ADVISORY e-ALERT      March 30, 2012
Advisory Law Group, a Professional Corporation  




No matter whether you are a physician (no matter your specialty) or an allied health professional, like it or not, the role of allied health professionals is growing.


From the medical doctor perspective, this brings an initial reaction of fear. From the paraprofessional perspective, this brings an initial reaction of opportunity. And from the hospital perspective, especially the hospital-with-"aligned"-providers perspective, this brings an initial reaction of the opportunity to play more competitors off of one another.


The latest tectonic event in this regard: A March 15, 2012, ruling of the California Court of Appeal, the state's intermediary level court, that was of little surprise to legal scholars but of tremendous angst to the California Medical Association and the California Society of Anesthesologists, in which the court affirmed that California law does not require that CRNAs be supervised by physicians. In other words, unless overturned by the California Supreme Court, CRNAs may practice independently in California.


Although there are e-Alert subscribers across the country, several elements of California law, and of the court's reasoning, are instructive as to the future of independent allied health professional practice nationally.


The court relied on California statutory law that states that the Board of Registered Nursing, and no other agency, is vested with the power to define the scope of nursing practice, as well as the fact that there is specific statutory authority for the fact that CRNAs may administer anesthesia to implement a treatment ordered by a physician - the surgeon.


And as recognized by the court, the statutory intent behind state's Nursing Practice Act was incorporated into that law itself: ". . . the Legislature recognizes that nursing is a dynamic field, the practice of which is continually evolving to include more sophisticated patient care activities. . . . It is the legislative intent also to recognize the existence of overlapping functions between physicians and registered nurses and to permit additional sharing of functions within organized health care systems that provide for collaboration between physicians and registered nurses. . . " (emphasis added).


What this means to you.


Whether you are an anesthesiologist or a CRNA, if you're based in California this means that it can almost be guaranteed that competition for exclusive contracts, both at ambulatory surgery centers and at hospitals, will increase as CRNA groups begin to seek those arrangements.


If you are an anesthesiologist practicing in a state that does not permit independent CRNA practice, it means that there will likely be increasing political pressure within your state for both an opt out from Medicare's physician supervision requirement and, if necessary, an expansion of the definition of nursing, and of the role of nurses, to accommodate it. In other words, competition is destined to get tougher for you, too.


If you are a physician practicing in another specialty area anywhere in the country, or if you are any other type of allied health professional, consider that this latest chapter in California, and this issue concerning CRNAs, is a bellwether as to the expanding future for allied health professional practice.


For each of you, the competitive landscape within healthcare is both dynamic and changing rapidly.


Competition, once limited to a somewhat benign concern that a group from across town would pick up a stray opportunity before you could, or even more remotely, seek to displace you in your current practice, has burgeoned.


In addition to aggressive local groups, there are true national groups in many specialty areas seeking to expand across the country, there are staffing services and practice management companies masquerading as groups, seeking to do the same thing, and now in some states, and soon in yours, there will be groups of allied health professionals who will be seeking those same opportunities.


This simply further underscores the fact that you must adopt actual business structures and must seek to provide unique value, what I called an Experience Monopoly, to your facilities, referring physicians, patients and the larger medical staff and community at large.


If you simply continue to provide a "service," even a good service in terms of clinical competence, you will only be providing a commodity, one that I can guarantee you will be provided for less or with more panache by one of your competitors in a race to the lowest bottom line.



Resolving Healthcare Market Pressure  


View Episode 39 of the Wisdom. Applied Videocast 




Several weeks ago, I noticed an acquaintance, "Dr. X," driving out of the upscale shopping center near my house. I waived hello, but wasn't sure if X had seen me.


Recently, X apologized for not having recognized me that day. He said that he's uncomfortable when he goes to that shopping area and is so highly focused on leaving, that he doesn't really notice what's going on as he drives out.


I asked what made him uncomfortable about the shopping area. The response: "The 'rich people,' you know, like plastic surgeons."


Confused and curious, I asked X what it was about the people at the shopping area that bothered him. The response: "They're just so stuffy and pretentious."


Although it is true that the shopping area parking lot sometimes looks like a Rolls-Royce and Aston Martin dealership, my experience with the people there is that they are as friendly or friendlier than the norm in the greater surrounding community: they generally appear happy, are smiling, and readily initiate or return a greeting.


So what is it about "rich people" that really bothered X?


X appears to have a moderately busy practice, but he is definitely not in the "rat race." Previously, I thought that that was a choice, but perhaps the conversation revealed something else, that he does not want to become more successful because he will become like those "rich people" whom he clearly dislikes.


I've noticed a similar phenomenon many times in the course of dealing with clients in their business relationships. Oftentimes, individuals and groups seem to be putting on the brakes, not pushing on the accelerator, out of some mistaken belief that they occupy some fixed rung, as in a caste system, outside of which they are not permitted to tread.


The concept of accepted beliefs, in this case, of limiting beliefs, has been described as a mimeme, or "meme" for short. Just as X might be holding himself back because he doesn't want to become like those "rich people" whom he believes are stuffy and pretentious, many internists believe that they are somehow "less than" the hospital administrator who tells then that the hospital-employed hospitalist will be seeing all of the internists' in-patients. And, on a greater level, many physicians today are willing to fall lockstep into line with hospital-centric notions of healthcare.


Have you bought into these, or other, limiting beliefs, and are they holding you or your group back in your career and business success?



Do You Make This Mistake Concerning Competition, published on on March 14, 2012. 

Protecting Traditional Practice in Today's "We" Society published in Pain Medicine News on January 2012 and in Anesthesiology News on March 2012.

To read other recent articles, click here

Mark's thoughts on RFPs for physician services, and on how physicians should deal with them, are the subject of a March 6, 2012 article by Kate Madden Yee published on 

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The materials presented in this Advisory e-Alert are educational only and are neither legal advice nor a substitute for it. Advisory e-Alert presents a general discussion which may or may not apply to your particular legal or factual circumstances. The distribution of Advisory e-Alert is not intended to create, nor does it create, an attorney-client relationship. Please do not send us confidential information without receiving explicit authorization from Advisory Law Group to do so. Do not take or avoid taking any action as a result of the materials presented in this e-Alert without first obtaining legal counsel.   
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 Update On The Company Model of Anesthesia Services: Jubilation Or Jail? Anesthesia Or All Specialties?


There's a growing trend among ASC's and their surgeon owners: establishing entities to coordinate the provision of anesthesia services to their patients - and to capture the profits.

This is the so-called "company model" of anesthesia services.

If surgery centers or their owners simply demanded a kickback from the anesthesiologists it would clearly be illegal.

But does the company model work? Should its participants be jubilant or prepare to be jailed? That's the $25,000 fine plus five years in jail plus exclusion from Medicare and Medicaid question.

And if it works for capturing anesthesia fees, will it work for internists seeking to capture the profits of gastroenterologists?

These are among the in-depth issues that we'll discuss on April 19, 2012, during the webinar Update On The Company Model of Anesthesia Services: Jubilation Or Jail? Anesthesia Or All Specialties? 

The investment is $249 if you register before April 2, 2012 and $395 thereafter - either way, only a very small part of your daily income; that is, unless you work for a company model entity.

When:  April 19, 2012
Time:    4:00 p.m. PST
Length: 45 minutes
Investment: $249 before April 2, 2012 - $395 thereafter  




Click here to register today!

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2012 ABU

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You're a physician who wants to form a medical group and, among other things, subcontract with or employ other physicians, enter into exclusive contacts, obtain significant stipend support money, create related entities to increase protection and the like. And you want to come up to speed on all of this immediately.

Or, you're the new leader of an existing group with complex practice and business operations -- you need to understand how to master the group's organizational, operational and leadership issues -- and you need to be brought up to speed immediately.


After having regularly dealt for many years with physicians in both of these contexts, we've designed a process to deliver immediate results: The Immediate Leader Experience™.


The Immediate Leader Experience™ takes place over a weekend in Santa Barbara, California and includes two nights accommodation at the Four Seasons Santa Barbara Biltmore Hotel. 


In two short days, you'll be entirely up to speed, totally prepared and confident.  You'll be armed with tools and sample documents.


Due to the nature of this program, admission is upon interview only -- there is extremely limited availability.


For further information on The Immediate Leader Experience™ follow this link.   
For information on Mark's mentor program, click on the following link:  The Advisor Program.