Few would argue that hospital medical and management staff is mostly stable. Yes, there is change, however it is incremental over time and not wholesale alteration. Imagine participating in a complete medical and management staff change every 7 days.
 
That was the case with the University of Miami’s Project Medishare Field Hospital Haiti. Hard working and dedicated volunteers comprised the entire staff model of this hospital. This paper discusses the challenges of building an organization able to withstand the rigors of constant human resource change and leadership from the bottom up in extreme conditions.
 
Day 4 of the tent field hospital Port-au-Prince airfield: 600 people within the camp and no toilets, no showers, no dumpsters, no sewers, no trash collection. The air was unmistakably heavy and rank. As I rose from my spot in the dirt that morning, this was the realization of the leadership that lay ahead: How can I lead this facility to care for the legions of patients and administrate this facility safely?
 
Lesson #1: Provide a clean, safe environment for everyone in your facility.
A critical component of any healthcare organization is safety. Here, hygiene is a primary factor; clean water, ample food, and sanitary facilities. While simple and taken for granted in the U.S., in Haiti, these limited or non-existent resources pose safety risks and prove quite a challenge. Adding to the complexity was the need to create solutions for the culturally different needs of the population within the camp — roughly 400 Haitians and 200 U.S. volunteers. Of the Haitians, this was comprised of patients, family members and workers, and of the volunteers, doctors, nurses and logistics staff. The solution for the Haitians was to prepare an area outside the medical tents for the family members in slit trench latrines, privacy walls for showers, and the use of discarded tent boxes for liquid bio-hazardous waste. Emptying bed pans just outside the door of the hospital was not acceptable. For the volunteers, not much was different — slit trench latrines, male urinal tubes, crude plywood showers. Fence the perimeter with 24 hour armed guards. Finally, the proverbial “Don’t drink the water” took on a whole-new sobering meaning.
 
Lesson #2: Know your mission, identify your strengths and weaknesses, and be able to communicate this precisely and confidently to your team.
Each group of new volunteers brought with them new fresh energy and different management ideas. Leading a facility undergoing constant change management is no picnic. Management change is challenging to the psychological well being of many workers, and can possibly contribute to inefficiency and frustration. This was the leadership lesson and the administrative task: how to establish and set protocols, procedures, and standards that could work with the ever changing self-actualized group of independent thinkers known as volunteers. This daunting task Included where and how to use the crowded facilities, eating and staying hydrated, creating medical records, death procedures, overcoming fatigue, language barriers, limited supplies, limited labs, limited diagnostics and unlimited patient volume and managing the ever-present security risk. The first task was personal — to understand the realities of a field hospital in a foreign land. There are many needs in this environment, but above all else lies patient care. If I was not able to articulate the realities, needs and differences to myself, then attempting to articulate this to 200 volunteers every week was not possible. The first big realization was adjusting my expectations of what could be done medically and physically, and then reconciling the ethical effect of this new expectation. Providing structure and communicating these expectations and realities each week was a key factor to success and to my own well being. The morgue has no air-conditioning.
 
Lesson #3: Leadership means recognizing it’s time for change, finding the courage to plan a change when conditions are utterly intolerable, and effectively implementing change even with there is resistance.
Project Medishare Field Hospital was the largest hospital in Port-au-Prince and provided the most technologically advanced healthcare facility Haiti had ever seen. From our three, and at times, four general ORs and the NICU, PICU, ICU, Lab, Pathology, and Medical Surgical units, our capabilities were remarkable. However, despite this achievement, our limited resources and lack of a sterile environment taught us that we couldn’t do everything for everyone. The truly amazing thing proved to be that we were able to make the most out of what we had: excellent medical skills, resourcefulness, hard work, tenacity, and an ideology that we could do what was needed. And we did. One reality of working in this environment included the understanding that everything required twice the effort for half the results.
 
The personal and professional gratification and growth I experienced is humbling to say the least. It’s easy to stay in the limelight when “It’s all good.” But leadership demands this gratification to be fleeting. Some call it “don’t rest on your laurels.”
 
Recognizing the changing environment from crisis care to general healthcare, (patient population), political and social change, (market), and financial constraints, (managing to a budget) all should signal to the leader to keep looking over the horizon.
 
Project Medishare Field Hospital was a 20,000 square foot fabric tent in a dirt field prone to flooding. Working conditions in our “office” was often over 110 degrees with ever-present jet aircraft noise and the acrid smell of jet exhaust. Even a simple one-on-one conversation required a private walk in the blazing sun. Executing higher levels of leadership and administration, such as preparing a business plan in these conditions, was no small feat.
 
Project Medishare Field Hospital at its peak was a 220 bed acute care and trauma hospital, treated or saved over 20,000 patients, performed over 1500 major surgical procedures. Employed 240 local workers, and housed over 3,000 volunteers from all over the United States.
 
Special recognition and thank you to Dr. Barth Green, Chief of Neurosurgery University of Miami. Dr. Green is the Founder and Visionary for Project Medishare and possesses ability to ‘Never Quit” like no man I have ever known.
 
Inquiries to donate may be made at www.Projectmedishare.org.


In this awareness that delusions no longer serve me, or the greater good, I ask the question, “Am I certain of my alignment with all that integrity with which I claim to be?” I have asked this question of myself recently, personally and professionally, and find that its application and relevance in the realm of compliance is undeniable. After having spent more than 15 years auditing and measuring compliance with regulatory requirements, accreditation standards, Federal and State billing rules and regulations in hospitals, physician practices, billing agencies and laboratories, I am compelled to share my insights.

As an objective observer and auditor whose role it has been to measure the delta that exists between what is, what is expected, and what we, as healthcare providers and administrators believe to be, I have first-hand experience that delusion is rampant in our industry.
 
And. All too often, we don’t want to look. We don’t want to know the truth. Like so many patients who walk the earth carrying their ills and their diseases without going to a physician until it is too late, delusional of the severity of their prognosis, we fear that knowing the truth may be painful, difficult to treat and expensive to cure … better not to look.
 
And. We all want to believe that our billing practices are compliant, that the code we have selected is the right one, that the procedure we have coded is billed for correctly with all the proper modifiers and supporting diagnoses. We all want to believe that if the Regulators demand our charts, our documentation, that it will uphold our belief that we are “doing the right thing”, caring for patients and documenting and billing accurately.
 
Unfortunately, as my experience has proven, rarely are our beliefs proven upon audit. The delta is more often than not, wider than we had anticipated. This is not to say that it is all overbilling either…in as many instances, and in equal measure, we find that providers are leaving monies due them on the table. In either direction, alignment is askew and we do a disservice to ourselves as providers by not collecting properly and to the Medicare program and the American people for payments received in error (too much or too little).
 
By not looking, the problem persists. The tumor grows. The disease advances in complexity and expense. The delusion serves to enable its perpetuity.
 
Alas, there is a cure. There is a prevention strategy. There are techniques by which we can become aware of the delta and address it proactively. In doing so, we can further the viability of any provider practice, identify efficiencies in the office, and implement controls to ensure ongoing compliance and right-coding and billing, as the Office of the Inspector General (OIG) has promised through promulgation of compliance program guidance.
 
Through a compliance program audit, facing the reality of whether we are truly in alignment with the Medicare and Medicaid billing rules and regulations can be the single best “wellness program” or financial risk management program for your practice: awaken to the reality, face the delusion, head on. Initiate a probe sample review of your Medicare claims today.
 
Here and now, we have the opportunity to cure, to prevent, to be proactive in our attempts to be in integrity with the billing rules. The reality is, PPACA and the Federal Government through Recovery Audit Contractors (RACs) are here to aggressively recoup dollars spent on healthcare errantly to fund the insurance for the un-insured. Defense or offense? Delusion or awareness? Know your delta. Know your compliance rate.


The move toward adoption of Electronic Health Records (or EHR) received a big boost with the passage of the American Recovery and Reinvestment Act of 2009 last year, which allocated billions of dollars in incentives and funding for hospitals and physician practices that adopt certified EHR systems.

Physician practices may be eligible to receive up to $64,000 for each eligible provider who can demonstrate meaningful use of EHR. Practices and providers who cannot demonstrate meaningful use of EHR by 2015 will be penalized through reductions in Medicare reimbursements.
 
What Are the Benefits?
Adopting EHR simply makes good business sense for most practices. The benefits of moving from paper to electronic patient records include:
• Greater efficiency and higher profits.
• More accurate logging and maintenance of patient data.
• Easier sharing and access to patient information.
• Less time spent juggling paperwork and more time spent with patients.
• Higher quality patient care and higher levels of patient satisfaction.
 
Perhaps most importantly, EHR gives practices more control over how patient data is logged, used and shared. All data and changes must be logged into the EHR system, and system access is strictly controlled via secure servers, applications and websites. This makes compliance with HIPAA requirements easier and more thorough.
 
There is a wide variety of EHR systems to choose from in the marketplace today. In order to choose the right system for you, be sure to take the time to assess the specific needs of your practice. Many different features and modules make up an EHR system—everything from e-prescriptions to PQRI reporting—so make sure you know which ones you really need in order to avoid spending money on ones you don’t.
 
For starters, how many physicians are in your practice, and do they all want to go electronic? In theory, every physician in a practice doesn’t have to use the EHR system, but in reality, there will be complications if everyone isn’t on the same system. Also assess the condition of the hardware and infrastructure you currently have and whether it is adequate to support an EHR system. If it isn’t, you may need to invest in upgrades before you can implement EHR.
 
Types of EHR Systems
Of course, your budget will also play a large role in what kind of system you choose. EHR systems can be purchased outright, or you can access a system via software as a service (SaaS). With an outright purchase, you’ll buy the hardware (including server) and software and also pay a licensing fee per physician and a yearly maintenance fee. With SaaS, you can lease to own the software or make monthly subscription payments.
 
Do some initial research into EHR vendors and then narrow your list down to your top three choices. (Ideally, you should choose vendors who are CCHIT-certified.) Invite each of these vendors to come into your practice to present demos of their systems. Push them outside the box by having them show you how their system will handle unique scenarios that are common in your practice. For example, you could give them an example of a patient with a specific medical history and/or specific symptoms and complaints and ask how their system would help you address them.
 
Get all of your physicians involved in the demo and EHR system selection process so that everyone is on board once the system goes live. And create a timeline that enables you to phase in implementation and allows plenty of time for physician and staff training. In addition, it’s wise to create a backup plan in case the system goes down.
 
It’s critical that you do everything you can to get your highest ranking and most experienced staff and physicians behind the move to EHR. There will likely be some speed bumps on the way to full implementation, so you’ll want these leaders to be champions and cheerleaders for EHR.


Family limited partnerships (FLP) are used to make assets unattractive to creditors. FLP assets become unattractive to a creditor. No longer can the judgment creditor execute directly upon the protected asset and force its sale. Instead the successful creditor receives a charging order from the court. This remedy is outlined by the Uniform Limited Partnership Act. This Act provides in a nutshell that the successful creditor "the assignee to receive … only the distribution to which the assignor would be entitled."

The drafters of the Uniform Limited Partnership Act inserted this charging order concept into the act to prevent the creditors of a partner from disrupting the partnership business. This is because under relevant partnership law the general partner, who is likely to be a family member or a corporation controlled by family members, can prevent distributions. The Internal Revenue Service has also held in Revenue Ruling 77-137 that the creditor with a charging order is treated as a substituted limited partner for tax purposes. As a result the judgment creditor is saddled with the tax consequences resulting from ownership without the capacity to force dissolution of the partnership or distributions from the partnership – a double whammy. Paying taxes on something they do not have which stops most creditors in their tracks cold.
 
FLPs are not to be expected to save income taxes; it is an asset protector. FLPs are most likely income tax neutral. However FLPs can be used to save estate taxes. FLP’s titled assets are discounted for estate tax purposes simply for one major reason. The FLP is jointly owned by multiple family members. Furthermore, the fair market value of the voting shares of the FLPs (the true owners of the FLP) are valued for far less money than for if the assets was owned independently by an unrelated third party. Assets owned independently are worth more than assets saddled with partners. Yes, other people find it hard to work with your family. As a result, the value of the FLP’s shares are worth less than otherwise owned.
 
As long as you are a United States citizen or resident and considering an asset protection structure, please have it implemented by a real tax expert with substantial experience. Remember, if you are ever told that an asset protection device (or indeed any foreign trust) will save you income taxes you are getting bad advice; and, in the process, probably being asked to commit a crime.


Now more than ever, healthcare organizations of all sizes and types need competent, reliable financial professionals to help them navigate the turbulence and complexity of the American healthcare industry. In South Florida, one such professional is Jeffrey Kramer, Certified Public Accountant, who has been providing exemplary financial services to healthcare clients since 1987. Kramer is a founding partner of Kramer Weisman and Associates, LLC, an accounting firm located in South Broward County that serves the healthcare, wholesale/distribution, technology, real estate, hospitality and manufacturing industries, as well as not-for-profit organizations.

“Approximately half of my clients are in healthcare,” says Kramer, “and that has been true throughout my career. I enjoy working with healthcare organizations and physicians. By being involved in healthcare, trying to help organizations survive and thrive, I feel that I am helping the community. The healthcare industry affects everyone.”
 
Kramer’s clients include large and small physician practices as well as hospitals and hospital systems, medical groups, managed care organizations and other “hybrid” health care organizations. He and his partner Lester Weisman and a staff of 10 provide a comprehensive menu of services that includes basic accounting, tax preparation and advice, management of IRS issues, auditing, financial forecasting and projection (for funding and licensing), forensics and litigation, consulting on special projects and due diligence on acquisitions.
 
Kramer is particularly focused on the challenges facing physicians and physician groups. He favors the development of “mega” physician groups, as a means of empowerment and fortification. “Mega groups offer substantial advantages for doctors. Often, doctors are trying to do business with managed care companies and hospitals – entities that are far larger and have enormous resources, including highly skilled teams of attorneys and CPAs. They are simply unable to negotiate because, by comparison, they lack power. They don’t have the resources to match these huge entities.
 
“Larger physician groups help level the playing field, with power, numbers and greater resources. The trend is towards larger groups with professional management, and a small independent practice can’t afford that. It’s expensive to hire a highly credentialed, skilled administrator, but you need that skill set to compete. Doctors are starting to recognize this, and to form these larger practices. It’s a transition for them; they are used to being independent, to running their own practices.
“I believe that we need better leadership in healthcare, and that physicians, along with politicians or administrators, should be leading the charge. Physicians are the ones who truly know what is needed to transform healthcare.”
 
Kramer compares physicians to other small business owners. “Doctors are getting squeezed these days, between rising costs and falling reimbursements. They are quite challenged, and need help like any other small business owner. They have to watch their finances closely and need to have a financial professional that they can trust, someone who can provide sound advice.”
 
Like many of his clients, including physicians, Kramer is himself a small business owner and can relate to the challenges they face. He started his company nine years ago. “I understand the concerns and challenges that my clients have because I have them too. I tend to develop strong relationships with my clients. They know they can call me, bounce things off me and seek my advice. I’m there for them.”
 
That is confirmed by client Chris Prestera, owner and Chief Executive Officer of Physician Advocates LLC. “I’m a broker to the healthcare industry for property and casualty insurance, specializing in medical malpractice. I have been a client of Jeff Kramer’s since I opened the agency 6 years ago. Jeff is a very capable accountant, as are his colleagues. At the end of the day, I know I will never have IRS concerns, because of Jeff’s prudence in managing my financials and my taxes. When I started my agency, he gave me excellent advice on how to financially structure the company. I would recommend him in a heartbeat, to anyone, and in fact I frequently have. Jeff is completely competent and trustworthy.”
 
Kramer is a Miami native who is a graduate of the University of Florida, where he earned his Bachelor of Science in accounting in 1986. He began his professional career as an auditor with PriceWaterhouseCoopers. He is married, with two children, and resides in West Broward County, where he enjoys tennis, photography and traveling.
 
Kramer is an industry leader who has published a number of articles and lectures on healthcare topics. He is a member of the American Institute of Certified Public Accountants, Florida Institute of Certified Public Accountants (where he has served on the Healthcare Committee), South Florida Healthcare Executive Forum (Board Member), Nova Southeastern University H. Wayne Huizenga School of Business and Entrepreneurship Young Entrepreneurs Council, Healthcare Financial Management Association and Memorial Hospital Foundation Planned Giving Committee (Board Member).