Stephanie Skernivitz

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Napa and Sonoma counties, located approximately an hour from San Francisco, are well known around the United States and the world for their superior wine and wineries. Here is just a sampling of the local vineyards. 

									http://www.blackstallionwinery.com/

				
One of Napa Valley's newest wineries is on the grounds of a historic equestrian center. Call for tours. 

				
Upholding its reputation since 1973 for generating world-class wines, Cakebread Cellars offers hospitality, in-depth tastings of wines, and tours through the production facility and vineyard. 

				
Gloria Ferrer Caves & Vineyards bears resemblance to old Spain with its red-tiled roof and stucco walls in the hills of the Carneros region. Tours daily. 

				
Korbel's California champagne tradition dates to the 1800s. The winery provides a historic tour retelling the story of this 125-year-old property. Tours daily. 

				
Established in 1982, this family-owned and operated winery uses organic and sustainable farming in the vineyard. 

									http://www.robertmondaviwinery.com/

				
Count on a memorable, elegant experience at this Napa Valley landmark while tasting wine or enjoying culinary events. 

				
At one of the oldest estates in California, the Centennial Museum tracks the estate's history and owner Francis Ford Coppola's history in film-making.

Articles

Napa and Sonoma counties, located approximately an hour from San Francisco, are well known around the United States and the world for their superior wine and wineries.

Wine: Enjoy some downtime at a local vineyard

One of the greatest-if not chief among-patient complaints is the actual time they have to wait before being seen by the physician, ophthalmologist, surgeon, or fill in the blank. 

"Patient flow is a constant challenge. It's very complex and changes constantly," said Derek A. Preece, MBA, who presented on "New ways to increase patient flow and reduce wait times." 

Preece, who has consulted for ophthalmology practices for 20 years, said practices should consider developing a system to analyze patient flow in their respective offices. He discussed how to design an optimized patient appointment schedule and offered suggestions for solving some common patient flow problems. 

"Anybody see a problem here? How many patients can he schedule per hour, spend 10 minutes per patient and stay on time? At the end of the first hour, he had done six appointments and four were waiting. At the end of two hours, he had done 12 and eight were waiting. No wonder he worked through lunch," he said. 

Yet Preece noted that remarkably nobody in the office, including the physician, had ever sat down to figure out how much time was really needed to see the patients. 

What the basic patient flow issue boils down to is the fact that practices lack good data and careful analysis, according to Preece. "We simply don't know how long it takes our physicians to see a patient. Therefore, we schedule without regard to this critical factor," he said. 

Often practices don't take into consideration that the time needed per exam will vary, depending on the type of exam. When each exam is scheduled for the same length of time, it's a train wreck waiting to happen, said Preece. 

The following are key principles when devising patient flow strategies: 

A physician time tracking sheet is recommended when beginning the patient flow process. One option is to hire a temp to time the physician for one day to gather the data prior to starting the analysis. Record on the tracking sheet each patient's name, exam type, and when the physician starts and ends each exam. Such data will give practices an indication of how much time is needed for each exam, especially if your practice offers several different types of exams. 

In short, the data needed to carry out the analysis are: types of exams; what percentage are considered short, medium, or long exams; and time needed to schedule each exam. Step two is to analyze the data. Basically, you will multiply physician's exam time by its percentage of total number of exams to get the weighted average exam time. The end goal is to discover how long the physician is taking per exam to know how many exams to schedule in a given timeframe. 

Because scheduling is usually done by the hour, determine how many short and long exams the physician is conducting per hour to build the appointment schedule. Determine the length of time per short exam (e.g., 4 minutes); medium exam (e.g., 8 minutes); and long exam (e.g., 12 minutes). 

A system should be put in place to analyze patient flow in the office. Designing an optimized patient appointment schedule and solving some common patient flow problems can make a difference.

How to maximize patient scheduling and expedite long office waits

If you find yourself in the midst of a buy-in, payout, or sale of your practice, a practice valuation may be worth considering. That's the latest advice from Mark E. Kropiewnicki, JD, LLM, and Daniel M. Bernick, JD, MBA, both of The Health Care Group, Inc. in Plymouth Meeting, PA, who presented on "Practice valuation and goodwill: What's behind door number three?"  

"The need for valuation may arise in the following scenarios: in the merger context between two ophthalmology practices, when two spouses (doctor and wife or doctor and husband) are getting divorced and there's dispute over the value of the ophthalmology practice, and in cases of lost earnings due to disability, for example," says Bernick, a principal of The Health Care Group and Health Care Law Associates. 

There are three basic components to valuing an ophthalmology practice: hard assets (e.g., medical and office equipment), accounts receivable (work performed in the past represents an asset), and goodwill (i.e., sum of all intangibles in the practice).  

Therefore, it's important to factor in the impact of hard assets on your practice valuation. First, practices must consider how to go about valuing the equipment in the ophthalmology practice. Bernick describes two conceptual approaches. "The first and most straightforward approach would be to have somebody come and tell us the value of each item in our practice. Theoretically that sounds like a good idea. But in practicality, to try to have one person with market experience appraising every piece of equipment and item in your office is not feasible," he explains. 

Instead, many people might opt for the second approach, which is based on book value. This essentially represents what is shown on your tax return, according to Bernick. A corporation would have a schedule showing the balance sheet of the practice. A line item applies to the original purchase costs of all equipment and leaseholds in the practice. From that, all tax depreciation taken to date on the items listed would be subtracted. The purchase price minus the depreciation results in the book value for tax purposes. 

"The problem with book value is that most of the time it far understates the true value of your equipment. If you were to buy a piece of equipment for $10,000 and you were to expense that, which you are allowed to do under IRS rules, the book value of that item immediately is zero, because you have fully deducted it," Bernick says. "That really isn't appropriate. The same would apply to items in your practice that would depreciate over a 5-or 7-year useful life under IRS rules. Therefore, adjustments are recommended. 

When valuing your practice, the first step related to adjustments is to take back all items that were expensed on your balance sheet and put them back on the sheet, Bernick explains. To arrive properly at a good value for hard assets, the assets must be added back to the book value. 

The second adjustment is to restate depreciation. Bernick recommends depreciating equipment, for example, on a slower basis. Practices can continue to write off hard assets very quickly for tax purposes to get the deduction, but should have a different approach for valuation purposes, which entails restating depreciation. Assume a minimum value for each asset of 20% of original cost. If you are using a 10-year useful life for items in your practice and the item is still in use, then it should at least have a value of 20% of the original cost. 

After adding up all modified book value items, subtract the debt to arrive at a final net value. 

The above calculations cover most hard assets, according to Bernick. Consider also making an adjustment for inventory. For example, if you keep a significant number of optical frames or inventory of contact lenses, determine how these will be added to the mix. One method is the physical inventory. When you select a date of valuation, you would physically count up all containers and frames and know what the cost per item is. "That may be difficult to assess because with your frames, they have different costs. Plus the inventory changes from day to day," Bernick says. 

If you find yourself in the midst of a buy-in, payout, or sale of your practice, a practice valuation may be worth considering. Typically goodwill is the largest value involved; even though a significant amount of hard assets are also involved. Therefore, it's important to factor in the impact of hard assets on your practice valuation.

Valuations, a good method for certain financial situations

The retail optical industry is down 2.5% in 2009, according to published industry data. The silver lining, however, is that compared with other industries those numbers aren't so bad, all things considered. 

That's the read from Arthur De Gennaro, president of Arthur De Gennaro & Associates LLC, a Lexington, SC-based ophthalmic practice management firm that specializes in optical dispensary issues. 

Although the percentage could be much higher, given the recessionary climate it is relatively low for a couple of reasons, according to De Gennaro. One, there was "an anomaly" earlier in the spring of this year, he said. 

Second, he said many patients don't go to the eye doctor for routine care. Many go for regular medical care and don't tend to delay those visits, thereby helping to stabilize the industry numbers. 

"Overall, the number of people affected in the optical world is not as high as you might imagine, given what's happening in other sectors," said De Gennaro, who spent 14 years as a chain store executive in the optical dispensing world. "The ophthalmology world fared the recession better than nearly everybody. The only exception to that are practices that did a lot of LASIK. They were down-really hard-40% or more." 

In agreement is Donna A. Suter, president of Suter Consulting Group, of Chattanooga, TN, who has been consulting private-care ophthalmologists for the past 20 years. She added that eye-care practitioners still have been impacted generally by the downturn in the economy. 

"However, health care is very inflation-proof," Suter said. "Many people have health-care funds available for these types of purchases that are not impacted. Pre-tax-dollar health spending plans covers cost of high-end eyewear. The general economic climate isn't an OMG worry for the ophthalmology industry. 

"However, any time there is a shrink in the budget, people start evaluating choices. My income may not change but I'm re-evaluating," she said. "The optician must be very conscious of reselling and reconfirming choices their customers may have made last time they were there. Explain to the customer his benefit. Re-educate about what is smart about this eyewear. We're establishing a new baseline of what is normal." 

De Gennaro concurs with the "new normal." Although sales did not drop as much as anticipated, he said that everyone prepared as if it would. Many of his clients devised new ideas to market their businesses better. A recession-or the threat of one-can force people to think more creatively about cost-saving measures. 

De Gennaro said one of his clients initiated a "Cash-for-Clunkers" sale, capitalizing on the concept introduced in the automotive industry. If customers brought in a pair of glasses to this particular ophthalmology practice, the glasses were donated to the local Lions Club. Customers then drew a folded piece of paper from a fishbowl; each paper contained a dollar amount that translated to a discount on their next pair of glasses. 

The retail optical industry is down 2.5% in 2009, according to industry published data.

The new normal: Marketing eyewear in tough times

 San Francisco is nearly synonymous with a high cost of living. The advent and financial success of the early years of the Internet revolution still lures high-income folks to the city by the bay. Property values and household income are among the top in the nation, which enables a profitable restaurant and entertainment scene. 

Financials aside, the international flavor of San Francisco-39% of its residents were born overseas-continues to intrigue. A significant number of immigrants came from Asia and Latin America.  

The Chinese, in particular, have made an imprint on the city since the 1970s, most notably in Chinatown, where the annual Chinese New Year Parade is recognized as the largest event of its type outside China.  

Today, the city boasts at least a dozen unique and simply San Francisco neighborhoods. The city is largely reminiscent of a coffeehouse culture, thanks to the social revolution of the 1960s, which has contributed to today's liberal activism, as Democrats and the Green Party heavily influence city politics. 

In addition, the city's large gay and lesbian population helps spark a politically and culturally active community.  

When visiting San Francisco, especially for the first time, don't miss these landmarks: 

 This suspension bridge stretches across the Golden Gate, which marks the entrance of the San Francisco Bay into the Pacific Ocean. The bridge is part of U.S. Route 101 and State Route 1. 

When the bridge was constructed in 1937, the internationally recognized symbol of San Francisco originally contained the longest suspension bridge span. Now, it is ninth in span worldwide and second to the Verrazano-Narrows Bridge in New York City. 

 In the middle of San Francisco Bay, this small island originally was used as a lighthouse, later a military fort, and then a military prison, succeeded by a federal prison until 1963. 

Alcatraz now serves as a national recreation area. It is a historic site run by the National Park Service, belonging to the Golden Gate National Recreation Area. 

Take a ferry to get to the island from Pier 33, close to Fisherman's Wharf. 

 The world's only remaining permanently operational, manually operated cable car system is right here in San Francisco. The San Francisco Municipal Railway, or MUNI, runs the transportation network. 

Two routes downtown near Union Square to Fisherman's Wharf are operational, as well as another route on California Street. 

The cable cars are recognized as one of two moving National Historic Landmarks. 

The Art Deco architecture calls attention to the Coit Tower, a 210-feet structure of unpainted reinforced concrete. 

Designed by architects Arthur Brown Jr. and Henry Howard, the tower was built on Telegraph Hill in 1933 through an inheritance gift of Lillie Hitchcock Coit to enhance the city's appearance. 

 San Francisco is home to the oldest Chinatown in North America. Built up in the 1850s, many films, songs, photographs, and articles of literature have featured San Francisco's Chinatown. This tourist attraction reportedly hosts more visitors than even the Golden Gate Bridge. 

If you're looking for some long-lasting performing arts companies, venture no further than San Francisco's War Memorial and Performing Arts Center. The War Memorial Opera House is home to the San Francisco Ballet, as well as San Francisco Opera, which is reportedly the second-largest opera company in North America. Or grab tickets to hear the San Francisco Symphony perform in Davies Symphony Hall. 

Perhaps one of the more famous venues, The Fillmore, earned its fame in the 1960s serving as the stage for musicians such as the Grateful Dead, Jefferson Airplane, and Janis Joplin. 

If you'd like to see a West-Coast Broadway number, stop by a slew of vintage 1920s-era venues in the city's theater district, such as the Orpheum or Golden Gate theaters. 

At the Museum of Modern Art in the South of Market neighborhood, peruse 20th-century and contemporary art masterpieces. Or stop by the Palace of Fine Arts, where the Exploratorium, a science museum, draws visitors to participate in hands-on, interactive exhibits. Or plan a trip to the city's natural history museum, the California Academy of Sciences.

For more information about the city, listen to the podcast at http://www.ophthalmologytimes.com/aaotravel09.

San Francisco is nearly synonymous with a high cost of living. The advent and financial success of the early years of the Internet revolution still lures high-income folks to the city by the bay. Property values and household income are among the top in the nation, which enables a profitable restaurant and entertainment scene.

San Francisco unmatched as a travel destination

San Francisco has cuisine to satisfy many taste buds. From dim sum to gnocchi, use this guide to map out your dining tour of the city by the bay. 

Note that price ranges for all restaurants are approximations based on dinner for one person plus beverage. Prices may be subject to change. 

  1900 Telegraph Ave., 510/286-0100
Price: $$$ 
Specialties include grilled New York strip with house-made Worcestershire sauce, butternut squash souffle with mushroom cream sauce, and fish and chips. 

				
Price: $ 
Ton Kiang holds the honor as top dim sum parlor in the city. Try the steamed dumplings and dim sum, salt-baked chicken, or crisp-skinned duck. 

  133 Steuart St., 415/896-5600
Price: $$ 
The fragrance of freshly cooked seafood and steamed dumplings takes diners on a venture to China. Specialties include Shanghai dumplings (when available), shrimp with green tea essence, and firecracker chicken baked in chiles. 

				
Price: $$$$ 
This spot is near the opera and symphony. It specializes in seared scallops with truffled mashed potatoes and crispy duck confit salad. 

				
Price: $$$$ 
Sample the parsley and garlic soup with snails, roasted quail, and foie gras lollipops, or the braised beef short ribs. 

				
Price: $$ 
Indian food at this popular Mission District spot includes the dosa or thin crepes that are stuffed with various fillings. 

				
Price: $$ 
There's an olive oil tasting on the menu, not to mention an impressive cheese room, in this Mission District restaurant. Specialties include meatballs with tomato and chard and cheese and salami service. 

				
Price: $$ 
The small, moderately priced restaurant features such entrees as Massachusetts dayboat scallops with Jerusalem artichoke puree and Pappardelle and pork sugo. 

									http://www.jdvhotels.com/dining/sanfrancisco/oizakaya

				
Price: $$ 
In the newly refurbished and renamed Kabuki Hotel in Japantown, this restaurant resembles a Japanese pub. Small plates include braised pork belly on house-made kimchi, tempura mushrooms, seaweed salad, and sashimi. 

				
Price: $$$ 
Expect to discover some of the most innovative Japanese food in the Bay Area. Menu features dishes prepared from the robata grill and wood-burning oven. Specialties are sashimi, herb-roasted big-eye red snapper, and pork prime rib. 

				
Price: $$$ 
Catch dinner and a movie at the same place. Food options include Northern halibut and artichoke and green bean salad. 

				
Price: $$$$ 
Aqua continues to serve up some of the most inventive seafood in the United States. Such exquisite entrées include black mussel souffle or lobster pot pie. 

				
Price: $$$ 
Spanish food in an airy California setting describes this Marina restaurant. Try crudo of Pacific lingcod with fennel, radish, and chopped egg, or steamed clams with chorizo. 

  2000 Hyde St., 415/346-0800
Price: $$ 
The restaurant turns out tantalizing tapas at this Spanish-inspired restaurant on Hyde Street. It is known for its tortilla espanola. Other signature dishes include ham and cheese croquettes, roast duck leg in prune sauce, and grilled oysters in romesco sauce. 

Greens Restaurant  Fort Mason Center,    

									http://www.greensrestaurant.com/

				
Price: $$$ 
Here the tofu tastes better than meat. But the real clincher is the extensive wine list. Sample the curries, tofu brochettes, and pizza. 