Friday , December 14, 2018

November 2013

Featured In This Issue

November 2015


Asked about when he started in the family business, M. Kale Hinnant quips, “Birth.” It’s a bit of an exaggeration, but Hinnant is the third generation in a business that spans eight decades. With only 6,000 practitioners nationwide, it’s a unique business started by his grandfather W.T. Hinnant for unique reasons.


In 1930, W.T. Hinnant was struck by a train while pushing his car off the tracks and lost a leg. At the time, no companies in North Carolina manufactured artificial limbs so Hinnant’s grandfather obtained a prosthetic leg from a company based out of Minneapolis.


“Back then,” Hinnant explains the history, “someone would travel to you, take your measurements, go back and make the prosthesis, and then ship it to you. You were left to adjust or repair it. There was no such thing as patient care; my grandfather had to make his own revisions to his prosthetic appliance. Some of his revisions were even later utilized by the Minneapolis Artificial Limb Company on their products.”


It immediately became obvious to Hinnant’s grandfather that he had the ability to help other amputees in the Carolinas, so he apprenticed with the Minneapolis prosthetics maker and, after learning the craft, opened W.T. Hinnant Artificial Limb Company in Charlotte in 1931.


The company keeps the name today but is more commonly known by the signage on their building in Charlotte’s South End—Hinnant Prosthetics.


Specializing in lower and upper limbs and hands and servicing North and South Carolina, the company has fit over 28,000 prosthetics since its founding and is one of the longest established and most recognized prosthetic and orthotic companies in the Southeast.


Started as a one-man operation, W.T. Hinnant’s sons, John and Milton, joined the firm after their graduation from the University of North Carolina at Chapel Hill. Kale Hinnant, Milton’s son and the current owner and manager, now employs three certified technicians who assist with the manufacture of prostheses, two office staff, and two certified prosthetists who instruct the technicians and fit the appliances.


Much has changed since the company’s founding. Educational requirements and certification for practitioners elevated what used to be a craft to a profession.


“In the early days, if you could cut something off a tree and make it work, you were a prosthetist,” Hinnant explains, “Our firm was the first in Charlotte to be certified by the American Board for Certification.


“We believe in education for our employees and we work to further their education and advancement. In order to stay current with the rapid technological advances of this field, our practitioners regularly attend seminars and continuing education classes provided by the American Academy of Orthotists & Prosthetists (AAOP) and various product manufacturers.”


Hinnant sets the example. He holds a B.S. in Accounting, a B.A. in Business, and is one of only six Fellows of the American Academy of Orthotics and Prosthetists (FAAOP) in North Carolina and was among the first 50 recognized for this educational achievement nationwide.


Technology Explosion


A seasoned veteran in the business, Hinnant emphasizes how keeping up with advances in technology is critical now more than ever.


“New applications of space-age materials, digital technology, and experience with combat injuries from more than a decade of war in Afghanistan and Iraq have spurred a high tech explosion in prosthetic science.


“War is the greatest driver of innovation in prosthetics,” Hinnant says. “Caring for amputee casualties promotes federal funding for developing better technology.”


Hinnant easily ticks off a list of recent technological breakthroughs.


High-tech prosthetics like the C-Leg and the Ossur Rheo Knee use a microprocessor to adjust prosthetic leg swing for a more natural gait, greater freedom of movement and reduced walking fatigue.


Advances in myoelectric-controlled upper extremity prosthetics, which use electronic sensors to translate minute muscle, nerve and EMG activity into prosthetic movement, continue to improve function.


The i-LIMB Hand features five fingers each powered by separate motors which someday may allow the individual use of each finger.


Hinnant Prosthetics utilizies the Omega Tracer CAD. This technology replaces the traditional time-consuming plaster casting process and creates a highly accurate, three-dimensional picture of an amputee’s residual limb producing the best possible socket design for the patient’s needs, physiology and lifestyle.


With better technology comes higher costs, so prosthetic prices vary widely. Lower extremity appliances’ price tags can range from $5,000 to $100,000-plus. Upper extremity prosthetics can cost $3,000 to upwards of $120,000-plus.


“You have to put patients in the right appliance,” says Hinnant. “When you meet with a patient you ask them whether they want to ambulate, what they do, what are their activities. You also ask about their aspirational plans; what they want to be able to do.


“The more technology, the more difficult a prosthetic is to maintain, so it’s not always just the cost of the prosthetic, but also the cost factor over time. But if the patient’s capable and would benefit from a certain appliance, then you just have to educate them so they’re aware.


“This is a very personal, customized product. About 10 to 15 percent of our patients have the higher-end technology, but high-end is a relative term dependent upon their needs and wants. I can put a $30,000 foot on a leg but is it going to benefit that particular patient? That’s the question.”


It’s All About Patient Care


“From the beginning of this company, it’s always been about patient care,” affirms Hinnant. “We don’t only fit patients physically, we fit them mentally. You’re dealing with the emotional issues of losing a limb. It’s the same grief as dealing with death. You have to allow the patient to grieve and get through it.”


One reason Hinnant understands his patients so well is that he’s known many of them for years. Amputees need lifelong care in terms of prosthetic adjustments, maintenance, repairs, and over the course of time, new or upgraded appliances.


Craig Winslow lost his leg to cancer 28 years ago. Hinnant Prosthetics provided him his first appliance and went through the training with him needed to adapt. Since then, they’ve cared for him over his five subsequent prosthetics.


Currently Winslow uses two prosthetics. As a Boy Scout Master and active dad of three boys, he has a waterproof leg for water skiing and family trips to the beach. He also has an everyday leg which, as a Jimmy Buffet fan, he decorated with a sunset beach scene. A past leg sports the logo of Winslow’s alma mater Florida State.


“I just live an ordinary life,” says Winslow. “My prosthetic doesn’t hold me back; it’s allowed me to get on with my life. When I wake up I put it on and I don’t take it off till bed that night. It’s so comfortable there are times I forget that I’m wearing it.


“That all comes down to Kale Hinnant,” Winslow continues. “He watches me walk and makes micro adjustments so that when I walk out of here, I can’t even tell I have it on. Even when I moved to Greenville, S.C., I still came back here for care.


“They spend time with me when I’m here. Kale not only helps me with my prosthesis, he’s become my friend,” says Winslow, holding up a wooden peg leg Hinnant had crafted for him to be a pirate for Halloween a couple of years back.


“A lot of my patients have become my friends,” Hinnant says. “This business continues for two reasons: we have good rapport with our patients and we travel all over North and South Carolina.”


Hinnant Prosthetics’ in-home service is an industry differentiator. Although many patients are treated in their Charlotte office or in their satellite office in Columbia, S.C., understandably some patients have difficulty traveling or can’t afford the expense.


“We will work with them in their home if it helps,” says Hinnant. “By working in their homes, we know the barriers they face and we can better determine the appliance that serves their needs. A lot of other practitioners can’t do that.”


But traveling to patients’ homes can have its challenges. Per Hinnant, “Google Maps can sometimes only get you so far—so you call them up and ask them if they have a ramp in front of the house or what color the car is in the driveway.


“One time I called a patient for directions and they told me to take a right at George’s Store. Well, I drove and drove but I couldn’t find any George’s Store so I called back. Turns out George’s Store had burnt down 10 years before, but that’s how they remember it.”


On-site fabrication is another differentiator for Hinnant Prosthetics. While the industry trend is to outsource manufacture to a central fabrication site, Hinnant Prosthetics continues to fit and make prosthetics in their Charlotte office just a short hallway away from patient care rooms.


“When patients come in, we can take care of them,” Hinnant explains. “We have the knowledge, the supplies, the equipment and the products right here. The prosthetists and the technicians can consult directly with each other and with the patient. It makes for a better patient outcome and that’s what we’re here for.”


Surviving in Changing Times


But Hinnant admits that he may have to change some of the ways he’s currently doing business. The industry is in a period of tremendous flux. A 2011 American Orthotic & Prosthetic Association State of the Industry report notes declines in net billings, profit margins and revenue per employee.


One reason is downward pressure on pricing. While Hinnant Prosthetics works with the U.S. Department of Veterans Affairs, Medicare, Medicaid, vocational rehabilitation and private insurance; Medicaid rather than private insurance now sets the standard on pricing. Medicare increases of only one to two percent can’t keep up with increases in the costs of materials and overall business expenses, which rise an average of five to 10 percent.


Recent changes in Medicare have also impacted the industry. In an attempt to identify improper payments and correct billing and coding errors, the Centers for Medicare & Medicaid Services (CMS) instituted Recovery Audit Contractor (RAC) audits.


Along with the audits, CMS issued a new prosthetic patient referral documentation guide for physicians known in the industry as “Dear Physician” letters. Both CMS actions create a huge compliance burden for the industry, especially for the small mom and pop firms.


Hinnant estimates that his compliance burden has increased from 10 to 40 percent. A recent industry article cites that 17 percent of small orthotic and prosthetic facilities have closed due to audits and that 75 percent have cut staffing.


Another factor affecting the business is a shrinking patient pool. Amputations from diabetic complications are 80 percent of Hinnant Prosthetic’s client base and account for the majority of prosthetic patients nationwide. Improvements in the care and treatment of diabetes and advances in surgical techniques have led to a marked decline in amputations. The Centers for Disease Control and Prevention reports U.S. amputations down 65 percent from 1996 to 2009.


These challenges leave Hinnant Prosthetics at a crossroads.


“What we need to do is decide what the best approach is going forward,” says Hinnant. “My goal is to structure the company to be an ongoing entity so that it can survive despite outside influences. I’m trying my best to maintain the business because I think it’s important. It’s important to my family’s legacy and to the people that work here to keep it going. But even more than that, I have patients coming to me all the time asking, ‘If you’re not here, what am I going to do?’”


Hinnant has decided to meet these challenges head on. Always active in the industry, Hinnant belongs to five national industry organizations, is past president of the North Carolina Chapter of the American Academy of Orthotists & Prosthetists and is currently on the board of directors for the North Carolina Prosthetic & Orthotic Trade Association. He believes that organizing, educating and being proactive and politically involved is the key to thriving in the future.


Currently he’s meeting with consultants to best craft a new business model. He’s also added administrative defense coverage to his insurance and retained The van Halem Group to assist him with Medicare audits.


“I don’t intend to let these adversities beat me,” Hinnant says. “How can I not fight to keep going when everyday, I see the adversity my patients face and fight and overcome all the time?”

Usually one would find it challenging to weave the terms health care and man cave into the same conversation, but at Vitality Health Services in Charlotte and Raleigh, that is the conversation.


With over 40 years’ combined experience treating the physical, sexual, endocrinal and hormonal issues that all men face, Drs. Michael Trombley and Douglas Brooks set out to create something new, innovative, and exclusively for patients just like them—“for men, by men.” Yes, even the staff is all men.


In their offices, patients are greeted with a large screen TV showing ESPN SportsCenter along with a collection of blatantly gender-specific reading materials like Sports Illustrated and Men’s Health. Throw in a beer tap and you’d practically have a sports bar.


“Studies show men are less likely to go to the doctor than their female counterparts, and reluctant to take action when they don’t feel physically or mentally well,” says Brooks. “Most men know more stats about their favorite sports team than their own body. Our goal was to create an innovative and affordable practice that could reduce traditional barriers preventing men from making their health care a priority.”


“Statistically, men are three times more likely than women not to see a physician,” notes Trombley, more precisely. “It’s not because men don’t care about their health. It’s because they don’t do well in a traditional medical office setting. We offer an alternative—a place where men can feel comfortable and at ease. We don’t have Sesame Street on the TV and kids running around. We don’t have a young woman at the front desk asking personal questions that most men are never going to feel comfortable answering.”


Vitality Health Services provides men with a safe and discreet environment to discuss and treat the embarrassing stuff—erectile dysfunction (E.D.), sexual performance issues, low testosterone, weight problems, vasectomy and even basic primary care.


Joining Forces


Both Trombley and Brooks are board certified in Family Medicine.


Trombley is a native of New York, obtaining his medical degree from the University of Rochester School of Medicine. He completed his residency in 1994 from Carolinas Medical Center Family Medicine where he served as chief resident. He first practiced as a physician at Cabarrus Family Medicine and subsequently at Lakeside Primary Care before joining up with Brooks.


He has also had associate faculty appointments with Duke Medical School and University of North Carolina Medical School, and been a travel speaker for Abbott Laboratories, Astra Zeneca Pharmaceuticals, Ortho-McNeil-Janssen Pharmaceuticals, and Xanodyne Pharmaceuticals.


Brooks is a West Virginia native, obtaining his medical degree from West Virginia University School of Medicine. He completed his family medicine residency at the University of South Carolina’s Palmetto Richland Memorial Hospital in 2000. He first practiced as a family physician with Morton Plant Mease Primary Care, the largest medical corporation in Tampa, Fla., and subsequently practiced as a family physician for Carolinas HealthCare System before striking out on his own.


Brooks is currently an adjunct professor with the University of North Carolina at Chapel Hill, serving locally as a preceptor for medical students during their four years of training.


Trombley and Brooks are 5-star physicians on and respectively, and both have received the Patient’s Choice Award given to only 5 percent of North Carolina physicians.


Both describe their prior practices as “traditional corporate medicine.”


“The genesis of Vitality Health Services came from our frustration over the direction of the health care industry and an attempt to return to the true patient and physician relationship and direct primary care,” says Brooks.


“We were both suffering from burnout with the current medical system,” explains Trombley. “I was diagnosing patients, but treatment decisions were being taken over by the insurance companies. It felt like a disservice to the patient. Medicine should be based on the relationship between a doctor and the patient.”


In addition to wanting to be his own boss and the freedom to practice medicine on his own terms, Brooks had always had an interest in men’s health issues, and felt there was a need for specialists in the field, just like women have gynecologists and children have pediatricians.


A recruiter helped put Brooks in touch with a small group of like-minded investors and that’s how he met up with Trombley. The two opened up Vitality Health Services in Charlotte, and the business model has worked so well that they added a satellite office in Raleigh.


Setting Themselves Apart


Making the decision to reclaim control of their respective careers, Trombley and Brooks began thinking outside traditional structure and focusing on the particular niche that they both found interesting, men’s health services. Alongside the unique “men’s club” approach to providing care, the two made a conscious decision to have an all-male staff as well, to further set their clients at ease.


Additionally, they made the decision not to bill insurance directly, which means clients pay directly and have the option to seek reimbursement from their own insurance carriers. While some might think this a concierge, boutique approach for a medical practice, it is in reality the opposite.


“By not billing insurance directly, we cut down on practice overhead and staffing, resulting in surprisingly affordable fees,” Trombley points out.


Brooks clarifies, “If we bill $100 through insurance, about $40 immediately goes to the insurance company. Then another $20 goes to pay the salaries of two more employees—a coder and a biller—that we have to hire. So why not have the patient pay us $40 directly, and keep the insurance companies and their medical opinions out of the picture.”


An initial visit to Vitality Health Services runs $300 which includes all necessary blood work and a follow-up visit. Subsequent office visits are only $100. Specific in-office procedures and treatments, such as vasectomy, are individually priced a-la-carte style. The model also works well for patients who have a flex-spending health care plan.


Trombley says, “Our goal is to show that we can provide first-rate quality care, but do so in a cost effective manner.”


In practice, for Brooks and Trombley, it’s all about putting the patient’s needs first and having the luxury of actually spending time with them.


“In my last job we were allowed 15 minutes per patient,” says Trombley. “That’s just not enough time. Here we can spend an hour with each patient. We’re dealing with sensitive and often embarrassing issues. Guys don’t just walk in and blurt out what’s wrong. It takes time for them to relax, feel comfortable and establish a sense of trust.


“By taking our time, we uncover so much more important information; it enables us to formulate a better diagnosis and better treatment plans that address all issues.”


Brooks concurs, saying, “Our patients feel like they actually have a relationship with their doctor. I would love to see a long-term study of my patients 30 years from now, because I truly believe the men I’m treating are going to live longer than those getting a 10 or 15-minute visit.”


Proactive and Progressive


Although the doctors treat more common male-specific issues like the dreaded E.D. (statistics show 40 percent of men are affected by age 40 and 70 percent by age 70), they are increasingly focused on treating more men in the relatively new area of testosterone replacement therapy. Andropause—a decline in testosterone production—is basically the male counterpart to menopause.


Both Trombley and Brooks are firm believers that low testosterone or “Low T” is often the root of many other male-specific problems like E.D., as well as being a contributing factor in more serious issues like hypertension, diabetes and high cholesterol.


Brooks explains, “Testosterone loss happens to every man. It starts in our 30s and continues from there. While women have been on estrogen tablets for 50 years, it is only now that we are starting to look seriously at male hormone replacement therapy.”


Typical symptoms of low testosterone are often reduced energy, moodiness, gain in belly fat and eventually sexual performance issues. However Trombley says the onset is so gradual the symptoms are often incorrectly attributed merely to aging. A low testosterone count is easily diagnosed with a simple blood test and current treatments run from pills to topical creams.


Although still a relatively new frontier in health care, both doctors are resolute in their convictions regarding the benefit of testosterone replacement therapy. Trombley says, “I firmly believe what we’re doing will absolutely become the standard of care. We’re just waiting for everybody else to catch up.”


He attributes the hesitation to insurance companies trying to categorize low testosterone as a disease. As the “normal” range for testosterone count (T-count) has been established as between 300 and 1,200 (all measures in ng/dL or nanograms per deciliter), Trombley says a patient with a 315 T-count will be summarily dismissed by insurance carries and most physicians as being within normal range.


“What we really need is a way to go back in time and learn what your testosterone count was at age 18 and try to restore it to those levels,” he explains. “The way we look at it in a proactive way is that if a patient has a T-count of 315, but is symptomatic, we treat him. There’s no reason to wait until he is at disease state.”


Both Trombley and Brooks can attest to the positive benefits they are seeing in testosterone replacement therapy. Trombley says, “We fix the patient’s testosterone and he suddenly feels 20 years younger, his relationship with his wife is amazing, he’s got more energy and is suddenly motivated to get back in the gym, and now naturally his blood pressure goes down, he’s not a threat for diabetes and his cholesterol is normalizing.”


As further evidence of their proactive and progressive approach to medicine, Dr. Trombley has undergone additional training in stem cell therapy as a promising treatment for erectile dysfunction.


Stem cells are defined by their capacity for both self-renewal and directed differentiation; thus, they represent great promise for regenerative medicine. Historically, stem cells have been categorized as either embryonic stem cells (ESCs) or adult stem cells (ASCs) and it was previously believed that only ESCs hold the ability to differentiate into any cell type.


Recently, however, numerous studies have demonstrated the ability of ASCs to differentiate into cell types beyond their tissue origin. Additionally, there is an abundance of stem cells in body fat which can be harvested via liposuction.


“This means that if a patient is suffering from E.D. due to loss of blood flow to the penis and has not had good results through conventional treatment, application of stem cells harvested through liposuction may be an option to increase blood flow and pressure in the penis,” Trombley explains excitedly.


Vitality Health Services is one of a handful of sites in the United States certified as part of a multicenter study for the application of stem cell research. Although investigational, Trombley is optimistic this may be a viable treatment used in offices in the future.


“Most people’s misconception is that all stem cells used in research are embryonic,” he clarifies. “Our investigational trial studies are non-embryonic and come from the patient himself. It’s a cutting-edge new approach of healing yourself, with your own cells.”


Brooks says, “I’ve never been happier since I began practicing medicine. Michael and I are two peas in a pod and finally doing exactly what we want to be doing—treating the whole male and improving our patients’ lives. It’s extremely rewarding for us and we know that it’s working because our patients keep coming back.”


“It’s such a relief to be free from an insurance company’s standard of care. We’re always looking for better options for treatment for our patients,” says Trombley. “We are ultimately committed to progressive medicine to help our patients enjoy healthier and longer lives.”

It’s flu season and Paul Walker is leery about getting a flu shot. At 75 and with a history of heart disease, the Kannapolis retiree knows he should participate in the annual roll-up-your-sleeve ritual. But Walker remembers his first flu shot in the 1970s. Three days later, he came down with the flu and missed work for six days.


“I haven’t made up my mind this year,” he says. Walker understands the risks. He knows that flu and flu shots change from year to year. So, if he decides to get the vaccine, does he also know what type of flu he’s protected against?


“No. I don’t,” he says. “I know they are numbered: 6, 1, 12; but I don’t know what that means.”


Walker’s uncertainty has merit. Flu vaccines are a gamble. A few months before flu season, scientists evaluate the data concerning the flu-like (short for influenza) illnesses around the country. They then guess which subtypes will prevail.


Of the two types of flu that frequently affect humans, A and B, the most dangerous is A. For the 2013 flu season, the Food and Drug Administration’s Vaccines and Related Biological Products Advisory Committee recommends protection against two A viruses, H3N2 and H1N1, and one B virus. Some 2013 vaccines will contain a second B virus component.


If guesses prove accurate, the United States will have a mild flu season. If the guesstimates are wrong or incomplete, we could have a replay of 2002 and 2009 when a novel and particularly nasty virus subtype emerged.


During those epidemics, scientists did not have a vaccine ready until the outbreak was well underway. Unlike measles and chicken pox, there is yet no universal flu vaccine. To defend against this massive health and economic disruption, we need accurate and rapid prediction.


The Flu Genome


Dan Janies (pronounced “Janus”) promotes a better way to understand and predict flu outbreaks. At 47, he is the Belk Distinguished Professor of Bioinformatics and Genomics at the University of North Carolina at Charlotte (UNC Charlotte). He neatly unites 21st century biology with big data.


Janies’ university appointment adds validity to the observation made by Michael Levitt when he was recently named a recipient of the Nobel Prize in chemistry. “Biology is very complicated and computers are powerful tools,” said Levitt, a professor of structural biology at Stanford University. “The prize,” he said, “is a belated recognition of the importance of the computer in biology.” More commonly, the combination is referred to as bioinformatics.


Janies believes that the way we describe the flu is outdated. He calls it a “legacy nomenclature based on weak technology.”


That legacy goes back to 1971 when two flu molecules, hemagglutinin and neuraminidase were first used to identify flu subtypes. Hemagglutinin (H) is responsible for attaching the virus to a host’s cell and allowing the virus to enter. The virus then hijacks the cell’s replication machinery to make new copies of itself.


Neuraminidase (N) allows the new viruses to enter and infect more cells and hosts. H and N were the perfect target for the flu vaccine. The H and N proteins are present on the surface of the flu virus and our immune system had no trouble finding them.


Flu vaccines stimulate our immune system to develop antibodies to H and N. If exposed to a live flu virus, these antibodies attack the Hs and Ns on the virus’s surface and, if all function as planned, we escape the flu.


The numbers 1 through 16 for H and 1 through 9 for N refer to the different types of hemagglutinin and neuraminidase. Each influenza virus is defined by only one type of H surface protein and one type of N. Within each subtype, there are also strains that arise from random mutations in the virus.


“I don’t think that way,” says Janies. For him, the entire flu genome, which contains six more genetic segments besides H and N, is the key to understanding and combating the disease.


“The genetic segments contain all the exquisite details—the building blocks of the virus. Knowing our enemy’s bricks and mortar will win the war against influenza,” he maintains.


Each living organism has its own unique genome. Virus, plant, bacteria, microbe, fungus and now human genomes are being studied and sequenced. Such work has led to a paradigm shift in understanding and treatment.


Cancer research is a good example. Some researchers have abandoned their focus on the organs where cancer arises—lung, pancreas, breast, skin—to instead focus on the cancer genome. They have found that different cancers share a number of genetic similarities. These scientists advocate treatment based on what genes are mutated, not the tissue involved.


For Janies, genome sequencing provides a much more accurate way of identifying a virus’s subtype. Once an expensive, tedious, painstaking process, sequencing costs have dropped a hundred-thousand fold.


“The H1N1 virus that our great-grandparents experienced in 1918 is a completely different H1N1 from what emerged in 2009,” says Janies. “The H still reacts to the 1 and the N reacts to the 1 antibody, but all the rest of the genes in the genome—all the internal genes—are completely different. That’s what genomics gives you—a clearer picture of what’s there. It illustrates where the legacy nomenclatures are wanting.”


“In the case of Severe Acute Respiratory Syndrome (SARS) in 2003 it took two months from detection of a novel virus to the public release of the genome,” says Janies. “For H1N1 in 2009, it was two weeks.”


Enter the Supramap


Interestingly, it is this ability to identify a particular virus by genome that made it possible to track a particular virus along with big data. Enter the Supramap.


In 2007, Janies and his colleagues at Ohio State University, the American Museum of Natural History and the Ohio Supercomputer Center developed Supramap to track the spread and evolution of pandemic (H1N1) and avian influenza (H5N1).


At the time, Janies was an expert in computational genomics at the Wexner Medical Center at Ohio State.


“Supramap does more that put points on a map—it is tracking a pathogen’s evolution,” said Janies, as the first author of the research paper on the Web-based tool that combines information about the genetic sequences of pathogens with geographic information on Google Earth, allowing researchers to predict and track where infectious disease will strike and how it may mutate.


Using Supramap, they initially developed maps that illustrated the spread of drug-resistant influenza and host shifts in H1N1 and H5N1 influenza and in coronaviruses, such as SARS.


Describing the transition of the Web service to an open-source, freely available phylogenetic analysis program, able to be used by other researchers, he described, “We package the tools in an easy-to-use Web-based application so that you don’t need a Ph.D. in evolutionary biology and computer science to understand the trajectory and transmission of a disease.


“The tool’s users can obtain a pathogens’ phylogenetic tree by submitting its genetic sequences to the system. Supramap then projects that information onto the globe, showing how diseases can mutate over space and time to infect new populations.”


In July 2012, Janies joined the faculty of the University of North Carolina at Charlotte as Belk Distinguished Professor of Bioinformatics and Genomics.


Janies, it seems, has always been the “inventive” sort. He received B.S. in Biology from the University of Michigan and a Ph.D. in Zoology from the University of Florida. He’s worked as a postdoctoral fellow and a principal investigator at the American Museum of Natural History in New York City where he lead a team that, using off-the-shelf PC components, built one of the world’s largest computing clusters in 2001.


He was attracted to UNC Charlotte by the ability to work with outside businesses and to conduct joint research and innovation.


Tracking the Spread of Infectious Disease


Seeing is believing and when you see the 3D visualization of Google Earth and influenza data that Janies and his colleagues have connected on the Supramap giving influenza height, width, depth, movement and meaning, you realize you are looking at an interactive “weather map of disease.”


Supra, Latin for over, is a good descriptor of what the map delivers,” Janies says.


For the Supramap for avian flu (H5N1), a flu that moves within bird populations and then jumps from birds to humans, for example, Janies and his colleagues accumulated data on outbreaks among hosts such as ducks, chickens, wild birds and humans in China, Russia, the Middle East, Africa and Europe. Hundreds of thousands of cases were classified by strain, location and host.


Janies and his colleagues then use specialized software and Google Earth to project the latitude and longitude of similar flu strains onto the globe. If the movement of a pathogen is related to bird flyways, for example, and those routes are shifting because of something like climate change, it can predict where the disease might logically emerge next.


The Supramap allows any user to input raw genetic sequences of a pathogen’s strains and build an evolutionary tree based on mutations. The branches are projected onto the globe with pop-up windows to show how strains mutate over space and time and infect new hosts. That is, in essence, what Janies calls the “crystal ball.”


Disease is visualized as a “tree” whose “roots” are the common ancestor of a particular flu strain. When an ancestor gives rise to descendant strains, the tree grows higher. Intermediate ancestors and other descendents are given less altitude. Outbreaks are connected with lines reaching across the globe. Finally, date of outbreak is factored in, giving the tree a temporal dimension.


For H5N1, the “tree” grew and shrunk from 1999 to 2006, as it moved over the landscape infecting new hosts.


“The idea of this evolutionary tree of the virus,” says Janies, “is to help predict where the next outbreak of the virus is likely to occur. The map gives us a whole new way of seeing the virus in action and understanding what it is—and isn’t—doing. In the meantime, we are working on mapping other diseases, such as MERS and H7N9.”


The role birds play in the origin and spread of flu is a fairly recent discovery, going back only to the 1990s, says Janies. “Influenza has many, many strains and most live in birds. Often those strains get into mammals and humans.”


One of the central questions in influenza research was which birds were the chief culprit in the spread of avian flu. The usual suspects were migrating wild birds and chickens and ducks sold and then shipped to distant locations.


With Supramap, Janies has found that domestic fowl were to blame in Indonesia, but in other regions both wild and domestic birds are responsible. In one interesting case, a smuggled eagle carrying the flu virus was caught in customs after being transported thousands of miles from Bangkok to Brussels.


Asia heads the list of places where most flus originate, but Janies is quick to point out that H1N1 began in Mexico, California and Texas.


“We are not doing a good job of observing flu around the world,” he adds. The World Health Organization operates the influenza surveillance system in partnership with national governments and places its limited number of observers in major cities. Flu in rural areas often goes undetected.


“Until a few years ago,” says Janies, “we just knew about influenza in Johannesburg and Cairo. We didn’t know anything about the rest of the continent of Africa. Without comprehensive influenza surveillance data, and the means to put it in context to inform inoculation programs, influenza prevention will struggle.”


When a pandemic breaks out, disease circles the globe, often leaping from species to species. Supramap doesn’t just track the spread of viruses, it tracks how the viruses are mutating as they jump into new hosts and encounter new medicines. Using Supramap, scientists might be able to stay ahead of the virus mutation curve and figure out when to switch medicines as the microbes adapt and develop resistance.

Few, if any, could have imagined the advances and changes in health care and medicine that have occurred over the last century. The innovation, invention, improvement, discovery and development related to diagnostics, treatments, drug therapies, techniques and cures have been extraordinary.


Fewer still may have anticipated health care delivery systems driven by health insurance, Medicare and Medicaid, or that today professionals and consumers alike would be working hard to wrap their heads around complex changes including those being brought about by the Affordable Care Act (ACA).


Nevertheless, at any given time, there have been individuals and groups whose foresight and determination have propelled health care forward for future generations.


Among them, in 1923, were Doctors James P. Matheson, Clarence N. Peeler, and Henry L. Sloan Sr. who established the 37-bed multispecialty group, Charlotte Eye Ear and Throat Hospital (CEET) on Seventh Street in downtown Charlotte. At the time, treatment of the eye, ear and throat was a single specialty, and the hospital was the first of its kind in the nation.


“There are not many practices in the entire nation that are 90 years old,” attests Jag Gill, CEO of the now-named Charlotte Eye, Ear, Nose & Throat, P.A. (CEENTA).


CEENTA has spent a little short of a century growing its practice from three to 74 physicians; from one office to 15 offices scattered across the extended Charlotte metropolitan region. Its staff is now 600-strong and cares for millions of patients each year. Combined, the offices form a tertiary center amid Charlotte’s two major hospital systems: Carolinas HealthCare System and Novant Health.


CEENTA offers a broad range of services that include eye care; ear, nose and throat care (ENT); audiology; sleep medicine; allergy; facial plastics; voice and swallowing care; and optical and contacts.


Its subspecialties include otology, neurotology, adult and pediatric otolaryngology, vitreoretinal diseases and surgery, glaucoma management and surgery, neuro-ophthalmology, pediatric ophthalmology, oculoplastics, corneal and refractive surgery, and more.


The group offers treatments around cochlear implants, ear tube surgery, hearing disorders, hearing aid services, voice disorders, sleep apnea, allergies, comprehensive ophthalmology (including cataract surgery), and optometric eye care, among others.


“We cover all of the subspecialties of ENT that you would get in a university or academic center,” says Steven Gold, M.D., CEENTA’s chairman and president on the ENT side. “There’s really almost nothing we need to refer elsewhere. It’s the same in ophthalmology.”


The practice is expected to reach $100 million in revenue this year. Growth has been steady over the years at a rate of approximately five percent.


Assuring Quality Outcomes


Still, the large and growing practice is not immune to the uncertainty that is currently the mood of health care.


“These are turbulent times in health care,” says Andrew N. Antoszyk, M.D., president of the ophthalmology side of CEENTA. “There is a lot of confusion right now as the ACA rolls out. What coverage will be available and to whom? What does a plan include or exclude? What impact will the ACA have on hospitals, physician practices and reimbursement policies? We don’t have all the answers right now.”


Drs. Gill, Gold and Antoszyk all agree, however, in the group’s philosophy and strategic plan.


“With all the confusion with insurance companies and the ACA, there are a lot of things out of our control,” explains Gold. “But we remain firmly in control of our commitment to providing the absolute best eye and ENT care, the most compassionate care possible to the whole region.” Gold says that there is not a companywide statement or consensus regarding the ACA, but “with 70 physicians, there is certainly a diversity of opinions.”


In general terms, the Affordable Care Act calls for reforms to reduce the inordinate rise in health care costs while maintaining quality, provide access to health care to millions of uninsured Americans, utilize Accountable Care Organizations (ACOs) to provide coordinated care, create transparency of costs, employ uniform electronic medial records, shift the paradigm of health care to one of wellness, establish metrics for quality health care and outcomes, and to construct formulas for value-driven reimbursements to providers.


While most of these initiatives will first, and most directly, be driven through primary care providers, specialists will also be increasingly impacted.


“Access is important,” stresses Gold. “There are still lots of people who slip through the cracks and don’t have health coverage. The bottom line, with the start of the ACA, is that supposedly there will be millions of people who become covered. That will be a good thing. If the ACA can deliver on its promise of providing affordable insurance to all, we at CEENTA see this as a positive.” However, both Drs. Antoszyk and Gold agree that it is unclear how this is going to transpire without spending more money.


“Value-based reimbursement for providers is something that will be here,” says Gill. “Before it gets here, we have to figure out how to measure value—what quality metrics should we be measuring?”


“The quality measures that are out there now are check boxes put into a computer about what was and wasn’t done. It doesn’t really tell you much about outcomes,” explains Gold. “It’s very difficult to tell how well someone is or if one patient with diabetes is getting better care than another patient with diabetes.”


While the CEENTA execs admit that there is a long road ahead, the firm has begun this work and considers itself to be a leader among private practices. “We collect data on outcomes, conduct peer review on cases, and go over film and CT scans and compare to operative reports. Most private groups are not yet doing this,” says Gold.


“One of the most important things we have to do is determine which quality care metrics we need to measure, then come up with a robust IT system to measure that data and get it to the payors,” says Gill.


Operating the Practice


The combined education, training and experience of CEENTA physicians is beyond impressive.


Gold completed medical training at Boston University School of Medicine in 1982, followed by residency at Naval Hospital in San Diego. His fellowship was through the University of Pittsburgh.

Antoszyk received his medical degree from New York Medical College in 1983, followed by internship, residency and fellowship at Duke University Eye Center.


Gill, new this year, came to CEENTA from Dignity Health’s Medical Foundation in California where he was president and CEO. He holds a master’s degree in Health Administration from the University of Missouri and a doctorate of science in Health Systems Management from Tulane University.


CEENTA operates under a 10-physician board of directors, five from each specialty. The board directs the administration while the administration presents ideas and proposals to the board.


The CEENTA staff is comprised of physicians, audiologists, optometrists, physicians’ assistants, nurse practioners and sleep and voice specialists as well as a chief executive officer and chief operating officer and employees in marketing, accounting, human resources, IT and electronic medical records (EMR).


“The culture here is one of collegiality and patient-first focus,” affirms Gill. “That is one reason I accepted this position. As long as we put the patient first, things always come out well in the end.”


New physicians are most often recruited by current physicians as well as from small groups looking to join a larger group, especially those without EMR systems. CEENTA remains open to considering practices who are interested in joining them.


“Keeping quality employees is always a challenge,” adds Antoszyk, “but we have developed a comprehensive employee package including generous salary and benefits, flexible working hours, continuing education and health care coverage that has been instrumental in helping us retain outstanding employees.”


According to Antoszyk, the goal is to operate in a more efficient manner since 80 percent of costs are fixed: “The recipe is simple: accommodate more patients in a timely and efficient manner. We plan to address this by hiring more providers and placing them in offices close to where patients live or work so that they can be seen quickly with reduced wait time. This increased volume will allow us to enhance productivity through more efficient use of our facilities and staff.”


“Costs are going up—inflation, increases in equipment costs, rent, utilities, salaries and benefits—areas every business has to contend with including health care,” continues Gill. “We are constantly striving to provide the highest quality patient care in a caring environment and we believe we are able to succeed because we have a compassionate and caring administration and staff that supports our outstanding clinicians.”


“Things can change quickly in health care but we have a three-year strategic plan,” Gill maintains. “We want to grow, provide quality care, measure and report that quality, and remain an independent practice.”


Innovation and Invention


In 1992, CEENTA started its own research department to coordinate Phase I-IV ophthalmology and otolaryngology clinical trials. The department grew into Southeast Clinical Research Associates where CEENTA physicians further studies in age-related macular degeneration, retinal vein occlusion, diabetic eye disease, macular edema, glaucoma, cataracts, dry eye, uveitis, chronic sinusitis, nasal polyps, Meniere’s disease, and otitis media.


“We are now heavily into clinical research, doing trials with pharmaceutical companies and the National Eye Institute,” describes Antoszyk. “We are particularly proud of our collaboration with Diabetic Retinopathy Clinical Research Network (DRCRnet) which has yielded ground-breaking treatments in the management of diabeth retinopathy and has been lauded by Congress on numerous occasions.


“This network is a unique collaboration between academic institutions and private practices that identifies clinically relevant problems and then develops protocols to answer the questions.


“One DRCR study—Protocol I—has completely changed how we manage diabetics with diabetic macular edema,” continues Antoszyk.


Innovation and invention are not new to the practice. In 1952, it was Dr. Beverly Armstrong of the firm who invented the tympanostomy, or ear tube and surgery, the most common surgical procedure performed on children in the United States that requires anesthesia. The design of the tube and the procedure remain the same today.


Relationship with the Community


Critical to CEENTA are the relationships its physicians have with the region’s two health care systems, Carolinas HealthCare System and Novant Health.


“It can be difficult to maintain a balance while affiliated with each of them,” says Antoszyk. “We must consider each decision with regard to the impact it will have on one or the other hospital system. Our goal is to provide surgical and medical support to both hospitals while remaining independent.”


CEENTA also takes part in the training of doctors with medical students and residents coming through on rotation. “We work with UNC Hospitals through Carolinas HealthCare System where they have a campus for third and fourth year medical students,” explains Gold.


Antoszyk continues, “Our focus is on providing quality care for all the senses above the neck, but we’re also very involved with giving back to the community.


“Through CEENTA Cares, the firm has been able to make a difference in the community, volunteering staff time, talents and energy to projects like Second Harvest, Habitat for Humanity and Wounded Warriors.”


One of the firm’s recent projects was dubbed “Runnin’ Up Rainier,” led by Dr. Scott Jaben. Last year, he had suffered a back injury that prevented him in his attempt to climb Mount Rainier, the second highest peak in the Pacific coast range. So, as part of his training to reattempt the climb, he started his virtual climb of the 25,000 stair steps via the stairs at the SouthPark office.


He invited employees and acquaintances to join with him from home, office or gym, with a goal of raising $50,000 for the Wounded Warrior Project.


“For those at the SouthPark office, that meant five daily trips up the stairs for the three months of the fundraiser,” says Antoszyk, “building strength, stamina and character, but more importantly, contributing to the community on behalf of the firm.”


Another of the firm’s projects, the CEENTA Cares Walking Team, recently raised $3,375 for the Charlotte VisionWalk supporting the Foundation for Fighting Blindness.


“Our staff is very active in community service and we foster that,” attests Gill.


In last month’s article, we discussed what succession planning really is. Succession planning is a process that all business owners will ultimately have to deal with. There is no if in the need for succession planning because one thing is sure—you as an owner will one day leave your business in one way or another—whether through retirement, disability or death. There is only when and how you should plan for these eventualities.


A succession plan is the specific planning which must take place in order to insure the survival and continuing success of the business after the departure of the owner—whether through the owner’s retirement, disability, death or after the sale of the company.


Succession planning involves planning for the transition of ownership, management, and control of the business from one generation of people to the next, as well as the particular terms and conditions under which the current owner(s) will leave the business.


The average life expectancy of a privately held business is only 24 years. On average, only 33 percent of businesses survive their founder(s). Only 12 percent of businesses survive the second generation of owner(s). Only 3 percent survive the third generation of owner(s).


In our experience, very few businesses really have a succession plan which sufficiently addresses all conditions under which the owner(s) leaves the business, i.e., retirement, disability, death or upon sale of the company. If you just look at owners of very successful businesses, only about 36 percent of these businesses have a succession plan. Approximately 53 percent of these owners have considered a succession plan, but have not implemented any plan. The remaining 11 percent have never even thought about succession planning.


Assume you are an owner of a successful privately owned company without a succession plan. What are the prerequisites for a successful succession plan?


First and foremost, you must have enough time between the development of your plan and your eventual exit as an owner in order to make mistakes. The biggest mistakes that owners make are lack of planning and picking the wrong management successors.


The only way to overcome these mistakes is to leave enough time in the process to correct them. Ideally, a business owner would begin implementing a succession plan at least 10 years prior to the owner’s expected exit. However, when your planning window is less than five years, the odds of implementing a successful succession plan diminish greatly.


Second, the business must be profitable and successful. Some businesses cannot be transferred to the next generation (or sold to anyone else). They simply do not deserve to live.


The third prerequisite is a qualified team of advisors. No one person knows all the answers. Not you. Not your lawyer. Not your CPA. Not your insurance and investment agent. Succession planning is best done with the right team of advisors who have the right expertise.


Fourth, you need a facilitator who is trained and knowledgeable about not only the succession planning process, but also about methods of building consensus between all the parties and stakeholders who need to “buy in” to whatever plan is developed.


Fifth, you need a good process. One that goes beyond your lawyer saying, “Well, here is the form of a buy-sell agreement that a lot of people use and also, you need to contact your insurance agent so you can get a life insurance policy for the buy-sell agreement.” That is not a process.


Finally, there are certain truths that must be embraced before embarking on the succession planning process. These include:


a. There is usually no one answer to the issues that will arise. The answer depends on many factors, including the goals and personalities of the owner and other key people involved in the business. There is, however, usually an optimum solution and succession plan for each particular business and owner.


b. It does not matter what actually is “fair” in the owner’s mind—just what is perceived to be “fair” by the owners and other stakeholders, and


c. The degree of consensus on a final plan is directly related to the perceived amount of input and meaningful participation by all necessary stakeholders.



Consensus on a succession plan is best obtained when there is an atmosphere that permits sharing of information (especially financial data) and a clear willingness to seek and give input before major decisions are made.


In next month’s article, we will discuss the particulars of a good succession planning process.

Managed IT for Business Today


Over the past several years, we’ve watched smart companies survive—and thrive—by learning to manage resources more effectively. Successful technology management, in particular, has undergone a sea change due not only to the uncertain economy, but also to changes in the technologies themselves.


Prior to the recession, most growing companies invested in an internal IT department to manage and maintain infrastructure, to install new equipment, and to provide day-to-day technical support. This structure provided the benefit of on-site IT staff to address concerns as they arise—especially important in an environment in which physical interaction with equipment was a daily necessity.


However, thanks to remote monitoring technology, physical management of IT equipment is now unnecessary on a daily basis. Today, in fact, the benefits of internal IT often are outweighed by the costs:


·      High staff overhead that does not easily flex with the business

·      Limited skill sets—the company gets only what the existing staff brings to the table, with little room for growth and change as the technology environment changes

·       Potentially low productivity,

o     Staff is available only during regular business hours, so if a problem occurs overnight, the entire business team must wait for the IT team to resolve the issue

o     Because the IT team spends their time in the weeds, there is little time to look for new developments and see better ways to support productivity

·        Staffing shortages during employee vacations

·        Knowledge transfer gaps when adding to or losing personnel


Essentially, the old structure leaves the traditional IT guy stranded on a desert island, disconnected from the wider world of best IT practices, and unable to leverage his strongest skills and talents to best support the organization.


Fortunately, current technology has sped the rise of a model of IT support that solves all of these problems: Managed IT. The outsourced, managed IT model provides all the services of an old-fashioned IT department, plus many additional benefits—without the overhead and headaches. A good managed IT company can complement current IT staff, freeing them to focus on their strengths and talents—or, when appropriate, manage the entire IT infrastructure.


The model works so well in part because remote monitoring enables fast and effective troubleshooting, diagnosis, and often problem resolution, without ever stepping foot on site. Complex problems requiring on-site presence can be addressed by specialized staff deployed to match the specific concern. In this newer model, businesses gain access to the proactive services and expertise of an entire team of IT experts at any time of day or night.


Of course, not all managed IT companies are created equal. To outsource effectively, companies should look for a managed IT program that offers these benefits:


·      Cost Containment. A flat fee based on a careful assessment of the client’s needs.

·      Flexibility. Multiple service levels, permitting investment in company growth simultaneous with cash flow preservation.

·      Team of Experts. Focused expertise across multiple platforms and technologies.

·      Modern Tools and Advanced Security. All the latest security and productivity tools.

·      24/7 Support. Monitoring and help desk available at any time, meaning IT crews identify and address problems immediately, no matter when they occur.

·      Advanced Security. Staying ahead of the latest security threats.

·      Technology Leadership. Proactive guidance in the best current tools for the client’s business, often acting as a CTO, always acting as a true partner to the business owners.


A well-managed move to a primarily outsourced IT model saves companies approximately 30 percent on technology costs over the long term—a percentage independently verified by a recent Berkeley study of the credit union industry. With so much to gain, few companies can afford to ignore the growing trend toward managed IT.

One way to start the dreaded but necessary BUDGET discussion with my private business clients is by admitting that, “I hate budgets”. Most of them quickly agree and then add, “Budgets take too long; budgets do not generate income; budgets are too complicated; budgets are always wrong…”


A budget, however, is really just a plan or a blueprint for the future. So why do private business owners react negatively when budgets are mentioned?


The budget is usually NOT the problem. The problem is in building the budget. Instead of participants cooperating to build a reliable forecast, they become adversarial. Owners or managers demand a “best case” budget, and they push for unattainably high profits while the budget builders low-ball their estimates to try to guarantee that their later performance can beat the plan.


When the budgeting process is properly managed, it can produce a reliable plan that can be used to steer your business into the future.


There are different types of budgets: sales budgets may estimate the quantities and products that will be sold, payroll budgets might show how many employees a company will hire and the wages that will be paid, production budgets may forecast the quantities and costs of items to be produced, etc. The income budget, however, is an overall profitability plan for the company, and it combines revenue and expense information from across all departments.


The final result is an annual income statement forecast that shows revenue, expenses and net profits by month. Even if the budgeting process is difficult, time consuming and imperfect, all private companies should work to develop a realistic annual income budget.


Keys to building a successful income budget:


1. Take time to plan. Small and mid-size business owners and managers are often too busy running their business to stop and manage the business. Building a forecast requires company leaders to set aside time to think and plan for the future.


2. Look backwards. Historical performance can help predict the future. During the budgeting process there are opportunities to study past performance and talk about ways to improve. Time is spent trying to understand prior revenue and expenses, and this can lead to future changes and improvements.


3. Get participation from all departments. Your accounting staff might put the pieces together, but a successful budget requires participation from all departments. This allows opportunities for questions and suggestions across departments, and participants take some ownership because they help develop the plan.


4. Start with revenue. Your sales team should provide the sales estimate. Company leaders then need to agree upon a single revenue forecast that all other departments use to forecast their costs. If annual revenue is expected to double, then manufacturing and purchasing departments may need to increase expenses to hire more employees, buy more inventory, etc. If annual revenue is expected to drop by half, then departments need to focus on cost reductions. Deciding upon expected annual revenue helps every other department plan for the future.


5. Accept net profit levels. Once all the revenue and expense estimates are combined, the income budget shows anticipated profits. These are estimates, but company leaders should be willing to accept the calculated profits, if all goes as planned. If the estimated profits are negative or too low, then continue working to build a better, realistic and attainable plan.


6. Compare the budget to actuals. After you finalize the budget, actual company performance should be compared monthly to the plan during the following year. If actual performance is significantly different than the budget, research and address the problems. To be the most beneficial, your budget should be a working document that is continuously referenced and updated, if needed.


Developing an income budget gives owners and managers the opportunity to plan for their company’s future success. This process should include participation from key employees and cooperation across departments.


The final budget serves as a financial map that can be followed, and actual results can then be compared to the forecast each month in order to track company performance against the plan.


All private companies should take time to develop an income budget to help them be successful next year. They should then follow this plan to improve their chances of earning actual profits that closely match their forecast.

Carolinas HealthCare System, which cares for more than 100,000 people with diabetes, is leveraging its expertise and extensive database to develop innovative ways of managing and preventing the widespread chronic condition beyond the doctor’s office.


The medical costs for a person with diabetes are 2.3 times higher than for those without the illness, and a 2012 study estimated that diabetes costs the U.S. economy another $69 billion in lost productivity. A person with diabetes is more likely to be unemployed and those with jobs miss two or three more days a year on average than a worker without the condition. Engaging individuals at the community and employee levels can help detect precursors for disease and disrupt unhealthy routines that lead to chronic illness.


Clinicians can identify who is at risk for diabetes, including those with prediabetes, and interventions, such as weight loss, nutrition and exercise, can prevent the onset of type 2 diabetes. Much of the vital education and intervention can happen at the workplace.


“We recognize of course that most people spend much of their time at their place of employment,” says Dr. Charles Rich, medical director for Corporate Health and Wellness at Carolinas HealthCare System and a practicing internist for 30 years who has worked extensively with diabetics.


“That environment, that location, the culture there and the employer’s understanding and commitment to helping people understand issues important to their health is very important to improving the health of the community.”


Almost 26 million adults and children—8.3 percent of the U.S. population—have been diagnosed with diabetes, and almost 2 million cases are added each year. An estimated 7 million are undiagnosed, and 79 million live with prediabetes.


“The importance of this disease to the health of our population, the health and wellness of the people we love and work with, is colossal,” Rich says. “It’s something that needs focused attention. It’s one of our major cost drivers. It’s a major cause of human suffering.”


With its diabetic population base one of the largest in the country, Carolinas HealthCare System is positioned to find new solutions, he says.


“We are laser-focused on this disease,” Rich says. “What can we do to impact this disease for our individual patients and for the population in general? Very importantly, we’ve created and maintain a very robust registry of our diabetics over a number of years. We have the metrics, we have the information on the population we serve.


“All of our clinicians provide very detailed information about their population and how they’re performing and how the system is performing around important measures to control that disease. It’s a very data-rich environment. We understand who we’re caring for.”


Big Data Yields Personal Solutions


Dr. Michael Dulin, chief clinical officer for analytics and outcomes research for Carolinas HealthCare System and a family medicine physician, says data analytics work can leverage information to improve outcomes for patients with chronic diseases such as diabetes.


“I think it really is the foundation for us transforming the health care delivery system so we can improve the outcomes of patients, specifically patients with chronic diseases,” he says, adding that the doctor’s visit is just part of the solution. “Health care is influenced by much broader contexts of the patient experience—home, work, community.


“Big Data allows us to think about all those different factors that impact a patient’s health. Are they getting exercise? Are they eating the right foods? Do they have access to resources?”


The data is so extensive that proactive interventions can be tailored to an individual. For example, it can reveal that a particular individual with prediabetes who lives near a greenway could join a local walking club in order to get more exercise.


Diabetes is unevenly distributed. Compared to non-Hispanic whites, the risk of diagnosed diabetes is 1.2 times higher among Asian Americans, 1.7 times higher among Hispanics, and 1.8 times higher among non-Hispanic blacks.


“Understanding individual risk and scores, having access to medical care, and taking small steps toward healthier living can mitigate the progress of diabetes,” Rich says.


Keeping Business Healthy


Carolinas HealthCare System has long focused on the workplace as an opportunity to boost wellness understanding and practice.


“We engage with many employers and have for decades,” Rich says. “We have a variety of services we can provide to them—including population assessment, current health assessment, identification of people at risk, and worksite-based consulting and programs. We work with them on establishing logical and good incentive programs to help motivate their employees to understand and seek appropriate attention for their disease.”


Employers’ interest, driven by rising health care costs, has accelerated in recent years. Today, 1 in 10 health care dollars is spent treating diabetes and its complications; 1 in 5 health care dollars is spent caring for people with diabetes.


“Employers are at different stages of understanding this, just like patients,” Rich says. “We’re there to help work with employers in any way. Many of these employers are very interested and committed to help provide financing for the health care of their employees. My perception is there’s more of a genuine than a simple bottom line motivation to have a healthy workforce.


“I think employers are smarter. It’s a more competitive world. Part of that is taking care of your employees and having a healthier workforce. If you take good care of your folks, you have engagement and commitment. Self-insured employers especially have a commitment to employees’ good health.”


Carolinas HealthCare System has its own workplace health initiative—LiveWELL—where physicians and other employees practice what they preach.


“We’re really trying to change our culture inside the health care system so we can be examples to our patients,” says Dulin, who has seen meeting snacks shift from cookies and candy to apples and popcorn. I feel like it’s been a very successful program to engage with people in the workplace to change behaviors.”


In the past few months, Carolinas HealthCare System has developed its ability to partner with employers and conduct data analysis to help improve the health of employees and hold costs down. Simple online surveys or data mining can identify at-risk people based on such factors as body mass index, glucose levels and family history.


“There’s an understanding that there’s a need out there. I think employers are looking for a different approach. I think it’s pretty cool to think about partnering directly between a health care provider and an employer,” says Dulin.


Solutions, for example, could include embedding a mid-level health care provider at the worksite so employees can be seen without scheduling an appointment and going to a doctor’s office.


“It’s about using the data to tailor the interventions so they are applicable to that individual,” Dulin says. “We actually have done it in the research area as a result of some pilot studies,” says Dulin, referring to a neighborhood exercise group that started more than two years ago is still operating.


“I think it’s those kinds of things we need to launch on a broader scale. We’ve done the piloting. We’ve started to think about it. All the foundational work is in place and the pilots have been going on for over a year and a half.”


Carolinas HealthCare System has already conducted a large predictive analytics project with asthma sufferers and plans to conduct a similar study for people with diabetes.


“Diabetes is our emphasis for 2014,” Dulin says. “I think it’s a very exciting time. I think we’re just at the beginning of the next wave of looking at how we deliver health care across the community. We’ve made investments, and we’re now launching the next wave on top of those investments. I would imagine 2014 is going to be a pretty exciting year for us.”


“We’re mission-driven,” Rich says. “That’s why we’re so keenly interested in helping employers. We realize at the end of the day that we’re about the health of our community, the population we serve, and the employer space is so vital.”

AdTrap et al.: Holy Grail of the Internet or Death Knell of Free Content


In this age of technology disruption, a fierce battle is brewing over Internet advertising and ad blocking that may transform the Internet and marketing into yet another iteration.


Ad filtering has existed for a number of years, initially introduced in protection software from companies such as McAfee and Symantec. Ad blocking, or the use of tools (software or hardware) to automatically remove most forms of advertising from Web pages—banner ads, text ads, sponsored links, sponsored stories, pop-ups and even video pre-roll ads on Facebook and YouTube—is a somewhat more recent phenomenon, rapidly gaining popularity.


To users, the benefits of ad blocking include quicker loading and cleaner looking Web pages free from advertisements, lower resource waste (bandwidth, CPU, memory, etc.), and privacy benefits gained through the exclusion of the tracking and profiling systems of ad delivery platforms. Blocking ads can also save minimal amounts of energy. Users who pay for total transferred bandwidth (pay-for-usage connections), including most mobile users, also benefit financially from blocking ads before they are loaded.


For advertisers, the ability to automatically render paid placements invisible without so much as an acknowledgement of being seen (no analytics generated), renders ineffective the principal benefit of digital advertising in the first place, arguably gutting its continuing popularity.


For businesses, online advertisements can be an important source of revenue. For online businesses, ad blocking directly damages the business model they depend upon for revenue, including popular ones like Facebook and Twitter. In some cases, it can even threaten their continued existence, and thus the cry that ad blocking may be the death knell to the otherwise free content available. Rather than let ad-free surfers use valuable resources without indirectly “paying” in the form of viewing ads, a few publishers have gone so far as to reject ad blocking visitors, but that has not been a satisfactory solution.


If widely embraced, ad blocking might actually have some unintended consequences for Web surfers. By rejecting anything that is easily identified as an advertisement, ad blocking software actually encourages more aggressive forms of generating revenue. If legitimate advertising is eliminated, content sites will feel the pressure to sacrifice editorial integrity by using artfully constructed advertorials, charge subscription fees for content…or be forced out of business.


Ad Blocking Tools


Ad blocking can be accomplished in a number of different ways. The most common method, browser integration, enables users to block ads by installing an appropriate Web browser extension. Extensions exist for all major Web browsers—Firefox, Chrome, Safari, Opera, Bing, Internet Explorer, etc., as well as Android and iOS—and are free, fast, and easy to install.


The most popular extensions are AdBlock and Adblock Plus (unrelated). AdBlock claims 80 million total downloads and 20 million regular users per week. Adblock Plus is the most downloaded browser extension—its downloads on Firefox alone grew from 100 million in 2011 to 200 million as of April 2013, a compound yearly growth rate of approximately 35 percent.


Both AdBlock and Adblock Plus, as well as most other ad-eradicating extensions, block ads automatically, but enable the user to allow ads by whitelisting designated pages or domains—like Google search results pages.


In an ironic twist, AdBlock has begun a crowdfunding campaign to raise money to fund online ads to tell people how to block online ads with their AdBlock tool! After just one month, AdBlock had already surpassed its goal of $50,000 at the beginning of September, which it indicated was enough to enable it to not only post online ads but also get space on a Times Square billboard.


Enter AdTrap


CNN Tech touted it as “The device that could change the Internet,” saying that the invention is either “a step forward for the Internet—or a death knell for free content.”


They were referring to Chad Russell and Charles Butkus’ invention called the AdTrap, which intercepts online advertisements before they reach any devices that access your Internet connection, allowing you to surf the Web—even stream videos—without ads.


Russell says his inspiration for the contraption came during a conversation about the early days of the Internet, which he describes as “just page, text and pictures—and that’s it.” Using the slogan, “The Internet is yours again,” Russell and Butkus wanted to recreate the Web-browsing experience with zero ads.


As opposed to ad blocking Web browser extensions, AdTrap is a piece of hardware created for the purpose of blocking ads across all devices, all platforms, and all browsers. So, rather than being limited to the particular device (desktop, laptop, tablet, phone) or specific browser, AdTrap, by comparison, works across every device connected to your network, including those across WiFi.


Russell and Butkus started AdTrap as a Kickstarter crowdfunding campaign early this year, generating interest and enthusiasm for the product idea and soliciting funds for its production.


In the course of 30 days, the AdTrap Kickstarter campaign garnered in excess of $210,000, more than the $150,000 they were asking for. Production began over the summer and devices started shipping out in August.


AdTrap is a white rectangular box that is lightweight and about the size of a wireless router and sits between your modem and router. It currently sells for $139 at and more than 10,000 units have been sold.


It takes only a few minutes to set up (you can watch on video) and works on most sites including YouTube, and Russell says “blocks about 98 percent of online ads.” (There are a couple of sites that they are working on solutions for, but that will be an ongoing project.)


AdTrap can be easily configured from a Web browser. Like online ad-cleansing tools, it also allows users to whitelist pages and domains where they still want to allow ads to be seen.


Says Russell says of his success, “I think it speaks to the mindset of people right now of their experience on the Internet…At some point, it’s gotten a bit much.”


Ad Blocking Going Mainstream

PageFair, a service that allows website owners to measure how many of their visitors block ads, issued a recent report on how ad blocking is threatening the business model of online publishers. Their data shows that ad blocking is being rapidly adopted by consumers, and in fact, becoming “mainstream.”


Based on measurements taken from hundreds of websites, they show that up to 30 percent of Web visitors are blocking ads, and that the number of ad blocking users is growing at an astonishing 43 percent per year, which if it were to continue unabated, would reach 100 percent by 2018. They estimate that a typical client with a 25 percent block rate loses about $500,000 a year due to ad blockers. They acknowledge, “The scale of revenue loss can be fatal.”


Not surprisingly, websites where ads are most often blocked tend to cater to the technologically savvy: Gaming sites had their ads blocked by one of every three visitors, technology sites by one of every four. For travel websites, by contrast, the figure was only five percent.


There’s a similar variation depending on which browsers people are using. Mozilla Firefox, a favorite of techies, heads up the list; over 35 percent of those who use it have installed an ad blocker. Google’s Chrome browser is not very far behind with over 30 percent. By contrast, only one percent of Internet Explorer users block ads.


The demand for ad blocking technology continues to increase. With AdTrap able to block ads on all Internet-enabled devices at one time, that may up the ante.


AdTrap founders Russell and Butkus have already engaged legal counsel in case advertisers get feisty. YouTube and Facebook, for example, depend on advertisements to generate the bulk of their revenue and could stand to lose billions of dollars and even shut down if they don’t adapt quickly.


Good or bad, this product could have massive implications for the near future of the Internet. We will see if ad-based businesses will be able to sustain themselves or if the news sites and small-time bloggers likewise sustain themselves without advertisements for income. Who knows, maybe AdTrap will single-handedly bring back balance to the Internet and create a Web 3.0!


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Publisher's Posts

What did we learn from the recent shutdown of the federal government? Or was anything learned from the shutdown? Depending upon your point of view, you will likely have different answers.


According to the Tea Party faction of the Republican Party, the federal government should have no role in our lives except for the bare essentials. The opposing view offers a different direction…that our government should encourage an economy that works for all of us and give kids a fair chance at a good life. From one perspective government is evil and overbearing and from the other government is a force for good.


Somewhere between those two philosophies is the essence of the budget debate that lies beneath the rhetoric and the partisanship that seems to be tearing us apart.


Government is a system of enabling or controlling public policy decisions for the benefit of the country and its citizens. Put more simply, government is a way to decide what we do together as a nation.


And so, what did we learn? We learned that 800,000 workers were laid off for 16 days. We learned that national parks and monuments were closed to the public. We learned that we did not save money…in fact, according the S&P Index, we actually lost $24 billion out of our economy. Cancer patients were not admitted and treated at the National Institutes of Health. And government agencies were unable to perform their regular functions supporting business growth and/or regulation.


The original purpose stated for the shutdown was to de-fund the implementation of the Affordable Care Act, which, in fact, has suffered more from inadequate planning and implementation than from the actual shutdown itself.


When all was said and done, what legislators agreed to do was to once again kick the can down the road. They effectively set up another deadline to resolve the differences over government spending (i.e. government activities) by putting federal workers back to work and setting up a “budget conference committee” made up of 29 Senate and House members to make recommendations December 13th and action by January 15th or the government will be shut down again. They also extended the raising of the debt ceiling to February 7th.


What perplexes most people about the federal budget are the numerous special interests that seem to control certain elements of the federal government that run contrary to one’s own interests. It is hard to comprehend all the special interests so we attack them as lobbyists, unions, corporations, banks, oil companies, environmentalists, non-profits, religious groups, teachers, doctors, lawyers, farmers, poor, rich, military and foreign. Everyone seems to attack other special interests apparently thinking theirs is the common interest.


The other overwhelming problem with public discussion of the federal budget is its enormity. Obviously, with $3.034 trillion in revenue projected and $3.778 trillion in spending for FY 2014, our budget is out of balance as a result of the recession and all the job losses.


But let’s take a closer look.


Nearly 61 percent of the $3.778 trillion in spending is applied to Social Security, Medicare and military retirement benefits. Mandatory spending of $2.308 trillion includes $860 billion for Social Security, $524 billion for Medicare, and $304 billion for Medicaid, and interest on the national debt.


The balance of federal spending is budgeted at $1.242 trillion to fund all the other functions of government. That spending is actually down from the previous year. Nearly half of that amount is directed toward military spending for about $644 billion. So that leaves roughly $598 billion for fixing roadways, schools, agriculture, etc.


Relative to the total spend, the federal government was shut down impacting a mere 16 percent. That’s not the part that’s sinking our boat. That’s not the part that will be twice as large 7 years from now if we can’t agree to do something about it.


So, where should we focus our limited time between now and January 15th to make the greatest impact on reducing our federal debt? With a grand total of about $17 trillion in accumulated debt obligations, primarily from Social Security, Medicare, military pensions and interest, the answer should be clear.


Obligations to the elderly in America will only increase every year. Nearly 10,000 baby-boomers retire every day. Medicare is posted at $524 billion in FY 2014, but that number is projected to rise to almost double that—over $1 trillion—by 2020.



Changes will be relatively miniscule if we make them now; they will be gigantic if we make them later. For example, one recommendation from the Simpson-Bowles Commission would save $585 billion over 10 years by slowly raising the Medicare eligibility age from 65 to 67 by the mid-2030s. It would also change how Medicare beneficiaries pay for Parts A and B (the programs that cover hospital care and doctor visits) and expand means-tested Medicare premiums, so the highest income beneficiaries would pay more for their premiums.


Even though retirees have paid into Social Security and Medicare for their entire working lives, that money has not been put aside and/or invested for future expenditures. It has been borrowed and spent for previous retirees. Add to that, the facts that we have fewer workers contributing to the systems than ever before and that older people are living longer lives and receiving more expensive and complex medical treatments.


With limited time, we must turn the focus and the attention of our elected officials to the long-term fiscal obligations that are more than we can afford. We have limited choices, but we must consider cutting benefits, raising taxes, means testing the benefits, and/or raising the retirement age. Unfortunately, those are the tough choices.


If we are to avoid another shutdown, we must act decisively. We should be discussing and determine what we want our government to do about these obligations. Our decisions will dramatically affect our children and their children over their lifetimes.


Failing to act is the worst choice we can make.


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