As the economy continues work its way back, we are beginning to feel the tightening up of the American consumer, and ultimately your practice.  Although the patient may still be coming to your practice, they may or may not be taking the more costly approach to care.  In business, cash flow is paramount.  When patient visits become less frequent and procedure mix is not what was anticipated we can begin to feel the crunch between living expenses and business cash flow.  Fortunately, banks are beginning to lend again, especially in the less impacted and more resilient spaces.

We have all heard the term “debt consolidation” before and many of us may have associated negative feelings toward the process because of what happened in the mortgage industry.  Balloon payments and variable rates have now left many in difficult situations and what initially appeared to be a good deal later was found to be detrimental.

Cash flow is the amount of income available to pay all debts at your practice along with the service of all of your personal needs at home.  What I have found in many practices is that at times money is spent to advance the practice’s technology or tenant improvements that cash flow is not taken into consideration as much as the interest rate offered.  After years of financing healthcare practices, I have found that many doctors decide to take shorter term notes, lease specials or zero interest programs that only last for 12 to 24 months.  Over time these types of loans begin to stack up and the payments can become too much to handle.  The compounding affect to this type of cash flow management is that when the hard payments begin to stack the flexible lines like credit cards and business lines only get paid to minimums.  The result is the perfect storm of business debt and negative cash flow that will create stress on the business and even more stress at home.

The solution to this type of problem is to talk to your banker about a complete business debt consolidation.  Consolidating all of your debt into one longer term note with friendly prepayment policies is the decision that could not only change the perspective at your office but also lighten things up at home.  Bank of America Practice Solutions offers this type of solution and the following is a real life example of how we changed someone’s life.

Current debt structure including original loan amount, term, rate, balance and monthly payment:

The total of all outstanding debt in the scenario is $424,500 with a monthly payment of $14,427.  This is real life and real life comes with stress, not only on a business, but also personally; this client has to feel overwhelmed and helpless.  The practice was a really nice operation with collections over $750,000 and income of $227,000 but the debt payment totaling $173,124 a year was smothering the doctor and could be felt throughout his life.

In this case we were able to pay off every debt that this existing and produced a 15 year term at 6.49%.  The monthly payment and monthly savings are listed below.  I do not think I need to go into detail on how this helped.

Let’s take a step back and realize that the best prevention and solution for this type of scenario is to consider cash flow before moving forward with any purchase.  If for some reason you have moved your practice into this position please contact me and discuss a complete refinance.  Many local banks will create a solution for you.  Most banks will not have access to a 15 year term but even a shorter term would very likely reduce your monthly expenses and increase your practice cash flow.  If your bank is unable to produce the result or you just want to comparison shop with another lender please feel free to contact Practice Solutions

For more information about the author or Bank of America Practice Solutions call 614-493-6360 or write robb.day@bankofamerica.com.

A new survey finds that patients’ expectations for healthcare providers have evolved. A majority expect their doctors to communicate with them proactively - even when they’re well - via texts, emails and proactive smartphone alerts.

Sponsored by Seattle-based communications firm Varolii, the survey polled 1,001 adults across the U.S.

Its findings may come as a surprise to some busy physicians. Nearly 80 percent of respondents say it’s their doctor’s job to keep them healthy - not just to treat them when they’re sick. And they wish there was more communication when they’re feeling OK: 70 percent of respondents say their doc has never checked on them when they weren’t sick in order to help them stay healthy.

“Today, quality healthcare goes far beyond the annual check-up or seeing a patient when they have the flu or are in pain,” said Vance Clipson, healthcare market manager for Varolii. “Innovative healthcare providers are moving away from focusing heavily on acute care, and instead shifting their focus to proactive care, patient wellness and chronic disease management.”

According to the survey, 50 percent of respondents said they believed texts, emails or smartphone apps with tips, reminders and encouragement could have helped them avoid a past health problem.

But this eagerness for more interaction notwithstanding, healthcare providers are lacking, they say. Just 25 percent of those polled said they felt their healthcare provider was accessible to them when they have questions or concerns. And 68 percent said their doctor has never sent them a text message or email regarding upcoming appointment reminders, discharge information or electronic health resources.

“Our survey found that 25 percent of people forget to take their medications on a regular basis,” said Clipson. “This is a huge problem for the healthcare industry, costing an estimated $300 billion annually. Healthcare providers have an opportunity to positively impact health and reduce costs with something as simple as a text message.”

In the age of the smartphone, the survey found physicians have some work to do. Just one in five healthcare providers are currently sending emails to patients. Just seven percent regularly send text messages, while only four percent make use of smartphone apps.

“We are in the era of the informed, digital consumer,” said David McCann, CEO at Varolii. “Healthcare providers need to leverage personalized, multi-channel communications if they want to engage with their patients in a meaningful and effective way.”

In the future, successful doctors, hospitals and health systems will shift their activities from delivering health services within their walls toward a broader range of approaches that deliver health, which will require providers to become less product-oriented and more customer-oriented.

So stated an editorial in the New England Journal of Medicine , by David A. Asch, MD, MBA, and Kevin G. Volpp, MD, PhD, from the Center for Health Equity Research and Promotion, Philadelphia Veterans Affairs Medical Center; the Penn Medicine Center for Innovation; and the Wharton School, University of Pennsylvania—all in Philadelphia.

Drawing on examples from failed business models, such as Eastman Kodak, Asch and Volpp noted that it is better to define a business by what consumers want rather than by what a company can produce.

“The analogous situation in healthcare is that whereas doctors and hospitals focus on producing healthcare, what people really want is health,” they wrote in the Sept. 6 editorial. “Healthcare is just a means to that end—and an increasingly expensive one. If we could get better health some other way … then maybe we wouldn’t have to rely so much on healthcare.”

To that end, Asch and Volpp suggested that there are three signals that healthcare could be missing.

One, “while much of recent U.S. medical practice proceeds as if health and disease were entirely biologic, our understanding of health’s social determinants has become deeper and more convincing,” they wrote. “An enormous body of literature supports the view that differences in health are determined as much by the social circumstances that underlie them as by the biologic processes that mediate them.”

Second, while traditionally there has been an implicit presumption that doctors and hospitals provide healthcare of consistently high quality, that presumption is now being challenged, as a result, “we’re getting much better at identifying, measuring, reporting and targeting health outcomes.”

For decades, health plans, states and the federal government have published quality data at the levels of conditions, populations, physicians and hospitals. Some of these data reflect processes—for example, which hospitals are better at giving aspirin to patients with acute MI—but more often data reflect outcomes, not just for patients within hospitals but for the populations surrounding them.

Also, the Mobilizing Action toward Community Health project has been publishing ratings of county-level population health. Finally, employers increasingly focus on employee wellness, on one side, and disease management, on the other. Research funding increasingly supports efforts to improve these measures and effectively communicate outcomes.
“This trend reveals an interest in what ultimately happens to individuals and populations,” Asch and Volpp wrote.

Third, healthcare financing is testing the pathways as well, in that payers will not reimburse for preventable readmissions and bundled payments will be issued for goals or episodes of care rather than visits. “Today’s standard approach of reimbursing for office visits and hospitalizations is likely to be displaced once better measures of outcomes can provide a substitute that’s more relevant to our key goals. If we can measure success, why pay for process?” they wrote.

“Doctors and hospitals who pay attention to the business they are actually in—defined by the outcomes their ‘customers’ seek—will leave the doctors and hospitals who don’t behind,” they concluded.

When it comes to satisfying patients as customers, practices need well-trained physicians, easy access to patients’ histories and long appointments — or at least the impression of long appointments, according to a Harris Interactive Poll issued Sept. 10.

“As other industries try to build customer loyalty, they are setting certain expectations for service,” said Vaughn Kauffman, principal and leader of the payer advisory practice at the consulting firm PwC. “And consumers are carrying those expectations into health care.

Harris researchers surveyed 2,311 adults between July 16 and 23. Eighty-four percent had visited a doctor’s office in the past 12 months. Of this group, 83% were satisfied or very satisfied with the encounter. When compared with other service industries, satisfaction scores were higher for restaurants and banks but lower for car dealers and health insurers.

Consultants who work with medical practices say many factors that go into making patients satisfied customers are easier to address than they sound. It’s important to do so, however, because satisfaction is becoming more critical in health care. Keeping patients happy can play a part in earning quality pay and persuading patients to come back and refer the practice to others.

For instance, 97% rated a doctor’s knowledge, training and expertise as important or very important with regard to creating a positive customer experience, although this factor is not readily changeable.

“That’s a given,” said Meryl D. Luallin, a partner with the SullivanLuallin Group in San Diego, which works with practices to improve the patient experience. “Patients take a doctor’s skills and training for granted. When you board a plane, you don’t stop by the cockpit to ask to see the pilot’s license. Patients typically make the assumption that somebody at the practice has already vetted the doctor.”

Other factors important to patients are easier to tackle. For example, 94% considered a physician being able to access a patient’s medical history as important or very important. Experts on the patient experience said this issue can be improved at practices with paper charts if physicians view them before entering the exam room. For physicians with electronic medical records who are not able to access the information until they are in the exam room, consultants suggest an introduction to the patient and then a brief explanation along the lines of, “I’m going to review your records, and then I’m going to give you my undivided attention.”

“It’s a little more challenging with electronic records because of the way a physician accesses the chart,” Luallin said.

This may help patients feel as if they have had a longer visit. Ninety-five percent in the Harris survey said time spent with the doctor is important or very important in being satisfied with the experience, but this does not necessarily mean lengthening appointments, which may be impractical or financially impossible for a practice. Consultants suggest that physicians sit in front of a patient rather than stand. Physicians who don’t look as if they are about to run out the door may give patients the impression of a longer visit.

“It’s all in the body language,” Luallin said.

Other surveys have suggested that consumers are less price-sensitive about health care than other industries but are more attuned to the service aspects. For example, a report on 6,000 consumers issued in July by PwC found that 69% said price was the No. 1 driver when considering leisure airline travel, but this was true for only 8% considering health care services. Forty-two percent said personal experience was the most important factor when choosing a doctor or hospital, but this was true for only 17% considering an airline ticket purchase.

ADDITIONAL INFORMATION:

With today’s margins becoming tighter, historically there have been only two options for physicians to increase compensation:  increase productivity or decrease costs.  Most private and hospital employed practices have taken measures to reduce their overhead and are operating lean.   Further, there are only 24 hours in a day, and while increasing productivity is a viable option for some physicians, it is physically impossible for those “super producers” to work harder.

A few minor tweaks to your revenue cycle could result in significant improvements to your cash flow, resulting in more compensation.  As a practice manager, there were several benchmarks reported  to the physicians I served monthly  This article focuses on three:

1. Net Collection Percentage

2. Days in Accounts Receivable

3. Distribution of Accounts Receivable in various aging cohorts

Net Collection Percentage, or the expected collections percentage net of adjustments, is calculated as follows:  ((Collections less Refunds)/ (Gross Charges less Adjustments))*100.  The ideal for this measure is around 98 percent.    In a perfect world, this number would be 100 percent.    A variance greater than 5% above the benchmark may indicate the billing company or staff may be inappropriately writing off charges.    Some possible reasons for these adjustments include: 1) accounts that were not filed timely according to your payer contracts, insurance payers paying less than the contracted fee schedule, or staff may not be working denials and old accounts.  A difference of 5% or more below the benchmark could indicate that 1) there are collectible receivables or 2) staff may be not adjusting enough off the accounts.

Days in Accounts Receivable is the number of calendar days between the day the service was rendered and cash was received.  While the following calculation looks daunting, it is very easy to enter the numbers on a spreadsheet for the calculation:  ((Total accounts receivable)/ (12 Months Gross Charges)*(1/365)).   An acceptable range for this benchmark is between 35 and 40 days.  We have seen some practices with days as low as 25.

The practice’s distribution of accounts receivable is another evaluation measure.  Typically accounts receivable is aggregated using the following categories:  0-30 days, 31-60 days, 61-90 days, 91-120 days, and 120+ days. When requesting the data, it is imperative that the report be generated by date of service.  This is the most objective way to analyze the report.

Billing staff frequently attempt to provide the report based on the date the insurance was billed, often with the excuse that physicians are not timely in submitting charges.  We frequently hear the excuse that “it will make the billing department/company look bad.”  Your practice should be paid as quickly as possible after the date you render a service.  If your staff knows you will be reviewing the report and it is provided for you based on the date the insurance was billed, there is a propensity for staff to simply rebill old claims without thoroughly working them, in essence making the numbers look better.

As a general rule, a majority of the outstanding accounts receivable should fall in the 0 to 60 days categories.  Many insurance companies have clauses in their contracts requiring claims be submitted within 90 days of service for consideration of payment.  If more than 20% of your accounts receivable is greater than 90 days old, you have reason for concern.  As mentioned earlier, adjusting these accounts without properly working them can inflate the Net Collections Percentage.

A few caveats with these benchmarks…These measures provide a snapshot of where you are today.  They should be provided by your practice administrator monthly as part of your dashboard report.  It is not uncommon for the measures to fluctuate.  Changes greater than 5 percent should be researched and explained by your staff.  Each of these areas is greatly affected by the processes and procedures in your practice.

For more information on how to improve your revenue cycle contact Steve Ratliff, Manager, Blue & Co., LLC, sratliff@blueandco.com or (502) 992-3830

Now that the Supreme Court has upheld the Affordable Care Act, expect increased marketing from insurance companies and health-care providers as they vie for the attention of consumers.

The law, slated for implementation by 2014, requires that states set up exchanges through which consumers can purchase health insurance regardless of pre-existing conditions. It also mandates that consumers show proof of coverage through their tax filings.

This means that insurance companies will continue to boost marketing aimed at a consumer base to which it never had to cater. And those that had put their marketing efforts on hold until the ruling was made will have to scramble to catch up, explained Lindsay Resnick, CMO of KBM Group, a WPP Health Services company. KBM works with a number of companies, including Wellpoint, Aetna, Blue Cross Blue Shield and Windsor Health.

“A lot of people over the last three months had been saying let’s wait for the decision — now [they're] three months behind,” he said.

Marketing issues aside, many health-related companies were moving forward as if the law would go into effect. Wendy Lund, CEO of health-care PR agency GCI Health, told Ad Age: “Many of our clients have been preparing for ACA implementation since the bill was signed in March 2010; most do not anticipate any immediate, significant changes to their core business. As for specific implications of ACA to health-care providers and insurers, it’s a little early to say. The hope is that reform will address several of the stress points in our health-care system, but the law will likely continue to evolve as the national discussion continues, especially in the context of the presidential election.”

Mr. Resnick said the next step for insurance companies will involve a lot of hyper-local targeting and attention to data. In many cases, health-care marketing agencies will be working closely with big consulting firms to look at clients’ segmentation and necessary changes to operational functions like call centers. “You better know in your markets who the uninsured people are who will now have access [to care], and who most likely will be taking advantage of the health exchanges.”

In the short-term, marketers will seek to forge loyalty with existing customers. Mid-2013 is when the budgets will start to grow and health companies will launch more aggressive efforts to attract new customers, he said. “There will certainly be a trend toward localization.”

Insurers’ actions pre-decision will also likely play a role in their loyalty strategy. A few weeks ago, three insurers — Aetna, Humana and United — pledged to uphold elements of the reform law, regardless of the Supreme Court ruling. As they look to forge loyalty, they can now remind consumers that they would have had their backs had the law been overturned. It’s a meaningful message in a much more competitive landscape where insurance brands have less room for distinction.

For health providers like hospitals, the Supreme Court decision means an influx of new customers and a short-term objective of setting expectations, Mr. Resnick said. “Say you have 15 million people pouring into [hospitals] with shiny new insurance cards. Providers have to figure out how to manage that. We’ll start seeing some marketing from providers around setting expectations in their community. We might see an uptick in mobile [marketing] or in the clinic market.”

Employers will also remain a b-to-b target for insurers, as the law mandates that businesses with more than 50 people distribute health benefits.

For some time I’ve been thinking about the language of healthcare. We all talk about taking the industry in a more patient-centric direction, but the language we use is anything but patient-friendly. At times, it isn’t even physician-friendly. I remember interviewing physicians as a part of a study I was conducting for an ACO (acronyms are even less friendly), and the doctors complained vehemently about the leadership’s use of terms like the “Triple Aim,” “interface engine,”  and “interoperability.” To them, this was business school speak, and didn’t reflect a true effort on the part of leadership to communicate effectively with the physicians.

Of course, we are an industry that loves its acronyms. Much of this is “insider speak,” whether we acknowledge it or not: EMR, EHR, ACO, PCMH, PPO, PCP, OTC, AQC. I could go on, but I won’t. As “providers” strive to improve quality, access andoutcomes, what do those terms mean to the average person on the street? (Providers is another word that doesn’t strike me as being very friendly.) Most people I know who work outside of healthcare don’t have a clue what we mean by “quality.” And even if they know what we mean by “outcomes,” is that the kind of language we want to use? At what point does a patient become an outcome? That sure doesn’t sound patient-friendly or patient-centric to me. It sounds like the kind of language we’d use if we were manufacturing widgets. We need to do better than that. There is power in language, and we need to use is intentionally.

Many experts expect shortages and maldistribution of dentists to be a problem in the future. But is this strictly a function of an inadequate supply of dentists to meet the demand?

Supply of Dentists

As stated in the www.staffcare.com white paper, “America is facing a dental shortage crisis. As the baby-boomer generation gets older, access to dental care will be paramount. Trends in dental school graduation rates and demographics suggest that the number of dental graduates will be insufficient to replace departing dentists.”

What’s more, studies concur that the supply of dentists is declining.

A study conducted by the Long Group, an independent research organization, predicts that the dentist population in the United States could be smaller by nearly 7,000 by 2019, assuming consistent dental school graduates of 4,500 annually.

The number of dentists in Kentucky is declining as well. Over the next decade, it is reasonable to assume that Kentucky will lose 250 to 350 practicing dentists, according to Dr. M. Raynor Mullins, of the UK Center for Oral Health Research.

But dentist population projections tell only part of the story.

Maldistribution

Of greater concern is the problem of maldistribution of dental care providers, which can result in limited access to dental care for poor and/or rural Americans.

“The current shortage in oral care providers is mainly a problem in rural areas,” says Dr. John J. Sauk, dean of the University of Louisville Dental School. “Louisville, Lexington and Frankfort are stable.”

In addition there are underserved dental specialties, such as pediatric dentistry – and many general dentists do not want to take kids as patients. “Children can be disruptive in a general dentist’s office,” Dr. Sauk says.

State dental schools are addressing the issues in a variety of ways - including recruiting rural Kentucky students (who are more likely to return to their home community), offering incentives for graduates to practice in rural locales, and providing charity services to underserved areas.

Even so, challenges remain. “The incentives are used sporadically, but they are getting better. “Small town living doesn’t always suit both spouses,” says Dr. Sauk.

“Further complicating the ‘access to care problem’ in rural areas of Kentucky and every other state in the United States are the two other elements in this ‘Perfect Storm,’ the student debt profile at graduation and the shifting population demographics. The entire country is experiencing a shift away from rural areas towards urban areas where jobs are concentrated in our increasingly knowledge-based economy,” says Dr. Sharon Turner, dean and professor of Oral Health Practice, University of Kentucky School of Dentistry.

Lack of Demand in Rural Areas

Yet the problem of underserved rural and poor localities is not just a result of a lack of dentists.

One of the key contributing factors to poor oral health in underserved areas may be insufficient demand.

“In low income and underserved areas, most practices are open. There is not a lot of elective dental work being done, especially cosmetic procedures. Certain specialties, such as orthodontists, are impacted more than others,” Dr. Sauk says.

“There are plenty of dentists who are open for business and ready to take patients, but the patients don’t come for appointments unless they have significant pain or infections, Dr. Turner says.

“This says to me that this access to care thing is a lot more complex than almost any of us has either realized or has been willing to admit. In addition to the lack of financial resources or lack of a dental practitioner with available appointments, there are literally a myriad of reasons that patients do not seek oral health care,” Dr. Turner says. “It’s a complex issue. Part of the problem is that there are a lot of barriers to adequate dental care beyond just having a dentist.”

The Cost of Dental Care

One major barrier would have to be the lack of robust dental insurance coverage and the resulting inability of many patients to pay for dental care.

Many people simply cannot afford to obtain routine, non-emergency or cosmetic dental care because they have neither the money nor the insurance to cover the cost of care.

Currently over a third of Americans don’t have dental insurance, the Staffcare white paper says. In Kentucky, an estimated 1,497,098 adults in KY have no dental insurance -   of any kind. Lack of insurance is one of the largest barriers to dental care.

Making matters worse, in Kentucky dentist participation in Medicaid and other state programs for the poor is miniscule, according to Dr. Sauk.

Only 33.5% of Kentucky dentists participate in the Medicaid/Passport/KCHIP programs according to a Kentucky Dental Provider Workforce Analysis. Dentists’ participation in state programs has been poor due to very low reimbursement rates that were not adjusted to keep pace with inflation in the 1990’s. Dental reimbursement rates were increased on July 1, 2001, but remain well below the usual, customary and reasonable (UCR) rates.

As Dr. Sauk says, “The average cost of running a practice includes overhead of 65 percent. Medicaid doesn’t come close to covering the overhead.”

According to the Kentucky Youth Advocates Essay on Kentucky’s Oral Health Outlook (2012) Kentucky providers are only reimbursed 51.9 percent of the median retail cost for services provided to Medicaid recipients. The low reimbursement rate, combined with the high rates of no-shows for appointments and long times waiting to receive reimbursement checks, cause many dental providers not to serve Medicaid recipients.

Other Barriers

Having observed that dental offices and clinics are often underutilized even by patients who do have Medicaid coverage or commercial dental insurance, Dr. Turner has determined that there are other factors at play.

As she says, “A good start on the list of these barriers to access to care would include low health literacy, fear of dentists, cultural beliefs and associated behaviors that place minimal value on oral health, lack of transportation, inability to get off work to seek preventive treatment, lack of motivation that may lead to embarrassment about oral health status once things are ‘out of control,’ inability of patients to ‘navigate’ the complex Medicaid and healthcare systems, a sense of general hopelessness over multi-generations, substance abuse, and a maldistribution of the dental workforce that does exist.”

“Each of these, as well as others that may be as yet unidentified, must be addressed if we are to have any impact on improving the oral health of the citizens of the Commonwealth,” She says.

Don’t blink. Tom Hart, M.D. and Tony Janckila, Ph.D. are demonstrating self-defense martial arts moves.

They’re at Synergy Martial Arts. Dr. Hart, a general surgeon with Baptist Surgical Associates, has practiced martial arts since college, starting with a Japanese style of karate called Chito Ryu. Since then, he has trained in Taekwondo, in which he holds a first-degree black belt, Tae Bahk Do, in which he is a fifth-degree black belt, and Shaolin-Do, where he is a first-degree black belt.

Synergy’s founder, Adam Robinson, says the school works primarily with children and teenagers. But Dr. Hart and Dr. Janckila, an adjunct associate professor in microbiology and immunology at U of L and technical director of the Special Hematology Laboratory at the VA Medical Center, are the only two on the mat this evening. They get together Wednesdays to work out and refine their techniques, drawing from different disciplines. The men move through a set of moves. Each combination of motions is a blur. “We broke it down into what we felt would be the most likely ways that we would be attacked empty-handed,” Dr. Hart says.

While martial arts is known for its self-defense value, other values also factor in. Some are physical – improved flexibility, strength, stamina and balance, says Dr. Hart. Others are familial; both Dr. Hart and Dr. Janckila have children who have trained in martial arts.

Another physician who saw this as a family-friendly activity is Tina Simpson, M.D., an OB-GYN with All Women. Her husband wanted to try martial arts, and she and her son and daughter were drawn into it as well. They joined Hwang’s Martial Arts and stayed about three years, all starting at the same level and advancing together to one level from black belt. “We had fun,” she says.

Dr. Simpson says there were several aspects of Taekwondo she and her family enjoyed, including the physical activity, the social element, and also the ways it builds discipline, confidence, respect and self-esteem. Beyond these, “I think it was good for our kids to see us be willing to get out of our comfort zone,” she says.

Charles R. Scoggins, M.D. also works out at Hwang’s. A surgical oncologist, and associate professor and vice chair of the Department of Surgery at the University of Louisville School of Medicine, he says he likes the exercise for the body, and for the mind, a relaxation similar to that of yoga. “I do Taekwondo, and also Judo,” he says.

Hwang’s Martial Arts Academy, on a Monday evening, was busy, with adults and children following their teachers’ instructions.

With Dr. Scoggins, too, this is a family activity; his wife and daughter also participate. Like her father, Chloe Scoggins, 14, recently got her black belt. She also helps teach other students. That – instructing – is part of the participation.

So, too, competition; it was necessary for advancement, Dr. Simpson says.

But what about the idea of martial – meaning warlike – arts? Isn’t there a danger of being hurt?

Dr. Hart, who competed for a short time but doesn’t now, says that with more experience comes more control over movements, technique and how and when to exert force. He used to worry about his hands when breaking boards. These days, he says, he trains with high-level people.

There is a realization that technique can trump power, Dr. Simpson says, that a well-placed move can bring down someone bigger. That, she says, is a confidence builder.

Dr. Scoggins, who also is about a year from his black belt in judo, and Dr. Simpson both say Hwang’s has a strong community service orientation, and Mimi Hwang, director of operations, says students need community service hours to reach black belt.

Hwang’s, Dr. Scoggins says, raised more than $40,000 this spring for Kosair Children’s Hospital, with a portion of that going specifically to the fight against leukemia.