Signature MD Daily Business Review / Signature MD Concierge Medicine Provider MDVIP A Monopoly? Lawsuit Says So September 4, 2014

MDVIP Corporate Office Headquarters at 1875 Corporate Boulevard NE in Boca Raton

MDVIP Corporate Office Headquarters at 1875 Corporate Boulevard NE in Boca Raton Melanie Bell

Boca Raton-based MDVIP Inc. is to concierge medicine as Hollywood is to movies.

It is very much the alpha dog in the growing health care niche, which once was the bastion of the rich but is now an available option to many workers through their employer’s insurance plans.

For an upfront annual fee, patients are given specialized attention by physicians with limited patient loads. Services can include house calls, longer appointments and greater access. Some high-end concierge doctors are available 24 hours, seven days a week and will even travel to a vacation location if a patient is ill.

But MDVIP’s competitors say there’s a reason why it dominates the industry, accusing it of creating a monopoly in many regions. An antitrust lawsuit filed against the company claims it has used courts and noncompete agreements with its doctors to bully its way to the top.

Signature MD Inc., a competitor based in Marina Del Rey, Calif., filed an antitrust lawsuit in July against MDVIP in Los Angeles. The lawsuit assigned to U.S. District Judge Dolly M. Gee alleges the company hobbles doctors by making them sign a two-year noncompete agreement.

MDVIP often files lawsuits to enforce the agreements in Palm Beach County, even against nonphysician employees who switch to competitors. The company in January 2013 sued Signature MD and some of its employees asserting theft of trade secrets.

Signature MD described the lawsuit as a “sham” in the antitrust lawsuit.

“MDVIP has no legitimate business justification for the restrictive covenant and uses it simply to hinder its competitors from hiring individuals who are experienced in the concierge medicine industry,” according to the lawsuit filed by Duane Morris attorneys Wayne A. Mack in Philadelphia and Cyndie M. Chang in Los Angeles. “Following the expiration of the restrictive covenant, MDVIP continues this anti-competitive conduct by filing lawsuits against its former patient advocates who work for competitors.”

MDVIP has filed a lawsuit in Palm Beach Circuit Court against three former employees, none of whom are doctors. The defendants are a former senior marketing analysts and two former patient advocates who now work for Signature MD. They are accused by MDVIP of improperly obtaining access to the company’s confidential and trade secret information.

Signature MD and two employees in the Palm Beach lawsuit are being defended by Gail McQuilkin, managing partner of Kozyak Tropin & Throckmorton in Coral Gables. She referred questions for comment to Signature MD’s CEO Matthew Jacobson.

Growing industry

Jacobson started Signature MD eight years ago with $300,000, and the company is projecting $27 million in revenue in 2014. He saw an opportunity for concierge medicine with the baby boomer generation getting older and primary care physicians getting squeezed by insurance companies.

“No one was going into primary care because they couldn’t make it any more,” Jacobson said. He estimates Signature MD is 10 percent the size of MDVIP.

He and his attorneys claim MDVIP is using the courts to bully competitors and former employees, and is in effect using the courts to conduct a form of corporate espionage.

“From my observation, the goal of their claims is to bleed us out, to deprive of us of our financial resources and to gather from the questions asked in depositions as much information competitive information and to harass our employees,” Jacobson said.

One lawsuit was filed against a Signature MD employee who worked for about three months in clerical support for MDVIP. The litigation claimed he had stolen trade secrets, Jacobson said.

He said the type of noncompetes MDVIP are forcing employees to sign are akin to what are given to top executives of the company who are duly compensated, not employees who make $40,000 a year.

“I just have never seen anything like this in any other industry,” Jacobson said.

MDVIP’s attorney, Jerome Hoffman of Holland & Knight in Tallahassee, did not return calls for comment by deadline.

MDVIP spokeswoman Nancy Udell said the allegations are completely without merit.

“Signature MD’s antitrust lawsuit against MDVIP in Los Angeles appears primarily to be an attempt to retaliate against the lawsuit MDVIP has brought in Florida against Signature MD for misappropriating MDVIP’s trade secrets,” Udell said in an email.

MDVIP started around 2000 and quickly became an industry leader. Its litigious ways started after it was purchased by Procter & Gamble Co. in 2009 and continued since its sale to equity investor Boston-based Summit Partners LLC in May, Mack said.

Employees targeted

MDVIP’s restrictive covenants prohibit physicians from practicing concierge medicine independently or with another concierge medicine membership program within a 10-mile radius of an existing office or within a 10-mile radius of any MDVIP-affiliated physician.

“They have foreclosed us from certain markets by tying up doctors with long-term contracts, which are in essence evergreen contracts,” Mack said. “We have been unable to sign up doctors or offer consumer choices because of these contracts.”

Mack maintains the contracts are unenforceable because doctors are not direct employees of MDVIP. They pay a royalty or franchise fee per patients for services, such as marketing, patient conversion and clerical support.

“If a doctor signs up with MDVIP, that doctor is stuck,” Mack said.

Patients generally pay $1,500 and $2,000 extra a year for concierge care. They still have co-pays where applicable and must maintain primary care insurance, including Medicare.

The antitrust lawsuit is seeking an injunction ordering the company to cease anti-competitive activities plus treble damages under the California Business and Professions Code.

MDVIP filed a motion to disqualify Duane Morris from representing Signature MD, saying the law firm learned confidential and proprietary trade secrets in previous litigation.

The alleged trade secrets relate to “the strategies and methods by which MDVIP identifies, evaluates and recruits physicians to affiliate with its wellness management program, transitions and supports of their practice in the program and the contractive provisions, including restrictive covenants,” the motion reads.

Gee has scheduled a hearing for Oct. 10. Mack calls the disqualification motion meritless.

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Signature MD

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Signature MD Medical Economics / Signature MD Direct-Pay Medical Practices Could Diminish Payer Headaches September 3, 2014

Most family practice and internal medicine physicians working in private practice today are burdened by ever-shrinking reimbursement rates and a growing list of administrative tasks required by insurance companies. In response, many primary care physicians are exploring alternative practice options, some of which are being encouraged by policy changes embedded in the Affordable Care Act.

Some doctors are embracing the economic security and reduced administrative burden that comes with employment. Others are selling their practices to hospitals and/or larger groups. And a small but growing number are showing interest in direct- pay practice models that allow doctors to reduce, or in some cases eliminate entirely, the administrative hassles and costs of dealing with insurance.

There are several models in which physicians collect a monthly retainer fee directly from patients instead of relying on fee-for-service reimbursement from third parties. Although the services provided for this charge varies, some of the benefits to physicians in adopting a direct-pay model include:

  • reducing patients panel sizes, often by as much as half,
  • minimizing administrative and staffing costs,
  • increasing the amount of time spent with patients, and
  • potentially increasing incomes

The services covered by the monthly retainer fee vary across practices. Often, however, patients can expect to have all primary care services covered, including care management and care coordination. Typically these include seven-day-a-week, around the clock access to doctors, same-day appointments, office visits of at least 30 minutes, basic tests at no additional charge, and phone and email access to the physician.

Although these models can look different, at their core, experts say, they share the common aim of providing high service levels, and increased access for patients.

Monthly membership models are especially attractive for patients with chronic conditions, but healthy people interested in a higher level of service find these models appealing as well.

Medical Economics spoke with experts to discuss some of the more common direct-pay practice models, along with some of their benefits and drawbacks.

direct pay practice model

Concierge medicine

Concierge medicine practices charge an annual fee that can range from $1,200 to $10,000, depending on the practice.

There are several models that physicians can choose from when transitioning a practice to concierge from traditional fee-for-service.

Full Conversion

One of the main goals in moving to a concierge-style practice is to reduce a practice’s patient panel size to just 300 or 400, rather than several thousand, which is now more typically the case.

Some doctors start with a full conversion of their practice whereby they terminate all patients who choose not to participate and pay the monthly retainer fee.

“It’s a high-risk, low-reward model,” says Matt Jacobson, founder and chief executive officer of  Signature MD, a national concierge medicine provider headquartered in Los
Angeles, California.

Benefits of this approach include reduced physician work hours and the ability to eliminate many of the administrative burdens that come with insurance contracts, but not much increase in income.

Immediate conversion to concierge medicine is also high risk. “What happens if you don’t get the 300 or 400 patients that you need? What if you only get 200?” Jacobson says. “You’re going bankrupt, or you’re working at the urgent care [center] or something else to supplement.”

Hybrid concierge model

In the hybrid concierge model, a physician delivers differing levels of care to two distinct patient groups–those who pay the concierge fee and those who don’t.

“If you pay me $2,000, you’ll have my cell phone number, and you’ll get to the front of the line at the office. If you don’t pay me $2,000 it’s business as usual,” Jacobson says.

Although doctors operating under this model can see a small increase in their income, they increase their clinical hours, Jacobson says.

In addition, there are ethical issues inherent in a two-tiered practice in which some patients pay for a higher level service than others. For example: does the physician spend 30 minutes with a healthy patient who has chosen the concierge model and only a fraction of that time with a patient facing myriad health issues who has chosen not to pay the annual fee?

Market segmentation

Jacobson describes a third model of concierge medicine–a market segmented approach–that he says was developed by SignatureMD. “It’s a high-reward, low-risk model,” he says.

Similar to other approaches, physicians seek to convert roughly 300 patients. The practice then brings on either a junior physician or nurse practitioner. Patients who participate in the concierge model will continue to see their doctor. Those not participating will see the new physician and/or nurse practitioner.

With this approach, Jacobson says, it’s feasible for physicians to more than double their income while reducing their workload by 25%.

According to Garrison Bliss, MD, president of Qliance Medical Group and founder of the second monthly fee practice in the United States, concierge medicine offers physicians many benefits. However, he cautions against a major trap of the model.

“In the concierge world, there’s this fear that if you didn’t do a bunch of exotic testing, and you didn’t have a cool new medicine that you knew about that other people didn’t know about, that it would be hard for people to believe they were getting better care from you,” Bliss says.

Direct primary care model

Bliss envisioned an alternate membership-based approach to routine and preventive care called direct primary care (DPC), which he started in 1997.

“I decided to come up with a healthcare model, rather than a business model. And then, to figure out what the business model would have to look at if we were a monthly fee practice,” Bliss says.

With DPC, the monthly fee for patients is lower than in concierge medicine–often ranging from $50 to $150. The size of the practice is generally larger as a result–600 to 800 patients as compared with 300 to 400 in concierge practices.

“We stopped being focused on the issue of getting paid and started being focused on the issue of what do we have to do for people,” Bliss says.

Markets for DPC

DPC is a small but growing movement, says Thomas Charland, chief executive officer of healthcare consultancy for Merchant Medicine, LLC. The two primary markets include individuals who have high-deductible health plans and see the value in paying a low monthly fee for increased access to primary care.

The biggest potential, Charland says, is among employers who have given up on a traditional approach to primary care. Many firms recognize that physicians with large panel sizes don’t have the time to spend with patients and must refer anyone with complications to specialists. That, in turn, is causing costs to skyrocket.

“If it takes off with employers it’s a game changer,” Charland says of DPC.

Building high-deductible insurance products that incorporate this model and that cover the services that direct pay practices don’t is an important step in moving this model forward. And it’s already happening.

“We’re involved in two instances of that in Washington State right now with, I think, more to come,” Bliss says.

Is Direct Pay right for your practice?

Experts offer these considerations when determining whether some form of direct pay model is right for your practice:

It must feel natural.

Physicians most likely to succeed using a direct-pay model are already operating as if they run one. “If you’re not already the guy who is taking the calls late at night, if you’re not the guy who is visiting your patients in the hospital…don’t do it because you will fail,” Jacobson says.

Carefully consider your monthly fee.

“I usually recommend that the doctor map out all of the fixed costs of his or her practice: facility rent and maintenance costs, utilities, equipment leases, staff salary, provider salary,” Bliss says.

Consider the size of your practice.

The next step is to consider how large a practice you want to operate. Once you’ve determined that, Bliss says, “divide the costs by the panel size and you have the annual fee you will have to get to make that work.”

Assess your patient pool.

Ask yourself how many of your patients will actually pay the fee. Jacobson’s firm employs a predictive model that relies on a range of information gleaned from a random sample of the patient population to determine the likelihood of success.

“If you don’t do that, you have absolutely no idea whether you’re going to succeed or not,” he says.

Connect with the community.

Charland says doctors should look for primary group companies operating in their area. In addition, they should become part of a community of practices and/or associations focusing on the type of model that they find most appealing.

Signature MD

Original Article

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Dr. Mohammad, Inspire Malibu InTouch, National Enquirer / Dr. Mohammad, Inspire Malibu Robin Williams Update August 26, 2014
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Dr. Mendieta Monsters & Critics / Dr. Mendieta Top Plastic Surgeon Assesses VMA Celebrity Butts VIDEOS August 26, 2014

One of the world’s top authorities on gluteal sculpting and enhancement is plastic surgeon, Dr. Constantino Mendieta, a Miami board certified plastic surgeon, who literally wrote the book on the subject schooling other physicians on what now is unquestionably the focus of women’s figures these days, a far cry from the boobtastic 1970s-1990s where breast implants were ubiquitous and almost a right of passage for many women.


Nicki Minaj in action at the 2014 VMAs

Dr. Mendieta is a frequent contributing expert to Monsters and Critics who shares his opinions on the female form and who can reshape and sculpt buttocks better than anyone. He explained in a past interview that there were four distinct body booty shapes, and the ideal was the “A” frame, the inverted “V” where the waist-to-hop ration was optimal.

Dr. Mendieta said,  ”Though the actual number varies around the world, most in our business agree that a waist-to-hip ratio of 0.7 is a significant indicator of female attractiveness compared to 0.9 for men.  Since the 2000 Grammys when Jennifer Lopez wore the famous low cut back green Versace dress that accentuated her bottom, women have sought to refine and sculpt their backsides and the trend is only increasing.”


As for last night’s 2014 MTV Video Music Awards? “Nicki Minaj’s anticipated ‘Anaconda’ performance really underscored the booty as sexual bait despite her poor backup dancer getting injured in rehearsal by one of the boa constrictors,” said Dr. Mendieta. “She has a really fantastic shape and knows how to work it for her stage show. It’s all about proportions and curves. The new approach does not just focus on the buttock… but the entire panorama. It is about waist, curves, silhouette and the actual shape of the buttock.”


The recipient of this year’s Video Vanguard Award, Beyonce performed a medley of songs from her most recent album with support from husband Jay Z and their adorable daughter Blue Ivy.

“Beyonce was also another great example of a woman whose lower half is strong, shapely and sexy too from good diet, workouts and her constant dancing on tour, a fantastic way to get your booty in great shape if squats and surgery are not for you,” said Dr. Mendieta.

Check out Beyonce at this year’s VMAs.



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Dr. Mohammad Fox News / Dr. Mohammad Heroin in the suburbs: An American epidemic August 22, 2014

Heroin needle_Reuters.jpg

A bag of heroin and drug paraphernalia are seen at an abandoned house.REUTERS/Bor Slana

“Here, want a blue?”

How could one little pill, legally prescribed to millions of people, be a dangerous way to have a good time?

Mike Duggan remembers those words. He said yes to a “blue,” a 30 milligram oxycodone. It sent him down a slippery slope that gave way to a bruising tumble. Less than three years later, he was shooting heroin into his veins on a daily basis.

“The idea of heroin terrifies you, but a blue oxycodone doesn’t scare you,” said Duggan, who founded an addiction recovery service called Wicked Sober.

Duggan told Healthline that his addiction began with a prescription for Percocet after a hockey injury in high school. A popular athlete in Arlington, Massachusetts, a Boston suburb, he liked to drink and have a good time on the weekends.

But the Percocet enticed him with a fierceness he did not at first understand. Soon, he was in college, and it seemed like everyone was popping that blue pill for fun. Before he knew it, he could not get enough oxycodone, the drug of choice for painkiller addicts according to research published in the journal Pain.

Heroin was cheaper and easier to get. The other addicts all “sold it to their friends to keep their own habits going, who sold it to their friends, and so on, and so on,” Duggan told Healthline.

‘Unacceptably High’ Rates of Heroin Use

Heroin use among young adults ages 18 to 25 has skyrocketed in recent years. In 2012, 156,000 people tried heroin for the first time, according to the National Institute on Drug Abuse. The agency has called that statistic “unacceptably high.” It has almost doubled since 2006.

Heroin is no longer a drug used primarily by the poor in inner cities. Now it is a cheap high for young, white suburbanites. Many of them became addicted while raiding their parents’ medicine cabinets in high school and selling the pills at school.

Jody* is the mother of a San Fernando Valley, California man named Alex, who has been sober for almost three months. Jody belongs to a group called BILY, or Because I Love You. The network of parents offer support to one another as their children wrestle with heroin addiction and other problems.

Many parents don’t know their children are abusing heroin. They often start by snorting or smoking it, so there are no needle marks.

“For a long time my head was buried in the sand, and I know it was,” Jody told Healthline. She said high school administrators in the Los Angeles suburbs themselves are in denial about the problem of opiate abuse in their schools. It’s brushed under the rug, she said. Nobody wants to talk about it.

Naloxone Brings Users Back from the Dead

Dr. Leonard Paulozzi, a medical epidemiologist at the U.S. Centers for Disease Control and Prevention, told Healthline that more and younger people are dying of heroin overdoses.

He said most of the CDC’s efforts have been focused on the issue of prescription painkiller addiction. “Heroin is a child of that original epidemic,” he said.

Between 2006 and 2010, heroin-related poisoning deaths increased by 45 percent. Earlier this year, U.S. Attorney General Eric Holder, armed with that statistic, urged law enforcement agencies nationwide to train and equip their forces to use the overdose reversal drug naloxone. During an acute overdose, naloxone rapidly blocks opioid receptors in the brain, throwing the user into instant withdrawal.

Naloxone is usually administered intravenously in emergency rooms, but nasal spray versions of the overdose antidote have also been given to community groups working with addicts nationwide. Paulozzi would like to see such a spray become available to the public and for insurers to cover it. Research published in the medical journal BMJ showed that naloxone spray coupled with overdose education significantly reduced overdose death rates.

An auto-injector version of naloxone called Evzio recently came on the market, but it is expensive, Paulozzi said. There is also a shortage of naloxone in the U.S.

Getting Help and, Maybe, a Way Out

Jody’s son Alex* found help at Inspire Malibu Treatment Center. After several previous failed attempts at getting sober, he has almost reached 90 days without using any drugs or alcohol.

Alex has been helped along by another type of drug, Suboxone, a controversial medication used to treat heroin addicts. Dr. A.R. Mohammad was among the first doctors in California to prescribe the drug, a combination of buprenorphine, a partial opioid antagonist, and naloxone, an opioid antagonist.

Between 2002 and 2011, the number of doctors prescribing buprenorphine in Utah increased 67-fold, to 1,088. The number of patients filling those prescriptions increased 444-fold, from 22 in 2002 to 9,763 in 2011, according to the CDC.

The medication treats addiction by acting on the same pleasure receptors in the brain that are stimulated by oxycodone or heroin. However, the medications are safer and generally do not induce the type of behaviors that disrupt a person’s life and render them unable to work.

Buprenorphine, brand name Subutex, can fulfill cravings that occur when a patient stops abusing illegal drugs. But it has the potential to be abused itself. Patients chop it up, snort it, and inject it. It now comes in a film that can be placed under the tongue, however, reducing the potential for abuse, Mohammad said.

If Suboxone is injected, it will cause uncomfortable withdrawal symptoms that do not occur when it is taken in oral form.

The new oral drugs are preferable to older treatments, such as methadone, Mohammad said, which is less effective and has a high potential for abuse. Another preferred treatment option is Vivitrol, an injectable form of naltrexone, another opioid antagonist.

Suboxone: A Better Drug to Depend On?

Critics of Suboxone contend that a person who takes it is not really sober. But Mohammad, his patients, and their loved ones say it saves lives.

Depending on the duration of opioid abuse, brain damage can be permanent. Mohammad makes no secret of the fact that he has patients who have been on Suboxone for 11 years, but he says there is no other way for them to stay clean.

“There is a deep misconception in society about using drugs,” Mohammad told Healthline. “Addiction is a chronic mental illness. It is a deadly disease and you can die from it.”

Patients do become dependent on Suboxone, he said. “But the difference between heroin and Suboxone is that on heroin, your life is completely screwed,” he said. “With Suboxone, you can have quality of life. What counts is good quality of life.”

Mohammad said patients return to work, become involved with their families again, and no longer meet the criteria for addiction as defined by the Diagnostic and Statistical Manual of Mental Disorders.

It is physically impossible for an addict to get high on Suboxone because of its chemical formulation, Mohammad said. And studies like this one that appeared in the Journal of Substance Abuse Treatment in 2010 show that people rarely abuse it.

Paulozzi called Suboxone “an intervention that’s proven to work. The hard part is making it available to everybody and convincing people to get into a program,” he said. “Most people who have a problem don’t think they need to get help.”

Efforts are under way at the federal and state levels to improve access to Suboxone. Doctor prescribing regulations and insurance coverage of the drug differ state by state.

Suboxone has plenty of opponents, mostly advocates of Alcoholics Anonymous-style 12-step abstinence programs, Mohammad said.

Duggan said Suboxone did not work for him, although he admits that it helps some people. He said Wicked Sober does not turn away those who are on it.

A lasting solution to addiction is “developing fellowship and getting out of one’s self,” Duggan said. “The best way is by helping other people.”

He said Suboxone has definite street value, and some sell it to get the drug of their choice.

Heightened Risk of HIV and Hepatitis C

Overdose isn’t the only danger young heroin addicts face. The issue of young, suburban white adults injecting heroin has been thrust into the spotlight because many of them are now contracting hepatitis C.

Massive outbreaks have occurred in suburban Boston, Wisconsin, Florida, Pennsylvania, and New York. A report produced last year by the Office of HIV/AIDS and Infectious Disease Policy confirmed “Rising rates of hepatitis C infection among young injectors, both male and female, primarily white, found in suburban and rural settings, who started opioid use before transitioning to heroin injection.”

More than half of the 17,000 new hepatitis C infections in the U.S. in 2010 were injection drug users, according to the National Institute of Drug Abuse.

But the risk of contracting an STI occurs apart from injection use, too. Research published last month in the Journal of Substance Abuse and Treatment showed that young adults (more likely to be white and middle class) were putting themselves at risk for HIV as well via unprotected sex with casual partners, often in exchange for drugs.

Alex said he indeed lowered his standards sexually while taking heroin. “It was pretty bad,” he said. “My standard in women went right out the window.”

As for sharing needles, he said he only did it once, during a failed attempt in rehab. “It was a last resort type of deal,” he said.

Getting Treatment Where It’s Needed — Fast

Addicts cannot get clean without significant help.

“To expect someone with a brain illness to manage their own life and do it on their own is an unrealistic expectation,” Duggan said.

Duggan’s work at Wicked Sober involves hooking addicts or their loved ones up with resources as quickly as possible. He does not operate a treatment center. Instead, he networks with a vast directory of resources to fast-track a person into treatment.

“The hard part is making [medications] available to everybody and convincing people to get into a program.”Most people who have a problem don’t think they need to get help.” — Dr. Leonard Paulozzi

You’ve got to strike while the iron is hot, he said, and you’ve got to make sure there is an iron-clad support system when the person is released.

Another problem arises when a parent or friend tries to get help for an addict and reaches out. Usually, a treatment professional says they have to speak directly with the patient if they are an adult.

“If someone says, ‘I do need help and I’m ready right now,’ to a loved one, it can take a day or two to find help,” Duggan said.

He recalled calling several times for help when he was an addict, but being told there was a waiting list or to call the next day. “My solution was to get high,” he said.

*Last names withheld to protect source privacy

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