December 21, 2018 – Billion Dollar Baby

Thomas J. Madejski, MD MSSNY President
Thomas J. Madejski, MD
MSSNY President

December 21, 2018
Volume 21  Number 46



Governor Cuomo’s announcement this week “Let’s legalize the adult use of marijuana, once and for all” is a 180-degree turn from previous comments in early 2017. However, this “evolution” came as no surprise. In the summer, he set up a multi-agency task force to analyze the pros and cons of marijuana legalization, which then concluded the positives outweighed the negatives.   The Task Force members then went on the road to sell the idea. MSSNY and county medical society physician leaders testified at many of these meetings to state our support for marijuana decriminalization but also our strong concerns with the public health implications of the legalization of marijuana. The projected revenues the state would gain from legalization range $600M to $1.3B.  MSSNY has had meetings with the Governor’s office and key Assemblymembers to discuss how best to limit the potential significant adverse public health threats such as youth addiction and increased driving while intoxicated.

Vaping-the Next Epidemic

The U.S. Surgeon General Dr.  Jerome Adams, on Tuesday declared electronic cigarette use among America’s youth “an epidemic” and called for new restrictions on the products. The action comes a day after release of a Monitoring the Future report, which confirmed that teen vaping nearly doubled in 2018, with one in five high school seniors reporting current use of e-cigarettes. More than 3.6 million teens in the U.S. reported that they regularly used the vaping products. Recommendations in an advisory by Surgeon General Jerome Adams, MD, include banning vaping from establishments now covered by indoor smoke-free air policies, further restricting youth access to e-cigarettes in retail establishments, implementing new price policies, and banning marketing to youth.

The survey also found that many students believe they are vaping “just flavoring.” In fact, just about all brands include nicotine, and Juul, a popular, high-nicotine vaping product, that has particularly high levels of it. We all know that nicotine in any form is a tough chemical to give up.  It seems we haven’t learned much about the lure of “cool,” parent-unapproved chemicals in spite of our knowledge of addicting chemicals

Dr. Adams was joined by U.S. Health and Human Services Secretary Alex Azar and FDA Commissioner Scott Gottlieb, MD. The Monitoring the Future survey (sponsored by the National Institute on Drug Abuse) confirmed that the rise in youth e-cigarette use during 2017 and 2018 was the largest-ever single-year increase in use of a single substance ever recorded in the 43 years of the survey.

Sales of Juul increased by 600% in 2017 alone, making it the best-selling e-cigarette on the market. The e-cigarettes, which resemble USB flash drives, have high levels of nicotine — as much in a single cartridge as a pack of 20 regular cigarettes. “This is of particular concern for young people, because it could make it easier for them to initiate use of nicotine through these products and also could make it easier to progress to regular e-cigarette use and nicotine dependence,” Dr.  Adams noted.

In Tuesday’s New York Times, Jan Hoffman, in a column titled “How to Help Teenagers Quit Vaping,”   offered advice on how to get kids to quit vaping. His advice is good but I think most parents don’t even know their kids are doing it. It does not have the telltale smell of cigarette smoke.

County Health Officials Opposed to Legalization

The New York State Association of County Health Officials released a statement Tuesday outlining concerns about adverse health impacts from marijuana legalization. The association said it remains opposed to recreational marijuana legalization. But if it’s legalized, similar to MSSNY, the group called for safeguards and research as well as additional funding for local health departments for increases in workload.

The group is also opposed to e-cigarettes. According to the group, E-cigarettes accounted for an increasing proportion of combined monthly e-cigarette and cigarette exposure calls to the U.S poison centers, increasing from 0.3% in September 2010 to 41.7% in February 2014. Longitudinal studies consistently suggest that exposure to tobacco advertising and promotion is associated with the initiation of smoking among adolescents and young adults. Marketing of e-cigarettes uses cartoons, promotes fruity tobacco flavors, and providers sponsorship of events such as concerts and sporting events, all forms of advertising and marketing designed to appeal to children and young adults.  For the above discussed reasons, both MSSNY and NYSACHO find it imperative to prohibit the advertisement of tobacco products and electronic cigarettes and NY State and therefore supports corresponding legislation.

MSSNY, working together with numerous public health advocacy organizations, is also calling on the Legislature to pass a law to create a statewide minimum age of 21 to purchase tobacco and e-cigarettes.  MSSNY also supports banning the use of flavored substances in vaped products.

Altria Nears a Deal to Take 35% Stake in Juul

According to the Wall Street Journal, Altria Group is nearing a deal to take a 35% stake in e-cigarette startup Juul Labs at a roughly $38 billion valuation, an investment that would make Juul one of the most valuable private companies.It would more than double what Juul was valued at just a few months ago, a sign of how quickly the startup has been growing and Altria’s desire to find growth outside its shrinking cigarette business.

While many groups have come together to alert the public to the health threats of nicotine, the developments around expanded use of e-cigarettes and marijuana show just how vigilant we need to continue to be.

Please share your suggestions or thoughts with me at

Thomas J. Madejski, MD
MSSNY President

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New York Exchange Enrollment Continues to Rise
As talks of health care reform continue to swirl in Albany and across the country, enrollment in New York’s Health Insurance Exchange continues to accelerate.  Even with the federal removal of the individual coverage mandate – an act widely expected to lead to a decrease in enrollment – this year is actually outpacing last year in New York.

According to the NY State of Health, more than 1 million New Yorkers had enrolled in non-Medicaid coverage in the Exchange through December 15, representing an increase of about 83,000 people over last year. New York’s uninsured rate is currently under 6%, with about three-quarters of the uninsured eligible for subsidized coverage.  Specifically, there were 247,411 enrolled in a qualified health plan; 776,481 enrolled in the Essential Plan; 413,576 enrolled in Child Health Plus, and 3,283,564 enrolled in Medicaid.

This week, as part of his “First 100 Days” Address, Governor Cuomo proposed to codify into law both New York’s Exchange as well as its “pre-existing conditions” protects for consumers.  While New York currently has a law protecting patients from being denied coverage because of a pre-existing condition, this law is tied to the federal ACA provisions that were put in doubt as a result of last Friday’s federal District Court Judge’s ruling that the ACA is unconstitutional.

In response to Judge O’Connor’s ruling, Dr. Madejski was quoted in several papers, including Newsday, Westchester Journal News, and Buffalo Business First, stating “While the ACA has many flaws that we urge Congress to work to fix, among its strongest attributes are its mechanisms to enable the purchase of health insurance coverage for millions through a variety of subsidy programs.” Amongst those flaws is the need to require exchange plans to offer out of network coverage.

With health insurance coverage through the Exchange under discussion in 2019, MSSNY will continue to push for measures to ensure patients have access to comprehensive and varied health insurance options, including out of network coverage.

Exciting Sections Meeting: Young Physicians, Residents/Fellows, Medical Students. Saturday, February 9, 2019 at the Marriott Courtyard in Westbury and MSSNY HQ. Hear national leaders in medical toxicology and social media in medicine. Read all about it here.

Judge Reviewing CVS-Aetna Orders DOJ to Respond to Community Concerns
US District Court Judge Richard Leon this week ordered the US Department of Justice to respond to numerous comments filed to it raising concerns with the proposed mega merger between CVS and Aetna.  According to media reports, this development is expected to delay approval of the merger until at least Spring 2019.

Among the comments to the US DOJ is a letter from MSSNY President Dr. Thomas Madejski summarizing MSSNY’s extensive concerns with this merger among corporate behemoths. The DOJ letter also appended testimony provided by MSSNY Immediate Past President Dr. Charles Rothberg at an October NY Department of Financial Services hearing.

The letter also summarizes the extensive concerns that had been raised by NY DFS Superintendent Maria Vullo, the American Medical Association (AMA), the American Antitrust Institute and New York State Assembly Insurance Committee Chair Kevin Cahill.

Moreover, last week, the Pharmacists United for Truth and Transparency (PUTT) and the Pharmacists Society of the State of New York (PSSNY) jointly filed a motion asking Judge Leon to stop CVS and Aetna from further integration while the Court determines the merger’s harmful effects.

The US DOJ had approved the merger in October under the condition that the companies sell Aetna’s Medicare drug plan business to preserve competition.  The acquisition of Aetna by CVS had also been signed off by every state reviewing the transaction, including New York, which approved the merger in late November with numerous conditions.

MSSNY’s letter to the DOJ highlighted that, even though the NY DFS had approved the acquisition, it did so highlighting several problems with the merger, including that the companies had not “provided any concrete analysis that the CVS/Aetna merger would result in specific reduced costs for New York consumers, or any business plan or study of asserted improved health outcomes to benefit New Yorkers.”

Moreover, MSSNY’s letter to the DOJ reiterated the extensive concerns articulated by the AMA.  Judge Leon’s concerns about the transaction included the strong opposition by the AMA, which had argued to the DOJ that it would leave consumers with fewer health care choices. In addition to Medicare prescription drug plan choices, AMA also raised concerns about reduced health insurance competition and patient community pharmacy options.  

Physician Compare 30-Day Preview Period Extended to 1/7
On November 30, CMS opened the 30-Day Preview Period for the 2016 performance information targeted to be publicly reported on Physician Compare starting in early 2019. The preview was scheduled to end on December 31 at 8pm ET. We are extending preview through Monday, January 7 at 8pm ET (5 PM PT).

For additional assistance with accessing the Quality Payment Program website, or obtaining your EIDM user role, contact the Quality Payment Program service center at

If you have any questions about Physician Compare, public reporting, or the preview period, please contact us at

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DFS Superintendent Vullo to Depart in February
New York Superintendent of Financial Services Maria Vullo announced this week that she would be stepping down from the position on February 1, 2019.  The many important activities engaged in by Superintendent Vullo include her close scrutiny and criticism of the defects of the many health care mega mergers such as the proposed Anthem acquisition of Cigna, and the proposed CVS acquisition of Aetna. In her statement announcing her departure she noted that “I am especially proud to have led DFS in cybersecurity, having promulgated a final regulation in March 2017 that is now the national standard for the protection of our nation’s financial markets.  I also am tremendously proud of our work to protect women’s rights in the face of federal assaults, by mandating insurance coverage of contraceptives and abortions without cost-sharing, providing essential coverage for women suffering from maternal depression, providing a special health care open enrollment period for victims of domestic violence, and implementing New York’s Paid Family Leave law.”

Assemblywoman Crystal Peoples-Stokes Named Majority Leader of NYS Assembly; Assembly Committee Chairs Mostly to Remain the Same
Assemblywoman Crystal Peoples-Stokes (D-Buffalo) was appointed by Assembly Speaker Carl Heastie to serve as the Assembly Majority Leader. The majority leader is responsible for the day-to-day operational duties of the Assembly chamber, including overseeing the floor during debates.  She will replace Joe Morelle, who just won election to Congress in his Rochester-area seat.

“Serving alongside Crystal Peoples-Stokes, I have had the opportunity to see firsthand how hard she works for the people of Buffalo and for families across our state,” Speaker Heastie, said. “Crystal is a trusted colleague who I have known for many years, and her experience and dedication to improving the lives of all New Yorkers is why I know she will make an ideal partner in leading the Assembly Majority. Crystal is widely respected by her colleagues and I am proud to appoint her as the next Majority Leader of the People’s House.”

Speaker Heastie also announced Assembly Committee Chairs for the 2019-2020 Session this week.  Many of the Chairs of Committees of strong interest to physicians and patients will remain the same.  The Assembly Health Committee Chair will continue to be Richard Gottfried.  The Insurance Committee Chair will continue to be Kevin Cahill.  The Higher Education Committee Chair will continue to be Deborah Glick.  The Assembly Judiciary Committee Chair will continue to be Jeffery Dinowitz.  The Codes Committee Chair will continue to be Joseph Lentol and the Ways and Means Committee will continue to be led by Helene Weinstein.   Assemblyman Marcos Crespo has been appointed chairman of the Committee on Labor, replacing Michele Titus.

Physicians File Class Action Suit Against ABIM
A class action lawsuit against the American Board of Internal Medicine (ABIM) was filed in a Pennsylvania federal court on December 6.  The plaintiffs include several physicians board certified in internal medicine who allege that the ABIM maintenance of certification (MOC)

requirements violate the federal anti-trust laws.  The physician plaintiffs allege that initially board certified internists have lost hospital privileges if they do not obtain MOC. It is also alleged that initially board certified internists have been removed from the list of “preferred physicians” by health insurers if they do not maintain MOC.  A similar action had been brought in an Illinois federal court by the American Association of Physicians and Surgeons (AAPS), but was dismissed on the basis that the complaint merely made general conclusions, and failed to provide sufficient specific details.

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U.S. FDA Panel Votes for Prescribing Naloxone with Opioids
On Dec 18, an advisory panel to the U.S. Food and Drug Administration recommended prescribing the opioid overdose reversal drug, naloxone, with addictive painkillers.

The panel, which concluded a two-day discussion on ways to make the potentially life-saving drug readily available, voted 12-11 in favor of labeling changes for opioids that recommend co-prescribing the overdose antidote.

Surgeon General Declares E-Cigarettes a Youth Epidemic
The US Surgeon General on Tuesday declared electronic cigarette use among America’s youth “an epidemic” and called for new restrictions on the products.

The action comes a day after release of a Monitoring the Future report, which confirmed that teen vaping nearly doubled in 2018, with one in five high school seniors reporting current use of e-cigarettes. More than 3.6 million teens in the U.S. reported that they regularly used the vaping products.

Recommendations in an advisory by Surgeon General Jerome Adams, MD, include banning vaping from establishments now covered by indoor smoke-free air policies, further restricting youth access to e-cigarettes in retail establishments, implementing new price policies, and banning marketing to youth. In his advisory, the Surgeon General singled out the new generation of e-cigarettes that have e-liquid contained in a cartridge, such as the brand Juul, as posing a particular risk to youth.

He added that despite these risks, approximately two-thirds of Juul users between the ages of 15 and 24 in one survey did not know that Juul always contains nicotine. (See Dr. Madejski’s comments in the introduction.)

MSSNY Symposium Call for Abstracts; Open through 4:00 pm Tuesday, January 22, 2019
MSSNY member residents, fellows and medical students are invited to submit abstracts for consideration for the MSSNY Symposium, to be held April 12, 2019 at the Westchester Marriott in Tarrytown. Submissions will be accepted until 4:00 pm on Tuesday January 22, 2019. See complete guidelines at

Please contact with any questions.

If you’d like to help score abstracts, contact

Dr. First Banner

3rd and 4th District Meeting Jan 25-27 at the Mirror Lake Inn in Lake Placid.

Physician Fee Schedule Final Rule: Understanding 3 Key Topics
Here are the answers to frequently asked questions::

Topic: E/M

Q: What parts of the history can be documented by ancillary staff or the beneficiary starting in CY 2019?
View the response here.


Topic: QPP

Q: How does the MIPS payment adjustment apply to clinicians, especially those who may switch practices during the performance year?

A: Below are the general rules on how the payment adjustment is applied, which is different than the legacy programs.

  1. A MIPS eligible clinician (NPI) who bills to the same TIN in the payment year as they did during the performance period will be assessed the payment adjustment under that TIN/NPI combination according to the final score earned from data submitted/collected under that TIN
  2. A MIPS eligible clinician (NPI) who bills to a (new) TIN in the payment year that they did NOT bill to during the performance period will be assessed the payment adjustment under that (new) TIN/NPI combination based on the most advantageous final score attributed to that NPI under any TIN/NPI combination for the performance period.


Topic: Changes to MIPS Requirements

  1. Are there any changes to the data completeness requirements for the MIPS Quality performance category in 2019?
  2. No, the data completeness requirements are the same as in Year 2 (2018) even with the update to the submission terminology. Individual clinicians or groups submitting quality measure data on QCDR measures, MIPS CQMs, and eCQMs must submit data on at least 60% of the clinician or group’s patients that meet the measure’s denominator criteria, regardless of payer. Individual clinicians or groups submitting quality measure data on the Medicare Part B claims measures must submit data on at least 60% of the applicable Medicare Part B patients seen during the performance period.

Additionally, we have a fact sheet that provides additional information and scenarios on the MIPS payment adjustments.

American Board of Specialties on Continuing Board Certification: Vision for Future Commission Releases Report
The report, Draft Report for Public Comment which includes the Commission’s key findings and recommendations, will be posted on the Vision Initiative website for comment through Tuesday, January 15, 2019 at 10:00 p.m. EST.

We strongly encourage you to review the draft report and offer your comments by the January 15, 2019 deadline.

The American Board of Medical Specialties and its 24 Member Boards are committed to working with stakeholders to improve the continuing certification process so that it becomes a system that demonstrates the profession’s commitment to professional self-regulation, offers a consistent and clear understanding of what continuing certification means, and establishes a meaningful, relevant and valuable program that meets the highest standard of quality patient care. The Boards will seriously consider the Commission’s findings and recommendations once finalized, as they continue implementation of improvements and pilots currently underway.

Kristin Schleiter, JD
VP, Policy, Government Relations and Strategic Engagement
American Board of Medical Specialties
Direct 312-436-2686
Mobile 847-636-2779

AM Best Rates MLMIC A+
AM Best has assigned a Financial Strength Rating of A+ (Superior) and a Long-Term Issuer Credit Rating of “aa-” to MLMIC Insurance Company (MLMIC) (New York, NY). The outlook assigned to these Credit Ratings (ratings) is stable.

The ratings reflect MLMIC’s balance sheet strength, which AM Best categorizes as strongest, as well as its adequate operating performance, limited business profile and appropriate enterprise risk management. The ratings also benefit from the financial support provided by MLMIC’s direct parent company, National Indemnity Company, which is ultimately owned by Berkshire Hathaway Inc. [NYSE: BRK.A and BRK.B].

MLMIC’s risk-adjusted capitalization, as measured by Best’s Capital Adequacy Ratio (BCAR) is categorized as strongest and AM Best expects it to remain at a similar level in prospective years. The balance sheet strength assessment also considers the company’s track record of positive reserves development, as well as good financial flexibility provided by its publicly traded ultimate parent Berkshire Hathaway Inc.

MLMIC’s insurance portfolio is concentrated in the medical malpractice line of business. The company underwrites risks only within New York state, which represents one of the nation’s most challenging market environments. However, management has been able to operate successfully through underwriting cycles while maintaining MLMIC’s leading market position within New York.

Health Affairs: First Estimate of Physicians Telemedicine Use
The December issue of Health Affairs, using data from the AMA’s 2016 Physician Practice Benchmark Survey, provides the first nationally representative estimates of physicians’ use of telemedicine. In 2016, 15.4 percent of physicians worked in practices that used telemedicine for a wide spectrum of patient interactions, including e-visits as well as diagnoses made by radiologists who used telemedicine to store and forward data. In the same year, 11.2 percent of physicians worked in practices that used telemedicine for interactions between physicians and health care professionals. We found that in addition to specialty, larger practice size was an important correlate of telemedicine use. This suggests that despite regulatory and legislative changes to encourage the use of telemedicine, the financial burden of implementing it may be a continuing barrier for small practices.

Heart Group: Statins’ Benefits “Greatly Outweigh” Their Risks
For most patients who meet criteria for statin therapy, the benefits “greatly outweigh” the risks, according to a new scientific statement from the American Heart Association.

Here are some of the group’s conclusions, published in Arteriosclerosis, Thrombosis and Vascular Biology:

  • Statins prevent primary cardiovascular events in 5% of patients treated for 5 years (who achieve a 77-mg/dL reduction in LDL) and prevent secondary events in 10% of those treated.
  • Myopathy, including rhabdomyolysis, owing to statin use affects less than 0.1% of treated patients.
  • Severe liver toxicity occurs roughly 0.001% of the time.
  • Statins “modestly” increase the risk for diabetes, most often in patients with numerous other risk factors.

The absolute risks for additional adverse effects are listed in Table 7 of the document linked below.

AHA scientific statement in Arteriosclerosis, Thrombosis and Vascular Biology

AHA/ACC 10-year CV risk calculator

PAI Submits Comments in Response to Anti-Kickback Statute Request for Information (RFI
PAI submitted comments in response to the Anti-Kickback RFI, supporting the Department of Health and Human Services’ (HHS) efforts to modernize the Anti-Kickback Statute as well as the Beneficiary Inducement Civil Monetary Penalty Law (CMP). In its comments, PAI submitted several recommendations that would provide physicians relief from the antiquated aspects of these laws/regulation, including encouraging HHS to take the following key steps:

  • Establish clear exceptions to the Statute and CMP restrictions for payment models and demonstrations and other arrangements that promote physician-led initiatives to value-based care.
  • Allow physicians to align with other high-quality providers (clinical and non-clinical, including social support organizations) for greater coordinated care and a more holistic approach to patient care.
  • Encourage physician-patient relationships through greater patient incentives and rewards that promote and support the delivery of high-value, low-cost care and contribute towards greater coordinated care that improves outcomes.

More detailed recommendations include:

  • Permitting physicians and practices to enter into group purchasing arrangements for medical equipment and social support services on behalf of their patients.
  • Modernizing the statute to allow and provide for the infrastructure support and financial incentives necessary for value-based arrangements, for both providers and patients. The current exceptions, safe harbors, and waivers limited to certain models should be expanded to other APMs, demonstrations, and similar arrangements.
  • Strengthening physician-patient relationship by better alignment, including equipping physicians with tools that can be used to incentivize patient adherence to their care plans and help ensure medication adherence.
  • Allowing cost savings from rebates and negotiated discounts to be passed down from pharmacy benefit managers (PBMs) to patients and holding PMBs to stricter standards.
  • Creating additional safe harbors that allow physicians to establish arrangements with electronic health record vendors to further promote interoperability and health information exchange.
  • Clarifying the definitions of “value,” “risk,” and “market/market share” under the Statute and in their application to value-based payment arrangements.


 “Public Health Preparedness 101” CME webinarJanuary 16, 2019 at 7:30am – Registration now open 

Are you prepared for a public health emergency?  And are you ready for one as well?  MSSNY’s next Medical Matters webinar is Public Health Preparedness 101 on January 16, 2019 at 7:30am.  Registration is now open for this program here.  Faculty for this program will be Kira Geraci-Ciardullo, MD, MPH and Arthur Cooper, MD, MS.

Educational Objectives:

  • Inform physicians and staff on how to prepare professionally and personally for a public health emergency.
  • Describe the importance of readiness in addition to preparedness

The Medical Society of the State of New York is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to provide continuing medical education for physicians.

The Medical Society of the State of New York designates this live activity for a maximum of 1.0 AMA/PRA Category 1 credits™.  Physicians should claim only the credit commensurate with the extent of their participation in the activity. 

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Beautiful Medical Office Suite Available for Sublease in Rockville Centre
Well-appointed medical office building with enclosed private parking. Large waiting room and reception area with adjacent kitchen. Three consultation rooms and large procedure room/operating suite. Flexible availability with all mornings available or 2 full weekdays and weekends available. Perfect for plastic surgeon/dermatologist/ENT/ObGyn/podiatrist or other medical MD. Contact Harriet at or 516-466-7000.

For Rent or Share – Woodbury, Long Island
Beautiful recently renovated Plastic Surgery Class C-M AAAA-certified Operating Room available for part-time share and available for rent. Centrally located on Long Island. Close to expressways.
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Wonderful office share in terrific location at great price. Available Monday, Wednesday, Friday and weekends. Choice of smaller windowed consultation room with adjoining exam room or big windowed consultation room with one or two exam rooms. Beautiful bright rooms, lovely reception area and front . First-rate building on 58th Street between Park and Lexington. Rent by day (about $180). Front desk and office management available if needed, along with many other amenities, including internet, ultrasound, EMG Kitchen, optional C Arm. Willing to make changes for new tenant. Call 646-642-0700.

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Physician Insights Wanted to Help Shape the Future of Primary Care
98point6 is a healthcare technology company committed to delivering more affordable, accessible, high-quality primary care. To support our mission, we need the insights of forward-thinking physicians that have opinions about the current state of primary care and are interested in the role technology can play in healthcare. Members of our exclusive Primary Care Council have no clinical responsibilities and are generally compensated for participation, which requires only a few hours per year. Interested? Learn more and apply today at

Internal Medicine Physician and Nurse Practitioner Wanted – Syracuse Area
Syracuse primary care practice recruiting for a highly motivated Internal Medicine Physician and Nurse Practitioner. Candidates should be interested in working closely with patients, care teams, and community partners, Send resume to

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If not you may be subjected to legal action! We can do a free audit of your website and let you know what corrections are needed.
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