more and more malignant – and then at some point it just starts growing like gangbusters.”

It can also be a challenge to diagnose melanomas in their beginning stages since they can mimic benign moles, on the patient and under the microscope as well.  There are numerous different criteria in the microscopic diagnosis of melanoma, Dr. Frazier explains, and obvious melanomas display nearly all of them.  Less obvious melanocytic lesions will have some but not all– and then some may show only one or two; these cases can be the most difficult and frustrating because the stakes are so high. Malignant melanoma is responsible for more than 75 percent of all skin cancer deaths.  And there isn’t one universal diagnostic criterion, such as a single gene mutation that positively identifies all melanomas.

That’s why it takes a trained and experienced eye to interpret the intricate patterns in ambiguous cases, and where a dermatopathologist’s fellowship training comes into play.  “Fellowship is such a good place to learn,” Dr. Frazier explains, “because as fellows, you’re doing a lot of footwork for the leaders in the field.  You’re allowing them to do research while you’re observing first-hand a lot of unusual cases that are often sent in consultation from other pathologists because of their difficulty.”

When a pathologist at DPL encounters such a problematic case, where the diagnostic criteria aren’t well represented or obvious, they confer with each other before reporting their findings.  If a consensus of opinion can’t be reached, they consult experts elsewhere around the nation.  “We’re on a par with the most sophisticated laboratories in the world,” Dr. Frazier says, “but at least once a month, we’ll need to send something to an acknowledged expert who has on-going research or is published on that particular problem” – simply because the stakes are so high. The bottom line in every case is, simply put, what is the best diagnosis.

But not all of their work involves potentially fatal skin disease.
In a good number of cases that they interpret, the doctors at Dominion Pathology Laboratories see less lethal cancers – but they emphasize that although death rates from basal cell and squamous cell carcinomas may be low compared to melanoma, these cancers can cause considerable damage and disfigurement if left untreated.

In other cases, the problem is dermatitis: a rash; an inflammatory process that may represent an underlying systemic disease or doesn’t respond to traditional treatment; sometimes a bacterial or fungal skin infection.   Rashes can be difficult to tell apart clinically but the appearance and pattern of inflammation under the microscope can help narrow down the process, if not diagnose it outright. Here again, accurate reading of any biopsy is critical.

That’s why the doctors of Dominion Pathology Laboratories are excited about some of the advances in their field, particularly with regard to some of the newer techniques available now that more specifically confirm or eliminate potential diagnoses. They’re also observing research underway in academic medical centers with interest, such as in situ hybridization and other molecular biology techniques that can be performed on the very same specimen that the glass slides are made from, in order to identify certain gene mutations associated with Stage IV melanoma.  “That technology will surely become more established in time, but it’s not yet ready for routine practice,” says Dr. Frazier, thankful that in Hampton Roads, a diagnosis of Stage IV melanoma is still relatively rare.

A consistent focus on service.
In the meantime, Drs. Frazier, Fair and Ryan focus on maintaining their reputation for unparalleled customer service.  In an age when automated phone systems are the (exasperating) norm, callers are often surprised to be greeted by a pleasant, efficient human being who responds with the same care and professionalism that the pathologists do when they read slides.  The doctors of Dominion Pathology Laboratories take pride in making themselves available to any physician who calls with a question or concern.  After almost 15 years, they are unwavering in their mission to give the best service available to treating physicians.

“We know how anxiously patients are waiting,” Dr. Frazier says, “so our goal is always to get those critical results to their physicians as fast and efficiently as possible.”

For more information, visit our website: dominionpathology.com
733 Boush Street, Suite 200, Norfolk, VA 23510 (757) 664-7901

Medical Consumerism, MRI Services and Your Patients

Jeffrey R. Carlson, MD

As physicians, we are concerned about the physical and emotional well-being of our patients. We work to diagnose illness and provide treatment solutions that will bring about positive results. However, there is another aspect of patient treatment that deserves our attention: the fiscal well-being of our patients.

With the rising costs of health care now being passed along to the consumer, patients are seeing their healthcare expenses skyrocket.  For those who must pay for insurance either partially or entirely, a family of four can easily spend more than $1,000 a month just to get basic health insurance.  Most have seen copayments double or even triple. Many annual deductibles are now over $5,000, and out-of-pocket expenses are going through the roof.

An unintended consequence of the Affordable Health Care Act is that families are having to weigh the cost of having insurance against the cost of housing, food and other necessities.  If a surgery will cost them, out-of-pocket, more than three months wages, how likely is it that surgery will be delayed or cancelled altogether?  Having to pay a copayment or coinsurance could mean that the family can’t afford their electric bill or groceries.

As physicians, do we work to ensure that the services we prescribe are in the best financial interest of those for whom we provide care?  We need to add another factor when thinking about our treatment options, where we also engage our patients regarding how the care we recommend will financially impact them.

Consider the MRI scan, a highly useful diagnostic imaging resource.  The difference in payments to hospitals vs. free-standing MRI providers for this service is astounding, usually totaling thousands of dollars.  With this shift to higher deductibles, the out-of-pocket cost to the patient can be enormous as well!

Consider the recent case of a patient who wanted to have her MRI scan at a free-standing clinic.  She was informed (by the insurance company) that the clinic was out-of-network and that she would have to access MRI services at a local hospital, which her insurance company assured her was in-network.  She followed the recommendation of her insurance company, assuming that she would receive the maximum coverage.  Imagine her dismay when she received her bill and learned that her out-of-pocket responsibility for the MRI was $1,800, even when going to an in-network MRI provider.  She felt cheated and was angry because no one told her she had any options.

How could this scenario have played out differently?  Her physician could have told her to compare prices and even to consider going out-of-network or self-pay for her MRI.  Why?  Because most free-standing MRI clinics charge an average of $700 – $1,000 for a self-pay MRI scan, and less for an out-of-network scan.  The cost savings for the patient would have been significant and their satisfaction during this encounter could have been greatly improved.

Physicians do not often see financial issues to be a consideration when treating most patients’ acute illnesses.  However, our patients would be more content with their overall healthcare experience and much better served if we started to do so.

CarlsonSmJeffrey R. Carlson, MD is the President and Managing Partner of Orthopaedic & Spine Center in Newport News, VA. He holds a fellowship in Orthopaedic Trauma surgery and a combined Neurosurgery-Orthopaedic fellowship in complex spine surgery from Brigham and Women’s Hospital in Boston.  osc-ortho.com

Evaluating Clinically Integrated Networks

What Should My Practice Consider Before Joining?
By Wythe Michael, JD

With the implementation of the Affordable Care Act, numerous Accountable Care Organizations (ACOs) have been established – especially ACOs focused on Medicare patients. More recently, we have seen an expansion of clinically integrated networks (CINs) that include a focus on contracting with non-governmental payers and broader participation from practitioners.

With third-party payers continuing to seek additional cost savings, we expect participation in CINs to continue to grow. 

CINs are groups of providers that have organized to manage care for specific patient populations. Participants in CINs can include hospital systems, groups of practitioners employed by a hospital, ACOs and independent local practitioners. CINs adopt protocols and policies to improve the quality, safety and cost effectiveness of the care delivered by practitioners. Although a hospital system will often help set up the organization and will assist in the management and operation of the CIN, CINs should be led by physicians.

Participants in a CIN enter into a participation agreement that governs the participant’s relationship with the CIN. The agreement requires individual practitioners to participate in the operation of the CIN – often on governing committees. It also requires participants to comply with the protocols and policies of the CIN. Importantly, the agreement typically gives the CIN the right to negotiate managed care agreements with third party payers, including the right to negotiate – on behalf of participants – fee-for-service arrangements and shared-savings payments.

For practitioners, the main benefit of participating in a CIN is that it allows the practitioners to jointly negotiate and enter into contracts with payers. With the expected cost savings and enhanced quality achieved by the CIN, this can result in higher reimbursement rates. Participating in a CIN also ensures that participants aren’t left out of important local provider networks.

One disadvantage of a CIN is a perceived loss of independence.  A second disadvantage is the potential cost of upgrading software and other EMR systems to work with the CIN’s system. A third disadvantage is the additional time practitioners must spend on CIN governance, operations and protocols.

In deciding whether to join a CIN, practitioners should consider, among other things, the following:

 Does the CIN require an upfront payment or capital contribution?

What are the EMR system requirements of the CIN?

What are the other participation requirements?

Is the CIN physician led? Are the physician leaders independent or part of a group employed by the hospital? How is the board elected?

Has the CIN adopted protocols?  If not, what is the process and timing for developing protocols?

What type of authority does the CIN have to negotiate payer contracts on behalf of participants?  Are any such contracts already in place?

Does the CIN permit practitioners to participate in another CIN?

How will cost-savings and quality bonus payments be shared with participants?

Is the CIN a narrow-network or more broadly based?

Will the CIN engage in promotional or marketing efforts?

How can the CIN terminate participants?  How can participants resign?

With third-party payers continuing to seek additional cost savings, we expect participation in CINs to continue to grow.  Accordingly, practitioners should be prepared to proactively evaluate potential CIN options.

WytheWythe Michael, an attorney with Goodman Allen & Donnelly, focuses his practice on the representation of healthcare providers.  Often acting as an outside general counsel, Wythe provides practical solutions to legal issues by working with practice groups and individual practitioners to understand and implement their business strategy. goodmanallen.com

Taking the Pain Out of the Real Estate Market

It starts with a Realtor who knows you don’t have time to waste

GreggIf any one personality trait could be said to define all physicians and health care workers, it would be this: they’re always busy.  In fact, it’s probably fair to say that anyone who chooses a career in medicine is volunteering to rest very little.  For those who dedicate their lives to caring for the sick, discretionary time is a precious and very rare resource, to be used judiciously and guarded with care.  These professionals, of necessity, take a no-nonsense approach to life, and to business transactions of any kind – including the often time-consuming venture of buying (or selling) a home.

It’s the successful Realtor who respects that, and knows how to get to the heart of the matter quickly.  It’s the exceptional Realtor who also knows that medical professionals have specific requirements when it comes to investing in a home.  And it’s the superior Realtor who knows the community so well that he was selected by one of Hampton Roads’ major medical organizations to be part of its recruitment process for incoming physicians.

Greg Garrett, a Realtor with 39 years of experience, was chosen by the organization to take potential employees on comprehensive tours of the areas in which they will be located, often even before their interviews are scheduled.  “There are 11 cities and counties in the Greater Hampton Roads region,” Garrett says, “and I’ve had the opportunity to get to know all of them well.  I’m able to show these professionals the neighborhoods in closest proximity to medical complexes and hospitals, and to talk with them candidly about housing costs, proximity of schools, houses of worship and shopping areas – and even how to avoid heavy traffic areas.”  By the time his tours are completed, these potential residents know that Hampton Roads is an exceptional and very desirable place to live.

“It’s taken me years to get to know our entire community so well,” Garrett says.  “I did it by not limiting myself to just two or three cities, as many realtors do.  But this is such a diverse area that I wanted to know all of it.  And I know that our region is truly remarkable.  And I know why.”

Greg Garrett not understands why Hampton Roads is remarkable, he has in his own way contributed to it.  He’s been active at the executive level in civic and community organizations like the Hampton Roads Economic Development Alliance, which is solely focused on working together to bring more businesses to Hampton Roads.

Greg Garrett founded Orphan Helpers to provide for the physical, spiritual, emotional and educational needs of orphaned, abused and incarcerated children.

Greg Garrett founded Orphan Helpers to provide for the physical, spiritual, emotional and educational needs of orphaned, abused and incarcerated children.

He serves on the Workforce Development Executive Board, also a public/private partnership of many Hampton Roads cities/counties.  “We’re helping people realize the current and potential job opportunities that exist here,” he says, “and we helping them get trained for those opportunities.”  He cites a number of individuals who have gone on to secure positions at the Shipyard after training, and many who have chosen careers in the military, and adds, “we have a strong medical presence here, which is making it easier to attract more world class physicians and health care professionals.  We want to create a workforce that is ready to assume the critical support roles in administration and technology, as well as to go to medical school.”

His commitment to the community extends beyond executive leadership, to a more personal level.  He has for years been a board member & is currently a teacher and mentor for students at Youth Challenge, a non-profit ministry that works with citizens throughout Hampton Roads to help them get free of drug and alcohol addiction.  “It’s an alternative to jail,” he explains.  “Judges have the option in some cases to sentence these individuals to a year under the custody of Youth Challenge, which is committed to restoring their lives, rebuilding their character and helping them return to the community prepared to live productive lives of integrity.”

He runs a Thursday night basketball program for youth and young adults, from 9pm to midnight, where he both plays, teaches and mentors at risk young men.  It’s been so successful that he’s trying to get the program started in other localities – and working with some of his players to become mentors themselves.

Greg Garrett’s heart for service to at-risk children and youth extends even beyond the limits of Greater Hampton Roads.  In the year 2000, while he was supposed to be planning for a cruise to celebrate his 20th wedding anniversary, he was researching the plight of orphans in Central America.  A trip to El Salvador became their gift to each other. After seeing firsthand the appalling conditions, they returned home determined to do something to help.  He founded Orphan Helpers, and began partnering with individuals, businesses, churches and governments to provide for the physical, spiritual, emotional and educational needs of orphaned, abused and incarcerated children.

The organization has grown, today serving about a thousand children each year in El Salvador and Honduras. Its success is a testament to the level of commitment Greg Garrett brings to all of his endeavors, be they charitable deeds or service to clients.  He is simply undeterred by challenges.

He puts so much of his heart and soul into serving his medical clients because he feels such an affinity for them and their needs.  His godfather was a doctor, but it was an early personal affiliation with doctors that shaped his approach.  He was still in high school when his father was diagnosed with cancer, and doctors and other medical personnel became part of everyday life.  He attended the University of Richmond (on a scholarship) for a year, coming home on weekends to help his mother with the family’s small real estate business.  “It was a natural progression from there,” Garrett says. “Before long, I had forgone college to help my mother full time, later joining another practice, and ultimately starting my own company, where my clients included more and more physicians.  It just grew organically, through word of mouth and referrals.”

“I’m inspired by health care professionals and their work ethic,” Garrett says, “and I’m respectful of their time.  I’m motivated to get the best possible result for them as quickly and efficiently as possible.”

Greg Garrett Realty

Adding Hours, Adding Revenue

ClockYour practice may be considering adding office hours to accommodate patient requests for more convenient appointment times and to increase revenue. But before you do, you need to carefully weigh the pros and cons. Here are some issues to consider.

Focus on Patient Convenience
Too many practices maintain hours that force working patients to take time off from work to make their appointments. The traditional 8:30 a.m. to 5 p.m. hours may be fine for patients who are retired, work shift hours, or are full-time students, but they can be tough on those who work during the day. Opening your practice an hour or two earlier, staying open later four evenings a week, or offering weekend hours would be a huge convenience for many patients.

It’s important that you determine whether you’ll have sufficient patient volume to absorb the additional hours you are open. One way to help increase patient volume is to promote your practice’s new hours through patient e-mails, website updates, office signage, and press releases to the local media.

Look at the Economics
Will it be financially worthwhile for you to extend office hours? We can help you run the numbers. For example, if practice overhead is $1,100 per work day and the average reimbursement per patient is $85, it takes about 13 patients per day to cover the overhead. For each additional patient, the practice incurs only variable costs before paying its providers. Once all costs are identified, a projection can be made of the potential profit associated with seeing more patients.

Evaluate Staffing Issues
If the demand exists, it might make sense to add a part-time physician to see patients during your additional office hours. You could reduce provider labor costs by having a physician assistant or nurse practitioner see the bulk of the patients.

MRDPictCopyright 2015 by DST. All rights reserved.

The general information in this publication is not intended to be nor should it be treated as tax, legal, or accounting advice. Additional issues could exist that would affect the tax treatment of a specific transaction and, therefore, taxpayers should seek advice from an independent tax advisor based on their particular circumstances before acting on any information presented. This information is not intended to be nor can it be used by any taxpayer for the purpose of avoiding tax penalties

Percutaneous fusion technique

Percutaneous  fusion technique
is relieving SI pain in post-fusion patients.

By John W. Aldridge, MD, FAAOS

Every year in the United States, approximately 150,000 hip replacements are performed, and more than 350,000 knee replacements.  By contrast, the number of spinal fusions done each year is a stunning 650,000, reflecting just how many Americans suffer from a seriously aching lower back.  The overwhelming majority of these procedures are successful, reducing or substantially relieving pain and restoring the patients to comfortable, active lifestyles.

HROSM_07_16However, orthopaedic surgeons have long recognized – and recent studies have shown – that in some cases, fully a third of these patients experience significant sacroiliac joint problems following fusion. Additional studies have shown that the incidence of SI joint degeneration after lumbar fusion is 75 percent at five years post surgery.  As arthritic patients, those who have suffered traumatic injuries, and even some pregnant women know well, SI joint pain can be debilitating, often resulting in discomfort equivalent to or even worse than that which brought them to our offices in the first place.  It’s a commonplace but vexing problem for orthopaedic surgeons, because until recently we have had very little to offer them.

About the only surgical option required a gigantic dissection to get down into the SI joint to put plates and screws in, and the destruction that caused actually made people feel worse than the SI joint did.  That’s why virtually no surgeons were offering it.

That’s changed within the last year or two with the introduction of the percutaneous fusion technique.  It’s a simple but effective minimally invasive procedure that is substantially reducing and even eliminating the effects of SI pain, including in post-spinal fusion patients.

In the operating room, the patient is positioned face down on the table, under either general or spinal anesthesia, depending on size, weight and presentation.  Using live imaging, the surgeon employs a specially designed system that prepares the bone to receive implants that will stabilize and fuse the SI joint.  One of two devices, either screws or pegs, depending on the quality of the bone, is used.  Generally, no larger than a one-inch incision in the lateral buttock is required to place the device into which the implants are threaded and placed across the SI joint and positioned before fusing them.  There are normally three implants, but again, that can vary depending on the patient.

The procedure takes about an hour, is easily tolerated, and some patients can even go home right after the procedure, although most stay overnight.  Patients use a walker for two or three weeks after the surgery, and they’re fully healed and out of pain after about six weeks.

The procedure has been a real godsend for patients with SI joint pain, especially those who experience it after a spinal fusion. Multiple published studies have documented the benefits of this procedure.  Nationally, fully 95 percent of patients say they’d do it again.  In my own practice, I’ve seen dramatic results when debilitating pain is reduced.

AldridgeDr. John W. Aldridge is a Board certified orthopaedic surgeon with Hampton Roads Orthopaedic & Spine Center who has been specializing in minimally invasive muscle sparing spinal surgery and total joint replacement surgery in the Hampton Roads area since 2002.  www.hrosm.com