Back in the day, our beauty options were pretty simple: cold cream, witch hazel, cocoa butter, petroleum jelly. Now with a zillion skin-care products and treatments available on drugstore shelves, at cosmetics counters and in doctors’ offices, it can take a minute to make sense of it all. So we’ve designed this primer to guide you through the maze and help you find your perfect match.

coming clean

Form-vs.-function Cleansers These come in so many varieties–gels, milk-based and soap-free formulas, disposable wipes–that it’s hard to know which is best for your skin. “In general, creamy cleansers are good for dry skin; gels or foaming cleansers are better for oily skin; soap-free cleansers are ideal for sensitive types; and wipes are convenient for all skin types,” says noted dermatologist Howard Murad, M.D.

The Main Ingredients You’ll get better results if you match the ingredients in your cleanser to your skin type, Murad says. Acne-prone? Look for cleansers with gtycolic acid or salicylic acid. Do you have dry skin? Seek out ingredients like lactic acid, glycerin or hyaluronic acid. If your skin is sensitive, choose fragrance-free products. “And if you’re unsure of your skin type or don’t have time for reading labels, try a soapless, nonirritating cleanser like Cetaphil,” says Heather Woolery-Lloyd, M.D., director of ethnic skin care at the University of Miami. More great picks: Biore Pore Perfect Blemish Fighting Ice Cleanser, B. Kamins Vitamin Face Cleanser.

Toning Up Cleanse, tone, moisturize–right? “Skin toners are not really necessary,” says Elaine Linker, cofounder of DDF (Doctor’s Dermatalogic Formula), a cosmeceutical skin-care line. “People like them because they are refreshing, can remove leftover makeup and other residue and can help return the skin to its proper pH balance after cleansing,” she says. But your skin will eventually return to its natural pH without any assistance. Ideally, your cleanser should remove all your everyday pollutants.

Murad disagrees. “Toners are the finishing touch to your cleansing routine,” he argues. “The process is more complete with this added effort.” Bottom line: It’s your choice. Two to try: Nivea Moisturizing Toner and Dr. Brandt Poreless Toner for Oily/Combination Skin.

For clients living in health care retirement communities, the Tax Court’s decision in Delbert L. Baker, 122 TC 143 (2004), provides additional flexibility in determining the portion of fees deductible as IRC section 213 medical expenses. CPAs should take note of the ruling.

BACKGROUND

Delbert Baker and his wife had an agreement with Air Force Village West Inc. (AFVW), a California retirement community, entitling them to lifetime residency. AFVW provided four levels of living accommodations and service, ranging from independent living to skilled nursing care.

Mr. Baker was a member of an ad hoc committee of AFVW residents using certified financial data provided by the community’s vice president of finance; he used the information to determine that approximately 40% of the couple’s monthly fees was attributable to medical care. Thus, the Bakers deducted that percentage of their costs on their 1997 and 1998 returns.

On audit, the service disallowed a portion of the Bakers’ medical deductions. Using a percentage allocation method (consistent with previous rulings), the IRS permitted only 19.01% of the monthly fees as a medical deduction.

TAX COURT MODIFIES METHOD

At trial the IRS switched gears and claimed the allowable medical deduction, instead, had to be based on actuarial calculations, taking into consideration health care utilization and longevity. The Tax Court disagreed, calling the actuarial method “so complex as to defy full explanation.” It concluded the certified financial data the Bakers had produced was sufficient to shift the burden of proof to the service under ItLC section 7491. The court cited the IRS’s 35-year history of allowing use of the percentage method.

While the Tax Court approved use of the percentage allocation method, it modified the approach used by both parties. Instead of allowing a percentage of the fees each resident paid, it held that the percentage had to be based on the number of community residents and a weighted average of their monthly service fees. Otherwise, occupants of larger units would receive a higher deduction based solely on the higher fees charged for such units, without regard to occupancy.

The chart reproduced in figure 1 shows the number of charges that were posted daily during a 1-month period in a hypothetical practice. The spikes in the number of postings (vertical bars) are not ideal. In general, it is better to issue a steady number of charges throughout the month so that you will receive a steady influx of payments.

Reasonable explanations can be made for the inconsistent pattern of charges illustrated in figure 1–for example, higher surgical charges on certain days or time off from the office. However, if charges are being dumped intermittently because you are understaffed with regard to the number of personnel or their expertise, you might consider retaining a dedicated billing employee or outsourcing the process to a competent service bureau. In the latter case, billing functions are performed in an environment where employees are not helping care for patients or answering the phones at the same time.

The pattern of posted payments shown in figure 2 will often mirror that of the posted charges. Once again, it is better to have fewer spikes and more consistency. You should monitor the steadiness of your billing and payment postings to ensure that payments will be received in a timely manner. Also, a failure to post payments promptly will result in your practice mailing outinaccurate statements, which means that your staff will be inundated with unnecessary billing calls.

Your software should check to ensure that no data elements are missing from your claims submissions. It is not uncommon that claims filing is delayed or submissions are denied because the form does not include some minor piece of information (e.g., the referring provider’s name or some patient demographic information). (1)

The software program represented in the figure has identified several data elements that were not included in charges entered via a handheld electronic superbill device. (2) This workfile should be completed daily by the individual who is responsible for your practice’s billing. The software audits each claim, notes any missing data, and forwards the claim to the work file with an explanation of what is missing.

When a biller communicates missing data elements to the rest of the staff at staff meetings, the result is improved office efficiency. Gradually, the percentage of clean claims filings should improve until it is rare to see a claim held for submission because of the omission of a minor data element.

Being one of the larger and more reputable integrated delivery networks may lead some to believe The Cleveland Clinic Health System possesses an unfair advantage when it comes to achieving clinical, financial and operational efficiencies. Nothing could be further from the truth.

Some organizations, whether large or small, employ deft strategic analyses and simply make astute tactical decisions for their facilities that position them on the pathway to prosperity. You don’t need to be highly regarded or sizeable to do that. You just need to be flexible and resilient. You try something. If it works, then great. If it doesn’t, reassemble the pieces and try something else. Occasion ally, you’re ahead of available market developments and offerings and have to make do. Eventually, you achieve success.

That’s how The Cleveland Clinic Health System, an IDN comprising 11 hospitals and multiple non acute care facilities in the Cleveland, OH, metropolitan area and south Florida, emerged victorious over a number of prominent hospitals and IDNs and earned the title of 2005 Materials Management Department of the Year by Healthcare Purchasing News.

During the last five years the materials management department at The Cleveland Clinic generated more than $66 million in cost reductions through various techniques and technologies that leveraged its considerable investments in people, innovation and technology.

Working to streamline processes for its customers, including clinical end users and administrative back office staff members, the department not only has embraced information systems to automate functions and improve productivity, but also has mastered the delicate balance between relying on internal expertise and external sources. While some organizations can attribute much of their success to the efforts and recommendations of a consulting firm, GPO or supplier, if not a combination of all three, The Cleveland Clinic instead maintains more control over its destiny, tapping outside experts when it fulfills an internal purpose–essentially using them as a means to an end rather than the end itself.

“Nurse Gordon on Trial: Those Early Days of the Birth Control Clinic Movement Reconsidered”This essay concerns a woman by the name of Adele Gordon. Adele Gordon was a nurse who, during the 1930s, operated a commercially-sponsored birth control clinic in the city of Milwaukee and who, in 1935; was arrested and tried for precisely these activities. However, while her story is the guiding theme of this narrative, her life (as well as the lessons to be learned from the history of medicine) invites us to consider the larger world in which her work took place, in particular the early days of the birth control clinic movement. Indeed, what this essay asks us to imagine is the presence of what I call the Irregular birth control clinic movement, a movement of clinics which continued to embody the supposedly lost radicalism of Margaret Sanger in the teens. And this Irregular clinic movement, in turn, invites us to re-think the efforts of the American Birth Control League in its quest for professionalization and the backing of the American Medical Association. Hence Nurse Gordon’s story is an important one in part, because she is an intriguing individual who embodied an uncommon sense of modesty and determination, dignity and pride. But also because Nurse Gordon offers us a new way to tell the story of twentieth-century birth control, encouraging us to appreciate the breadth of the birth control clinic movement, the malleability of the birth control institution, and the American Birth Control League’s efforts to contain them both.

INTRODUCTION

Contingency management interventions are based on a robust basic science literature supporting a position that drug use is a form of operant behavior (1, 2). As such, the probability of using drugs should be influenced by the environmental context in which drug use occurs. More specifically, the availability of alternative nondrug reinforcers should decrease use if they are available in sufficient magnitude and according to a schedule that is incompatible with drug use (3-5). These observations form the conceptual basis for the contingency management approaches to drug abuse treatment, which have proven effective at initiating periods of abstinence (6).

One commonly used type of contingency management intervention was popularized by Higgins and colleagues (7-9). In this procedure, patients receive “vouchers” for the provision of biological samples (urine or breath) that indicate no recent drug use. Hence, the procedure is often called Voucher Based Reinforcement Therapy (VBRT). These vouchers are withheld when the biological sample indicates recent drug use. Once earned, vouchers are exchanged for goods or services that are compatible with the development of a drug-free lifestyle.

VBRT has proved to be successful at initiating periods of abstinence compared to standard treatment regimens (10) and has produced relatively long periods of abstinence (11-13). Most individuals achieve some period of sobriety with this approach.

Just a few weeks after MinuteClinic unveiled plans to ramp up expansion on the East Coast, a brand-new, start-up called Wellness Express opened its first outlet last month at a Longs Drug store here. The company has two more clinics set to open this month and hopes to expand with Longs and other retailers on the West Coast.The Wellness Express Clinic operates along the same lines as MinuteClinic, with a limited menu of services focused on common ailments like bronchitis and strep throat that can be diagnosed easily and treated with antibiotics. The idea is to give people a quick and convenient alternative to an emergency room or urgent care visit.

“We didn’t invent this idea; it’s been around for a while with MinuteClinic,” Wellness Express president Wesley Chan, M.D., who heads a team of physicians behind the venture, told Drug Store News at the Wellness Express Clinic’s April 19 grand opening event. “We just thought it was time to bring the concept to California.”

The glassed-in clinic occupies about 200 square feet at the back of the store and consists of a waiting room and exam room. A list of prices and services hangs on the wall, and appointments aren’t necessary. Clinics are staffed by a nurse practitioner or a physician’s assistant licensed to write prescriptions, and the average visit takes about 15 minutes. The clinics also provide screenings for common ailments like high cholesterol and diabetes.

The quick turnover is attributed to the restricted menu of services–anyone with a serious ailment outside the Wellness Express Clinic’s scope is referred to a doctor–and the fact that clinics don’t deal with insurance. “We don’t bill insurance companies, but we provide patients with the paperwork,” Chan explained.

Chan said the company chose the Sacramento suburb of Davis for its first clinic because of the demographics. “There are plenty of students and young families and a lot more, people without insurance than you would think, he said.

By the end of this month, Wellness Express is slated to have two more clinics open at Longs Drug stores in the cities of Sonoma and Salinas. Company chief executive officer Paul Kaufmann said he hopes to open more clinics with Longs, but doesn’t have an exclusive contract with the 470-store chain. The company is currently in discussions with other chains and “some big-box retailers,” he said.

IN A SMALL town, they say, everyone knows your business. A county judge in Iowa is pushing that tendency to an extreme by requisitioning medical information from a local women’s health clinic.

The trouble in Storm Lake, a town of about 10,000 in Buena Vista County, started in late May when an abandoned newborn, possibly born prematurely, was left for dead in a local recycling center. With the police department at a loss for leads, County Attorney Phil Havens sought access to the names and address of every woman who took a pregnancy test at the town’s Planned Parenthood clinic during a nine-month period. Once authorities had the names, they would check that each woman gave birth to a living infant; when this wasn’t possible, they’d question the mothers.

After some legal back and forth between Planned Parenthood and the courts, Judge Frank Nelson ordered the clinic to hand over the information by August 17 or risk being charged with contempt. Jill June, the president of Planned Parenthood of Greater Iowa, refuses to compromise her patients’ privacy. “What they’ve asked us to do is wrong;’ she says. “It violates the laws of Iowa, it violates the confidentiality and trust these women place in us. As much as we’d like to help with the investigation, we simply cannot cooperate.”

Havens, the county attorney, who did not return calls for comment, argues that pregnancy test information is not protected by doctor-patient privilege laws because the test could be performed and interpreted by non-medical personnel. But Judge Nelson took a slightly different tack, according to Randall Wilson, legal director of the local American Civil Liberties Union. In response to Planned Parenthood’s assertion of doctor-patient privilege, “he cited a case suggesting that privilege only applies when you’re in court.”

Wilson is concerned about the precedent that would be set if the judge’s order stands. “It would say that anytime officials want to go on a fishing expedition in medical records, on a hunch or just because under the law of percentages it might sometimes result in finding evidence, they can;’ he says. “It would basically wipe out any expectation of privacy in medical records.”

West Salem officials said Tueusday they were disappointed the village will lose its medical facility when Franciscan Skemp Healthcare opens its new Onalaska clinic in 2006.Franciscan Skemp plans to close the site in downtown West Salem after it completes the new $11 million clinic at Theater Road and Hwy. OS in Onalaska in mid-2006. West Salem clinic physicians would be shifted to Onalaska.

Teresa Schnitzler, West Salem village administrator, said it will be a major loss for the community.

“The loss I feel is going to be for the elderly,” Schnitzler said. “Basically, we’re looking at more of a drive. To me, it’s a loss of convenience.”

But Schnitzler said she understood the reasons behind the decision. “When you need a test, you get sent to LaCrosse because they don’t have room for the equipment. With the consolidation, they’ll have all that equipment on site.”

Cheryl Brenengen, a business owner and member of West Salem’s downtown revitalization organization The Village People, said she, too, was disappointed to hear the clinic will be closed.

“I understand St. Francis is doing what they must to continue their pursuit of excellence in health care, but I think if they totally move the clinic from West Salem, it’ll be a big loss,” Brenengen said, News of the move hit West Salem Trustee Diana Engel especially hard because her husband, Dr. Charles Engel, practiced at the clinic for nearly 35 years.

“I’m just sick about it,” Engel said. “Think of all the people around that are going to be affected by it, like the elderly. It’s just so easy to get there.”

“It’s the way things are evolving,” Engel said. “We had the old doctors who made house calls, then we had the clinics and now we’re going to regional centers. it’s evolution - it’s the next stage. You have to have the big equipment, and you can’t get it in the little clinic here.”

Four family practice physicians and a certified nursemidwife now work at the West Salem clinic. The clinic building is outdated and can’t be expanded, said Dr. Joseph Krien, a family physician at the West Salem clinic.

”They (patients) will have specialty care closer to home, but they can still see me and other West Salem family practice physicians,” Krien said. “It’s easy access for West Salem patients. Many of them don’t mind driving to Onalaska for their shopping.”