vol.22 no.1 January 2014 - Amazon Web Servicesrepconnectdocuments.s3.amazonaws.com/MDSI/REP-jan.14.pdf · 2014. 4. 3. · practices could both avoid penal-ties and earn a bonus (.5

vol.22 no.1 • January 2014

Medical DistributionHall of FameBill McLaughlin, Sr. and Yates Farris

4 January 2014 • www.repertoiremag.com

contents

repertoire magazine (ISSN 1520-7587) is published monthly by Medical Distribution Solutions Inc., 1735 N. Brown Rd. Ste. 140, Lawrenceville, GA 30043-8153. Copyright 2014 by Medical Distribution Solutions Inc. All rights reserved. Subscriptions: $49.00 per year for individuals; issues are sent free of charge to dealer representatives. If you would like to subscribe or notify us of address changes, please contact us at the above numbers or address. POST-MASTER: Send address changes to Repertoire, 1735 N. Brown Rd. Ste. 140, Lawrenceville, GA 30043-8153. Please note: The acceptance of advertising or products mentioned by contributing authors does not constitute endorsement by the publisher. Publisher cannot accept responsibility for the correctness of an opinion expressed by contributing authors. Periodicals Postage Paid at Lawrenceville, GA and at additional mailing offices.

in every issue

Publisher’s Letter ................................................................................................................6

Practice Points .....................................................................................................................8

Windshield Time .............................................................................................................20

Tech Talk ...........................................................................................................................64

QuickBytes ........................................................................................................................73

New Products ...................................................................................................................73

$128 Question/Classifieds .............................................................................................74

Great savings, better outcomesConsolidating purchased-service contracts leads to substantial savings and the potential for higher quality outcomes for Spectrum Health... .....................................16

idn opportunities

HIDAHIDA’s Health Reform Update................................................................................................13

ObesityWith the right solutions, physicians can care for obese patients .................................................... 57

disease states

Treasures from the Past

D.J. O’Connor – pg 67

Medical Distribution Hall of Fame

Fit for 14Fitness and exercise don’t have to be a drag in 2014! ....... 71

healthy reps

22pg

long-term careSoft surface contamination: not a hard problem to solve

Privacy curtains, bed linens and employee uniforms can be a haven for bacteria in long-term care settings. ..... 47

trends

Why patient experience is so important .......................................................................44

Numbers RacketNew cholesterol guidelines stir up a hornet’s nest, but monitoring LDL through point-of-care testing still important. .........................................48

Colonoscopy is test of choice……but only because doctors push it over fecal occult blood tests and flexible sigmoidoscopy. ............................................................................54

10pg

Opportunity amidst UncertaintyIndependents have a good story to tell the supply chain executive whose IDN has just purchased a physician practice

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publisher’s letter

6 January 2014 • www.repertoiremag.com

Exceptional Contributions

Brian Taylor

editorial staffeditor

Mark [email protected]

managing editorGraham [email protected]

senior editorLaura Thill

[email protected]

art directorBrent Cashman

[email protected]

corporate vice president

Scott Adams [email protected]

(800) 536.5312 x5256

director of business development

Micah McGlinchey [email protected]

(800) 536.5312 x5268

publisher

Brian Taylor [email protected]

circulation

Laura [email protected]

Wai Bun [email protected]

new media and

events manager

Alicia O’[email protected]

Subscriptionswww.repertoiremag.com/

subscribe.aspor (800) 536-5312 x5259

2014 editorial boardTracy Howard : Cardinal Health

Bill McLaughlin Jr. : IMCO

Bob Miller : Gericare Medical Supply

Linda Rouse O’Neill : HIDA

Jim Poggi : McKesson Medical Surgical

Brad Thompson : NDC

Chris Verhulst : Henry Schein

repertoire is published monthly by mdsi 1735 N. Brown Rd., Suite 140, Lawrenceville, GA 30043, Phone: (800) 536-5312, FAX: (770) 709-5432; e-mail: [email protected]; www.medicaldistribution.com

The New Year is often the time when all the “best of ” lists come out, and we read the ratings of top performers in an industry, or tune in to award shows honoring them.

Certainly, healthcare distribution is no different, and so we prepare to recognize and honor several people who have made exceptional contributions to the industry. Our annual Hall of Fame event will take place in February, and we are pleased to add the names of Bill McLaughlin and Yates Farris of IMCO to the distinguished list of previous inductees. Both of these men have long careers in the industry and have been in leadership positions wherever they have been along the way. Bill joined IMCO in its earliest days, and since taking it over has led it to great heights and created a strong, unique organization providing a voice and a place for the independent dealers. Certainly one of Bill’s shrewdest moves was convincing Yates to join the team back in the 1995. Together they’ve been strong advocates for the independents, and provided a host of creative marketing platforms across a myriad of healthcare markets. Read both of their stories in this issue.

The annual “roast” this year will also have a new twist to it in that we will for the first time also recognize the respective winners of the Repertoire/HIDA Excellence in Sales Awards. These are the winners as voted by their working peers, who in 2013 stood out among a strong field of contenders for doing extraordinary work. This year’s winners are Nate Williams from Midmark and Chuck Ryan from McKesson. Their stories will ap-pear in the February issue with coverage of the Hall of Fame event appearing in either the March or April issue.

It’s a great way to kick off 2014, which promises to be another year characterized by change and confusion and a lot of moving parts that will challenge all of us in the business. But we know that the industry is full of capable and innovative people – future Hall of Famers for sure – that will embrace the challenges ahead and produce solutions to current problems and ones we have yet to see.

We’d like to congratulate our honorees and wish everyone a safe and prosperous New Year!

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January 2014 • www.repertoiremag.com8

Editor’s note: Welcome to Practice Points, by physician practice management experts Capko & Morgan. It is their belief – and ours too – that the more education sales reps receive on the issues facing their customers, the better prepared they are to provide solutions. Their emphasis is on helping physicians build patient-centered strategies and valuing staff ’s contributions.

Non-participation in programs like the PQRS and the Meaningful Use (EHR) incentives has been quite common among our clients – and, I would suspect, among yours. Many practices have perceived the rewards to be too thin, and the hassle too great, to make compliance with every program worth the effort. This is es-pecially true for practices that don’t have many Medicare patients (and so don’t perceive a large incentive

upside) or are lukewarm about con-tinuing in Medicare (and so may be-lieve they’ll avoid penalties when they stop accepting it).

From incentives to penaltiesAs of the end of 2013, though, we’re reaching a tipping point. Key initia-tives are shifting from incentives to penalties. Group practices will shift from earning a PQRS incentive to a PQRS penalty deduction (+.5 percent

to -1.5 percent) from their 2015 reimbursements based on whether they successfully report in 2013.

ePrescribing is also shifting: 2013 was the last full year in which practices could both avoid penal-ties and earn a bonus (.5 percent of Medicare payments) for partici-pating. To avoid a penalty for 2014, practices must participate by June 30. Meaningful Use also converts to a 1 percent penalty on 2015 re-imbursements for non-participa-tion in 2013. The Value Based Pur-chasing Modifier (VBPM), which increases or decreases Medicare reimbursements for large groups starting in 2015, relies on the PQRS as a data source – so large practices will be exposed to an ad-ditional 1 percent penalty.

The Payment Revolution It may have started without your clients

A Journal of the American College of Radiology study earlier

in 2013 showed that fewer than 20 percent of physicians

are participating in Medicare’s Physician Quality Report-

ing System (PQRS) – despite the fact that they could have earned

as much as 2 percent of their Medicare billings per year as a bonus

if they’d joined the program when it started in 2007.

By Laurie Morgan, Capko & Morgan

ePrescribing is also shifting: 2013 was the last full year in which practices could both avoid penalties and earn a bonus (.5 percent of Medicare payments) for participating.

www.repertoiremag.com | November 2012 | repertoire : 9

Sharing best practices on ePrescribing – e.g., tips learned from one client

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Taken together, these penalties have the poten-tial to significantly decrease practice revenue. Prac-tices are starting to realize real money could be lost. Plus, they’re boxing themselves out of more compre-hensive programs like the Patient-Centered Medical Home (PCMH) that draw from several of the other initiatives – and have much bigger upside potential.

What’s more, many programs that start as gov-ernment initiatives inspire private payer versions – for example, Accountable Care Organizations (ACOs), which also “pay for performance,” have been embraced by private insurers (by some counts, private ACOs now outnumber Medicare’s by three to one).

With opting out of these initiatives becoming more costly, any opportunity a rep has to assist his or her practice clients in getting on the bandwagon can make a big difference. For example, technology ven-dors can help practice staff learn how best to extract reporting data from medical records systems or even just recommend a reporting registry. This can be real valuable to smaller practices. Sharing best practices on ePrescribing – e.g., tips learned from one client that you can pass on to another – is another great way to bring value to your clients. Even simply help-ing practices reach out to resources who can help them crack the code – whether consultants like us, or just practice managers and physicians you know who’ve succeeded – is of huge value. One of the best values we bring to our clients is to introduce them to other practice owners and staff and help them build their network – and, reps in the field typ-ically work with many more practices, and are so in an even better position to help practices make new connections than we are.


distribution

“Distributors who have been successful in retaining business have proactively worked with the [hospi-tal] system; met with the appropri-ate stakeholders, that is, decision-makers; and delivered solutions to meet their unique needs,” says Dave Rose, vice president, busi-ness development and corporate programs, National Distribution & Contracting, Nashville, Tenn. NDC is a member service organization providing distribution, logistics, marketing and other services to more than 300 independent medi-cal, physical therapy, rehabilitation and dental product distributors.

“In large part, our distributors have been successful in retaining business, but not without selling their unique value proposition and how it translates into measurable and sustainable value for the hos-pital system,” he says. “Those who have been successful have also taken the initiative to understand and im-plement GPO contracts, assist with contract compliance and product

formularies for their customers. They have become an anchor tenant at the facility and positioned themselves as a partner who can solve problems and provide solutions.”

Rose began his career in the healthcare industry with C.R. Bard, Inc., holding various sales positions in the Bard Urological Division. He was also the Southeast region manager of extended care for General Medical Corp. (now McKesson Medical-Sur-gical) and vice president of sales and marketing for Chester Labs, a manu-facturer of personal care products in Cincinnati, Ohio.

Steps to takePhysician-office distributors under-stand the “status quo” is no more, says Rose. “It goes without saying that decision-makers will be differ-ent, and new relationships/partner-ships will be forged. [Independent distributors] will need to deliver easy-to-implement, cost-effective, supply solutions to meet the needs of the new business relationship.” Distribu-tors must realize the new customer will demand a more collaborative and transparent relationship.

Successful distributors welcome these changes as opportunity, and they give IDN/hospital supply chain executives compelling reasons to do business with them, says Rose. “Cus-tomers need to have confidence they are in better hands with you than without you.”

Opportunity amidst UncertaintyIndependents have a good story to tell the supply chain executive whose IDN has just purchased a physician practice

Distributors get understandably nervous when their physician-

practice customers are acquired by a hospital or hospital sys-

tem. After all, hospital supply chain executives don’t know

them, nor are those executives always aware of the cost to serve non-

hospital customers. Challenging as the situation is, independent dis-

tributors can retain the business of newly acquired physician practices,

provided they demonstrate their unique – and quantifiable – value to

hospital supply chain executives.

“ Change and uncertainty always bring opportunity for those who are flexible and creative.”


distribution

One way to start is to demonstrate that independent distributors can react quickly and decisively to customer requests, he says. What’s more, independents have a great story to tell about their ability to serve providers across the care continuum.

“What a perfect time to sell the benefits of partnering with a regional distributor,” he continues. “What a won-derful window of opportunity that allows independents

to tell their story of relentless service, and to say, ‘I’m the company who, unbeknownst to you, has been a viable sup-ply solution for years.’ What a great platform to increase your company’s visibility and expand relationships beyond your day-to-day customers.”

Tough questionsNon-hospital distributors can expect some tough questions about pricing from hospital/IDN supply chain executives. They must be ready with answers, says Rose. “It is our re-sponsibility, as distributors, to educate the customer about the cost variances to serve different market segments. We need to explain, and more important, demonstrate, the dif-ferent costs associated with serving a physician clinic vs. the hospital. It is not unusual for the independent distributor

to drive 15 miles to drop off emergency equipment or sup-plies, in low unit of measure, to a physician office for a com-munity event, such as a school sports program.

“Distributors will hear the need to reduce overall cost – not necessarily at the product level, but to improve ef-ficiency and savings across the entire operation,” he con-tinues. “They will hear that the customer will want to be an active participant in the process, who wants visibility and some control of the supply chain decisions and process. Large providers who buy physician practices will need the distributor to leverage GPO contracts and support con-tract compliance.” Distributors will need to be prepared to help their customer navigate GPO contracts, compliance and reporting issues.

What’s more, non-hospital distributors will need to le-verage technology to provide cost-effective solutions that will give the IDN/supply chain team real-time visibility to both process and price, says Rose. “[Distributors] can ex-pect to assist with common ordering platforms that allow customer input and control. The independent will position itself as a partner/consultant who can assist the hospital/IDN with product formularies and offer suggestions for reducing overall cost.”

Opportunity“Change and uncertainty always bring opportunity for those who are flexible and creative,” says Rose. “The independent distributor is a viable option for hospital systems to serve their newly acquired physicians. Today, nearly half of the alternate site market is being serviced by the independent distributor.

“The benefits of working with a local company are obvi-ous and numerous. They can adapt quickly to change, make decisions and do more in far less time than larger companies.

“Customers will always want choice. The independent that is currently serving the physician market is very well positioned to help the hospital/IDN with their alternate care supply chain needs. Existing customers can be a tre-mendous advocate for independent distributors by mak-ing introductions and providing referrals. The hospital/IDN customer needs their help, and expertise, beyond the hospital walls.”

Here’s what independents have to sell supply chain executives whose hospital or IDN has just acquired some physician practices:

• Ability to understand and implement GPO contracts.

• Ability to serve providers across the care continuum.

• Ability to react quickly and decisively to customer requests.

• Ability to service customers on a moment’s notice.

• Ability to assist the hospital/IDN with product formularies.

Selling points

“Our distributors have been successful in retaining business, but not without selling their unique value proposition and how it translates into measurable and sustainable value for the hospital system.”

www.repertoiremag.com • January 2014 13

HIDA’s Health Reform UpdateBy Linda Rouse O’Neill, Vice President, Government Affairs, HIDA

The following update by the Health Industry Distributors Association (HIDA) is designed to keep healthcare distributors and other key stakeholders current on the latest government-affairs related topics.

On November 27, the president signed the Drug Quality and Security Act (H.R. 3204) into law, creating a national prescription drug pedigree monitoring system. This devel-opment marks a major legislative victory in our industry’s efforts to create a uniform, national pedigree solution, but it also represents the culmination of several years of hard work by HIDA. All of our member priorities were included in the final bill, which allows distributors to conduct busi-ness the same way in all 50 states.

HIDA key wins• Provides a national uniform solution

immediately preempting the current patchwork of state pedigree laws.

• Exempts convenience kits, combination products, and IV solutions – among other medical items – from traceability requirements.

• Fixes language so that all companies – C corporations, S corporations, LLCs, etc. – can conduct intracompany transfers of pharmaceutical products. Previous legislation tied the definition to the tax code and C corporations only.

• Removes a proposed mandate requiring medical-surgical distributors to provide all required pedigree information in one initial document to be passed through the supply chain.

• Establishes national licensure standards for pharmaceu-tical wholesalers that ensures uniformity in all 50 states for the provisions outlined in the bill around such issues as background checks, physical inspections, bonding requirements, and fingerprinting.

Advocacy success sometimes comes down to small de-tails that can make a big difference. In this instance, it was

the difference between “may” versus “shall” when craft-ing legislative text. “Shall” is a mandate which can some-times be good for clarity, yet can become burdensome for those it affects. With regard to how required pedigree data is passed down to customers, HIDA’s GA team secured “may” so medical-surgical distributors would have flexibil-ity when implementing potential final legislation. Knowing when to push for “may” versus “shall” in this instance was a key to success for distributor and manufacturer interests.

HIDA and the industry came together in 2012 and formed the Pharmaceutical Distribution Security Alliance

(PDSA), recognizing the need to safeguard patients by having uninterrupted access to safe and authentic FDA-approved medicines. This coalition of more than 25 in-dustry stakeholders met with members of Congress to ensure the industry’s priorities were included in any must-pass future supply chain legislation.

HIDA Government Affairs also conducted over 300 meetings on Capitol Hill over the last several years to educate staff on the importance of creating a clear federal standard that preempts state pedigree laws. This

HIDA advocated for a uniform national pedigree solution to replace the patchwork of competing and overlapping state pedigree laws. Replacing inconsistent state requirements that were costly, inefficient, and left the integrity of the pharmaceutical supply chain at risk with a national law was a significant victory for distributors, manufacturers, and patients alike.


hidabicameral and bipartisan effort was key for a Congres-sional working group to release draft pedigree legisla-tion on Oct. 24, 2012, which was the most comprehen-sive draft to date and included all of HIDA’s member advocacy priorities.

This draft started the legislative process which cul-minated this fall after several months of negotiating and finalizing details for a national pedigree solution during the August Congressional recess. The House of Representatives passed H.R. 3204 on September 28, 2013 by voice vote. A voice vote, which signals there was no opposition to the bill, in a time when Congress has been very partisan demonstrates the depth of ef-fort of HIDA, its members, and industry partners in ensuring every congressman supported the bill. HIDA also applauded the leadership of Chairman Fred Upton (R-MI) and Representatives Bob Latta (R-OH) and Jim Matheson (D-UT) for their tireless leadership and com-mitment to getting a bill through the House.

Before the bill was signed into law by the president, it had to pass through the Senate for review and approval.

Most anticipated a smooth and speedy process due to the fact that Senate lawmakers had been equally engaged in the negotiations and bill drafting. However, no one ex-pected the October government shutdown to delay Senate passage of the bill by nearly two months. Fortunately, nor-mal day-to-day government operations resumed by mid-October and the Senate unanimously passed the bill on Nov. 18, 2013.

The unanimous Senate passage was a testament to the work of HIDA and all involved including Senate champions Richard Burr (R-NC) and Michael Bennet (D-CO) along with Chairman Tom Harkin (D-IA) and Ranking Member Lamar Alexander (R-TN).

The FDA is now tasked with the responsibility of im-plementing and enforcing H.R. 3204 over the next several years, and it’s up to us as an industry to ensure a smooth rollout takes place. HIDA will continue to provide updates and deadlines as they affect distributors, manufacturers, and providers alike. As always, you can learn more about pedigree and other industry issues by contacting us at [email protected] or visiting www.HIDA.org

• Prior to Jan. 1, 2015: The federal Prescription Drug Marketing Act of 1987 (PDMA) requirements remain in place during the interim period between enactment and the start of Phase I requirements.

• Jan. 1, 2015: Phase I begins requiring manufacturers, wholesalers, and repackagers to comply with applicable traceability requirements and engage with only “authorized trading partners.”

• July 1, 2015: Dispensers must comply with applicable traceability requirements.

• 4 years after enactment: Manufacturers must have all product serialized.

• 5 years after enactment: Repackagers must have all product serialized.

• 6 years after enactment: Wholesalers must only engage in transactions with serialized product.

• 7 years after enactment: Dispensers must only engage in transactions with serialized product.

• 10 years after enactment: Trading partners must be compliant with Phase II. Phase II is self effectuating (does not require final FDA regulations) and requires an interoperable electronic system that traces serialized product at the unit level through the supply chain.

Key dates

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idn opportunities

Consolidating purchased-service contracts leads to substantial savings and the potential for higher quality outcomes for Spectrum Health.

By Laura Thill

It came as no surprise. When the consulting firm

Christopher Baskel used to review spending

patterns at Spectrum Health (Grand Rapids, Mich.)

identified nearly $300 million in annual non-salary expenses with

the potential for cost savings, the system director of supply chain

management knew exactly where to begin: purchased-service contracts.

“They told us we were doing well and in the lower third nationally for supply

cost as a percent adjusted patient day,” Baskel recalls, noting that he already

knew as much. “We have over $1 billion in non-salary expenses, including elevator

maintenance, temporary labor, employee benefits, nursing, IT, human resources and

more. I suggested we begin with that. As a result, they found that approximately a half

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idn opportunities“As your organization grows, your opportunities grow

as well,” he continues. So, when Spectrum Health added another hospital, the IDN also added more employees, benefits, nurses, elevator contracts and more. The job was getting done, he adds, but in a decentralized – and ulti-mately more expensive – fashion.

No noviceWith over 31 years of experience in healthcare sup-ply chain management, Baskel is no rookie at recogniz-ing cost-savings opportunities. Prior to joining Spectrum Health, he worked with two large academic medical cen-ters and a community-based 10-hospital health system. He joined Spectrum Health in 2002, where he is responsible for enterprisewide logistics and contract management. In addition, he and his contract team have implemented over $40 million in cost savings through 1,100 distinct

projects, ranging from devices to service agreements. In 2003, he helped create Great Lakes Hospital Purchasing Network, a VHA supply network comprising 12 non-owned health systems in western Michigan, and in 2005 started the Michigan Minority Business Development Council for Healthcare. As chairman, he has helped the council establish over $5.2 million in new business for 18 minority business establishments in Michigan.

Most recently, Baskel and his contract team worked with Spectrum Health’s cath lab and operating room man-agement teams, including the physicians, to reduce the supply cost for cath lab and cardiac rhythm management (pacemakers and defibrillators) products; drug-eluting stents (for a savings of $5.1 million); and hips and knee ($1.1 million in savings). “Our efforts earned Spectrum Health the VHA national award for physician preference cost reduction, as measured by VHA’s PriceLYNX bench-mark data against 1,600 hospitals,” he says.

So, nearly two years ago, when the opportunity presented itself to consolidate purchased-service contracts, Baskel and his team “launched a cam-paign to do just that,” beginning with elevator ser-vice. “Even two years ago, I don’t think consolidating purchased-service contracts was on many people’s radars,” he says. “Now it’s becoming a much talked about opportunity.

“We identified nine decentralized purchased-service contract opportunities to standardize across our health system,” he continues. “The first, elevator service, is now complete. In this process, we identified 12 indi-vidual elevator service contracts across our health sys-tem, six of which were with the same company. Each of the 12 contracts was implemented without a purchase order, in a decentralized format, each with separate in-dividual contract expiration dates.”

After finishing this project, Spectrum Health now has one cen-tralized elevator service contract and has saved 22 percent in the process, Baskel points out. “This is a good example of how we can mitigate risk and ensure the high-est quality outcomes, as well as save cost,” he says. The healthcare in-dustry is consolidating, he adds. As this happens, supply chain execu-tives such as himself must continue to find more efficient ways to man-age multiple contracts.

Next on the agendaBaskel continues to consolidate Spectrum Health’s non-PO expense contracts, currently focusing on temporary labor. This can be tricky, he points out, as every depart-ment – IT, human resources, nursing, etc. – has tempo-rary labor. Still, “this is something we would like to see under one roof,” he says, joking that he told the human resources department, “You need to look at temporary labor once every 30 years whether you need to or not!” What human resources may not realize, he adds, is that temporary labor spans many departments. “Health sys-tems don’t always realize how decentralized they are.”

As many a pioneer can attest, with new ideas comes pushback. “It’s not what we know, but what we don’t know [that scares us],” he says. Yet more and more administra-tors and staff at Spectrum Health have bought into the need for consolidation of purchased-service contracts over the past 10 years.

“ Every dollar we save is probably better than revenue. But, you can’t see, feel or touch it. So, out of sight, out of mind.”


idn opportunities

In time, Baskel anticipates tackling purchased-service contracts across nine different areas at Spectrum Health. Benefits, such as long- and short-term disability insurance and consultant fees are on his radar and may be his next project. “It’s a matter of priorities,” he says. “Where is it important to save money and improve quality? Do we want the best printer paper or the best surgical products?

“Getting people on board is always the first chal-lenge,” he continues. “So two years ago, I used the consult-ing card. Once the consulting firm said it was necessary to consolidate purchased-service contracts, it got the at-tention of our top executives. Today, it’s part of our value analysis stream,” he says.

In fact, he envisions the consolidation of purchased-service and all non-salary spend to eventually be on every-one’s radar at hospital systems across the country. At least,

he sure hopes so. “It has to be,” he says. “Where are we going to get the revenue for healthcare reform?” When it comes to consolidating non-salary expenses, the savings may not be visible to everyone at first, he notes. “Every dollar we save is probably better than revenue. But, you can’t see, feel or touch it. So, out of sight, out of mind.”

As supply chain executives know all too well, there are many considerations that impact healthcare spending. “Years ago, a CFO said, ‘I thought we had an outstanding new contract on X-ray film,’” says Baskel. “I told him we did. There are so many factors involved, such as utiliza-tion and waste, which drive up the total cost. The lower price paid at the pump did not ring true. All he saw at the year end was a higher film spend than the previous year.” Which is why it’s so important to increase awareness within the IDN, he adds.

“ Even two years ago, I don’t think consolidating purchased-service contracts was on many people’s radars,” he says. “Now it’s becoming a much talked about opportunity.”

Looking forward, Christopher Baskel, system director of supply chain management, Spectrum Health, anticipates some changes on the healthcare horizon, particularly with regard to physician prefer-ence items. “Supply chain contracting, in conjunction with our physician partners, will begin to use evidence-based medicine and quality outcomes in defining specific product attributes (not brand preference), which will establish the clinical standards required for contract awards,” he says. The stage will then be set for the emergence of generic equivalents to physician-preference products.

And, why not, he says. Particularly with regard to such standard items as, say, shoulder anchors used by sports medicine surgeons, now that the patent has expired on brand names, the generic products are essentially the same quality at a third of the price, he points out. “It is not difficult to figure out what the savings would be for a large IDN spending [over] a million dollars on an annual basis for this product. When a process using evidence-based medicine is used to make decisions, it will all come out in the wash. In the early 1980s, doctors would have balked if someone suggested they offer their patients generic pharmaceuticals. And, look where that market is today!”

A look ahead


WindshieldtimeChances are you spend a lot of time in your car.

Here’s some automotive-related news that might help you appreciate your home-away-from-home a little more.

Mazda goes greenEach year, Green Car Journal selects the Green Car of the Year. At press time, the journal publicized its five finalists, including the redesigned 2014 Mazda3. Mazda’s third-generation compact car features the Skyactiv® technology suite, with Mazda3’s base 2.0-liter four-cylinder Skyactiv-G engine. The high-compression ratio powertrain reportedly gener-ates 155 horsepower and 150 pound-feet of torque, with fuel-economy figures of 30 mpg in the city and 41 mpg on the

highway, according to EPA estimates. In addition, the car’s i-ELOOP regenerative brak-ing system is designed to cap-ture energy typically lost during braking and convert it to elec-tricity to help power interior components. The i-ELOOP system reportedly is capable of improving fuel-economy by as much as 10 percent. The other Green Car of the Year final-ists include the Audi A6 TDI, BMW 328d, Honda Accord and Toyota Corolla.

Reliable picksJapanese automakers have historically been known for building some of the most reliable vehicles in the world. But Consumer Reports 2013 Annual Auto Reliability rankings show that auto-makers from Europe and the United States are also capable of building reliable vehicles. While, three Japanese brands – Lexus, Toyota and Acura – captured the top three spots in the survey, Audi, Volvo and GMC were included in the top 10 spots of this year’s survey, which was conducted by the Consumer Reports National Research Center. Hybrids and electric cars continue to do well. The Toyota Prius, Lexus ES 300h, Toyota Prius C, and Honda CR-Z hybrids, as well as the Nissan Leaf electric car, were among the top models. The survey – believed to be the largest of its kind – bases its findings on CR subscribers’ experiences with 1.1 million vehicles. Consumer Reports uses the survey data to compile reliability histories on vehicles and predict how well new cars that are currently on sale will hold up.

Poor scores, high insuranceDrivers with poor-credit-based insurance scores re-portedly pay 91 percent more for auto insurance than drivers with excellent scores, according to a recent in-suranceQuotes.com report. Drivers with median credit are said to pay 24 percent more than those with excel-lent credit. Credit is one of many factors that insurance companies use to evaluate risk and calculate premiums. Other factors include driving record, age, gender and past claims. Insurance scores, like credit scores, are cal-culated using information in credit reports (including late payments, credit card balances and credit inquiries). However, they’re used to predict the likelihood of a future insurance loss, instead of a consumer’s credit-worthiness. Three states (California, Massachusetts and Hawaii) prohibit the use of insurance scores in setting car insurance rates.


Don’t be caught without!Magic Tank LLC now offers Magic Tank ®, an emergency gasoline substitute that’s reportedly safe (and legal) to store and transport and works in any gasoline-powered combustion engine. Available in half-gallon bottles, Magic Tank® is said to work like traditional gasoline. A gallon of the fuel substitute is designed to provide the same gas mileage as a gallon of regular gasoline. And because the substitute is derived from gasoline, it shouldn’t harm engine components or sensors. It con-tains no lead or gum forming agents, and has a ten-year shelf life. In addition, the flash point of Magic Tank® is a minimum of 105 degrees F compared to gasoline’s flash point of around -40 degrees F. So, whereas gaso-line can spontaneously combust when left in a hot car, Magic Tank will not.

Shopping tips Car shoppers can learn a lot about a new car, even before they take it out for a test drive, according to Edmunds.com, a resource for car shopping and automotive information. At the start of any test drive, Edmunds.com advises car shoppers to ask themselves several questions, including the following:

• Is it easy to get in and out of the car without stoop-ing or banging my head?

• Does my body type match the pedal positions? If not, are the pedals adjustable?

• Is the seat comfortable and easily adjustable? Is there a lumbar support adjustment?

• Is there ample head-, hip- and leg-room in both the front and back seat?

• Are the gauges and controls easy to read and use?• Do the side and rearview mirrors offer good vis-

ibility? Are there potential blind spots?• Is the trunk space and cargo area sufficient?

Is the vehicle easy to load?

Once the test drive begins, shoppers should pay atten-tion to listen to – and feel – the engine. They should consider their personal requirements in a car. For ex-ample, drivers who regularly drive into the mountains, should find a hill to see how the car climbs. Those with a daily highway commute, should test the car on a freeway and see how the car accelerates into traffic and performs at higher speeds. Finally, shoppers should evaluate new cars for braking, steering and handling, suspension and in-cabin ergonomics.

Winter readyAutoPartsWarehouse.com has compiled a list of key proj-ects to help drivers prepare for winter ski trips, snow-boarding trips and more, including the following:

• Prepare tires.

• Install mud flaps.• Install auxiliary lighting.• Equip car and cargo area with protective mats.• Install trailer hitch or roof-mounted rack.• Replace windshield wipers.• Check antifreeze.• Change oil.• Wash and wax car to protect the paint from road salt.• Equip car with an emergency kit.

In addition, winter drivers should remember to re-move snow and ice from the vehicle before driving; accelerate slowly; reduce speed; allow for much great-er distances when driving behind other vehicles; know the brakes; take turns slowly; continuously scan for potential road hazards; and be aware of other drivers. Before drivers attempt any vehicle service or repair, however, the company advises them to consult their vehicle owner’s manual.

Those with a daily highway commute, should test the car on a freeway and see how the car accelerates into traffic and performs at higher speeds. Finally, shoppers should

evaluate new cars for braking, steering and handling, suspension and in-cabin ergonomics.


Medical Distribution2001

George Blowers, Welch Allyn

Jim Stover (William T. Stover), National Distribution & Contracting

DeWight Titus, F.D. Titus & Sons

2002Bob Barnes, Durr-Fillauer

Karl Bays, American Hospital Supply

Pat Kelly, PSS

Ron Stephenson, Indiana University

2003John McGuire Sr.,

Colonial Hospital Supply

Haworth Parks, Parks Inc.

2004Bill McKnight,

McKnight Medical Communications

George Ransdell, Ransdell Surgical

Medical Distribution Hall of Fame Inductees

Bill McLaughlin, Sr.


Hall Fameof2005

Max Goodloe, General Medical

2006Gil Minor III, Owens & Minor

2007Elliot Werber, Kendall Corp.,

F. D. Titus & Sons, Bergen Brunswig

2008Bill and Lew Allyn, Welch Allyn

2009John Moran, Welch Allyn

2010John Sasen, PSS

2011Scott Fanning and Don Kitzmiller,

Midmark Corp.

2012Ted Almon, Claflin Co.

Cindy Juhas, Hospital Associates.

2013Rob Saron, Bovie Medical Corp.

2014Bill McLaughlin, Sr., IMCO

Yates Farris, IMCO

Yates Farris


medical distribution hall of fame

“I don’t think there’s anybody anywhere in the in-dustry who feels more strongly about the independent distributor than Bill McLaughlin,” says Al Borchardt, Midland Medical, Lincoln, Neb., a long-time IMCO member. “Without question, he is committed to distri-bution through the independent network. He lays out a very good scenario to a lot of manufacturers about

what distribution brings to them. His greatest strength may be his understanding of distribution and ability to negotiate product lines.”

“One thing that makes Bill differ-ent is, he always takes the long view,” says Mike Marks, co-founder, Indian River Consulting Group. He has his eye on long-term shareholder value vs. ‘How do I get my sales up this year?’

“Bill has been the passionate, ‘mother bear’ for the independent dis-tributor ever since I‘ve known him,” Marks continues. “If anyone criticizes independents, he gets his back up.”

McLaughlin himself is clear on what he considers his marching orders, and that of IMCO, to be: “Our mis-sion is to be a vital part in helping our regional member distributors achieve

success and be competitive with those that are on a national level, through solid relationships and programs with our ven-dor and distributor partners,” he says.

“The IMCO model is also empowered by a strong level of trust and family values, in addition to an expanded line of IMCO and select member private label, select re-distribution and national account support.”

Bill McLaughlin has built a strong IMCO organization through tenacity, passion, loyalty and smarts.

A herder of cats, a dog with a bone, a visionary, a deep thinker, a man of compassion. All are terms that those who know him call Bill McLaughlin, CEO of IMCO.

of theChampion

Independents

Bill and Sue McLaughlin

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medical distribution hall of fameParke DavisMcLaughlin spent his early growing-up years in California. His first job was selling newspapers at Hollywood Park Race Track in Inglewood. His father was an inventor and engineer, and his mom worked in a secretarial position. The family moved to Crystal Lake, Ill., northwest of Chi-cago, when McLaughlin was in high school, so his father could take a job in Skokie, Ill., as a design engineer. He attended Northern Illinois University in DeKalb, major-ing in biological science with pre-med/dental as well as minors in microbiology and chemistry. In 1968, upon his graduation, he went to work for Parke Davis (now Pfizer), an old-line pharmaceutical company, which also had a line of med/surg products, including gauze, dressings, instru-ments, gloves, drapes, even EKG machines.

While selling pharmaceuticals, McLaughlin found he enjoyed speaking with doctors and getting to know the mar-ket, and picking up selling skills. When the company (which

was acquired by Warner-Lambert in 1970) split its sales force into med/surg and pharmaceuticals, he joined the med/surg side as a sales trainer, calling on hospitals, clinics and nursing homes in the Chicago area. It was a chance to continue to work closely with distributors, he says.

In 1975, he joined Zuck and Eaton, a regional med/surg distributor in Rockford, Ill., as vice president of sales and marketing. “I did everything but handle the books,” he says. Following that, he became a regional manager for Medix, a Madison, Wis.-based full line distributor. (Me-dix was ultimately purchased by Owens & Minor.) He was responsible for the Rochester, Minn., location, which in-cluded the Mayo Clinic.

Later, McLaughlin joined General Medical (now McKes-son Medical-Surgical) as a regional manager in La Crosse, Wis. Later, he was given the opportunity to develop a Minne-apolis branch. He met with success, and as a result was asked to work in the company’s corporate office in Richmond, Va.,

as director of physician marketing. Later, he became director of hospital and long-term-care marketing, and then assistant vice president, which primarily involved vendor relation-ships and acting as a liaison with dis-tribution locations nationally.

It was at General Medical that McLaughlin got his first exposure to international business. He began to work with overseas companies – pri-marily Asian firms – to build on the distributor’s domestic private-label program. His experience in interna-tional negotiations caught the atten-tion of Tsefong, a Taiwanese compa-ny whose factories were later relocated onto the Chinese mainland, which produced products on an OEM basis as well as under its own brand name – Ultimed. After eight years with Gen-eral Medical, he joined Ultimed.

At Ultimed, he learned the fine points of negotiating with the Chinese,

“I don’t think there’s anybody anywhere in the industry who feels more strongly about the independent

distributor than Bill McLaughlin.” – Al Borchardt

Bill, Olympic medalist Dot Richardson 2005


such as where to sit at the table, how to exchange business cards, etc. “Plus I made a lot of friends,” he says. He also gained credibility in the business and learned the importance of nurturing long-term relationships built on trust. It’s a les-son he says IMCO practices every day.

IMCOIn 1989, he had an opportunity to join IMCO, which at the time had a staff of three (under the direction of IMCO founder Richard Appell), about 50 distributors, 90 vendors and combined sales of about $120 million. (Today, IMCO employs 21 people, has about 170 dis-tributor locations, 212 vendors, and combined member sales of about $4 billion.)

“It was a great opportunity for me, because I could utilize my knowledge and relationships to support inde-pendent businesses across the United States and Canada, which I so strongly believe in,” he says.

Of Childrey he says, “Roy taught me the value of history and reinforced the value of the independent dealer, all at a time when GM operations and sales were being centralized.”

Glen Radabauch “was a believer in developing sell-ing skills,” he says. “Thanks to his tutelage, I was able to grow within the sales ranks and become a sales trainer for the company.” He exposed McLaughlin to the five rules of selling: attention, interest, desire, conviction and close.

George Crispin “was a little less by-the-book than Glen,” he says. “But he was really good on planning, how to work with accounts, understanding the power shifts [within accounts]. Anything but pricing; pricing was the last thing we did.”

Jack Richards “was very smart, a strategist,” says McLaughlin. It was Richards who gave McLaughlin a chance to develop the company’s branch in Rochester, Minn. The Medix owner was demanding. “If you were in a military operation,

you couldn’t find a better guy [to be with] than Jack. He knew the rules and knew how to win – but it was all above-board, ethical, honest. He was a very, very good negotiator. I took very careful notes. I felt I was a neophyte in martial arts deal-ing with a master.”

McLaughlin also owes a debt to late writer and speaker Og Mandino, author of The Greatest Salesman in the World. “The ten sacred scrolls in the book say it better than any book I’ve ever read on the subject.”

MentorsAsk Bill McLaughlin about mentors, and he names several:

• Roy Childrey, to whom McLaughlin reported for a time when he was senior vice president of sales at General Medical.

• Glen Radabauch, McLaughlin’s first manager at Parke Davis.• George Crispin, his med/surg manager at Parke Davis in Chicago.• Jack Richards, owner, Medix.• Author and sales trainer Og Mandino.

Bill, Yates 1993 convention

1. Data on fi le. 2012.

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Bill McLaughlin likes fast cars, so it is serendipitous that IMCO was founded and is still located in Daytona Beach Fla., home of the Daytona International Speed-way. But it’s no coincidence that one of IMCO’s most successful promotions is called the Win-ner’s Circle. Introduced in 2001, the most recent iteration – in

2013 – found more than 550 salespeople participating.

“The idea fits the IMCO model, since we operate by trade class and collectively,” explains McLaughlin. “The idea is to have national promotions working in concert with select participating vendors – all sell-ing the same thing at the same

time during set time segments. This includes all sales material, promotional costing and terms, with close vendor rep and man-agement involvement. National distributor awards and recogni-tion is given to high achievers and sales management. Atten-tion is given to specific markets, sales cycles, etc.”

Winner’s Circle

“Anyone who meets [Bill McLaughlin] can feel that energy and can’t help but to be drawn in to his passion,” says IMCO Di-rector of Member Relations (and McLaughlin’s daughter) Angie Euston. “I remember watching him at the recent HIDA confer-ence on the show floor as I was sitting in the IMCO booth. He was like a kid in a candy store – smiling ear to ear, practically bouncing with energy, so ex-cited to be talking about IMCO, our members and business with industry colleagues.”

“If you were to meet Bill McLaughlin Sr. for the first time, you would instantly know how passionate he is about the health-care distribution business and keeping the independent dis-tributor strong and competitive in our changing landscape,” says IMCO Vice President Bill McLaugh-lin Jr. “He will continuously ask you different questions to get to know you and remember one key fact about you. He may not always be

outspoken, but he is intently lis-tening to everything you say. And if you want to compete with him in something, you will also not meet many people as competitive as he is.”

“Bill is a dog with a bone,” says Mike Marks, Indian River Consulting Group, referring to McLaughlin’s tenacity and pas-sion for independent distribu-tion. “And he’s a deep thinker. He’ll keep stewing over some-thing until he figures it out.” And, once having figured it out, he has the ability to energize others to make things happen. “He’s a cat herder,” says Marks. “He has more patience than I do.”

“Bill sees the value of all of us getting in the same boat and rowing in the same direction,” says Al Borchardt, Midland Medical. What’s more, he remains “very, very committed” to the concept of exclusive geographic regions.

“Bill is a visionary,” says Yates Farris, IMCO’s vice presi-dent, primary care markets,

who joined McLaughlin at IMCO in 1995. “He sees the big picture. And he’s aggressive,” the proof being IMCO’s growth since McLaughlin assumed control of the organization.

“Bill and I are as different as night and day,” says Farris. “Maybe that’s why we get along so well.” McLaughlin may seem crusty to those outside the orga-nization, but he’s a caring, giving person, says Farris. “I have seen him do things for people that you wouldn’t believe.”

Adds IMCO President Deb Bullock, “There are things peo-ple don’t know about Bill. He’s a very sensitive person, very kind. He doesn’t tell the stories of the behind-the-scenes things that he and [his wife] Sue do for our members and employ-ees.” What’s more, McLaughlin is open to promoting women, says Bullock, who joined IMCO 16 years ago with the opportu-nity to grow the organization’s long-term-care business.

Passion is the difference


Since assuming control of IMCO, McLaughlin has worked hard to grow the business while main-taining the original philosophy of the organization.

“IMCO has always been very selective in where we add members to minimize overlap substantially by trade class,” he says. “This allows us to operate more as a team. Consequently national promotions of our design, in addition to ongoing vendor pro-grams – the Winner’s Circle is an example – allow participating members and vendors to promote on a national level during select periods of time. With roughly 1,000 full time member salespeople, we can make a substantial impact for participating manu-facturers during the promotional periods. This al-lows IMCO members to participate as a national company, but with many locations offering local and regional service to the targeted providers.”

McLaughlin is proud of IMCO’s programs, in-cluding its training programs (covering sales skills as well as products) and market-specific programs. “Another successful program has been our advisory meetings, which we hold twice a year. These meet-ings are specific to trade classes, such as physician, long-term care and acute care, where our advisors meet with vendors for the purpose of acquiring knowledge and building sales together.

“IMCO operates its national convention as a program,” he continues. “This is important, because in our case, it brings about 94 percent of our mem-bers together at the same time. It’s the barometer of any association’s strength.”

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2012 Convention finale



New opportunitiesMcLaughlin continues to pursue growth wherever he and his members perceive opportunity.

“He is a true champion of the independent distributor and is always thinking of new ways that IMCO and our members and vendors can evolve and grow,” says IMCO Director of Member Relations Angie Euston. “I can’t tell you how many times we’ve had a conversation that has started with, ‘I had an incredible idea come to me in the middle of the night that can help our distributors/ven-dors; what do you think?’

“He is a visionary and thinks out of the box. One of my favorite parts of working for our family busi-ness is seeing this side of my father and watching him turn an idea into a successful program or action for our members and vendors. By sheer force of will, he makes things happen.”

For example, in August 2013, IMCO named PSS veteran Bob McCart as its vice president of national ac-counts. “Bob’s addition, together with support from Su-zanne Lord [vice president, sales and marketing, Med/Surgical Information Services International] and our state-of-the-art software, mean IMCO is well-positioned to take advantage of national account opportunities,” he says. “This includes old-style national accounts using various member locations across the country to service regional

and national providers of various trade classes with com-mon pricing and terms.”

He is also excited about IMCO Home Care, a recent initiative intended to offer independent home care pro-viders competitive pricing, products and services, such as education, compliance, financing and marketing. IMCO Home Care includes HME/DME providers as well as hospice and VNA operations. “This new model promises to bring business to many of our members throughout the country,” he says.

The future is bright for IMCO and for independent distributors, says McLaughlin, noting that independents maintain about 45 percent of the physician market busi-ness and more than 50 percent of the long-term-care market. Yet they face challenges as well.

“The challenges include adapting to [the Afford-able Care Act], changes in technology, and getting out of silos and operating as a team. The more we all pull together, the more strength we have in negotiations and in promotional activity, the more benefits we can pro-vide our customers, and the greater the profits for our membership and our supportive vendors. The greatest challenge – and our greatest opportunities – include continued penetration into the lab and equipment mar-kets, expanded redistribution opportunities, and greater national account support.”

“Bill has been the passionate, ‘mother bear’ for the independent distributor

ever since I‘ve known him.” – Mike Marks

IMCO_Pirates IMCO Staff, 2010 IMCO Convention


“One of McLaughlin’s greatest strengths is his tenacity as a ne-gotiator, says Al Wicks, CEO, C&S Medical Supply Inc., West Read-ing, Pa., and an IMCO board member since 1984. He listens to his distributor members and lets them set the agenda.

“Over the years, the board members and I have known that Bill is very loyal to people,” continues Wicks, who considers McLaughlin a family friend as well as business associate. “It’s not always about getting the

best price. It’s about loyalty. Over the years, he has done everything he can for certain manufacturers who’ve had troubles. He’s played both sides of the fence.”

Says Bill McLaughlin Jr., “A day does not go by that he isn’t working to help at least one member or vendor grow their business, even if it is getting a better price on a basic com-modity product or getting that first sit down meeting with one of our members. Selfishly, I would also add that he is a great mentor as well.

“There is not a day that goes by where he doesn’t call me or

e-mail me something that will help me grow, and does the same for my sister, Angie [Euston]. He has created a great company from the foundation up and wants to see all of us at IMCO continue its unwavering commitment to all of our members and vendors for many more years to come.”

McLaughlin’s passion comes out in everything he does, including negotiations, says Ken Mosher, Omni International Corp. Mosher first met McLaugh-lin in the mid-1970s, when

Mosher was selling exam gloves for Tillotson, and McLaughlin was at Zuck and Eaton.

“Bill obviously does his job extremely well, trying to get the best prices and programs,” says Mosher. “He has done that since the first time I called on him as a sales rep, and he continues to do so today. His passion comes out in everything he does, in-cluding negotiations.

“But I never walked out of a meeting feeling Bill got the up-per hand. I don’t think he looks for that. Instead, he looks for that balance between negoti-ating the best possible price

and helping [the manufacturer] promote products.” McLaughlin brought that same passion and fairness to the table when he was on the manufacturing side, adds Mosher.

What’s more, McLaughlin values long-term relationships, notes Mosher. “He’s not the guy to jump in for 10 cents off a widget. He also gets behind a program 100 percent. If you are honest, fair and competitive, the odds are you’ll be in that building [with McLaughlin] for a lot of years.

“He has helped small and medium-size distributors com-pete with the larger companies out there,” Mosher continues. “He has been able to bring knowledge and new ideas to these distributors, and he’s been able to move in different directions. He’s hard-working, loyal, sincere, and extremely knowledgeable – a guy I’m proud to call my friend.”

“Bill is very, very strong at negotiating,” says Al Borchardt, Midland Medical. “He has a sharp mind on the whole thing; he knows how to get through it; he can take a look, identify the problem and come up with a solution. The vendor leaves [the table] knowing that it is a two-way street. It has to be; everybody has to benefit, or else it’s not a good deal.

“If Bill has a hallmark, that’s it. For him, it has to be a win/win all around. Over the years, that certainly has been why IMCO has been so successful.”

Tough – but fair – negotiator

“ A day does not go by that he isn’t working to help at least one member or vendor grow their business.”

– Bill McLaughlin Jr.



“Yates is someone you really can’t forget,” says Dave Myers, executive vice president, Seneca Medical, Tif-fin, Ohio. “First, how many people do you get to meet with a name like ‘Yates?’ Second, Yates has an ability to immediately make you feel comfort-able and important to him. He has an amazing smile, a positive attitude, and pays close attention to you during a conversation. Third, he’ll be the guy with a group of people around him. Not that he’s a ringleader, per se; but he’s nor-mally involved in something fun, interesting and engaging.”

Yates Farris, vice president, primary care markets, is being inducted into the Medical Distribution Hall of Fame, along with IMCO CEO Bill McLaughlin.

Air Force medicFarris was born in Charlotte, N.C., and reared in nearby Bessemer City, N.C. It was a little textile town, he says, with a population of about 3,000. His dad spent much of his professional life as a Greyhound bus driver, traveling from Charlotte to Atlanta, or Charlotte to Charleston. His mother was a superintendent in one of the big mills, and also spent time working in the hotel industry.

Come draft age, Farris intended to pursue air traffic control and warning. But he was colorblind, so he became

a medic instead. In the Air Force, be-ing a medic was more like being an LPN, he explains. “We did everything – worked in the emergency room, sutured, treated lacerations, casting.” Stationed in Turkey, he worked in a 40-bed hospital that supported mis-sile sites near the Soviet border.

After his discharge in 1963, Far-ris became a sales trainee for NCR

Corp. in Charlotte, but he soon discovered that corporate life wasn’t for him. An Air Force buddy had gotten a job at Winchester Surgical Supply, a Charlotte-based med/surg distributor, and called Farris a year later with this message: “I know they’ll hire you if you come down here.” In Feb-ruary 1964, Farris joined the company.

OJTFor a couple of years, he unloaded trucks and picked orders for Winchester. Occasionally, he joined other team members at office setups. “I was called a sales trainee, but our training was OJT,” he says. He started in the field in 1966 and stayed there for 17 years. In 1983, he became sales manager/vice president, and remained in that role until Winchester’s own-ers sold the company to PSS in 1995.

“Sales was kind of what I always wanted to do,” he says. “Even when I was in the Air Force, I knew that.

Yates Farris doesn’t do games or

pretense. He acts out of honesty and a general concern

for people.

Want to know how to spot Yates Farris in a room?“Look for the guy who people are gravitating to,” says Dick Moor-

man, vice president sales, Midmark Corp. “It would be a pretty good chance that would be Yates Farris. Yates is always about you … not about him. It is what endears you to him. He is not fake about his interest in others. He is real, and he really cares. You can feel it when you talk with him. He is the real deal.”

TheRealDeal


medical distribution hall of fameI don’t even know why. But I remember at the time think-ing, ‘If I could become a salesman and make $10,000 a year, I would have arrived.’” The Air Force experience as a medic didn’t hurt the young salesman. “I could talk the language,” he says. “I knew how products were used, be-cause I had used them. And that helped me tremendously.”

Farris became a “certified sales consultant” through the American Surgical Trade Association (now the Health Industry Distributors Association) at the association’s an-nual meeting in Las Vegas.

But he credits much of his success in sales to an expe-rienced, top-performing Winchester rep named Bill Jetton. A U.S. Marine who had seen action in Iwo Jima, Jetton had gained distinction for reaching a million dollars in sales in an all-physician territory. “We’d meet him at 6 a.m. on Saturday mornings, and he would give us two hours of ex-cellent training,” recalls Farris. “He probably did more for

me as a salesperson than anybody ever had. You couldn’t help but model yourself after him.”

It wasn’t just Jetton’s sales technique, but his discipline and philosophy of taking care of customers, that affected Farris. “His idea of customers was, ‘You can’t do enough for them,’” he says. “He knew more about his customers than anybody else knew about theirs. He knew everything they had in their office, where they kept it, how much they used in a month.”

Fostered camaraderie“Winchester was our biggest distributor,” recalls David Allyn, director, corporate social responsibility and medical schools, Welch Allyn, who went to North Carolina after starting his career with the company. “I have to say, there couldn’t have been a better person for me to get to know than Yates. He took me under his wing; made sure I was doing my job, al-

ways testing me, pushing me, making sure I was coming in with an order in hand. But he was always fair, and he made me feel comfortable.”

Farris’ influence on the Win-chester team was obvious. “You could feel their camaraderie,” says Allyn. “The friendships were more than business relationships. All the reps – even the new guy in Tennes-see or in eastern North Carolina – were connected. Everybody looked to Yates as the trusted one; every-one felt comfortable with him at the helm.” And Farris mentored many top-performing reps, including some who ultimately joined Welch Allyn, PSS and other firms. “He definitely had a huge impact on their careers.”

In 2012, Farris was awarded the Jana Quinn Inspirational Award by Professional Women in Healthcare. One of the nominations came from Phil Childrey, formerly IMCO’s di-rector of equipment development, who had died in a motorcycle acci-dent shortly before Farris received the award. In his nomination, Chil-drey recalled that he had run across Farris soon after Childrey started working for Midmark in 1989. “I believe Yates deserves to receive this award because of the many ways

“ His genuine concern for the other person and his ability to listen deeply has been a tremendous strength for him.”

– Dick Moorman

Yates, Winners Circle 2011

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“Yates has a way with people,” says Jerry Shelton, retired president of Tarheel Physicians Supply, Wilmington, N.C., an IMCO member since 1995. He and Farris first crossed paths when Shelton was a sales rep with Johnson & Johnson’s Ar-brook division, and Farris was a young rep for Winchester.

“People genuinely like him. He’s very knowledgeable of his products, and very well-respected by his customers.

He is probably one of the most knowledgeable people I have ever met in medical distribu-tion. He understands it, he understands the people, and he understands how it works.

“He has been a tremen-dous mentor to an awful lot of people without even knowing it,” continues Shelton. “He has a sincere desire to help people.”

Victor Amat III, American Medical Supplies and Equip-ment, Miami, Fla., served with Farris on the IMCO board (when Farris was still with Winchester) as well as the HIDA Physician Advisory Council. “He’s always current on industry happenings

and changes, and often offers the best insight on industry issues,” says Amat. “He is always sharing information from his distribution days with all of the IMCO members.”

To this day, Amat uses a formula Farris shared with him 15 years ago to calculate and forecast sales growth for salespeople based on company goals. “Yates is always trying to help you succeed,” says Amat. “He doesn’t take himself too

seriously, and always puts the needs of others first.

“I think we can all learn a valuable lesson from Yates. This industry, like many others, is about people and how you con-nect with them. In my 28 years of medical distribution, I have yet to hear anyone say anything nega-tive about Yates Farris. He is kind, compassionate, a good listener and a great communicator.”

Says IMCO Director of Member Relations Angie Euston, “Yates has an incredible ability to connect with people and is a natural mentor and teacher – patient, listening, guiding and always helpful. He is dedicated

to the independent distributor and is always ready and willing to help a member/vendor in need with support, nurturing advice or listening ear. I’m very blessed to have a mentor like Yates to help me over the years and teaching me to trust my instincts.”

Southern charm and kindness may be Farris’ most notable traits, notes IMCO Vice President Bill McLaughlin Jr. “But as soon as you start talk-ing about healthcare distribu-tion or fishing, he becomes very animated and will tell you great stories and lessons about anything you want to know. Yates is a great resource for many of us at IMCO, with his ideas and experiences that he has had throughout his years in this industry.”

Farris is a strategist, who looks at all sides of an issue before jumping in,” continues McLaughlin Jr. What’s more, “Yates has impacted so many people in our industry, both on the vendor and distribution side, as a friend and mentor, that his openness and willing-ness to help others would be his greatest contribution.”

“Yates is one of the nic-est people you’d ever want to meet,” says IMCO President Deb Bullock. “He is a kind and good person, a mentor to the world. He always listens. He encour-ages everybody – in our office and in the industry. He touches everybody who meets him. Yates doesn’t know a stranger. He loves people, truly.”

People person

“ He doesn’t take himself too seriously, and always puts the needs of others first.”

– Victor Amat III

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that he has helped me when he had nothing to gain by doing so,” he wrote.

“Throughout my career, Yates has stayed in touch with me. He always spoke with me like I was important to him and like he cared about my success. I personally know many people in our industry that credit Yates Farris with their suc-cess, both professional and personal. I believe that Yates truly does what he does for others only out of the goodness of his heart. I don’t know another person like him in this regard.”

“Yates was a great sales manager,” says Moorman. “He held his team accountable, yet they wanted to be held accountable, because they could tell Yates was working in their best interests. That is a unique quality/ability/gift/strength that too few people possess. Yates has a way of inspiring people to be better. He has always led by example and you won’t outwork him.

“As good as Yates can make you feel, one should not take that as him being soft,” continues Moorman. “If you get in a negotiation with Yates, you usually end up giving him what he wanted …. and you feel good about that fact that you did! It is my belief that his genuine concern for the other person and his ability to listen deeply has been a tremendous strength for him.”

Yates Farris has a rare skill: He knows how to listen to people. That’s according to those with whom Repertoire spoke.

“I have watched Yates in action,” says Dave Myers,, ex-ecutive vice president, Seneca Medical, Tiffin, Ohio. “I’d have to say his greatest strength

would be his interpersonal and conversational skills, in particular his listening skills. He doesn’t come off as having

an agenda. He’s genuine, and by getting to know the person he’s speaking with, he builds a level of confidence and trust with that person.”

Says Victor Amat III, Ameri-can Medical Supplies and Equipment, “Yates is a great listener and can have a con-versation with anyone. What makes him unique is that Yates can have a conversation with a warehouseman or a CEO. When Yates speaks with you, he makes you feel like you are the most important person in the room. That is why he has been successful in this industry and in his life.

“As much as our industry has changed over the years, Yates’ ability to connect with people is his greatest asset.”

The power of listening

“ Yates is a great listener and can have a conversation with anyone. What makes him unique is that Yates can have a conversation with a warehouseman or a CEO.”

–Victor Amat III

Yates at Sales Training for Success

Newcomer Reception 2012



Yates Farris “really understands the value of relationships, and makes sure everybody is taking advantage of that,” says David Al-lyn, director, corporate social re-sponsibility and medical schools, Welch Allyn. “Independents tend to be smaller, and they have a harder time getting the atten-tion of manufacturers,” he says. “Yates has made sure indepen-dents were leveraging their value to the manufacturers.”

“His knowledge of the medical market is second to none, and he has led many

meetings and focus groups and has shared his vast knowledge with all,” says Dick Moorman, vice president sales, Midmark Corp. “Yates has shown our industry how you should conduct business and how you should conduct yourself. He would always take the time to listen…I mean really listen, to hear what it was you were try-ing to say. The ability to listen with an open mind and not

immediately challenge what you are saying is something we could all learn from Yates.

“Yates has been – and is – a terrific salesman. He has been and is a terrific leader of men, and he is and always will be my terrific friend.”

Says Dave Myers, executive vice president, Seneca Medical, “Yates’ greatest strength would be helping others, or their busi-nesses, gain visibility into new or different ideas. He always tries to share what’s working in the industry to address a

particular issue or challenge, or help make a connection with someone who can help you.

“As an independent, you have to rely on resources outside of your company, and Yates has been that resource for so many companies, includ-ing Seneca Medical.”

“Yates is that guy who the first time you meet him, you like him,” says Al Borchardt, president and owner, Midland

Medical, one of IMCO’s first members. “He has a very keen mind on how distribution works; I think that’s why the combination of Yates and Bill has worked so fine. Yates is a staunch student and defender of distribution, and he has the ability to communicate its value to manufacturers.

“Yates has that capability to put you at ease,” he contin-ues. “He also has that ability to identify problems, break them down to a manageable level, and offer a solution. And it will be one that is fair and equi-table to all parties.“

Farris looks forward to more years of helping independents remain a strong force in the market. “With hospitals buying physician practices, it’s mak-ing the customer base smaller,” he acknowledges. “But change always brings opportunities.”

Independent physician distributors may find the going tough, as they typically have little or no relationship with hospital supply chain executives, he says. “But independents will adapt,” he says. They will do so by communicating to supply chain executives whose hospital has just acquired some physician offices that those offices need a different type of service than the acute-care hospital.

“Independents are more flexible [than big nationals],” he says. “They can change their operational routine quicker. They’ll survive. Some

Standing up for independents

“ As an independent, you have to rely on resources outside of your company, and Yates has been that resource for so many companies.”

– Dave Myers


IMCOWinchester was an IMCO member, and it was through that relationship that Farris and McLaughlin became friends. In fact, Farris served on the IMCO board of directors. “One thing led to another,” he recalls. “I had agreed to come to work for IMCO even before Winchester was sold.” In fact, he gave Winchester six months notice; the company sold to PSS just a couple of months later.

Making the transition to IMCO in 1995 wasn’t difficult for Farris. In fact, it was a move he had looked forward to for some time. “At Winchester, I was a regional/local type person,” he says. “I worked the Carolinas.” Working for IMCO gave him an opportunity to work on a national scale. “I knew a lot of the peo-ple in our membership; I thought it was a different challenge.”

The move didn’t disappoint. “I think of all the oppor-tunities I’ve had to work with the various people through-

out the country, that I wouldn’t have had if I had stayed in Charlotte. It’s the people in this industry who make it, and this is a small industry. It’s a thrill. We go through changes; but everybody steps up to the plate.”

The mid-1990s was a crucial time for independents. Consolidation was rampant, and national distributors were gobbling up smaller ones. Farris felt he could make a contribution, helping independents remain viable. And he believed that McLaughlin could lead the charge. “Bill was aggressive, and he had already made huge changes in IMCO,” he says.

“Bill and I are as different as night and day. Maybe that’s why we get along so well. I have seen him do things for people that you wouldn’t believe. He’s good to his em-ployees, and he’s a strong negotiator. He walked the walk,” first as a pharmaceutical rep, then med/surg.

The industry was much different a few decades ago.

Yates Farris joined Win-chester Surgical Supply in Char-lotte, N.C., in 1964. “I went to work for Sinclair Stewart, a great guy, a Southern gentleman, a very good businessman,” he says. “But business was done much differently back then.

“When people say, ‘This is a family business,’ [Stewart] meant it. He felt that every em-ployee was part of his family.”

So, when young Farris became engaged to his wife-to-be, Kay, Stewart called both of them in for an interview of sorts. “We met with him, and he asked a lot of questions you can’t ask today,” recalls Farris. What church were the two go-ing to attend? When were they thinking of having children? “He felt an obligation to try to take care of us,” says Farris.

Later, when the young couple bought their first

house, Stewart called in Farris to ask him more ques-tions. How much did they pay? How much were the monthly payments? How many years was the mort-gage? “He got all the details.”

The questions had a pur-pose, because every time a Winchester employee bought a house, had a child or experi-enced another significant life event, he or she would get a raise to help make ends meet.

Those were the days

are already doing different things, diversifying into other markets. There are opportuni-ties everywhere.

“I feel there’s a great future for independents. They may have a different look over the years, but they’ll make it.”

Farris and his wife, Kay, have been married since 1965. They

have two sons, both living in Charlotte. Yates III (nicknamed Trae), is an operations supervi-sor for US Airways. He and his wife have a 12-year-old girl. Brad is an operations supervisor for Estes Express Lines; he and his wife have two daughters.

The Farris family has a mountain home in Little

Switzerland, N.C. In his off-hours, Yates enjoys tennis, fishing (inland waters) “and, until I got too old, played men’s softball, officiated basketball (youth to men’s leagues), and umpired base-ball (youth, and eventually worked my way to doing College Baseball, Division II).”


trends

For providers, customer service isn’t just limited to a patient’s inter-actions with their doctors and nurses. “It’s not just about how we inter-face with patients; it’s also about how we interact with each other,” said Jim Merlino, M.D., Cleveland Clinic’s chief experience officer. “There are things that we bring to what we do every day that are going to impact how we care for people.”

Providers are being slammed with changes in every direction. The brunt of these changes, such as declining reimbursements and the medi-cal device tax, have directly affected the bottom line in every facet of the continuum. In response, hospitals are collaborating or consolidating, phy-sician groups are aligning themselves with provider systems, etc.

Why patient experience is so important

By Alan Cherry

Healthcare providers and the sales reps who ser-vice them are part of the

largest customer service industry in the world. The importance and urgency for providers and their suppliers to adopt a more custom-er-oriented mindset was the topic of Welch Allyn’s recent, inaugural Patient Experience Summit.


trends

At the same time, consumers have more power than ever before. “Reform today is very different,” said Mer-lino. “It requires us to look at, and pay attention to [the patient quality survey]… it’s how we achieve our success.” The providers who will be the most successful are those that provide the best care experience, not just those who are the best at curing ailments, he said.

Suppliers take noteLikewise, successful distributors, manufacturers and sales reps will be those who provide the best overall experience

for their customers – providers and provider systems, ac-cording to speakers. That will call for more transparency, particularly in pricing.

Suppliers will commit substantial resources to im-proving and maintaining open lines of communication with hospitals and health systems, said Steve Inacker, pres-ident, hospital sales & services for the Medical Segment of Cardinal Health. “[Cardinal’s] goal and mission is to

make sure that we are doing everything we can to make healthcare more efficient and more cost effective, so that our customers – the caregivers – can spend more quality time with their patients.”

Sales reps can play a role, even though they may not be on the “front line” of providing a patient experience, Inacker continued. “[When] a patient can’t be rolled into the OR…because a product wasn’t available, we affect the patient wait time.”

Holiday gift baskets won’t cut it. Instead, suppliers need to find out what things frustrate or slow down mem-

bers of the hospital staff, and then figure out what their company can do to fix it.

Suppliers also need to commu-nicate to people all across the care continuum. Once the trend of verti-cal integration settles down, provider systems will focus on horizontally integrating across their enterprise, said Mike Stoecklein, director of net-work operations, ThedaCare Center for Healthcare Value, Appleton, Wis. Models such as the Patient-Centered Medical Home will become the new industry standard, as providers look for ways to ease the hassle on patients.

“We know from the start, when you go into the hos-pital, before you ever have anything elective done, pretty much what you are going to need when you come out,” said David Sand, M.D., Fidelis Care, the New York State Catholic health plan. As this trend becomes increasingly popular, companies that are able to provide value and transparency across the continuum will be the ones that come out on top.

Alan Cherry is editor-in-chief of Dail-E News, a daily electronic news source from MDSI, publisher of Repertoire.

“ It’s not just about how we interface with patients; it’s also about how we interact with each other,” said Jim Merlino, M.D., Cleveland Clinic’s chief experience officer. “There are things that we bring to what we do every day that are going to impact how we care for people.”

Holiday gift baskets won’t cut it. Instead, suppliers need to find out what things frustrate or slow down members of the hospital staff, and then figure out what their company can do to fix it.


long-term care

Soft surface contamination: not a hard problem to solvePrivacy curtains, bed linens and employee uniforms can be a haven for bacteria in long-term care settings.

Taking extra precautions can pay off, particularly with infection prevention. But, what your long-term care customers may not realize is that hard surfaces, such

as counter tops and medical equipment, are not the only potential sources of contamination in their facilities. Patho-genic bacteria can also exist on privacy curtains, upholstered furniture, bed linens and even employee uniforms. As prod-ucts become available to address soft surface contamina-tion, distributor sales reps have an opportunity to offer cus-tomers some viable solutions.

Taking extra precautions can pay off, particularly with infection prevention. But, what your long-term care cus-tomers may not realize is that hard surfaces, such as coun-ter tops and medical equipment, are not the only potential sources of contamination in their facilities. Pathogenic bacteria can also exist on privacy curtains, upholstered fur-niture, bed linens and even employee uniforms. As prod-ucts become available to address soft surface contamina-tion, distributor sales reps have an opportunity to offer customers some viable solutions.

Raising awarenessUntil recently, the issue of soft surface contamination has not been widely discussed or inves-tigated, so the awareness and under-standing level among long-term care staff is likely quite low, according to Clorox Healthcare. But, recent studies supporting the link between soft sur-faces and infection transmission have put this issue on more people’s radars. Clorox cites studies showing bacteria like vancomycin-resistant enterococci (VRE) can be transferred to uphol-stery and fabric cushions, and then to people. In another study, 65 percent of nurses who treated patients with methicillin-resistant Staphylococcus au-reus (MRSA) had MRSA-contaminated uniforms. Yet another study shows a multidrug-resistant Acinetobacter

baumannii outbreak was linked to contaminated privacy curtains, clothing and linen, and was found to contribute to the spread of S. aureus infections, including MRSA.

The rep’s roleTraditionally, laundering has been the only viable option healthcare facilities have had for killing microorganisms on soft surfaces, notes Clorox. Today, however, a number of product solutions exist, ranging from antimicrobial fabrics and furniture, to disposable barriers (e.g., chair coverings, curtain liners, disposable curtains) and spray products, some of which are designed to kill bacteria on soft surfaces in 30 seconds.

Distributor sales reps can keep their customers informed about the issue of soft surface contamination and solutions to address it by sharing informational materials and tools – soft surface technical reports, educational posters, checklists, quizzes, product information and directions for use – pro-vided by manufacturers, as well as strategies and product so-lutions to help stop the spread of infection via soft surfaces.

Some long-term care customers may find antimicro-bial fabrics and furniture too costly, particularly given that the efficacy of such solutions remains largely unsupport-ed by scientific evidence. In addition, disposable barriers

and curtains can add significant vol-ume to a facility’s waste stream. Reps should remind them that simple-to-use, cost-effective solutions do exist. For example, EPA-registered sprays are available, designed to eliminate bacteria from both hard and soft sur-faces. For facilities resistant to using spray products, reps should recom-mend that they incorporate soft sur-face cleaning practices into discharge cleaning occasions, or when residents are not present.

By educating long-term care cus-tomers about the risk of soft surface contamination, sales reps can help them make informed decisions to keep their patients and residents safe.

By asking a few probing questions, such as the fol-lowing, sales reps can initiate a discussion about the risk of soft surface contamination:• “How often do you launder your privacy curtains?”

• “How often do you clean the chairs and sofas in your wait-ing rooms and lobby areas?”

• “Are you aware that infec-tious bacteria can live on soft surfaces, such as curtains and chairs, for up to three months?”


trends

That’s the point of recently released – and contro-versial – guidelines on the treatment of blood cholesterol to reduce atherosclerotic cardiovascular risk (things like coronary heart disease, carotid artery stenosis, peripheral artery disease, and abdominal aortic aneurysm) in adults.

The traditional answer has been relatively simple: Watch the numbers; if they’re bad, get them down. In other words, if the patient’s harmful cholesterol – that is, low-density lipoprotein cholesterol, or LDL – is high, then give him or her statins and advice about diet and exercise, and knock those numbers down.

But the new guidelines – issued by the American Col-lege of Cardiology and the American Heart Association, in collaboration with the National Heart, Lung and Blood Institute, take some of the focus off the numbers, and shift it instead to identifying patients most at risk of devel-oping cardiovascular disease.

That said – and this is important for sales reps – the LDL numbers identified by point-of-care testing still con-stitute an important part of identifying those patients. In other words, cholesterol is one factor that can contribute

to heart attack or stroke – but there are others.“From our perspective, we

are still very much following the developments and associated de-bate,” says Stephen Riendeau, vice president, domestic sales, CardioChek. “We do believe that there is and always will be a value in ‘knowing one’s numbers’ as it relates to lipids in particular. We believe that the guidelines will continue to evolve and that the discussion that has been gener-ated is very healthy and will ulti-mately lead to a better standard of care for individuals at risk for cardiovascular disease.”

Focus was too narrowAccording to the guidelines, there is no evidence to support continued use of specific LDL-C and/or non-high-density lipoprotein cholesterol (non-HDL-C) treatment targets. “Rather, the appropriate intensity of statin therapy should be used to reduce risk in those most likely to benefit,” say the authors.

Numbers RacketNew cholesterol guidelines stir up a hornet’s nest, but monitoring LDL through point-of-care testing is still important

It seems simple: Doctors should prescribe statins for the heart patients who are at risk for

heart attack, stroke and death. The question is, how do you identify those patients?

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trendsWho are those people most likely to benefit? The panel developing the guidelines identified four groups:

• Individuals with clinical ASCVD (atherosclerotic cardiovascular diseases), including acute coronary syndromes, or a history of myocardial infarction; stable or unstable angina; coronary or other arterial revascularization; stroke; TIA, or transient ischemic attack, characterized as a “warning stroke”; or pe-ripheral arterial disease presumed to be of athero-sclerotic origin.

• Individuals with primary elevations of low-density lipoprotein cholesterol (LDL-C) ≥190 mg/dl.

• Individuals 40-75 years of age with diabetes, and LDL-C 70-189 mg/dl without clinical ASCVD.

• Individuals without clinical ASCVD or diabetes, who are 40-75 years of age with LDL-C 70-189 mg/dl, and have an estimated 10-year ASCVD risk of 7.5 percent or higher.

The risk calculatorAccording to the American College of Cardiology, the doctor can gauge that 10-year risk by reviewing the pa-tient’s medical history and overall risk for heart attack or stroke. He or she will likely want to know three things:

1. Whether the patient has had a heart attack, stroke or blockages in his or her heart, neck or arteries in the legs.

2. The patient’s total cholesterol and LDL cholesterol levels, as well as his or her age, whether the patient has diabetes, whether the patient smokes, whether the patient has high blood pressure, and whether the patient has low HDL (so-called “good” choles-terol).

3. The patient’s lifestyle habits (exercise, diet), as well as other medical conditions, previous drug treat-ments, and family history.

If there is any question about the patient’s risk of develop-ing atherosclerotic cardiovascular disease, the doctor may order additional tests, including:

American College of Cardiology President John Gordon Harold, MD, MACC, posted a defense of the AHA/ACC Guideline for the Assessment of Cardiovascular Risk – which came under attack for potentially leading to mil-lions more Americans receiving statin drugs – on the ACC website Nov. 18. Here’s a portion of his defense.

In defense of the guidelines

A story in today’s New York Times raises concerns about the new AHA/ACC Guideline for the Assess-ment of Cardiovascular Risk, which offers a new and improved approach to estimating a patient’s 10-year risk of developing atherosclerotic cardio-vascular disease (ASCVD).

With one in three Americans dying of cardiovas-cular diseases and stroke, there is a critical need to improve prevention. For this reason, the ACC and AHA stand behind the new guideline and related tools, the process in which they were created and the degree to which they were approved by the panel of experts.

Among the major changes, the guideline, for the first time ever, focuses on estimating risk for both heart attacks AND strokes, whereas previ-ous guidelines only focused on heart attack risk. The guideline also provides estimates applicable

to African-Americans. “The ability to estimate risk for a more broadly based ASCVD outcome that is more relevant to contemporary populations, especially women and African-Americans, and the ability to provide risk estimates specific to African-Americans, are the major advances of this approach,” the Expert Panel writes.

Both the guideline and the risk calculator are based on the best evidence available as deter-mined by the expert panel. That being said, the resulting discussions raised by the Times article are important ones for all of us to have as we move forward with tracking patients and reviewing new evidence and research over time. Science is an evolutionary process and there is no doubt, as with all guidelines and tools, that new science will lead to updates and improvements.

Source: American College of Cardiology, http://blog.cardiosource.org/post/new-guideline-and-tools-intended-to-drive-discussions-about-individual-risks-and-treatments/

trends

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• Coronary artery calcium score, which detects the presence of plaque or fatty build-up in the artery walls.

• High-sensitivity C-reactive Protein (CRP), a blood test that measures CRP, a marker of inflammation or irritation in the body (higher levels of which have been associ-ated with heart attack and stroke).

• Ankle brachial index, that is, the ratio of the blood pressure in the ankle compared to blood pressure in the arm, which can predict peripheral artery disease.

Why the controversy?The guidelines triggered an outcry from vari-ous groups and individuals, who complained the guidelines overestimate the risk of cardiovascular disease and will lead to millions more people tak-ing statin drugs. But the American Heart Associa-tion and American College of Cardiology stood behind them.

The so-called risk calculator provides an estimate of a patient’s 10-year risk of having a heart attack or stroke and is one compo-nent healthcare providers should use as they discuss whether or not a patient would ben-efit from a statin drug, which lowers artery-clogging LDL cholesterol, said Mariell Jessup, M.D., president of the American Heart Asso-ciation, in a statement.

“These guidelines should enable a discus-sion between a patient and their healthcare provider about the best way to prevent a heart attack or stroke, based on the patient’s person-al health profile and their preferences,” said

“There is and always will be a value in ‘knowing one’s

numbers’ as it relates to lipids, in particular.”


trends

In addition to the AHA/ACC Guideline for the Assessment of Cardiovascular Risk, the American College of Cardiology and the American Heart Association, in collaboration with the National Heart, Lung, and Blood Institute (NHLBI) and other specialty societies, released three related guidelines, all focused on the assessment of car-diovascular risk, lifestyle modifications to reduce cardiovascular risk, and management of elevated blood cholesterol and body weight in adults.

Treatment of Blood Cholesterol to Reduce Atherosclerotic Cardiovascular Risk in AdultsThis guideline focuses on the use of statins for primary and secondary prevention of ath-erosclerotic cardiovascular disease (ASCVD) in

higher-risk patients. The Expert Panel recom-mends statin therapy for individuals at increased ASCVD risk who are most likely to experience a net benefit in terms of the potential to reduce ASCVD events and the potential for adverse ef-fects. They also suggest the use of statins to pre-vent both non-fatal and fatal ASCVD events – an approach, they say, that can not only reduce the large burden of disability from non-fatal stroke and non-fatal coronary heart disease events, but also reduce increasing healthcare costs.

Guideline for the Management of Overweight and Obese AdultsThis guideline addresses the appropriateness of the current BMI and waist circumference cutpoints used to determine risk in overweight

and obese adults across diverse populations; the impact of weight loss on risk factors for cardio-vascular disease and type 2 diabetes; optimal behavioral and dietary intervention strategies; lifestyle treatment approaches, such as commu-nity-based programs, for weight loss and weight loss maintenance; and benefits and risks of vari-ous bariatric surgical procedures.

According to the Expert Panel, the “information will help providers decide who should be recom-mended for weight loss, and what health improve-ments can be expected.” However, they suggest that further research into the benefits of weight loss and the risks associated with overweight and obesity are needed. In addition, the authors note that further research is needed into the role of new weight loss

drugs, as well as the type of pa-tient most likely to benefit from surgical interventions.

Guideline for Lifestyle Management to Reduce Cardiovascular RiskThis guideline provides updates to dietary and physical activity

recommendations for adult patients with high LDL-C and/or hypertension. Not surprisingly, the recom-mendations for lowering both LDL-C and blood pressure included a focus on aerobic exercise three to four times a week and a diet high in vegetables, fruits and whole grains. The guideline provides ad-ditional sodium recommendations – no more than 2,400 mg of sodium/day – for treating hyperten-sion. The Expert Panel noted that further reduction of sodium intake to 1,500 mg/day is associated with even greater reduction in hypertension, and is recommended if achievable by patients.

Together, these four prevention guidelines re-leased Nov. 12 were among five initially commis-sioned by NHLBI starting in 2008. A fifth guideline addressing hypertension was expected to be initiated in early 2014.

To read about each of these guidelines, go to http://www.cardiosource.org/news-media/publications/cardiology-magazine/2013/11/new-accaha-prevention-guidelines-address-blood-cholesterol-obesity.aspx

Additional guidelines

According to the Expert Panel, the “information will help providers decide who should be recommended for weight loss, and what health improvements can be expected.”


trends

John Gordon Harold, M.D., presi-dent of the American College of Cardiology. “The risk calculator score is part of that discussion, because it provides specific infor-mation to the patient about their personal health. A high score does not automatically mean a patient should be taking a statin drug.”

Point-of-care still importantFor Repertoire readers, point-of-care cholesterol testing will remain an im-portant tool for physicians.

Says Riendeau, “We believe that the guidelines increase the importance of overall lipid testing as it relates to assessing the risk of the patient. Total cholesterol and HDL cholesterol are two of the key components of the ‘risk calculator,’ which providers will use to determine whether patients should be prescribed statins.” Point-of-care testing will allow providers to complete that risk assessment while the patient is in the office.

“Regarding LDL, that is still very much a part of the debate,” he con-tinues. “We believe that testing for LDL will continue to have significant value in the determination of cardio-vascular disease risk as well as the ongoing management and compli-ance to drug regimens. LDL reduc-tion in at-risk individuals is inargu-ably a very important goal.

“Finally. just applying very simple math, if the population of statin us-ers doubles as suggested, the number of individuals who are likely to get their lipids tested, either as part of a screening process or as a tool for monitoring and compliance, is almost certain to increase. We are excited to be an industry leader in the point-of-care lipid testing space.

“There has never been a better time for providers to explore point-of-care lipid testing as a solution for their practices.”

The newly released AHA/ACC Guideline for the Assessment of Cardiovascular Risk supersedes the “Third Report of the Na-tional Cholesterol Education Program (NCEP) Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel III),” published in 2001 and updated in 2004.

That report identified low-density lipoprotein (LDL) as a major cause of coronary heart disease, and asserted that clinical trials show that LDL-lowering therapy reduces risk for coronary heart disease. For these reasons, ATP III continued to identify elevated LDL cholesterol as the primary target of cholesterol-lowering therapy. As a result, the primary goals of therapy and the cutpoints for initiating treatment were stated in terms of LDL.

The 2001 guideline recommended that in all adults aged 20 years or older, a fasting lipoprotein profile (total cholesterol, LDL cholesterol, high density lipoprotein (HDL) cholesterol, and triglyceride) should be obtained once every five years. The guide-line characterized LDL, total cholesterol and HDL as follows:

LDL cholesterol:• <100: Optimal.• 100-120: Near optimal; above optimal.• 130-159: Borderline high.• 160-189: High.• >190: Very high

Total cholesterol:• >200: Desirable.• 200-239: Borderline high• >240: High

HDL Cholesterol • <40 Low • ≥60 High

Source: Third Report of the National Cholesterol Education Pro-gram (NCEP) Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel III), http://www.nhlbi.nih.gov/guidelines/cholesterol/atp3xsum.pdf

Simpler times


trends

Centers for Disease Control and Prevention researchers reviewed colorectal cancer screening data from CDC’s 2012 Behavioral Risk Factor Surveillance System to esti-mate the percentage of people aged 50 to 75 years who reported getting screened as recommended by type of test.

They found that among adults who were screened as recom-mended, colonoscopy was by far the most common screening test (62 percent). Use of the other United States Preventive Services Task Force recommended tests was much lower: fecal occult blood test (10 percent), and flexible sig-moidoscopy in combination with FOBT/FIT (less than 1 percent).

Colorectal cancer is the second lead-ing cancer killer among men and women in the United States, fol-lowing lung cancer, according to the CDC. Screening tests can prevent it or detect it at an early stage, when treatment can be highly effective. That’s why clinicians recommend that people aged 50 years and older

get tested with one or a combination of these screening tests:

• Fecal occult blood test (FOBT) or fecal immunochemical test (FIT) done at home every year.

• Flexible sigmoidoscopy, done every five years, with FOBT/FIT done every three years.

• Colonoscopy done every 10 years.

Bad news, good newsThe bad news about colorectal can-cer screening is this: Roughly one in three adults aged 50 to 75 years have not been tested for colorectal cancer as recommended by the USPSTF. That’s approximately 23 million people who are at risk, according to the CDC.

The good news is that the percentage of the U.S. adult pop-ulation that is up-to-date with recommended colorectal cancer screening increased from 54 per-cent in 2002 to 65 percent in 2010, primarily due to an increased use of colonoscopy, according to the CDC. Use of FOBT and sigmoid-oscopy declined steadily over the same period.

The irony about colonoscopy is this, according to CDC research-ers: Studies have shown that if giv-en the option, many people would prefer FOBT/FIT. Furthermore,

research shows that when given a choice, people are simply more likely to get screened. In other words, by backing off their insistence on colonoscopy, doctors

Colonoscopy is test of choice……but only because doctors push it over fecal occult blood tests and flexible sigmoidoscopy

About one in three adults aged 50–75 years have not been screened for colorectal cancer ac-cording to national guidelines.

Of adults who have been screened, colonoscopy is the most commonly used colorec-tal cancer screening test. Only one in 10 screened adults have used fecal occult blood tests.

Blacks and whites had equivalent colorectal cancer screening rates. Compared with whites, a higher percentage of blacks across all income and education levels use FOBT.

Source; MMWR Vital Signs: Colorectal Cancer Screening Test Use—United States 2012, Centers for Disease Control and Prevention, Vol. 62, Nov 5, 2013

If there is such thing as a popularity contest for colorectal

cancer screening, colonoscopy would win hands-down.

But the biggest reason colonoscopy outpaces the fecal

occult blood test and flexible sigmoidoscopy – both of which

are considered effective at detecting cancer early – is that

doctors are far more likely to recommend it, or to not even

bring the other two options to their patients’ attention.

Key points

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trends

would probably see more patients getting some kind of screening test done.

CDC emphasizes there are circumstances in which colonoscopy is the preferred method for colorectal cancer screening. If there is a strong family or personal history of inflammatory bowel disease, for example, it is preferred.

Speaking at a recent telebriefing for media, CDC Di-rector Tom Frieden, M.D., M.P.H., pointed out that the cost of the various colorectal cancer screening options isn’t – and shouldn’t be – a factor in determining which is preferred. Stool tests should be repeated every year, he said, and positive results lead to colonoscopy. “So it’s not clear you’re saving money doing one over the other.”

The benefits of early cancer detection decline sharply with age because older patients are more likely to die of comorbid conditions or other causes, according to a study published in the Nov. 19 issue of Annals of Internal Medicine.

Published guidelines differ on when to stop screening elderly patients for cancer. For example, the U.S. Preventive Services Task Force recommends stopping colorectal cancer screening at age 75, whereas the American College of Physicians recommends taking the patient’s comorbidities and life-expectancy into consideration before stopping screening.

Researchers used Medicare data on elderly patients without cancer to develop tables estimat-ing life expectancy for those with and those without comorbid conditions. They found that patients with higher levels of comorbidity had shorter life expectancies than healthy patients of the same age, and concluded that using life expectancy rather than chronological age to individualize cancer screening strategies could maximize benefits of screening and minimize potential harms.

That said, a complex issue such as cancer screening should also incorporate individual patient preferences into the decision-making process, the researchers said.

Healthcare providers can do a better job of making sure more patients are screened for colorectal cancer, says the Centers for Disease Control and Prevention. Here’s how, and why.

• Many people aren’t aware that they need to be tested, nor are they notified when it is time to be tested. The healthcare provider can and should take a proactive approach.

• Most healthcare systems rely on doctors to remember to offer colorectal cancer screening tests to their patients. Nurses and other office staff should also talk with patients about getting tested, and doctors can be reminded to offer testing whenever patients are due, whether they come in for a routine check-up or when they are sick.

• The provider can mail out FOBT/FIT kits that can be completed at home, and then follow up with those whose tests are positive.

• Providers should train a “patient navigator,” that is, someone on staff who explains to patients how to prepare for the test and what to expect from it, and then makes sure people show up for their appointments.

Source: Centers for Disease Control and Prevention

How to increase colorectal cancer screening

Experts weigh cancer screening strategy based on life expectancy

CDC emphasizes there are circumstances in which colonoscopy

is the preferred method for colorectal

cancer screening.


disease states

The toll it takesThe World Health Organization (WHO) defines over-weight and obesity as abnormal or excessive fat ac-cumulation that may impair health. Body mass index (BMI) – an index of weight-for-height often used to classify overweight and obesity in adults – is defined as a person’s weight in kilograms, divided by the square of his or her height in meters (kg/m2). A BMI greater than or equal to 25 is considered overweight, according to WHO. A BMI greater than or equal to 30 is obesity. Al-though BMI provides a useful population-level measure of overweight and obesity, as it is the same for both sexes and for all ages of adults, it is considered a rough guide because it may not correspond to the same degree of fatness in different individuals.

ObesityWith the right solutions, physicians can care for obese patients.

As long as obesity continues to be a problem for the country, physicians need solutions for caring for their larger patients. Distributor sales reps can

service their physician customers by understanding their challenges in caring for overweight and obese patients, and by providing the best solutions for them to do so.


disease states

WHO attributes 44 percent of the country’s diabetes problems, 23 percent of the ischemic heart disease

problems and between seven and 41 percent of certain cancer issues to overweight and obesity

The fifth leading risk for global deaths, overweight and obesity account for at least 2.8 million adults deaths each year. In addition, WHO attributes 44 percent of the country’s diabetes problems, 23 percent of the ischemic heart disease problems and between seven and 41 percent of certain cancer issues to overweight and obesity.

Children’s health, too, is impacted by overweight and obesity. In 2011, more than 40 million children under the age of five were overweight, reports WHO. Overweight and obesity are becoming more and more prevalent in low- and middle-income countries, particularly in urban settings. In fact, over 30 million overweight children are living in developing countries, compared with 10 million in developed countries.

Overweight and obesity have become more widespread largely due to people’s higher intake of high-fat foods, coupled with less physical activity due to urbanization and changes in work forms and modes of transportation. Re-ducing the rate of overweight and obesity requires educa-tion and policy changes, especially with regard to health, agriculture, transportation, urban planning and food pro-cessing, to name some. Changes such as these can’t come soon enough, particularly given the range of diseases linked with a raised BMI, including:

• Cardiovascular diseases (heart disease and stroke). • Diabetes.• Musculoskeletal disorders, such as osteoarthritis.• Certain cancers, such as endometrial, breast and colon.

The rep’s roleAs obesity continues to plague people across the country, so too should sales reps stay focused on the issues af-fecting physicians who care for this population, as well as the products available to help them do so. Doctors in any specialty and market, including hospital, physician practice and long-term-care, inevitably must deal with obesity. As medications help obese patients better man-age their diabetes, heart disease or other conditions as-sociated with being overweight, they live longer and are more mobile, and it becomes increasingly necessary for physicians to accommodate them.

Even physicians who do not perform bariatric surgery may see obese patients for related illnesses, such as dia-betes or hypertension. And obese patients become sick with flu and infections, just as other patients do. Some-times, physicians must accommodate an obese family member with larger chairs in the waiting room. Medi-cal products have been up-sized in recent years as well. Some examples include:

• Higher-capacity automated external defibrillators, which are said to work better on obese patients.

• Exam tables, once designed to accommodate pa-tients up to 325 pounds, but now designed to hold patients as heavy as 450 pounds. Some tables are engineered to hold patients weighing 650 pounds or more, although people in this weight category often are treated in hospital settings.

Overweight and obesity, as well as their related diseases, are largely preventable, according to WHO. For one, people can limit their intake of foods high in fats and sugar. They can eat more fruits, vegetables, legumes, whole grains and nuts. And, they can engage in more physical activity. The food industry can do its part by making more nutritious choices available and marketing these options responsibly. And, businesses can help by promoting healthy habits and exercise among their employees.

Reducing obesity

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disease states

• Wheelchairs with wider seats. (Generally, a seat dimension of 32 inches wide or more is necessary for full patient support.)

• Bariatric scales.• Lifts to assist caregivers in moving larger patients

from their wheelchair to exam tables.• As in the hospital market, physicians who care for

obese patients require larger table paper, gloves, gowns and slippers, longer needles and larger dia-pers, as well as larger blood pressure cuffs.

Bariatric equipment: the pros and consDistributor reps should be upfront about the pros and cons of using bariatric equipment in physician practices. For

instance, a bariatric table is designed to handle both larger and smaller pa-tients. But, larger-capacity tables are wider and require more office space to house. In addition, the wider dimen-sion forces the physician to stand far-ther away from patients, which can be particularly frustrating for, say, plastic surgeons who must stand very close to their patients. Another issue that may hold back physicians from adding oversized equipment is the need for wider doorways to accommodate it.

The cost of purchasing bariatric tables and other equipment is higher than that of standard equipment. But it’s money well spent, according to experts. Practically speaking, physicians need to consider worker/patient safe-ty issues, and how they impact their need to redesign their offices to accommodate larger patients. They must weigh the cost of updating equipment with the cost of liability for staff or patient injuries. Sometimes, they can’t afford not to address this issue.

In the long run, providing better patient care pays off for both doctor and patient, even if it does cost more up-front. If an obese patient has a good experience at a physi-cian practice, he or she will tell his friends, who may also want to go to that practice.

• American Society for Metabolic and Bariatric Surgery, www.asmbsfoundation.org.

• Obesity Society, www.obesity.org. • American Society of Bariatric Physicians,

www.asbp.org.

• National Institutes of Health, www.nih.gov.• National Association of Bariatric Nurses,

www.bariatricnurses.org.

For more information on bariatrics and obesity, visit the following websites:

Distributor reps should be prepared to ask their physician customers some pointed questions, such as the following, to determine their need for bariatric equipment and supplies:

• “Who does your patient base include and what problems do your patients present?”• “Do you see any obese or morbidly obese patients? If so, how do you accommodate them?”• “If you don’t presently see any obese patients, are you equipped to treat any who may visit

your practice in the future?”• “What changes, if any, has your practice considered making to better accommodate obese patients?”• “How would you handle a 500-pound patient if he or she walked into your office today?”• “How old is your exam table, and how well would it accommodate obese patients?”• As your patients get older and potentially gain weight, what equipment needs do you project?

Ask the right questions

Practically speaking, physicians need to consider worker/patient safety issues, and how they impact their need to redesign their offices to accommodate larger patients.


disease states

Thanks to the American Disabilities Act, many medical facilities today are designed to accom-modate the needs of their disabled patients. Wheelchair ramps and wheelchair-accessible doorway and hallways are increasingly becom-ing the norm. Ironically, though, those accom-modations often stop at the exam room.

For many patients – including wheelchair-bound and obese patients – traditional manual or box exam tables are not accessible or practical. In fact, they can present a physical risk for both the patients and the caregivers examining them.

The benefits of barrier-freeOver 50 percent of patients who are 65 years or older have some form of disability, according to Midmark Corp. And, over one-third of the U.S. population is

obese. Together, these groups account for a major segment of office visits. Barrier-free exam tables designed to accommodate these patients limit the risk of injury due to slips or fall when they attempt to access the table. In addition, when caregivers and staff help patients onto manual and box exam tables, they, too, are at risk for injuries from heavy lifting and straining. Plus, the American Disabilities Act guide-lines stress the importance of making adjustments to accommodate all patients.

Over the past 10 years, the design of barrier-free exam table has been enhanced to meet the need of a broader spectrum of patients. New tables feature increased weight capacity, from 325 to over 600 pounds. The upholstery is wider today (from 28 to 32 inches) and many tables can be low-ered to an 18-inch seat for easier patient access.

Barrier-free scalesMeeting the needs of all patients should be a priority for your customers.

Editor’s note: Repertoire would like to thank Midmark Corp. for its assistance with this piece.

Distributor sales reps should review with their cus-tomers their patient populations to ensure their equipment needs are fully met. Often, the cost of adding a second barrier-free exam table is offset by the disruption a practice may experience in scheduling around a single higher-capacity table.

By asking a few probing questions, such as the following, sales reps can initiate a discussion of barrier-free tables with their customers:

• “Doctor, do you have overweight or obese patients with mobility issues?”

• “Have your clinicians and nurses expe-rienced problems assisting overweight, obese or disabled patients onto manual or box style exam tables?”

• “Have you or your clinicians/nurses ever had to examine overweight or obese pa-tients in a side chair because they couldn’t access a manual or box style exam table?”

When doctors are focused on caring for in-dividual patients, they may lose touch with their patient profile trends and not notice an increase in the number of overweight, obese or disabled patients visiting their practice. As such, they may not recognize a need to add barrier-free exam tables. Sales reps should educate their customers on changing patient trends by asking:

“Doctor, are you aware that one in three people in the United States are obese and that 50 percent of patients over 65 years have some form of disabil-ity? This represents a major segment of office visits.”

Price, too, can be an issue for some doc-tors. Barrier-free exam tables range in cost from $4,000 to $8,000 for high-weight capacity tables with integrated scales. And, while payback will vary by practice, benefits such as reduced risk of injury, improved workflow, and enhanced pa-tient care and satisfaction are important points for reps to make.

Working with customers


tech talk

Tipping the scaleSales reps should help their customers select scales that will continue to meet their needs in years to come.

Digital vs. mechanicalAs more physicians automate their practices, digital scales are becoming increasingly important for a couple of reasons. First, some doctors feel digital scales can do more than their mechanical predecessors, and do it more accurately, with the capacity to enhance office efficiency and workflow. Scales that are integrated with a facility’s EMR system can auto-matically transmit weight, height and BMI if available. Digital height rods, which enable the scale to automatically calculate BMI, also are becoming popular. All of this informa-tion can be downloaded from the office computer system when a staff member is ready to pull the patient’s electronic chart. Eliminating any manual input reduces the possibility of transcrip-tion errors. This is especially important when recording weight, as doctors use weight to formulate the proper dosage of medications. Incorrectly inputting a patient’s weight can lead to over- or under-dosing of medication, as well as incorrectly diagnosing someone as obese or underweight.

Second, federal regulations are pushing physicians to digital scales. Physicians caring for Medicare patients can collect as much as $44,000 over five years provided they are meaning-ful users of an electronic health record, per the Health Information Technol-ogy for Economic and Clinical Health Act (nicknamed the HITECH Act) of

2009, which was part of the Ameri-can Recovery and Reinvestment Act, otherwise known as the “stimulus act.” Those who fail to do so will start to experience cuts to their Medicare reimbursement beginning in 2015. (Medicaid providers stand to collect as

much as $63,750 over six years if they are meaningful users of EHRs.) As such, physicians and hospitals will be required to incorporate information on their patients’ body mass in-dex (BMI) in their EMR/EHR systems, making it essential to have a digital scale with these capabilities.

That said, some physicians still prefer traditional mechan-ical scales, because they are not affected by power surges or faulty batteries, and they rarely require service. In fact, many

mechanical scales sold in the 1960s continue to be used in practices today. Nevertheless, compared to mechanical scales, digital scales have no moving parts to troubleshoot or mechanically re-calibrate. Repairs usually are done at a modular level, and calibration is ac-complished through the scale software. And, digital scales are becoming more affordable. Typically, they retail for $499 to $850, compared with $250 to $450 for mechanical scales. And while it’s true that digital scales need to be replaced every seven to 10 years, given how rapidly the technology changes, some physicians prefer to replace them even sooner.

The more information physicians have, the better the decision they can make. Scales are no exception. As their sales rep, it’s your job to help them navigate the various options at their disposal and make the selection that best serves their practice.

When selling scales, there’s much more to consider than patient weight. The technology physicians acquire today could impact the decisions they make tomorrow. Particularly as the country

moves closer to “meaningful use” of electronic medical record systems, physi-cians should think about adding scale solutions that enable them to connect the scale to the office electronic medical record.

Editor’s note: Repertoire would like to acknowledge the assistance of Health o meter Professional Scales.

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design saves space when not in use and contracts to a slim

6.6-in profile.

HIGH-CAPACITYWEIGHING


tech talk

More and more doctors today are discriminating among the types of scales they purchase for their practices. Whereas the average physician’s scale offers a 350-pound to 450-pound range of capacity, scales designed for bariatric patients offer a capacity of 600 pounds to 800 pounds. In addition, manufacturers sometimes offer scale capacities of over 1,000 pounds, designed to weigh wheelchair-bound patients. These systems use low-profile platforms and ramps for easier patient access. Some scales can be reprogrammed to accommodate 800 pounds of weight. But, if the structure or design of the scale is not upgraded as well, an 800-pound patient cannot stand properly on it.

Scales designed for bariatric patients generally offer some of the following features:• Higher capacity load cells (an integral weighing component).• Wider and low-profile weighing platform, enabling the patient to comfortably step up and stand

on the scale.• Built-in handrails to prevent the patient from falling.• Built-in, flip-down seating options, enabling the patient to sit or stand while being weighed.• Sling seat and lift features for raising and weighing immobile patients. (Some hospital beds now

have built-in scales to monitor the weight of immobile patients.)• Electronic weight indicators to supply body mass index (BMI) data and transmit this information

to a PC screen or printer. (Research today indicates that BMI is critical in determining whether a patient should be treated for bariatric issues.)

Although health providers would like to see obesity-related issues diminish in the future, experts foresee it will continue in years to come. As such, the need for bariatric products should continue to grow.

Editor’s note: Repertoire would like to thank Detecto for its assistance with bariatric scales.

Bariatric scales

Scale sales

• “What are the primary types of patients you see? Do you see many wheelchair-bound patients?”

• “Has your patient base changed within the last few years? Do you work with different age and weight requirements and therefore require different scales?”

• “How often do you use your office scales? How long do you expect them to last before replacing them?”

• “In addition to basic weigh-ins, do you need to analyze your patients’ body composition?”

• “Do you plan to implement EMR in the next six to 18 months? If so, perhaps you should con-sider purchasing a digital scale rather than a mechanical unit.”

• “How old are your current scales? Are they accurate?”

Distributor reps should ask their physician customers some pointed questions to gauge their need for new scales, including the following:


repcorner

Antique medical equipment never gets old for D.J. O’Connor.By Laura Thill

There’s a saying: One person’s

trash is another person’s treasure.

As far as D.J. O’Connor is con-

cerned, there’s truth to this pearl of wis-

dom. When his father, David, purchased

Mass Surgical Supply (Holyoke, Mass.) in

1979 and prepared to move the business

to a new location, O’Connor made a dis-

covery that would keep him busy for the

next 34 years.

“When my father purchased the business, we moved it to a new a retail space and two storehouse facilities,” says O’Connor. “During the move, I discovered multiple boxes of old medical equipment, both new and used. I found the equipment fascinating, and being part packrat, I couldn’t throw any of it away. Some of the new equipment was still in boxes, with directions and information on purchasing accessories and replacement parts, making it fairly easy to figure out its use. The used equipment, or new equipment without directions, was challenging to learn about.

“I had two great resources: my father, David, who had been in the business since the 1960s, and my predecessor, Jack Trainer, who began in 1945 and worked with us until his retirement in 1986,” O’Connor continues. Trainer in particular had an expansive knowledge of medical equip-ment, he recalls. “I would have him over to my house,

the PastTreasures from


repcorner : D.J. O’Connor

throw a sheet over the kitchen table, and lay down the antique equipment. Then we would just start talking.”

When past meets presentO’Connor’s new hobby quickly be-came a lesson in history. “One of the first equipment pieces that caught my interest was a used W.A. Baum desk model blood pressure unit,” he says. “The case is made of wood, and the mercury reservoir and reading tube are one continuous piece of glass. In the late 1980s, John Baum was kind enough to use the serial number to trace the year and origin of sale. He also sent me photos of how it would have looked new.”

The blood pressure unit was just the beginning for O’Connor. There was a slew of instruments from National Electric Instrument Co., Inc., a com-pany originally located in Long Island City, NY. Most of these instruments were still in their original packaging – wood cases labeled:• Complete Specialists Diagnostic Set.• National Simplified

Control Cautery.• Complete Body Cavity Set.• National Battery Box.

“The battery box powers many of the light sources,” O’Connor ex-plains. “Two wires coming from the light source would slide into a posi-tive and negative port on the battery box. The design of the instruments has not changed a lot over the past 80 years, but the power source has.

“These National Electric Instrument Co. pieces are some of my favorites, be-cause most are new and complete, and I can relate them to their modern coun-terparts,” O’Connor continues, noting that for many pieces, the sales sheets are intact, listing prices and accessories, as well as notes to practitioners, such as:

Every collector has his favorites. Often they are items that tell a unique story. For D.J. O’Connor, owner of Mass Surgical Sup-ply, it was a couple of crates of old medical equipment, some dating back to Civil War times.

“One of my best donations to my antique medical equipment collection was from a Holyoke, Mass., family doctor named Gard-ner Cox,” says O’Connor. “He and his sister were Holyoke family doctors from the 1950s to the ’90s. Their father was a physician who practiced in Holyoke, and their grandfather was a physician from Vermont who settled in Holyoke after being in the Civil War.

“Gardner called me one day and said, ‘D.J. it’s time, meet me at my Beech St. office,’” O’Connor continues. “He had retired from his practice several years earlier and was working part-time at the local Soldiers Home. When I met him at his office, he ex-plained that, for health reasons, he was selling his building and retiring from his part-time work. He gave me several boxes and milk crates full of items that had belonged to him, his sister, his father and his grandfather. The day Jack and I opened all that stuff and spread it over my kitchen table was unbelievable.”

Indeed, the contents would pique the interest of collectors and non-collectors alike. There were:• Amputee kits from the Civil War. • A Boehm urological scope and cautery set with

the receipt in the leather-covered, velvet-lined case.• A receipt dated December 18, 1924, from

Charles Lentz & Sons (Philadelphia, Pa.).• Canvas-wrapped Home Delivery Tools containing sounds

and speculums, some with date stamps from the 1800’s. • A variety of delivery forceps.

“Of course, I had to go back and talk to Gardner about these items,” says O’Connor. “First, I wanted to know why he gave them to me rather than his children. He told me, ‘You have interest in this stuff and they don’t.’”

Their discussion moved on to his grandfather’s Civil War equipment, O’Connor recalls. “He told me his grandfather was in a regiment from Vermont. Most of the regiment was wiped out, and the remaining soldiers were sent home.” After the war, Gard-ner’s grandfather set up shop in Holyoke as a family doctor.

O’Connor was especially interested in the canvas-wrapped delivery instruments. “Gardner told me, ‘Back in the day, we brought you into this world and pronounced you at the end.’ These pieces are the best additions to my collection because of the way Gardner Cox presented them to me.”

True standouts

MANY PHYSICIANS HESITATED to invest twenty dollars or more in a single illuminated speculum adaptable to the examination of only one cavity of the hu-man body, but – how many progressive practitioners will fail to avail themselves of the opportunity to obtain a complete set for the examination and treatment of all body cavities – in patients of all ages, of both sexes, at so a low a cost?N100 Body Cavity Set $65.00

Other pieces in O’Connor’s collection include several from George Tieman and Co., including a Knapps’ Single Disk Ophthalmoscope and a Tonsi-lotome, both manufactured from 1864-1886. “The Tonsilotome was a little more difficult to date,” he says. “Normally you can use the maker’s printed la-bel pasted inside the wooden case to establish an approximate date of manufacture. But, when I sent the label inside the Tonsilotome case to Tieman, they could find no record of it. Based on the street address on the label, we estimate the date of manu-facture to be between the 1860s to the 1880s. Rich-ard Moriarty, of the George Tieman Co., was very helpful and provided copies of old catalog pages and manufacture labels. These pieces are also finely packaged in leather-wrapped cases with imprinted designs, velvet-lined and neatly partitioned with fine metal clasps for closure.”

Occasionally, O’Connor will encounter an interesting piece of antique equipment at a flea market or thrift shop, but “they usually have no idea what it is,” he points out. For the most part, he collects pieces from customers who are looking to retire or upgrade to new equipment. “Many of my customers know of my fascina-tion with old medical equipment,” he says. “One of my customers recently purchased some new exam room furnishings and needed to remove an old Birtcher electrosurgical unit. It was on its own wooden mobile cabinet, comparable to a large tabletop autoclave with cables and wires big enough to start a car. My customer asked me if I could get rid of it for him, and with a smile I said, “ As long as you don’t mind me keeping it for its history.”

One man’s treasureO’Connor is happy to share his collection with his friends and family. The problem is, “their curios-ity usually fades away” before he’s wrapped up his presentation. In fact, even the pros are amazed by

repcorner

Increase your sales, while helping your customers deliver better patient

care with AdenoPlus!

Acute conjunctivitis, commonly known as pink eye, is extremely contagious, with a transmissible infection rate of up to 50% between close contacts, and is misdiagnosed in nearly half of all cases.1

References [1] Kaufman HE. Adenovirus advances: new diagnostic and therapeutic options. Curr Opin Ophthalmol. 2011;22:1-4 [2] FDA Section 510k number (K110722) for RPS Adeno Detector Plus™; March 15, 2011. *CPT stands for Current Procedure Terminology (CPT®) is copyrighted by the American Medical Association. QW modifier is added to cpt code to identify that the test is CLIA-waived.

• CLIA-waived • Easy to use• 90% sensitivity2

• 96% specificity2

• CPT®code 87809QW*• Results in 10-minutes• No additional equipment needed• Reduce unnecessary antibiotics

Contact your RPS rep [email protected]

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R

Countless Eyes at Risk

Increase your sales, while helping your customers deliver better patient

care with AdenoPlus!

Acute conjunctivitis, commonly known as pink eye, is extremely contagious, with a transmissible infection rate of up to 50% between close contacts, and is misdiagnosed in nearly half of all cases.1

References [1] Kaufman HE. Adenovirus advances: new diagnostic and therapeutic options. Curr Opin Ophthalmol. 2011;22:1-4 [2] FDA Section 510k number (K110722) for RPS Adeno Detector Plus™; March 15, 2011. *CPT stands for Current Procedure Terminology (CPT®) is copyrighted by the American Medical Association. QW modifier is added to cpt code to identify that the test is CLIA-waived.

• CLIA-waived • Easy to use• 90% sensitivity2

• 96% specificity2

• CPT®code 87809QW*• Results in 10-minutes• No additional equipment needed• Reduce unnecessary antibiotics

Contact your RPS rep [email protected]

877.921.0080

R

Countless Eyes at Risk


repcorner : D.J. O’Connor

the number of pieces he has amassed. “I talked to the Wisteriahurst Muse-um about my interest in contributing my equipment to a local museum to showcase medical devices of the past 150 years,” he says. “The museum of-fered to have a college intern spend time at Mass Surgical Supply and catalogue the items, which I thought

would be great.” But, when the museum di-rector and her assistant visited Mass Surgical Supply and saw his col-lection, they clearly were overwhelmed, he admits. “They realized it would be a far greater undertak-ing than they expected to catalogue the items,” he says. “We agreed that I would pare down the items to be displayed, and we would revisit the

idea at a later date.”As for his physician customers,

they are happy to see his hobby move forward. “Many of my customers know about my [interest in antique medical equipment] and often give me new items and say, ‘Add this to your collection.’”

Mass Surgical Supply was born in 1945, follow-ing the merger of two Holyoke, Massachusetts-based companies – Holyoke Surgical Supply and Trudea Dental Supply. And while the company continues to sell a range of products – from sutures to autoclaves – to local dentists, owner D.J. O’Connor considers himself a medi-cal products distributor first.

“When my father, David, bought Mass Surgical Supply in 1979, I had just graduated high school,” says O’Connor. “I worked for my father during summers and vacations, organizing stock, build-ing shelves, making deliveries and whatever else he needed me to do.” In 1983, the elder O’Connor

asked his son to join him full-time in business, which he did. Nearly 35 years later it is still “one of the best decisions I ever made.

“My father handed me a large drug-rep style briefcase, filled with catalogues from Medisco Federal, Graham Field, Graham Medical (founded locally in Holyoke), Johnson & Johnson, 3M and several other mainstay companies. He pointed out that for most of the questions customers asked, the answers could be found in these cata-logues.” Today, in addition to owning and running Mass Surgical Supply, O’Connor continues to log about 30,000 miles each year making regular visits to local customers.

Mass Surgical Supply: From father to son


healthy reps

Physical activity can reduce the risk of chronic dis-ease, improve coordination, facilitate weight loss and boost self-esteem. The problem is, for many,

it’s not fun. But, that doesn’t have to be the case, accord-ing to The Mayo Foundation for Medical Education and Research. With careful planning and pacing, fitness can become a lifetime habit, it points out. Mayo offers seven tips for staying motivated:

• Set goals. Start with simple goals and then prog-ress to longer-range goals. Make goals realistic and achievable, as it’s easy to get frustrated and give up when goals are too ambitious.

Fit for 14Fitness and exercise don’t have to be a drag in 2014!

Having a chronic disease, such as heart disease, diabetes, asthma or back or joint pain, doesn’t necessar-ily rule out exercise. Exercise can have important health benefits, according to The Mayo Foundation for Medical Education and Research, however it’s important to talk to your doctor before starting an exer-cise routine.

Mayo addresses some common questions regarding the impact of exercise on chronic disease:• How can exercise improve a chronic condition? Regular exercise can help you manage symptoms and

improve your health. • Heart disease. Strength training can improve muscle strength and endurance, make it easier to do

daily activities, and slow disease-related declines in muscle strength.• Diabetes. Regular exercise can help insulin more effectively lower your blood sugar level. Physical

activity can also help you control your weight and boost your energy.• Asthma. Often, exercise can help control the frequency and severity of asthma attacks.• Back pain. Regular low-impact aerobic activities can increase strength and endurance in your back

and improve muscle function. Abdominal and back muscle exercises (core-strengthening exercises) help reduce symptoms by strengthening the muscles around your spine.

• Arthritis. Exercise can reduce pain, help maintain muscle strength in affected joints and reduce joint stiffness.

• What exercises are safe? Your doctor might recommend specific exercises to reduce pain or build strength. Depending on your condition, you might also need to avoid certain exercises. In some cases, you might need to consult a physical or occupational therapist before starting to exercise.

• What steps must I take to get started? Depending on your condition, your doctor might recommend certain precautions before exercising. For instance, it’s important for diabetics to check their blood sug-ar level before any activity. Taking insulin or diabetes medications that lower blood sugar might require you to eat a snack before exercising to help prevent low blood sugar. If you have arthritis, applying heat or taking a warm shower prior to exercising can relax joints and muscles, relieving any pain. Also, wear shoes that provide shock absorption and stability during exercise.

Exercise and chronic disease


healthy reps

Frigid temperatures shouldn’t prevent one from exercising outdoors. However, it’s important to do so safely, according to The Mayo Foundation for Medical Education and Research. Fitness buffs should do the following:

• Dress in layers. Start with a thin layer of synthetic material, such as polypropylene, which draws sweat away from your body. Avoid cotton, which stays wet next to your skin. Next, add a layer of fleece or wool for insulation. Top this with a waterproof, breathable outer layer. In espe-cially cold weather, a face mask or scarf can warm the air before it enters your lungs.

• Protect hands, feet and ears. Wear a thin pair of gloves under a pair of heavier gloves or mit-tens lined with wool or fleece. Wear shoes a half-size or one size larger than usual to allow for thick thermal socks or an extra pair of regular socks. A hat or headband helps prevent frostbite.

• Consider weather conditions and wind chill. Wind chill extremes can make exercising out-doors unsafe even if you dress warmly.

• Select appropriate gear. If it’s dark when you exercise outside, wear reflective clothing. To stay steady on your feet, choose footwear with enough traction to prevent falls.

• Use sunscreen. It’s as easy to get sunburned in winter as in summer.• Heed the wind. If possible, do the second half of your workout with the wind at your back.• Drink plenty of fluids. It’s as important to stay well hydrated when exercising in cold weather

as it is when exercising in warm weather.• Know the signs of frostbite and hypothermia. Frostbite is most common on exposed skin,

such as the face, nose and ears. It also can occur on hands and feet. Early warning signs include numbness, loss of feeling or a stinging sensation.

Cold weather tips

• Make it fun. Find sports or activities that you enjoy, and vary the routine. If you’re not enjoying your workouts, try something different. Join a volleyball or softball league. Take a ballroom dancing class. Check out a health club or martial arts center.

• Make physical activity a part of your daily routine. Schedule workouts as you would any other important ac-tivity. During the day, take the stairs instead of the elevator. Walk up and down sidelines while watching the kids play sports. Pedal a stationary bike or do strength-training exercises while you watch TV at night.

• Track your progress on paper. Seeing the benefits of regular exercise on paper may help you stay motivated.

• Join a group. Invite friends or co-workers to join you when you exercise, or orga-nize a group of neighbors to take fitness classes at a local health club.

• Reward yourself. When you reach a long-range goal, treat yourself to a new pair of walking shoes or new music to enjoy while you exercise.

• Stay flexible. If you’re too busy to work out or simply don’t feel up to it, take a day or two off. The important thing is to get back on track as soon as you can.

When designing a personal fitness program, consider your fitness goals. Think about your fitness likes and dis-likes, and note your personal barriers to fitness. Then con-sider practical strategies for keeping your fitness program on track.

The Department of Health and Human Services recom-mends that healthy adults include aerobic exercise and strength training in their fit-ness plans. This includes:• At least 150 minutes of

moderate aerobic activity – or 75 minutes of vigorous aerobic activity – each week.

• Strength training exercis-es at least twice a week.

Healthy guidelines


Adults on board Teens aren’t the only ones on board with smartphone and tablet technology, according to a recent online survey by The Harris Poll. About 52 percent of U.S. adults own or use smart-phones, while 33 percent own or use tablets. These ownership figures rise for parents of children under 18: 69 percent own smartphones and 44 percent use tablets. Indeed, smartphone and tablet technologies are becoming a parenting tool for some: For parents with children under 18, 47 percent surveyed admitted to using a smartphone – and 44 percent a tablet – to keep their children entertained. Nearly 18 percent have used a standard mobile phone and 17 percent an eReader. About 20 percent claim to have not used any device to occupy their children. At the same time, parents with children under 18 ap-pear to be more likely to use their smartphones or tablets for:

• Mapping or navigation functions • Social media • Locating restaurants • Watching videos •Purchasing goods or services.

Not your lossTired of travel hassles? You’re not alone, according to Vanguard ID Systems, which notes that some 26 million bags go missing at airports every year. In response, the company has introduced its E-Ink based ViewTag® with a display that changes via the traveler’s phone. The tag acts like a digital license plate, allow-ing fliers to control the process of checking bags at home by using their cell phone through the tag’s QR Code or embedded NFC module. Fliers are notified via text message where their bags are located throughout their trip. Fully customizable to

include logos and personalized artwork, the ViewTag® re-portedly is created with an environmentally safe material and currently holds numerous RFID (radio-frequency identifica-tion) related patents for RFID Tags.

Facebook, anytimeAmerican smartphone users may have to wait awhile, but users in Africa can now access Facebook on any mobile phone, without Internet or data connectivity, using Facebook USSD, from Sin-gapore-based mobile technology startup U2opia Mobile. Avail-ability of the service with MTN Nigeria is said to have brought U2opia Mobile’s African footprint to nearly 100 percent.

Smokin’ alarmMiniature smoke alarm First Alert® Atom™ was recently named a 2013 Chicago In-novation Award winner. The alarm measures 1.5 inches in diameter and weighs less than two ounces, and is available in a number of decorative finishes.

BYODHuawei, a global information and communications technol-ogy solutions provider, announced the launch of its one-stop, bring-your-own-device (BYOD) mobile office solution. The company’s BYOD solution offers one-stop services and prod-ucts for enterprise network, security and devices, as well as man-agement platforms. It is said to facilitate flexibility and consis-tency among enterprise customers.

Editor’s note: Technology is playing an increasing role in the day-to-day business of sales reps. In this department, Repertoire will profile the latest developments in software and gadgets that reps can use for work and play.

DETECTO’s new 7550 Wall-Mount Fold-Up Wheelchair ScaleDETECTO announced the release of its new USA-made model 7550 wall-mount wheelchair scale, which features a unique fold-up storage design that saves space when not in use. With its spacious 32.3-in W x 33-in D (82-cm W x 84-cm D) folding platform extended, the 7550 eas-ily accommodates most wheelchairs. The slim 6.6-inch (17-cm) profile takes up minimal space when installed in a confined medical facility hallway, clinical office, or patient room. When you’re ready to weigh, simply lower the platform and the gas spring lifting mechanism will gently lower it into place. The patient may be easily rolled onto the scale, while a platform lip will hold the wheelchair securely in place for weighing. DETECTO’s 7550 digital wheelchair scale features a high 1,000 lb x 0.2 lb / 450 kg x 0.1 kg capacity for bariatric weighing, two-way easy-access ramps, 99 stored wheelchair tare weights, 200 stored transactions, sturdy steel construction for

long-lasting durability, Body Mass Index calculation, pushbutton and keypad tare, alphanumeric keypad, 14-digit patient IDs, and optional Wi-Fi for efficient EMR/EHR. For more information, visit: www.detecto.com/cs_product/7550-wall-mount-fold-up.

New Product


classifiedsINDEPENDENT SALES REPS &

DISTRIBUTORS NEEDEDES Medical Inc., who manufactures Medical Compression

Garments and Pain Pumps, is seeking Independent Sales Reps and Distributors who currently call on Plastic Surgery Offices,

Hospitals and Surgical Centers.

Our privately held company headquartered in New York City has been in business since 1998 and is looking for candidates to cover exclusive territories throughout the U.S. and Internationally.

Strong relationships with these type of facilities are essential for this position. High commission plan and discounts

in place for right Sales Reps and Distributors.

To view our full line of products and learn more about our company, go to www.esmedical.com.

If you are interested in this opportunity please submit your resume to: [email protected]

DIRECTOR, CONTRACTS & REBATES

NDC seeks a leader with experience managing the contract and rebate process/administration for GPOs, including membership, pricing tier/eligibility information and fee processing. This includes rebates, rebate discrepancies and denials and meeting monthly rebate and reporting deadlines for NDC’s manufacturer partners and GPOs.

The right individual will possess a working knowledge of Excel, Access, AS400 and SQL, and will be confident managing a team with responsibility for large amounts of data. Familiarity with special pricing and rebate processing in the healthcare industry required.

We value our employees at NDC and offer a robust compensation and benefits plan.

Please submit a cover letter with salary requirements, along with your resume, to [email protected].

Dealmed Medical Supplies is looking to expand its field sales force in the New York, tri-state area.

If you have 2+ years of direct sales experience or have strong, established, relationships with medical

offices – you may be a good fit. By working with us you will enjoy a competitive compensation plan that includes: a base salary, bonuses, commissions,

a protected territory, pre-paid gas card, lap-top, cell phone, paid time off, and

full expense reimbursements… But more importantly – you will enjoy an opportunity

to grow with an independent and privately funded medical supply distributor.

Please submit your resume or email us with any questions at:

[email protected]

NOW HIRING

$128 QuestionRepertoire’s $128 Question for

each month is available on our Facebook page, Twitter, and Blog.

RepertoireMag.com. In November we asked:

What sci fi animated flick’s cast was packed with the voices of actors whose other roles included Jason Bourne, Sid the Sloth from Ice Age, one of Charlie’s Angels and the President of the United

States during an alien invasion?

Answer: Titan AE

CoNgrAtulAtIoNs to Alex HIgINbotHAm, ComedICAl

More patients, less providers and

healthcare trending patients away from

hospitals and into non-acute care settings.

That’s what the future holds. At Midmark,

we see this as an opportunity.

The perfect mix of precision positioning

and comfort, the Midmark 630

HUMANFORM™ procedures table is

the new benchmark in efficient,

patient-centered design.

See what the industry will be talking about.

Call 1-800-MIDMARK or visit

midmark.com/HumanForm.

Midmark 630 HUMANFORM™ Procedures Table Enhanced positioning, shaped by you.

Midmark Corporation, Versailles OH USA

Repertoire Jan 630 Table Rev2 Resized To Correct Specs.indd 1 12/10/13 3:27 PM

HOSPITALS

GROUP PURCHASING ORGANIZATIONS

INTEGRATED DELIVERY NETWORKS

SURGICALCENTERS

CLINICS &COMMUNITY HEALTH CENTERS

CLINICIANS’OFFICES

Welch Allyn and you. One team. One goal.Improving outcomes across the continuum of care.

With the broadest range of connected devices and EMR partners and our extensive support teams, together we can help to improve the patient care experience for everyone.

Visit the Vitals for Success Portal to access your tools atwelchallyn.com/distributor.

©2013 Welch Allyn MC10789

Documents

vol.22 no.1 January 2014 - Amazon Web Servicesrepconnectdocuments.s3.amazonaws.com/MDSI/REP-jan.14.pdf · 2014. 4. 3. · practices could both avoid penal-ties and earn a bonus (.5