St. Louis Medical News July 2014

s t l o u i s m e d i c a l n e w s . c o m JULY 2014 > 1

Keith Mankowitz, MD

ON ROUNDS

Building Up a Medical CityHospitals and health systems keep construction dust whirling

On June 19, Mercy offi cials will break ground on the Mercy Medical Building, an $8 million capital improvement project on an 8-acre campus at South Service Road West near Mattox Drive in Sullivan ... 5

Raising Millions through Laughter and TearsMartin Short headlined gala benefi ting cancer research at Siteman Cancer Center

Cancer got personal at The Foundation for Barnes-Jewish Hospital’s annual illumination-gala on April 26 ... 9

December 2009 >> $5

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By LyNNE JETER

A healthy medical market is often re-fl ected in new construction taking place. Healthcare construction activity isn’t hav-ing an impact – yet – on medical offi ce properties in the St. Louis metro area, but signs are promising.

BJC HealthCare is preparing to build new towers on the North Campus and Children’s Hospital, both scheduled to open in 2018, as part of the $1 billion planned renovations to the Kingshighway campus over the next decade. The health-care system is also planning to add a second building to its Alvin J. Site-man Cancer Center.

Outside St. Louis yet with local ties, Catholic Health Initiatives (CHI), an

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(CONTINUED ON PAGE 8)

By LyNNE JETER

“When you walk in to a new situation like this, it’s like drinking water from a fi re hose.” – Bev-erly Bokovitz, MSN, RN, Offi ce of the President, St. Anthony’s, St. Louis.

SOUTH ST. LOUIS COUNTY – Beverly Bokovitz’s fi rst day on the job as CNO for St. Anthony’s was in the midst of a blizzard she jokingly refers to as “snow-mageddon.”

“It was brutal; it was wild,” said Bokovitz, MSN, RN. “I really walked into the fi re. Actually, it was a great way to come into the organization because I really got to see it under stress. Everyone

Leading St. Anthony’s with a Servant’s HeartBeverly Bokovitz, CNO, promoted to Offi ce of the President


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By LUCy SCHULTZE

When someone looks young, fit and healthy, it seems unthinkable that they might be at risk for sudden death from a heart condition.

Yet for Keith Mankowitz, MD, the hidden threat that hypertrophic cardio-myopathy can pose has earned a special focus within his cardiology career.

“Just knowing that about 70 young athletes die every year is very concern-ing,” said Mankowitz, director of the Hy-pertropic Cardiomyopathy Center at St. Luke’s Hospital.

A longtime former member of the medical faculty at Washington University School of Medicine, Mankowitz has de-voted time to offer screenings for young athletes and lectures for parents, coaches and fellow physicians.

“I’m an athlete myself, and I was a coach for my kids,” Mankowitz said. “I was really aware of any potential prob-lem that anyone could have and wanted to make sure I became familiar with the condition — and help others become fa-miliar as well.”

That special interest fits within the broader practice Mankowitz brought to St. Luke’s when he joined the hospital in February. The transition has been a smooth one, with Mankowitz joining his former Wash U colleague Craig Reiss, MD, who had made the move in July 2013.

“I was happy at Wash U, and had this opportunity to practice in the beau-tiful outpatient setting at St. Luke’s, with excellent support staff and a colleague I have tremendous respect for,” Mankowitz said. “We have all the technology we need to provide state-of-the-art medicine in this wonderful, friendly setting.”

Mankowitz and Reiss practice as Heart Health Specialists LLC. Their of-fice is located on St. Luke’s Hospital’s campus in the Mr. and Mrs. Theodore P. Desloge Jr. Outpatient Center.

Mankowitz is a member of the Amer-ican College of Cardiology and has been recognized among the “Best Doctors” in St. Louis from 2006-13. He is board certi-fied in cardiology and internal medicine.

A native of South Africa, he holds a medical degree from the University of the Witwatersrand in Johannesburg. He came to the United States in 1989 and completed his residency and fellowship at Wash U, where he joined the faculty in 1996.

His interest in medicine stretches back as far as primary school, when the anatomy and physiology of the body — and especially the workings of the heart — began to fascinate him.

“Cardiology is like a puzzle,” he said. “The patient presents you with various complaints. You examine the body and

put together the findings, and you work out what’s going on.

“Every patient is a challenge, and it’s very stimulating. They are all different, and it’s very rewarding to make the right diagnosis and provide them with the right treatment.

“To see them back so much better — that’s the best part.”

Among his patients, most are treated for issues that can be managed with medi-cations. When the current guidelines in-dicate an angioplasty, bypass or other invasive procedure is in order, he handles referrals to invasive cardiologists and car-

diothoracic surgeons.“I’m the gatekeeper and make sure

they get the right treatment,” Mankowitz said. “It’s my goal that our patients re-ceive state-of-the-art care, so I make sure to send them to the best person in the area for the care they need.”

That role is made easier by the access to swift care that Americans enjoy, he said.

“This is an excellent medical system,” he said. “Patients have wide-open access to doctors and procedures, and not having to wait for procedures is very important.

“It’s hard to imagine that, in places like Europe, England and Canada, you might have to wait several months for something like a bypass.”

At St. Luke’s, Mankowitz’s practice leans more toward outpatient than inpa-tient care, but the teaching aspect he en-joyed at Wash U will continue.

“I have a residency program here and will be involved in that,” he said. “That’s very stimulating for me as well.”

In his work in the area of hypertro-phic cardiomyopathy, Mankowitz has focused on screening young athletes. The condition involves a thickening of the heart muscle, which forces the heart to work harder to pump blood.

Since many patients have no symp-toms, the condition can go undetected until, during an athletic event or strenuous exercise, a severe arrhythmia causes sud-den collapse or death. Hypertrophic car-

diomyopathy can be managed medically or, in some cases, with a pacemaker or im-planted defibrillator — if only the young athletes who have it can be identified.

“What I’ve done in the past and what I want to continue doing is to provide these screening programs,” Mankowitz said. “In them, we take their history, per-form a physical exam, ECG and echo, so that we can make sure they don’t have anything that can cause harm to them. Screenings for athletes over the age of 40 will also include an exercise stress test.”

While Mankowitz has been able to provide some free screenings in his past position, he is currently available to see teams or individuals on a fee-for-service basis.

“If patients cannot afford it, we’ll make a plan,” he said. “It’s important to make sure these young kids are appropri-ately evaluated.”

Mankowitz’s own experience as a young athlete back in South Africa in-cludes playing soccer, rugby and cricket as well as competitive swimming. Today, at 50, he runs nearly every day, plays soccer once a week and swims regularly.

“I’m very passionate about my sports and want to continue doing them,” he said.

Otherwise, his off hours are focused on his family. He and his wife, Janice, have four children: Ari, 23; Gabriella, 21; Eytan, 18; and Talya, 13.

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rose to the occasion beautifully.”On July 1, Bokovitz added a new post

to her plate when she was elevated to St. Anthony’s Office of the President.

“Bev has done a stellar job revitalizing our nursing department,” said St. Anthony’s CEO Michael Rindler. “Her promotion is affirmation of the importance of clinical leaders leading the new St. Anthony’s and recognition of the profound importance of nursing in our future development.”

Bokovitz replaced Jack Mitstifer, MD, who moved into the role of senior advi-sor. “Jack’s leadership was instrumental in transforming our Emergency Department,” said Rindler, adding that St. Anthony’s would “further benefit from his expertise as we continue to improve our emergency services.”

The first-of-its-kind Office of the Presi-dent leadership model in St. Louis has four members: Rindler, Bokovitz, CMO David Morton, MD, and Christopher Bowe, MD, president of St. Anthony’s Physician Orga-nization. As a team, they operate the 767-bed comprehensive healthcare complex, Level Two trauma center and four urgent care clinics to serve residents in nine Mis-souri and Illinois counties centered on St. Louis.

“The biggest challenge in the first six months, as in any new role, was getting to know everyone,” she said. “When you come into a new role like this, you want to be there for everyone. I’m a people person. My challenge was finding time to meet ev-eryone’s needs and develop relationships.”

Bokovitz tempered the high adrenaline rush of the challenge by practicing patience.

“It takes a little bit of time,” she said. “You have to step back a little bit. But when you walk in to a new situation like this, it’s like drinking water from a fire hose.”

Rising to the Top Bokovitz didn’t take the traditional

path to healthcare executive. In fact, grow-ing up, she dreamed of being a broadcaster. Bypassing college to get married and start a family, she didn’t consider a nursing career until she worked as a nurse’s assistant when her children were very young.

“I fell in love with the profession and pursued a nursing degree to be an RN,” she said.

Bokovitz didn’t consider medical school because “I didn’t see it as anything I necessarily had a draw for,” she said. “Nursing touched my heart. I really love taking care of patients. Then once I got into management and leadership, I loved that, too.”

Her first job was cardiac nurse at the Cleveland Clinic in Ohio. Soon after join-ing, clinic administrators noticed leadership traits in Bokovitz that she didn’t even no-tice.

“It was pointed out to me to consider becoming an assistant nurse manager,” she said. “I’ve been very lucky in that every role, I’ve gotten a promotion and been able to take advantage of additional leadership opportunities. Sometimes, you’re lucky enough to gravitate to a field where you feel needed and valued. Being a nursing leader and hospital administrator has really

worked well for me.” Bokovitz also focused on educa-

tion past a nursing degree earned from Cuyahoga Community College. She earned a master’s degree in nursing from Case Western Reserve University as an adult and geriatric nurse practitioner, and is working on her doctorate in nursing leadership from Waynesburg University, which she anticipates completing by year’s end.

A valuable in-between post to facilitate well-rounded skills as a C-suite leader, she served as COO/CNO of Affinity Medical Center in Massillon, Ohio.

“I really enjoyed the COO role,” she said. “There was a challenge to it, and I like challenges. I worked with all departments, including IT, human resources, security, and a whole range of hospital operations. The role was invaluable to my growth. As a result, I’m more strategic with a better global view.”

Immediately before joining St. An-thony’s, Bokovitz served as senior vice president and CNO from 2007 to 2013 for the Akron General Health System in Akron, Ohio. Under her leadership, Akron General’s nursing division earned Magnet Status in 2013 from the American Nurses Credentialing Center.

Fresh InitiativesIn mid-spring, St. Anthony’s rolled out

the American Nurses Association-sponsored DAISY Award Program to reward and cel-ebrate the extraordinary clinical skills and compassionate care given by nurses.

“We thought we might have two or three nominations,” said Bokovitz. “We had 78! I was floored! Patients want to talk about the people who provide such good care. The letters were so heartfelt; it was amazing.”

DAISY winner Allyson Anderson re-ceived this nomination from a patient: “Al-lyson listened to everything I said and never left me in pain. She had an awesome bed-side manner and calmed me down when the pain or anxiety was too much. She was also great with my husband and children, and gave the children games to occupy themselves while she took care of me. My children wanted to stay with her! Seriously, she deserves a lot of recognition and did an amazing job! In every aspect, she always had time for the patient – me!”

Bokovitz also championed the hospi-tal’s successful hand hygiene program with a high priority on improving quality and reducing the risk of passing on infections to patients.

For the fiscal year beginning July 1, the leadership team is focusing on integra-tion into the Office of the President, along with strategic goals that involve focusing resources on cardiovascular and other ser-vices lines, managing costs, and maximizing revenue.

“My passion has always been meet-ing the needs of the community,” she said. “We’re responding right now to family-cen-tered group feedback related to issues from education to presence in the community, to hospital direction and room for improve-ment. It’s going to be a great year.”

Leading St. Anthony’s, continued from page 1

By LAUREN SULLIVAN

It’s 2 pm on a Tuesday and you’ve just finished seeing a pa-tient. As you head to your next appointment a member of your staff hands you a notice letter. This letter indicates that a patient of yours has sought legal advice and his attorney is notifying you of the intent to bring suit. Your mind is rac-ing. Which patient was he? What was the diagnosis? What tests were done? What were his follow up appointments like? Where is his file? What are my next steps? This could cost me my practice. However, I have a patient right now and these questions can be answered later.

When a physician is faced with a medical malpractice claim the repercus-sions can be emotionally, physically, men-tally, and financially depleting. Being prepared for such an instance will not eliminate all of these factors. But, there are steps one can take to ensure their own protection should such an event arise.

Upon the arrival of said letter, one should contact their medical malprac-tice insurance company and forward any documentation on hand. It is natural to replay the surgery or visit in your head, but it is important not to discuss the po-

tential claim with members of the staff or those that were present

during the “situation.” Shall a lawsuit come to fruition

these conversations will most likely be

recounted and typically reflect poorly upon the physician.

In addition, it is imperative that

the patient’s records are not modified and it will only hurt a doctor’s

defense if this oc-curs. This file should

be kept in a safe spot and remain un-tampered.

A patient’s file, even more so the physician’s notes

within this file, become incredibly vital when a potential claim arises. Documen-tation can be overlooked, but its impor-tance cannot be overstated in the context of a procedure that involves others. Fol-lowing a procedure or examination, im-mediately dictate notes on actions made, issues that occur, and anything observed. These transcripts are far more accurate than attempting to recall a situation. The statute of limitations is typically two years in most states. Although, the discovery of the injury or if the patient was a minor can be a major dynamic in affecting the stan-dard two year limitation. Any confusion over a physician’s actions reflects poorly in a case. Note taking can be tedious, but it can mean the difference between winning and losing a suit.

Should there be an occasion in which you feel that an error is being made, speak up. Being silent will put you on the de-fensive later. While an operating room may not be the most ideal place for such a discussion any reservations had during a procedure must be expressed. Do not hesitate to appropriately resolve a possible issue right then and there.

Being prepared for a possible claim and taking the right steps prior will only reduce the chances of a negative outcome. Documenting what you do and remaining pro-active will allow you to avoid the ex-pense, the emotional drain, and the set-back in your professional life. Defending yourself can be grueling, but with the right tools the outcome can be favorable.

Lauren Sullivan is a Marketing Associate for Galen Insurance Company. Galen provides medical malpractice insurance for physicians and ancillary. She can be reached at [email protected]

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By LyNNE JETER

On June 19, Mercy officials will break ground on the Mercy Medical Building, an $8 million capital improvement project on an 8-acre campus at South Service Road West near Mattox Drive in Sullivan. The 19,800-square-foot building, with clinic and outpatient hospital departments, will feature 10 physicians’ offices and services for X-rays, ultrasound, blood and other medical testing. When completed in 2015, the new facility will serve Sullivan and the surrounding communities. (See “Building the Nation’s First Virtual Care Center” in this edition about Mercy’s most high-profile construction project.)

SLCHThe $1.4 million renovation of St.

Louis Children’s Hospital (SLCH) he-matology and oncology clinic adds infu-sion, isolation and exam rooms. SLCH president Joan Magruder is spearheading construction activity at one of the area’s largest hospitals, producing $459 million in revenue in 2012. McGrath & Associ-ates, general contractor and construction manager of the 6,177-square foot project, slated for completion this summer, is im-plementing a “multifaceted infection con-tainment program” during the renovation because bone marrow transplant patients are vulnerable for infections because of their already- compromised immune sys-tems. Also in the mix: HEPA filtration, an-terooms, dedicated elevators, and cleaning and wrapping of construction material and debris. Another challenge: renovating the bone marrow transplant suite adjacent to an active sleep lab. McGrath is collabo-rating with Simms Building Group of St. Louis on the project, with the Lawrence Group as the architect.

St. Luke’s Hospital St. Luke’s Hospital has several con-

struction projects underway to provide enhancements to high-level patient care, said Don Miller, St. Luke’s vice president of operations.

“We’re in the process of a three-year lab/surgery remodel that includes reno-vating the entire second floor of its West Medical Office Building and part of the second floor of its main hospital building to create efficiencies through better loca-tion of services and to improve clinical quality with technology enhancements and redesigned clinician workspace,” he said. “The project includes enhancements to our operating room suites; relocation and expansion of lab services; enhance-ments to existing and additional same-day surgery patient rooms for pre/post-opera-tion recovery immediately adjacent to the operating rooms; and a new waiting area for families immediately adjacent to the pre/post-operation patient rooms. The construction is happening in phases to en-sure no interruption in patient services.”

At St. Luke’s Women’s Center, the first phase of the recently renovated cen-ter on the hospital campus, is finished and now open to patients.

“Specifically, it’s located on the sec-ond floor of St. Luke’s East Medical Of-fice Building,” explained Miller. “The final phase will be complete in early Au-gust. The renovated center enhances the experience for patients, providing greater

convenience and comfort. In addition to its mammography services, the center also offers centralized breast ultrasound, SonoCiné, stereotactic core biopsies and a high-risk breast clinic.”

About half of St. Luke’s Birth Care Suites and the nursery have recently been renovated, Miller said, noting that “other suites and the waiting area are currently undergoing renovation.”

Des Peres HospitalDes Peres Hospital in St. Louis, a

Tenet Health property, doesn’t have con-struction plans in the works at this time, according to spokesperson Simone Valle. Neither does St. Anthony’s Medical Cen-ter in St. Louis, noted spokesperson Joe Poelker.

Building Up a Medical CityHospitals and health systems whirling up construction dust

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By LyNNE JETER

At SSM Cardinal Glennon Chil-dren’s Health Center, the Bob Costas Cancer Center has been transformed into a colorful underwater world. Faith the Turtle guides families through the experi-ence, which features a 23-foot submarine, bubble walls, coral fields and tropical fish. “It takes patience to move through cancer treatment, and Faith is the embodiment of patience and the manner in which we approach the care of our cancer patients – through faith and compassion and ex-cellent care,” said a hospital spokesper-son. “These latest renovations were made possible through the generous donations from individuals and grateful families to the Costas Center.”

Last fall, SSM Cardinal Glennon Children’s Medical Center opened the Rally Squirrel Treehouse in the Level 1 Dan Dierdorf Emergency and Pediatric Trauma Center. The hospital mascot, Rally, guides families through the safety tree house, which provides tools like the Rally Theater to educate families about environmental safety, home safety, di-saster preparedness and sports safety to decrease the risk of injuries to children. It also offers digital custom home safety evaluations to families visiting the medical center. Many donors facilitated the cre-ation of the Rally Squirrel Tree House, including Robert Smith, the Arthur and Helen Baer Foundation, Board of Gov-ernors members Dan Dierdorf and Chris Pronger, and The Bodley Group through the Dierdorf Pronger Golf Classic. Tivoli-Too of St. Paul, Minn., designed the tree house.

SSM St. Joseph Hospital West is in the midst of the first phase of a $15 mil-lion capital improvement project, which

has several components under Koenig Building Construction to expand the SSM Medical Group practice to promote physi-cian growth for primary care services in the community. Specifics include increas-ing the number of beds that can be moni-tored with telemetry cardiac monitoring, allowing the ability for “telemetry every-where,” construction of a new second C-section operating room (OR) and reno-vation of the existing C-section OR, which at should be completed.

Construction is near completion of new dietary kitchen space in the lower, Lakeview level of the hospital. Previously, this space had been shelled and held for this expansion.

Construction of the core and shell space for the hospital’s Outpatient Diag-nostic Testing Center and Laboratory, which will result in a new two-story ex-panded outpatient testing services and laboratory, is being built in an existing courtyard located in the heart of the hos-pital.

Renovation of the existing firehouse, purchased several years ago by SJHW, is being comleted for MFP project team use during construction periods.

Miscellaneous lower Lakeview level projects include the renovation and re-location of existing support spaces to en-hance support capabilities.

Construction activity at St. Mary’s Health Center is focusing on improving all aspects of a woman’s well-being, including the new Rosetta Boyce Kyles Women’s Pavilion. “Women’s health historically has progressed from a focus on the conditions related to the female reproductive tract to now include the diverse set of conditions that affect women differently, such as dia-betes, obesity, depression, heart disease, osteoporosis, breast disease, cancer and dermatologic conditions,” saidi a hospital spokesperson. “The new pavilion will be located on the fifth and sixth floors of SSM St. Mary’s. Plans for the new pavilion are yet to be finalized.”

At SSM DePaul Health Center, SSM Behavioral Health is renovating five be-havioral health units – three adult units, an adolescent unit and a children’s unit. This renovation includes upgrading the existing infrastructure of approximately 40,000 square feet of space, and remod-eling the area to enhance the therapeutic environment for patients. The project

should be finished next spring. In addition, a unit in the emergency

department is being renovated to provide a specialized center dedicated to behav-ioral health assessments and behavioral health patients. This new space will be complete by fall 2014.

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Cox Medical CenterAcross the state, of some importance

to local physicians is the April 24 topping out ceremony of Cox Medical Center Branson, a 60,000-square-foot project of Springfield-based, not-for-profit Cox-Health that should open by year’s end with a new emergency department (ED) and expanded coronary care unit (CCU). The existing ED serves 37,000 annually; the new, larger ED will serve up to 60,000 patients every year. The expanded CCU, with 20 private rooms, will be located on the second floor of the new three-story fa-cility, replacing the existing 14-bed unit.

To make room for the renovation/expansion, the Medical Plaza Two build-ing was demolished.

“This project … is a statement of sta-bility and confidence in our community,” said William Mahoney, president and CEO of Cox Medical Center Branson.

Construction managers, Beck Group, provided architectural support.

Los Angeles-based CBRE Group (NYSE: CBG) is also heavily invested in the Cox project, providing launch gap analysis, facilities planning, project work review and validation, and master pro-gram schedule and budget development and maintenance services. The firm also submitted the certificate-of-need (CON) application, selected the project delivery team, project staffing plan, and project implementation plan development in-volvement.

“The impact of this project is far-reaching,” said CBRE Healthcare man-aging director Steve Higgs. “Assisting in delivering superior care to the community is our main focus and ultimate goal.”

Building Up a Medical City, continued from page 5


On May 13, Mercy officials broke ground on the nation’s first virtual care center, marking another milestone in its pledge to transform healthcare.

“Telemedicine lets us provide the best possible care to people where and when they need it – even when patients wouldn’t otherwise have access to specialists, such as neurologists and pediatric cardiologists,” said Mercy CEO Lynn Britton. “The center will bring together the nation’s best telehealth professionals to reach more pa-tients, develop more telemedicine services and improve how we deliver virtual care through education and innovation.”

The four-story, 120,000-square-foot center located in Chesterfield will open next year. It will accommodate nearly 300 physicians, nurses, specialists, research-ers and support staff, delivering round-the-clock care via audio, video and data connections to locations across Mercy and outside of Mercy through partnerships with other healthcare providers and large employers. Mercy estimates the center will manage more than 3 million telehealth vis-its in the next five years. The center also will be a hub for advancing telemedicine through research and training.

“There’s a decreasing number of phy-sicians in both rural and urban areas, while at the same time there’s a growing senior population that will require more care,” said Tom Hale, MD, executive medical di-rector of Mercy’s telehealth services. “Tele-medicine will have a significant impact by letting virtual physicians and nurses be the first point of triage and care for patients in the hospital, emergency room or even at home. Mercy’s virtual care frees up physi-cians while also attending to patients faster than before, and our specialists bring a level of expertise that would be impossible to share without telemedicine.”

Representing an investment of ap-proximately $50 million, the new facil-ity will serve as the command center for all of Mercy’s telemedicine programs – a growing list that includes the nation’s larg-est single-hub electronic ICU (eICU) and features more than 75 other services, in-cluding:

SafeWatch eICU. Using in-room, two-way audio, video and computer con-nections, Mercy doctors and nurses pro-vide constant monitoring of a hospital’s ICU patients. These critical-care special-ists use high-tech tools to identify abnor-malities, uncover potential problems and assist with care when a patient’s attending physician isn’t present in the ICU.

Telestroke. Many community emergency rooms across the country don’t have a neurologist on hand. With Mercy’s telestroke program, patients who come to the ER with symptoms of a stroke can be seen immediately by not only an emer-gency room doctor, but also by on-call

telestroke neurologists to help diagnose the patient and order lifesaving stroke medica-tion if necessary.

Pediatric Telecardiology. In re-cent years, due to the lack of technology and distance of patients to a Mercy facility, it sometimes required a week or more to get results of an echocardiogram. A virtual pediatric cardiology team minimizes turn-around time for patients, producing results

in 24 hours or less. Telesepsis. Mercy’s electronic

health record automatically searches for more than 800 warning signs to identify patients at risk for sepsis and alerts doc-tors, so they can move aggressively to pre-vent it.

Teleradiology. A remote radiology medical team provides nonstop support to radiology groups to minimize turnaround

times for patients and maximize produc-tivity.

Telepathology. Available at all hours, an online pathology medical team will quickly provide general and specific diagnostic services.

Nurse-on-call. Experienced regis-tered nurses provide 24/7 health advice with this nationwide telephone triage ser-vice.

Home Monitoring. Mercy pro-vides continuous monitoring for more than 1,000 patients diagnosed with congestive heart failure, therefore reducing hospital-ization and readmissions and helping them live longer independently.

“With a decade of telemedicine experi-ence behind us, Mercy is now a recognized leader in this vital health care field,” said Britton. “We’ve pioneered a telehealth plan that no longer limits advanced care because of age, illness or geography. We can deliver a higher level of care to more people, and the virtual care center is at the heart of it – providing care for today while also devel-oping the health care of tomorrow.”

Crafting the Nation’s First Virtual Care CenterNew center helps Mercy expand access to healthcare for patients everywhere


PRoVIdEd By CHARLES GRBCICH

When it comes to managing the wealth you’ve accumulated in any one stock, have you ever asked yourself, “How much is too much?” Holding a large position in one stock generally increases your risk level compared to a well-diversified portfolio. (Keep in mind, however, that diversifica-tion cannot eliminate the risk of fluctuating prices and/or uncertain returns.)

An investor with a significant portion of his or her wealth in one stock may have accumulated that concentrated position in a number of ways, such as:

• Equity compensation, including stock options and restricted stock

• Building sizable positions of com-pany stock in an employer-sponsored re-tirement plan

• Being a corporate insider and subject to further “windows” or restrictions to fol-low upon sale of the stock

• Selling a business and receiving stock in a publicly-traded company in return

• Inheriting sizable stock positions built over multiple generations

If you find yourself in a situation where you need to increase cash flow, reduce your portfolio’s risk profile by diversifying your investments, or reduce adverse income and estate tax consequences, your Financial Advisor can help you sort through your circumstances and work with your tax and legal advisors toward your objectives. The following descriptions give an overview of several alternatives you may want to con-sider for managing your concentrated eq-uity position.

Gradually selling and reposi-tioning. Sometimes the simplest strategy can be the most appropriate. You can grad-ually sell shares and reinvest the proceeds into investments that may better meet your changing needs. By selling over time, you can spread your gain (and corresponding tax liability) over time, perhaps several tax years (discuss this with your tax advisor). Not only can this strategy help you diver-sify your portfolio and maintain full control of after-tax proceeds, it can also help you

retain control of your financial situation, stopping and starting the sale of shares as needed. This gives you the chance to re-invest proceeds over time, adjusting your investment selections as appropriate.

You may want to combine this basic strategy with more advanced strategies, such as hedging or establishing a charitable remainder trust. (Note: if you are a cor-porate insider or manager, your company’s policies may not allow certain hedging or options-based strategies. Be sure to check with corporate counsel before embarking on any of these alternatives.)

Estate planning and charitable techniques. Many individuals with sub-stantial positions in one stock look for strat-egies that can help reduce overall income and estate tax liabilities and achieve philan-thropic goals. There are charitable giving strategies that can provide you a current income tax deduction, a continuing source of income for you, and a way to potentially avoid paying current capital gains tax on appreciated assets. Some strategies also can help shield the donated assets from estate taxes. And when you consider current in-

come tax rates and estate tax rates, you and your heirs may benefit substantially from these techniques.

Borrowing against your stock. This alternative helps you generate cash without selling your stock and avoids gen-erating a current tax liability. You diversify your portfolio by purchasing other stocks with the loan proceeds. When you borrow on “margin,” or use your stock as collateral, you can often borrow 50% (and in some cases more) of your position’s market value at competitive interest rates as long as the stock meets certain minimum qualifications.

Margin borrowing involves a high degree of risk and may not be suitable for all investors. With this strategy you must maintain a minimum amount of equity in your margin account. Market conditions can magnify any potential for loss. If your collateral stock’s price drops, you may re-ceive a margin call, which means you will be obligated to bring your account into bal-ance by depositing cash or other stocks im-mediately. Otherwise, you may be forced to liquidate all or a portion of your position.

Understand your alternatives.

When it comes to managing the wealth you’ve accumulated in one stock, you need to understand the suitability of each alterna-tive in relationship to your individual cir-cumstances. In fact, one or more of these alternatives may be inappropriate for your situation. The appropriateness of certain al-ternatives also depends on market behavior and the availability of particular contracts, stocks or products. Your Financial Advisor, working with your tax and legal advisors, can help evaluate these and other strategies.

This article was written by Wells Fargo Advisors and provided courtesy of Charles Grbcich First Vice President-Investment Officer in Chesterfield, MO at [email protected].

Wells Fargo Advisors does not provide legal or tax advice. Be sure to consult with your tax and legal advisors before taking any action that could have tax consequences. Any estate plan should be reviewed by an attorney who specializes in estate planning and is licensed to practice law in your state.

Trust services available through banking and trust affiliates in addition to non-affiliated companies of Wells Fargo Advisors.

Wells Fargo Advisors, LLC, Member SIPC, is a registered broker-dealer and a separate non-bank affiliate of Wells Fargo & Company.

©2013 Wells Fargo Advisors, LLC. All rights reserved.

Alternatives to Help Meet Your Investment Goals

Englewood, Colorado-based, non-profit health system, and affiliate St. Vincent Health System (SVHS), based in Little Rock, Ark., are acquiring Mercy’s Hospi-tal in Hot Springs, Ark. Chesterfield-based Mercy, led by CEO Lynn Britton, reports annual revenues of roughly $4 billion.

Also, Memorial Hospital-East is con-structing its new 207,000-square-foot, 94-bed full-service hospital Shiloh, Ill.

“There’s not been much change from 2013 yet this year,” said Anne Dulle, who authored the healthcare and office market overview of real estate services for CBRE in St. Louis.

Analyzing the first-quarter 2014 (1Q14) information on a Metro Area basis:

Class A properties account for only 21 percent of the total market. With one exception, Class A properties are roughly

89 percent occupied, with an average rate of $24.06 per square foot.

Class B properties account for the majority of the market – 77 percent – and remain approximately 85 percent occupied, with an average asking rate of $19.46 per square foot, or 20 percent less than Class A space.

Class C properties account for a very small percentage of the market and are 84 percent occupied with a 10 percent lower rate than Class B space.

“Relatively speaking, the rates and vacancy continue to fluctuate ever so slightly from year to year,” said Dulle.

According to CBRE, the vacancy rate for medical office properties in the St. Louis metro area was 16.1 percent for 1Q14, basing trends on building with a square footage of 10,000 square feet or larger. That number accounts for approxi-mately 87 buliding totaling some 4 million square feet of rentable building space.

“The overall vacancy rate includes sublease space on the market, which makes up a very small percentage of the overall market,” explained Dulle.

The average direct asking rate for medical/office space is $21.50 per square foot; pure medical rents average $22.06 per square foot.

“Full service gross represents a slight decrease over the previous quarter and still remains lower than the rate of $23.59 in 2006,” she said. “The first quarter of 2014 overall isn’t much different from the fourth quarter of 2013.”

The regions of St. Louis command-ing the highest Class A rates are in South St. Louis ($25.13), followed closely by St. Charles ($25.08), West County ($24.90),

Central ($24), and North ($21.23).Other hot topics being discussed in

real estate circles:Still University is proceeding with its

$25 million, 79,000-square-foot dental clinic. Students will transfer to this loca-tion in their third year of dental school to complete clinical work. The first two years will have been spent at the new Missouri School of Dentistry & Oral Health on its campus in Kirksville.

Total Access Urgent Care is expand-ing to its fifth location, taking over the former Blockbuster space on Chippewa in South St. Louis. Existing locations include Webster/Rock Hill, Chesterfield, South County, and Town and Country.

Dulle pointed out several market ob-servations:

• Acquisitions collaborations and mergers continue with hospitals and private practices.

• Demand is increasing for larger of-fice suites, with a minimum of 4,000 square feet.

• Demand is increasing for Class A quality locations and properties.

• Office suites of 1,000 square feet or less continue to be sought for geo-graphically expanding practices via satellite offices.

• The geographic expansion of ur-gent care centers continues.

• Market share focus may lead to hos-pital specialization emphasis.

• Benchmarking revenue and ex-penses remain important to drive success.

• The focus is shifting to patient con-venience, efficient service, and sat-isfaction.

Robust Healthcare, continued from page 1

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Cancer got personal at The Foundation for Barnes-Jewish Hospital’s annual illumination-gala on April 26, when award-winning actor, writer and comedian Martin Short enter-tained guests while also sharing his personal story of losing his wife, Nancy Dolman, to ovarian cancer in 2010, and his mother to breast cancer when he was a teenager.

The springtime gala at-tracted more than 500 guests to The Ritz-Carlton in downtown St. Louis, and raised a record-setting $2.1 million for cancer research at the Alvin J. Siteman Cancer Center at Barnes-Jewish Hospital and Washington Uni-versity School of Medicine in St. Louis.

This year’s take represented the most ever raised at the gala, specifically earmarked for the foundation’s Cancer Frontier Fund, created to help Siteman researchers accelerate breakthroughs des-tined to change the face of cancer.

Funds are already supporting re-search on developing vaccines to pre-vent breast cancer, personalized vaccines to fight melanoma, a drug to reduce a

life-threatening side effect of bone mar-row transplants, a genetic test to prevent overtreatment of oral cancer, and other groundbreaking projects.

Kenneth H. Suelthaus, board chair for The Foundation for Barnes-Jewish Hospital, said the money raised has al-lowed the foundation to make more than 30 Cancer Frontier Fund grants worth $5.7 million since 2010.

“We award grants to innovative re-

search that wouldn’t necessarily receive funding through tradi-tional channels,” he said. “We look for game changers. The Cancer Frontier Fund gives Site-man researchers the resources that turn clinical trials into treat-ments. And it’s all possible be-cause of the generous St. Louis community.”

Money raised for the Cancer Frontier Fund is already making a difference in cancer care, noted Tim Eberlein, MD, director of the Siteman Cancer Center, which treats nearly 55,000 pa-tients annually.

“This fund allows us to study the newest ideas that have the greatest promise,” he said.

“For example, through gene sequencing, we’ve been able to create personalized cancer vaccines that use the patient’s own immune system to fight cancer. This could have huge implications for patients with breast cancer and melanoma, initially, as well as many other cancers in the future.”

Gala co-chairs Danny Ludeman, for-mer president and CEO of Wells Fargo Advisors, and Joe Stieven, president and CEO of Stieven Capital Advisors, LP, led

community support for illumination this year. Wells Fargo Advisors and Stieven Capital Advisors were presenting spon-sors of the gala, which included a cocktail reception, dinner, luxury auction, Fund-A-Cure and Short’s performance.

“Cancer touches far too many of our loved ones,” said Ludeman. “Everyone at the event clearly understood the urgency of supporting breakthrough cancer re-search at Siteman so we don’t lose more of our loved ones to this awful disease. Their generosity was overwhelming.”

Stieven said he was moved by the emotional, personal stories shared at the gala.

“The diagnosis of cancer is devastat-ing for families,” he said. “Fortunately, lifesaving treatment based on leading-edge research is available at Siteman Cancer Center. That’s why I’m so thrilled by the outpouring of support. Cancer research just took a giant step forward, thanks to our generous donors at illumination.”

Siteman, one of the largest cancer centers in the United States, is the only cancer center in Missouri to hold the prestigious Comprehensive Cancer Cen-ter designation from the National Cancer Institute and membership in the National Comprehensive Cancer Network.

Raising Millions through Laughter and TearsMartin Short headlined gala benefiting cancer research at Siteman Cancer Center

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By STEVEN M. LAIdERMAN

“Heads I win; tails, I can’t lose,” is a phrase commonly used to describe the benefits of an estate planning technique called a Grantor Retained Annuity Trust or GRAT.

The GRAT technique is particularly attractive in our current low interest rate environment. It’s a technique to transfer wealth to children or others within one generation of the person setting up the GRAT with little or no gift tax cost.

I recently set up a GRAT for Nor-man, who has an estate in excess of the current exclusion from estate tax of $5.3 million. IRA assets comprise a significant portion of his estate; he’s already tak-ing his required minimum distributions and believes he has plenty of assets. He makes annual exclusion gifts to each of his children and grandchildren, currently $14,000 each, without any estate or gift tax consequences. So, he was very inter-ested in other ways to pass wealth without using up much of his exclusion.

Norman established a GRAT. He placed $1 million of investments in an ir-revocable trust that pays him an annuity for a period of years. The annuity is gen-erally a percentage of the value of the as-sets transferred into the irrevocable trust. Since Norman is considered the income tax owner of the irrevocable trust, there’s no gain or loss recognized when he trans-ferred his investments to the GRAT. Fur-ther, any income, gain or loss during the term of the GRAT will be included as part of Norman’s taxable income, just as if he never set up the GRAT.

Norman set up a 2-year GRAT. This

means that each year the GRAT will pay him back a fixed percentage of the value of the GRAT, with interest. That’s right, in two years he gets back all of his money, with interest!

So, what’s the point? Well, the benefit is found in the way

the IRS calculates annuities. Each month, the IRS publishes an assumed interest rate to these and other transactions. For exam-ple, the IRS assumes for June 2014, Nor-man will only realize a 2.2 percent return on his investments in the GRAT. But Nor-man knows that he can on average earn significantly more income or growth in value on his stocks and other investments. So, after the trust pays him back his invest-ment with a whopping 2.2 percent return, whatever is left (including any apprecia-tion) can pass to his children or other heirs with little or no gift tax cost.

Norman asked what would happen if he didn’t earn 2.2 percent because the stock market or other assets in the GRAT might decline during the two years. Ac-tually, he gets all of his money back, and that’s it. So, the primary risk is the trans-action cost of upfront money to set up the GRAT. Even if he dies during the term, all or substantially all of the GRAT assets will be paid to his estate.

That’s why a GRAT is sometimes de-scribed as a “tails, I can’t lose” technique. Even if Norman gets his investments back, he can turn around and re-gift them to an-other GRAT.

A negative aspect of the GRAT is that it’s not generally used to pass wealth to grandchildren or more remote descen-dants because of the generation-skipping transfer tax consequences.

A GRAT can be for a short term, such as two years, to take advantage of the fact that investments tend to increase and decrease over time. If a GRAT is for a lon-ger term, the assets may average a lower return. That’s why the U.S. Treasury has recently indicated a proposal that a term of no less than 10 years may apply.

A more sophisticated method of set-ting up a GRAT is to use business interests and other assets that allow for the use of discounts in valuation for minority interest or lack of marketability. That discounting in value allows for more value to be shifted to the children or other heirs.

Also of note, Norman can be trustee during the period in which the GRAT is paying him the fixed annuity. Also, even after the annuity is paid, under current tax law, if the assets remain in trust for his children, Norman can continue to be considered the income tax owner. So, he can reduce his estate further by paying the taxes on the assets that pass to his children, and this isn’t considered a gift to his chil-dren when he pays the taxes.

So, if someone is looking for a way to transfer wealth, with little or no gift tax cost, a GRAT may be one great solution.

Steven M. Laiderman, principal of The Laiderman Law Firm PC, an estate planning, probate, and business law firm based in St. Louis, has extensive experience in estate planning. His business practice focus also extends to business tax planning, entity creation, succession planning, and the negotiation of business sales and acquisitions. He also represents clients in the negotiation of real estate leases, sales and acquisitions. A frequent speaker, he also serves as an adjunct professor at the Washington University School of Law, teaching estate planning and family wealth management classes. He may be reached at [email protected].

theEstatePlannerBY STEVEN M. LAIDERMAN

Heads I Win; Tails, I Can’t LoseHow to give away money at virtually no cost


Medical Mortgage adds two new Specialists

Locally owned and operated First Integrity Mortgage Services announced the hiring of two licensed Mortgage Bankers, Mi-chael Burge and Vinh Tran for its medical mortgage program. Burge is 30 year career mortgage veteran. Vinh Tran immigrated from Vietnam 35 years ago and has practiced real estate and mortgage banking the last 10 years.

Both Tran and Burge are charged with spear-heading the further de-velopment and marketing of the firm’s mortgage program known as PowerPlus for Healthcare Profession-als.

“I am overjoyed to be working on the PowerPlus for Healthcare Profession-als program. Obviously the healthcare field is the largest industry in the St. Lou-is region. And, the program recognizes that when it comes to employment there is no better job security field to be in. My Underwriters love borrowers in the healthcare field”, said Michael Burge.

Vinh Tran adds, “This program re-wards these typical lower risk borrowers

with meaningful cost reductions. Quali-fied borrowers do not pay PMI – period, even with a 5% down payment! My cli-ents reduce their payments, more cash or qualify for more home. These loans are for borrowers desiring to purchase or refinance up to $750,000” in both Mis-souri and Illinois.

St. Joseph Hospital West named one of nation’s 100 Great Community Hospitals

SSM St. Joseph Hospital West has been included on the Becker’s Hospital Review list of 100 Great Community Hos-pitals based on its accolades, quality of care, and service to its community.

The Becker’s Hospital Review dis-tinction comes on the heels of St. Jo-seph Hospital West being named one of the nation’s 100 Top Hospitals by Truven Health Analytics for excelling in multiple categories related to clinical standards, patient safety and financial stewardship.

Hospitals with fewer than 550 beds from rural or suburban areas were con-sidered for inclusion to the list. The selections were made by the Becker’s Hospital Review editorial team based on numerous rankings and awards from the American Hospital Association, iVantage Health Analytics, CareChex, and Truven Health Analytics.

Older Adults Feel Less Hip and Knee Pain When Moving to the Grooving

Dancing eases hip or knee pain and helps older adults move better, accord-ing to a small Saint Louis University study.

After dancing, over several months they reported less pain and were able to walk faster, according to Jean Krampe, Ph.D., assistant professor of nursing at Saint Louis University and lead author of the article.

The findings are significant because older adults who walk too slowly are more likely to fall, become hospitalized or require care from others, Krampe said.

Doctors and nurses recognize gait speed as the sixth vital sign that can help us predict adverse outcomes for older adults, Krampe said.

Walking just a little more rapidly can make enough of a difference for a person to get across the street more quickly or get to the bathroom faster, which keeps them functional and inde-pendent. In our study, those who danced didn’t walk dramatically faster, but they had a meaningful change in their walking speed said Krampe..

In addition study participants who danced reported that they reduced their consumption of pain medicine by 39 percent and those who didn’t dance said

they took 21 percent more pain medi-cine.

Krampe and her colleagues from SLU’s School of Nursing and SLU’s de-partment of physical therapy conducted the 12-week study with 34 residents of a senior citizen apartment complex, who were mostly women and an average age of 80. All said they had pain or stiffness in their knees or hips, in most cases caused by arthritis.

Researchers divided the study par-ticipant into two groups. Nineteen vol-unteers were in the group that danced for 45 minutes up to two times a week and 15 did not receive dance therapy. They otherwise engaged in similar physi-cal activities. Overall, the average partici-pant in the dance group attended 21 out of 24 sessions.

The research was published this spring in Geriatric Nursing. It was funded by the University of Iowa Hartford Center for Geriatric Nursing Excellence Grant, Saint Louis University School of Nursing and the Sigma Theta Tau International Delta Lamda Ann Perry New Investigator Award.

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St. Louis Medical News July 2014

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