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vol.26 no.4 • April 2018


Rates Down Providers are making progress on reducing healthcareassociated infections

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APRIL 2018 • VOLUME 26 • ISSUE 4

PUBLISHER’S LETTER Amazon isn’t coming to healthcare – they are already here...................................................6




LIS and the Physician Office Lab

Wholly MACRA!...........................................................................8



Providers are making progress on reducing healthcareassociated infections


Cracking the Code Bundled-payment programs are alive and well. The proof is a brand new program – Bundled Payments for Care Improvement Advanced – which was introduced in January by the Centers for Medicare & Medicaid Services.


Justin Freed, Regional vice president of supply chain, California/Texas, Providence St. Joseph Health, Renton, Washington.................................................................................12


What if the United States had the best healthcare and nobody showed up? What happens when care becomes cost-prohibitive?



repertoire magazine (ISSN 1520-7587) is published monthly by Share Moving Media, 1735 N. Brown Rd. Ste. 140, Lawrenceville, GA 30043-8153. Copyright 2018 by Share Moving Media. All rights reserved. Subscriptions: $49.00 per year for individuals; issues are sent free of charge to dealer representatives. If you would like to subscribe or notify us of address changes, please contact us at the above numbers or address. POSTMASTER: Send address changes to Repertoire, 1735 N. Brown Rd. Ste. 140, Lawrenceville, GA 30043-8153. Please note: The acceptance of advertising or products mentioned by contributing authors does not constitute endorsement by the publisher. Publisher cannot accept responsibility for the correctness of an opinion expressed by contributing authors. Periodicals Postage Paid at Lawrenceville, GA and at additional mailing offices.

April 2018


APRIL 2018 • VOLUME 26 • ISSUE 4


POST ACUTE In the Dark

State Medicaid agencies fail to report critical information about assisted living services................... 33

High-tech Home Care........................................................ 34 Surgical Wound Monitoring from Home............ 36

HIDA POST ACUTE INSIGHTS Aging Population, Hospital Partnerships to Drive SNF Patient Growth.............................. 37

HEALTHY REPS Health news and notes.......................................... 38

Automotiverelated news 40


Sarah Alasya: Save a Victim


44 HIDA GOVERNMENT AFFAIRS UPDATE Congress Tackles Vital Public Health Legislation..................................... 48

Technology news



April 2018


News........................................................................................... 54





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Amazon isn’t coming

to healthcare – they are already here Last month, I wrote about a trend I am seeing where manufacturers are returning to

you, the distribution sales rep, a place that has made the best of the best successful for decades. I believe this is happening for multiple reasons, but one specifically stands out – your relationship with the practice. Recently, I read an article in The Wall Street Journal titled: “Amazon Targets Hospital Supplies.” News flash, Amazon has been doing that for almost a decade. As I travel around the country talking with suppliers (both manufacturers and distributors), I love discussing Amazon, because everyone has an opinion on whether they will be successful or not. Some have high hopes for Amazon, some try and fight them, some are afraid of them, and some just shrug them off and say they will never be able to break in to this space. Scott Adams My opinion is simple, Amazon has found its way into the healthcare space and will continue to grow. They also focus on one important thing – the buyer – and his or her buying experience. Amazon is here to stay. However, I do not believe Amazon will displace distribution. Everyone in the industry will get better at determining what the provider needs and making it easier to buy products. Which doesn’t mean offering the lowest price. In many cases, the products being bought on Amazon today are higher priced than if they were bought on a GPO contract or an LVC. People are not buying from Amazon to save money, they are buying because of convenience. Suppliers today must wrap their mind around this fact. The trap of convenience shapes all our buying patterns. This ties in to the trend I mentioned at the beginning of this letter. Manufacturers are returning to you because of your relationships. The same is true as to why not everyone will switch to Amazon. The relationships you maintain in your accounts, combined with an ease of doing business, (the second part relies heavily on what your organization is doing to make purchasing convenient), will continue to keep the manufactures coming back to you and your customers buying from you. Never underestimate the power of relationships, and the value you bring both upstream and downstream in the supply chain. From Repertoire and the Suppliers who advertise in this magazine we see huge value in you, thank you for all you do every day! Dedicated to the industry! R. Scott Adams

repertoire is published monthly by Share Moving Media 1735 N. Brown Rd., Suite 140, Lawrenceville, GA 30043 Phone: (800) 536-5312, FAX: (770) 709-5432; e-mail: info@sharemovingmedia;

editorial staff editor

Mark Thill managing editor

Graham Garrison editor-in-chief, Dail-eNews

Alan Cherry art director

Brent Cashman


April 2018

vice president of sales

Jessica McKeever (800) 536.5312 x5271 director of business development

Alicia O’Donnell (800) 536.5312 x5261 sales executive

Tyler Moss (800) 536.5312 x5279 sales executive

Lizette Anthonijs (800) 536.5312 x5266


Scott Adams sadams@ (800) 536.5312 x5256 founder

Brian Taylor

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2018 editorial board Richard Bigham: IMCO

Eddie Dienes: McKesson Medical-Surgical


Joan Eliasek: McKesson Medical-Surgical


Doug Harper: NDC Homecare

Ty Ford: Henry Schein

Laura Gantert

Mark Kline: NDC


Bob Ortiz: Medline Pam Wedow: IMCO Home Care

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By Jim Poggi

LIS and the Physician Office Lab Wholly MACRA!

In my experience working with highly skilled and pro-

fessional distributor account managers, LIS systems remain one of the product lines they shy away from. In this article I intend to de-mystify LIS, make sense of it in light of MACRA requirements and give you confidence to hold discussions about this key connectivity tool. As the world continues to become more connected and interdependent, EMR and LIS are necessities for customers managing moderate complexity or high complexity labs. The distribution account manager who masters “the language of connectivity” will have a distinct advantage over those who hope the customer never asks … and who continue to ignore the changes all around them.

Risk vs. reward Why does this seemingly harmless connectivity and reporting tool create such anxiety, and why do so many polished professionals do their best not to engage customers in conversation about it? Often, it is a concern that the solution will not meet customer needs, and will frustrate the customer, putting the rest of the business at risk. From time to time, I hear “Yeah, I had a customer get a LIS from me about 5 years ago – or I know someone who did.” Fill in the blanks with a long and unsuccessful implementation, lack of features the customer expected, higher cost than hoped and jeopardy to the business.


April 2018

Sound familiar? It only takes one difficult or unsuccessful customer experience with unfamiliar products to scare off even the most seasoned veteran. Why put your business and customer relationships at risk, right? And besides, there are plenty of direct LIS companies. Let them do the work and get the headaches. There is no ongoing reagent trail to LIS anyway. However, it doesn’t have to be that way. An LIS system provides key features and advantages for the physician office lab performing moderate complexity testing. For example: • Test orders placed in the EMR can go directly to the LIS to create test orders seamlessly for the instruments the lab uses – that’s efficient. • Quality control packages make it easy to review and understand performance of every test the lab performs – confidence in results. • An LIS system captures all patient results, and sends them to EMR and patient records. This assures patient records are complete and enables billing for all tests performed. • An LIS system provides a variety of management reports about which tests were performed, by whom for which patients and when. This allows efficient oversight of the lab and careful attention to patient test results. It simplifies lab administration.

• LIS implementation helps enable the physician practice to comply with two of the four MACRA performance categories: Improvement Activities and Advancing Care Information, which together comprise 40 percent of the needed MACRA performance metrics. • It automates record keeping for the lab, leading to better preparation for an inspection. Good organization simplifies the inspection experience. So, if that’s all true, what does it take to develop a successful LIS solution, and how does the account manager avoid the pitfalls mentioned earlier? Attention to the basics. It takes a comprehensive understanding of customer needs and requirements, selection of the right LIS solution, a well-detailed implementation plan agreed by the customer, LIS company and instrument manufacturers, and follow up during the implementation phase and post implementation.

Understanding of customer requirements You need to know the following: • Which lab instrument systems they want to interface • W  hat EMR(s) they use •W  hether they want bi-directional or unidirectional connectivity • Are they replacing a current LIS, or is this a first LIS? • I f replacing a current LIS, why do they want to change? •W  hat do they THINK the benefits of the LIS will be? How realistic is their viewpoint?

Implementation Make sure your LIS supplier takes the lead on implementation, because they are the experts. Hold a kickoff meeting with the iTmplementation team and customer to begin the process. Hold milestone meetings on a fixed schedule with all involved. Uncover and immediately report and resolve implementation issues with the team involving the customer in the process. Make sure customer training is carefully planned and customers are fully engaged. Maintain active customer communication every step of the way until they sign off on final implementation.

A well thought out LIS system solution helps your customers in many ways and adds to your credibility as a key resource and consultant.

Post implementation

Following implementation, hold a team meeting, without the customer, post customer sign off to assess how the implementation went and any learnings that could make the next implementation smoother. Meet with the customer 30 days or so post implementation with the LIS supplier (and key instrument manufacturers if needed) to review progress, assess any further training needs or customer questions regarding use of the system. Continue to hold progress report meetings at appropriate intervals. A well thought out LIS system solution helps your customers in many ways and adds to your credibility as a key resource and consultant. LIS systems will have increasing importance as MACRA is implemented.

Developing a solution Share what you learned with your most trusted LIS supplier (or ask your lab specialist or other colleagues who they recommend). Set time with your LIS supplier to meet with the client to establish or confirm the detailed customer needs. Have your LIS supplier work with the instrument manufacturers and EMR company to assure needs are clearly understood, time frames and costs are established and each company has a lead person involved and an overall plan is established. Be present and participate actively. Share the implementation plan and proposal with the customer; close for agreement on costs, timing, and customer responsibility for training and implementation.

Things to remember Remember, you are the quarterback; use the expertise of the entire team. Good customer expectations and diligence in uncovering needs are critical to a good result. EMR connectivity (how long it takes to get the EMR to respond and help with their end) is always the rate limiting factor on implementation speed. The EMR company will change an interface fee; make sure the customer understands this in advance. You can do this, and your customers need LIS and EMR connectivity to maximize their MACRA performance in Improvement Activities and Advancing Care Information.

April 2018


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Contracting Executive Profile Justin Freed, Regional vice president of supply chain, California/Texas, Providence St. Joseph Health, Renton, Washington

Editor’s note: Justin Freed was selected as one of the “Ten People to Watch in Healthcare Contracting” by the Journal of Healthcare Contracting, a sister publication of Repertoire.

Formed in 2016 with the merger of Renton, Washington-

based Providence Health & Services and St. Joseph Health System of Irvine, California, Providence St. Joseph Health is a 50-hospital system with facilities in seven states. The system employs 106,000 people, and recorded 23 million visits/admits in 2016, and $21 billion in revenue. Prior to becoming regional vice president of supply chain, Justin Freed was executive director of supply chain at Loma

Linda University Medical Center, where he worked for more than six years. He also worked at Adventist Health West, where he held leadership positions in supply chain and human resources. He has a bachelor’s degree in business administration from Southern Adventist University and a master’s in health administration from Loma Linda University. Freed’s areas of responsibility include supply chain, engineering and hospitality for the 18 Providence St. Joseph hospitals in his region. His

I worked closely with our system sourcing team as well as the local surgeons and hospital executives to renegotiate pricing with an off-contract vendor, saving the region over $800,000 annually. primary focus is working with hospital executives, leadership and physicians on improving service value and lowering supply expense costs. Journal of Healthcare Contracting: What has been the most challenging and/or rewarding supply-chain-related project in which you have been involved in the past 12-18 months? Justin Freed: When I joined Providence St. Joseph two and a half years ago, my primary

Justin Freed


April 2018



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focus was to support the California region supply chain team while improving supply chain performance, whether it be contract compliance or service. A number of surgeons in the region were using an off-contract total joint vendor. I worked closely with our system sourcing team as well as the local surgeons and hospital executives to renegotiate pricing with an off-contract vendor, saving the region over $800,000 annually. It was truly a team effort among surgeons, supply chain and hospital execs to achieve the savings goal, which will help in future projects and initiatives. JHC: Please describe a project on which you look forward to working in the next year. Freed: I look forward to: •C  ontinuing the integration work of the Providence St. Joseph supply chain organization. •M  easuring the service value and performance at each of our 50 hospitals. • I dentifying and developing best practices to share and cross-pollinate throughout the system, while eliminating uncontrolled variation by partnering with our caregivers, physicians and strategic vendors.

11/30/17 11:27 AM

• Continuing to engage and develop relationships with our hospital executives and physician leaders to maximize our supply chain influence and effectiveness. JHC: In what way(s) have you improved the way you approach your job or profession in the last 5-10 years? Freed: Healthcare supply chain is continuing to evolve and advance in order to catch up to supply chain in other industries. Being open to new ideas, thoughts and strategies is something I try to build into my professional DNA. I was extremely lucky early in my supply chain career to be mentored by Brent Johnson and Joe Walsh of Intermountain Healthcare. I met them while I worked at Loma Linda, and they allowed me to spend time with them and their teams, which was great exposure early on for me. JHC: What do you need/want to do to become a better supply chain executive in the coming year(s)? Freed: I want to continue to be exposed to creative thinking and innovation that advances my development as a supply chain executive. Engaging with supply chain leaders in other industries allows me to open my mind to new concepts and strategies to improve outcomes and lower the cost to serve patients.

April 2018



Rates Down Providers are making progress on reducing healthcareassociated infections

Healthcare in the U.S. is safer now

than it was 10 years ago, according to recent data compiled by the Centers for Disease Control and Prevention. The incidence of central-line-associated bloodstream infections (CLABSIs) dropped significantly between 2008 and 2016, while catheter-associated urinary tract infections (CAUTIs) have dropped as well, most markedly in non-ICU locations. And while surgical site infections are on the decline, progress may be slowing following some procedures. The data was published recently by CDC in “Healthcare-associated Infections in the United States, 2006-2016: A Story of Progress.”


April 2018

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Health focus: Infection prevention “Infection preventionists nationwide are seeing the positive effects of HAI [healthcare-associated infection] reduction efforts initiated in the early 2000s,” says Marie H. Wilson, BSN, BS, RN, CIC, infection preventionist at Methodist Dallas Medical Center. “CDC’s National Healthcare Safety Network – NHSN – established a new baseline comparison for HAI Standardized Infection Ratios – SIRs – with data aggregated from 2015,” says Wilson, who is a member of the communications committee of the Association for Professionals in Infection Control and Epidemiology. “As a result of this ‘rebaseline,’ it’s now harder to achieve lower SIRs – a sign that fewer infections are predicted. This is a direct result of HAI prevention initiatives seen nationwide, including safer and reduced use of indwelling devices and antimicrobial stewardship programs.” “The CDC’s report confirms we’re driving the needle of change toward zero HAIs.”

Changes over time in CLASBI SIR (standardized infection ratio) in U.S. hospitals using 2006-8 baseline, NHSN 2006-2016

National action plan In 2009, the U.S. Department of Health and Human Services published the “National Action Plan to Prevent Health Care-Associated Infections: Road Map to Elimination,” which set five-year goals for HAI prevention. CDC publishes yearly reports to help each state identify its progress and target areas that need assistance. The data used in these reports comes from two surveillance systems: the National Healthcare Safety Network (NHSN) and the Emerging Infections Program Healthcare-Associated Infections Community-Interface (EIP HAIC). In addition, CDC and other federal agencies, such as Centers for Medicare and Medicaid Services, the Agency for Healthcare Research and Quality and the Office of the Assistant Secretary for Health, work together to develop tools, recommendations, and programs that offer infection prevention strategies. In its most recent report, CDC examines the nation’s progress preventing five of the most common infections: • Central-line-associated bloodstream infections (CLABSI). • Catheter-associated urinary tract infections (CAUTI). • Select surgical site infections (SSI). • Hospital-onset Clostridium difficile infections (CDI). • Hospital-onset methicillin-resistant Staphylococcus aureus (MRSA) bacteremia (bloodstream infections).

Central Line-Associated Bloodstream Infection (CLABSI) Nationally, CLABSIs dropped roughly 50 percent between 2008 and 2016. The data also shows a reduction in

Proportion of CLABSIs by location in US hospitals, NHSN 2015 (N=26,029)


April 2018

Changes over time in non-yeast CAUTI SIR in US hospitals using 2009 baseline, NHSN 2009-2016

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Health focus: Infection prevention Changes over time in catheterization utilization ratio (urinary catheter days per patient days) in U.S hospitals, 2010-2016

Proportion of MRSA bacteremia events by type of onset, NHSN 2016 (N=72,852)

the use of central lines. “Carefully determining the necessity of central lines before insertion is a CLABSI prevention strategy,” points out CDC. The magnitude of SIR (standardized infection ratio) declines from 2012-2014 leveled off, a trend that was more pronounced on wards, to which the majority of CLABSIs were attributed in 2015, says CDC. And recent unpublished data suggests that, at least among adult intensive care unit (ICU) patients, declines in CLABSIs caused by Staphylococcus and Enterococcus spp. have outpaced declines in infections caused by gram negative and fungal pathogens.

seen progress in ICUs as well. Data also indicates a reduction in urinary catheter usage – a key prevention strategy for CAUTI. Although CAUTIs that include those caused by yeast declined on wards from 2012 through 2014, they failed to decline in ICUs. However, using the more clinically relevant CAUTI definition, which no longer includes yeast, and applying this retrospectively as well as in the new baseline, there were yearto-year declines in CAUTIs in both ICUs and wards from 2012 through 2016. The removal of yeast from CAUTI reports from 2009 through 2014 shows that reductions in wards – to which a slight majority of CAUTIs were attributed in 2015 – were more pronounced. However, there were also declines in the ICU SIR, resulting in successive yearly relative declines of 6-8 percent in the CAUTI SIR from 2012 through 2014.

Catheter-associated Urinary Tract Infection (CAUTI) After an early lack of progress, CAUTIs have been steadily declining over the past few years. The gains have been most marked in non-ICU locations, but recent years have

Changes over time in surgical site infection SIR after any of 10 surgical care improvement project (SCIP) procedures in U.S. hospitals using 2006-8 baseline, NHSN 2010-2014.

“Carefully determining the necessity of central lines before insertion is a CLABSI prevention strategy.”

Surgical site Infections Overall, the incidence of surgical site infections has dropped since 2010. That said, progress may be slowing following some procedures.

Clostridium difficile Infection (CDI) SCIP procedures are: vascular (i.e., abdominal aortic aneurysm repair or peripheral vascular bypass surgery), coronary artery bypass graft, other cardiac surgery, colon surgery (colon or rectal), hip arthroplasty, abdominal hysterectomy, knee arthroplasty and vaginal hysterectomy.


April 2018

Crude rates of healthcare-associated CDI are decreasing, reflecting declines in nursing home-onset infections along with some declines in hospital-onset CDI, says CDC. An assessment of CDI events reported to NHSN demonstrates that





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Health focus: Infection prevention Changes over time in CLASBI SIR (standardized infection ratio) in U.S. hospitals using 2006-8 baseline, NHSN 2006-2016

nearly 70 percent of reported events had their onset in the community in 2015.

Methicillin-resistant Staphylococcus aureus Bacteremia (MRSA Bacteremia) There has been major progress since 2005 in preventing MRSA bacteremia due to declines in hospital-onset and community-onset, healthcare-associated bacteremia.

Much of the progress reflects improvements in preventing insertion-related CLABSIs. More than 80 percent of reported events in 2015 had their onset in the community. There has been little or no decline in community-associated “The CDC’s MRSA bacteremia, suggesting a need for a comprehensive, mulreport tidisciplinary, community-based confirms we’re driving public health approach to prevention of invasive infections the needle caused by this common skin orof change ganism, says CDC. toward “The fact that the community zero HAIs.” burden of MRSA bloodstream infections isn’t worsening is a testament to the work infection preventionists are doing in collaboration with physicians and pharmacists on antimicrobial stewardship programs,” says Wilson. “CDC’s National Action Plan for Combating AntibioticResistant Bacteria (2015) outlines several goals and objectives many groups and individuals can employ to reduce the impact of multidrug-resistant organisms across the board.”

Editors note: “Healthcare-associated Infections in the United States, 2006-2016: A Story of Progress” may be accessed at Source for all figures: “Healthcare-associated Infections in the United States, 2006-2016: A Story of Progress,” Centers for Disease Control and Prevention.

Joint Commission’s goals for patient safety The Joint Commission created its National Patient Safety Goals in 2002 to help accredited organizations address areas of concern regarding patient safety. They are updated regularly. The 2018 National Safety Goal No. 8 – Healthcare-associated infections – contains the following components: • Comply with either the current Centers for Disease Control and Prevention hand-hygiene guidelines or the current World Health Organization hand-hygiene guidelines. • I mplement evidence-based practices to prevent healthcare-associated infections


April 2018

due to multidrug-resistant organisms in acute care hospitals. • I mplement evidence-based practices to prevent central-line-associated bloodstream infections. • I mplement evidence-based practices for preventing surgical site infections. • I mplement evidence-based practices to prevent indwelling catheter-associated urinary tract infections (CAUTI). Source: Joint Commission

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Health focus: Infection prevention

Toolkit for Infection Prevention If your long-term-care customers are having difficulty

controlling catheter-associated urinary tract infections, refer them to the “Toolkit To Reduce CAUTI and other HAIs in Long-Term Care Facilities,” from the Agency for Healthcare Research and Quality, part of the U.S. Department of Health and Human Services. Based on principles and methods from the Comprehensive Unit-based Safety Program (CUSP), the toolkit provides resources to enhance leadership and staff engagement, teamwork, and safety culture, in order to facilitate consistent use of evidence-based practices. The toolkit includes instructional materials and resources in infection prevention best practices (e.g., foundational infection prevention strategies, CAUTI prevention, antibiotic stewardship), resident and family engagement, quality improvement, and sustainability to guide the facility through implementing an improvement project to reduce healthcare-associated infections. The toolkit’s resources were used by long-term-care facilities that participated in the AHRQ Safety Program for LongTerm Care: HAIs/CAUTI, which successfully reduced rates of catheter-associated urinary tract infections.

The toolkit is organized into three main sections, which facilities can use to implement an improvement project to reduce CAUTI and other HAIs. Each section contains guides, tools, slide sets, and videos to support implementation. • Implementation. The guide provides guidance about how to start and implement a program, as well as information about the Long-Term Care Safety Toolkit Modules, educational bundles and other resources to facilitate implementation. • Sustainability. The guide provides long-term-care facility teams with an overview of how to successfully sustain improvements made during and after a project is implemented. • Resources. This section aggregates all of the instructional guidance, tools, and resources cited throughout the project. The Toolkit may be accessed at professionals/quality-patient-safety/quality-resources/ tools/cauti-ltc/index.html

Contact Precautions: When to Stop. When is it safe for hospitals to discontinue contact pre-

cautions – gloves, gowns, masks, etc. – for patients with multidrug-resistant bacteria? The Society for Healthcare Epidemiology of America published new guidance on the topic in January, in Infection Control and Hospital Epidemiology. “Because of the virulent nature of multidrug-resistant infections and C. difficile infections, hospitals should consider establishing policies on the duration of contact precautions to safely care for patients and prevent spread of these bacteria,” said David Banach, M.D., MPH, an author of the study, and hospital epidemiologist at University of Connecticut Health Center. “Unfortunately, current guidelines on contact precautions are incomplete in describing how long these protocols should be maintained.”


April 2018

According to the guidance document, hospital personnel should weigh how much time has elapsed since the last positive culture to determine if contact transmission is likely. The guidance also advises on patient characteristics that could determine the duration of care. For Clostridium difficile infections (CDIs) specifically, the recommendation is to continue contact precautions for at least 48 hours after the resolution of diarrhea, and to consider extending if CDI rates are elevated despite infection prevention and control measures. Insufficient evidence exists to make a formal recommendation on whether patients with CDI should be placed on contact precautions if readmitted to the hospital, according to SHEA.

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What if the United States had the best healthcare and nobody showed up? What happens when care becomes cost-prohibitive?

We routinely hear about how great

healthcare is in this country, with our stateof-the-art technologies, digital health, and the best labs, doctors, distribution network, products, treatments, medications, innovation, hospitals, etc. Often the pundits say if only we could run it like a “real” business, we could eliminate all the idiosyncrasies, fraud and abuse. But the fact that we’ve By Bruce Stanley been trying to run healthcare like a business for quite some time and haven’t fixed many of our systemic failings makes me wonder about the merit of that belief. Having a “business-like” vision isn’t in and of itself wrong. What seems to have evolved, however, is that profitability has become paramount. Just look at healthcare CEO salaries and ask yourself, “How many patients has that person treated lately?” Probably not many. Using a “business approach” to healthcare leads to greater interest and financial returns in ongoing treatment. In fact, treatment is where the money is. One doesn’t have to look far to see glaring examples: diabetes treatment, opioid overprescribing, extravagant pharma advertising, and to some extent, the push for new digital health devices and apps. Then there’s the explosion of medication costs. The news often highlights the high cost of orphan drugs for patients with rare diseases. But what about the costs for patients with mainstream chronic diseases?


April 2018

There are probably hundreds of examples, but one that personally comes home to me is prescription pancreatic enzymes, which have stratospherically increased in price over the last decade. One must question, what’s changed? And what about hospital funds being used to create gardens dedicated to the spouse of the CEO – the same CEO who shut down clinical departments needed by the community?

Disappearing patients During the Vietnam War era, many uttered the slogan, “What if we had a war and nobody came?” Similarly, I question what would happen to our healthcare system if patients simply didn’t show up for care. Even today, individuals with “good” insurance refuse to have certain tests done, return for a follow-up doctor visit or pick up a high-priced medication from the pharmacy. The costs are unaffordable and the value of the treatment questionable.

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We have convinced ourselves that the healthcare in the USA is the best in the world. In many ways, that’s true. But what if it becomes so cost-prohibitive that care becomes available only to the wealthy and well connected? In a recent conversation, a colleague shared with me how her critical life-sustaining maintenance medication has risen dramatically in price since 2000. She described that her drug underwent numerous patent changes but nothing materially changed. It became a new drug with new protections. Never did the drug’s manufacturer consider how the skyrocketing costs would affect the patient both with her medication regimen or lifestyle. Nor did they appear to care. When patient care becomes so segmented and only the wealthy have access to it, support systems like insurance, innovation, manufacturing, distribution – which are all predicated on volume – collapse. Where does that leave the rest of our industry? Maybe we need to rethink the approach that healthcare needs to run solely like a business, and return to the belief that healthcare is about creating cures and healing patients.

“Maybe we need to rethink the approach that healthcare needs to run solely like a business, and return to the belief that healthcare is about creating cures and healing patients.”

Bruce Stanley is a global supply chain, business development and contracting operations advisor and consultant with over 30 years in the healthcare industry. In 2011, he co-founded The Stanley East Consulting Group, in Ipswich, Mass., a consulting practice specializing in supply chain, contracting, business development, order fulfillment and project management for small and medium-sized companies, startups, and companies in transition or divestiture. He is also a published author of many observational commentaries on healthcare processes, and an adjunct MBA professor teaching global supply chain, contracting and healthcare informatics and regulations. He previously served as senior director, contracting operations, for Becton Dickinson.

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April 2018



Cracking the Code Bundled-payment programs are alive and well. The proof is a brand new program – Bundled Payments for Care Improvement Advanced – which was introduced in January by the Centers for Medicare & Medicaid Services.


Repertoire readers may recall that neither former HHS

Re-engineer care along the continuum

Secretary Tom Price or Centers for Medicare & Medicaid Services Administrator Seema Verma were fans of mandatory bundled programs. In fact, they cancelled one program for cardiac care and scaled back another for orthopaedic joint replacement. But they didn’t count out voluntary programs. Neither has Price’s successor, Alex Azar. In bundled payment programs, a group of acuteand non-acute providers agree to share the financial rewards of providing cost-effective, high-quality care to patients across a 90-day period (called a “Clinical Episode”), or bear the penalty for providing care that is too costly or of poor quality. Each provider continues to receive its fee-for-service reimbursement from Medicare. But if, collectively, they care for a patient across an entire Clinical Episode for less than the Medicare “target” cost (while maintaining certain quality standards), they share the savings. The whole point is this: Providers across the care continuum are encouraged to work together to reduce the cost and improve the quality of a patient’s care.

Some of the fine print in BPCI Advanced differs from that in the original BPCI program, which was launched in 2013. But its intent is the same: • Support providers who are interested in continuously re-engineering care. • Eliminate unnecessary or low-value care, increase care coordination and foster quality improvement. • Test a payment model that creates extended financial accountability for improved patient outcomes and reduced spending. • Stimulate rapid development among providers of new, evidence-based knowledge, that is, the Learning System. • Increase the likelihood of better health at lower cost through patient education and ongoing communication throughout the clinical episode.

April 2018

“This effectively is a stake in the ground for the continued growth of value-based programs that reduce costs and deliver better care,” says Clay Richards, CEO and president,







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POST ACUTE naviHealth, a Cardinal Health company that focuses on care transitions. “The administration has always supported voluntary models where providers can opt in, embrace a more flexible model structure, and qualify for greater incentives. The industry has been hungry for more programs like BPCI, and we believe BPCI Advanced signifies the future of value-based care.” Says Mark Hiller, vice president of bundled payment services at Premier, BPCI Advanced “most definitely indicates a strong movement toward value-based payment, with bundles being one of the most impactful models amongst several others that are now qualified for Advanced Alternative Payment models under MACRA. “Bundled payments are a tried and true mechanism that promotes integrated processes, operational efficiencies, physician engagement/alignment, and cross-continuum relationships for both patients and healthcare organizations.” Post-acute providers will be pivotal in bundled payment programs, says Hiller, pointing out that skilled nursing facilities made up almost half of the BPCI participants. BPCI Advanced will launch on October 1, 2018, and the Model Period Performance will run through December 31, 2023. CMS said it would provide a second application opportunity in January 2020.

Redesign care delivery

“This effectively is a stake in the ground for the continued growth of value-based programs.”

Clay Richards

A BPCI Advanced “Clinical Episode” begins either at the start of an inpatient admission to an acute-care hospital (a so-called Anchor Stay) or at the start of an outpatient procedure (an Anchor Procedure). Inpatient admissions that qualify as an Anchor Stay will be identified by MS-DRGs, while outpatient procedures that qualify as an Anchor Procedure will be identified by HCPCS codes. The Clinical Episode will end 90 days after the end of the Anchor Stay or the Anchor Procedure. BPCI Advanced will initially include 29 inpatient and three outpatient “Clinical Episodes.” Participants selected to participate in the program will be held accountable for


April 2018

one or more Clinical Episodes, and may not add or drop such Clinical Episodes until Jan. 1, 2020. Types of services included in a Clinical Episode are: • Physicians’ services • Inpatient or outpatient hospital services that comprise the Anchor Stay or Anchor Procedure • Other hospital outpatient services • Inpatient hospital readmission services • Long-term-care-hospital (LTCH) services • Inpatient rehabilitation facility services • Skilled nursing facility (SNF) services • Home health agency services • Clinical laboratory services • Durable medical equipment (DME) • Part B drugs • Hospice services CMS has selected seven quality measures for the BPCI Advanced Model. Two of them – “All-cause hospital readmission” and “Advance care plan” – will be required for all Clinical Episodes. The following five measures will only apply to select Clinical Episodes: • Perioperative care: Selection of prophylactic antibiotic. • Hospital-level, risk-standardized complication rate following elective primary total hip arthroplasty and/or total knee arthroplasty. • Hospital 30-day, all-cause, risk-standardized mortality rate following coronary artery bypass graft surgery. • Excess days in acute care after hospitalization for acute myocardial infarction. • AHRQ patient safety indicators, including pressure ulcer rate, in-hospital fall with hip fracture, iatrogenic pneumothorax rate, perioperative hemorrhage or hematoma rate, postoperative acute kidney injury, postoperative respiratory failure, perioperative pulmonary embolism or deep vein thrombosis, postoperative sepsis, postoperative wound dehiscence and unrecognized abdominopelvic accidental puncture/laceration.

Cracking the code “While we’re not surprised BPCI was successful, the results of our partnerships as a risk-bearing BPCI convener have and continue to exceed expectations,” says Richards. “With the more than 50 hospital partners we’re working with across the country, we’ve helped achieve more than

“We have witnessed incredible success for those organizations who ‘crack the code’for bundled payments.”

Says Hiller, “We have witnessed $83 million in total annual gross savincredible success for those orgaings while improving the quality of nizations who ‘crack the code’ for care for patients. With the recent bundled payments, both in medical BPCI Advanced announcement, we’re bundles and surgical bundles, thus particularly encouraged by CMS’ proving the bundled-payment model emphasis on care redesign and tying is a triple win for hospitals, physiperformance to more quality meacians and patients. Some providers sures – measures that go beyond just find the concepts of bundles to be ‘checking the box’ and that really put the way care should be coordinated the patient forward. across the continuum – applying “BPCI provides the unique Mark Hiller many bundled payment-like conopportunity for providers to drive cepts to other service lines. change and improvements in healthcare,” he continues. “The disappointment may come for those organiza“Whatever the arrangement, we’ve seen a real coalescence tions that are unable to gain leadership and organizational around a program like BPCI – one that is shared across alignment in time to succeed and make a difference in the continuum by all providers in that we can continue their bundled payment program. Timing is everything and to do better in patient outcomes, patient quality and in is crucial to success.” driving value.”

The 32 Clinical Episodes The 29 inpatient Clinical Episodes in BPCI Advanced are: 1. Disorders of the liver excluding malignancy, cirrhosis, alcoholic hepatitis 2. Acute myocardial infarction 3. Back & neck except spinal fusion 4. C  ardiac arrhythmia 5. C  ardiac defibrillator 6. C  ardiac valve 7. Cellulitis 8. C  ervical spinal fusion 9. C  OPD, bronchitis, asthma 10. C  ombined anterior posterior spinal fusion 11. Congestive heart failure 12. Coronary artery bypass graft 13. Double joint replacement of the lower extremity 14. Fractures of the femur and hip or pelvis 15. Gastrointestinal hemorrhage 16. Gastrointestinal obstruction 17. Hip & femur procedures except major joint

18. Lower extremity/humerus procedure except hip, foot, femur 19. Major bowel procedure 20. Major joint replacement of the lower extremity 21. Major joint replacement of the upper extremity 22. Pacemaker 23. Percutaneous coronary intervention 24. Renal failure 25. Sepsis 26. S imple pneumonia and respiratory infections 27. Spinal fusion (non-cervical) 28. Stroke 29. Urinary tract infection The three outpatient Clinical Episodes are: 1. Percutaneous coronary intervention (PCI) 2. Cardiac defibrillator 3. Back and neck (except spinal fusion)

April 2018



A new look BPCI and BPCI Advanced share a number of features. For example, both are voluntary programs, and both allow hospitals or physician group practices to assume responsibility for bundles of care. However, BPCI Advanced diverges from BPCI in several ways: • BPCI Advanced establishes the first-ever outpatient episodes – percutaneous coronary intervention, cardiac defibrillator, or back and neck except spinal fusion – all of which are identified by a Healthcare Common Procedure Coding System, or HCPCS, code. Additional clinical episodes may be included in future model years. • BPCI Advanced is an Advanced Alternative Payment Model (Advanced APM) under the Quality Payment Program. In addition to the potential for participants to receive payments under the model, eligible clinicians

who meet threshold levels of participation in BPCI Advanced for a year will receive a 5-percent APM incentive payment under the Quality Payment Program (available for payment years from 2019 through 2024). • BPCI Advanced will take into account patient case mix. Preliminary target prices will be provided in advance of the first performance period of each model year and will be adjusted during the semi-annual reconciliation process to calculate a final target price that reflects patient case mix during the applicable performance period.

Lessons learned What are the top three lessons learned by providers in bundled payment programs over the last five years? Per Clay Richards, CEO and president of naviHealth, a Cardinal Health company, they are: 1. Don’t underestimate the importance of data analytics. Hospitals need to compare their data against national and regional benchmarks to identify high-cost areas that can benefit from clinical interventions and care redesign. This includes drilling into the data not only by episode, but also by individual physician. A successful game plan for the program begins with the data. 2. Hospital leadership must be committed to true change management, and must demonstrate a willingness to think outside the box in terms of care improvement. Episodes of care should be


April 2018

designed holistically around the patient, which requires a mix of new methodologies and capabilities for hospitals – ones that demand an increasing focus on individualized care plans and post-discharge planning, with the goal of returning patients to the highest functional status while preventing unnecessary complications and readmissions. 3. Hospital leadership must understand that continuous process improvement takes time. They need to commit to high quality value-based care, and they need to evolve as BPCI Advanced continues to change.


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Bundled payments programs: Not a side project Bundled payment programs are not for the weak of heart or for health systems lacking solid leadership. A study in the Journal of the American Medical Association in January reported that only 12 percent of eligible hospitals signed up for the voluntary BPCI program, and 47 percent of them dropped out within two years. “The BPCI national trend factor (which has been modified for BPCI Advanced) continued to create downward compression on the target prices in the later years of BPCI,” says Mark Hiller, vice president of bundled payment services at Premier. “These diminishing returns were most likely one of the primary factors related to an early departure. “In addition, internal organizational alignment is critical. There are negative implications for a hospital if bundled payments are treated as a side ‘project’ versus a dedicated, systemwide endeavor. We have found that some of these factors contribute to a hospital’s success compared to those that drop out of the program.” Says Clay Richards, CEO and president, naviHealth, “Many hospitals did not choose to participate in BPCI due to the nature of uncertainty and perhaps the perceived inability to influence post-acute outcomes. For those hospitals that did participate, several may have jumped into the program not understanding the full scope of participation, or perhaps engaged without convener support, or without adequate preparation to implement the processes and capabilities required to impact post-acute outcomes. “In our experience, those health systems that remained in the program have seen steadily increasing results as adoption of care redesign has increased and alignment of stakeholders across the continuum has improved. CMS has solved some of the pricing uncertainty and transparency concerns that are present in BPCI. There’s also an aspect of time and care delivery trending toward value-based care. As payers


April 2018

continue to incentivize this type of care, there will be greater and greater uptake.” Readiness for change A readiness for change is perhaps the most significant predictor of a health system’s success with bundled payment programs, says Gina Bruno, vice president, clinical strategy, naviHealth. “Successful hospitals and those that appear most ready for BPCI Advanced have made an organizational commitment to valuebased care and have worked to foster a culture change, where care is managed and coordinated across the recovery journey.” They have invested in clinical decision support technology as well as clinical resources – including care coordinators or care navigators – to drive more informed decisions about post-acute care, and to monitor patients’ postacute progress, says Bruno. In addition, they are selecting post-acute providers with consistently high outcomes, with the staff and resources to meet the needs of their patients, and a willingness to work collaboratively to use data to monitor performance. That said, patient choice remains paramount; patients and their families are the ultimate decision-makers about who will provide their post-acute care, she says. “It’s not an easy task. Many systems have taken months if not years to formulate these processes and all that comes with it. But they realize that there is benefit to doing this work beyond just Medicare and BPCI.”

CMS has solved some of the pricing uncertainty and transparency concerns that are present in BPCI.

In the Dark State Medicaid agencies fail to report critical information about assisted living services

State Medicaid agencies covering assisted living ser-

vices are failing to report some critical information about beneficiaries’ health and welfare, according to the United States Government Accountability Office (GAO), which released a report in January. According to the GAO: • Twenty-six state Medicaid agencies could not report to GAO the number of critical incidents that occurred in assisted living facilities, citing reasons including the inability to track incidents by provider type (nine states), lack of a system to collect critical incidents (nine states), and lack of a system that could identify Medicaid beneficiaries (five states). • State Medicaid agencies varied in what types of critical incidents they monitored. All states identified physical, emotional, or sexual abuse as a critical incident. A number of states failed to identify other incidents that may indicate potential harm or neglect, such as medication errors (seven states) and unexplained death (three states).

• State Medicaid agencies varied in whether they made information on critical incidents and other key information available to the public. Thirty-four states made critical incident information available to the public by phone, website, or in person, while another 14 states did not have such information available at all. GAO recommended that the Centers for Medicare & Medicaid Services clarify state requirements for reporting program deficiencies and require annual reporting of critical incidents. HHS said it would consider annual reporting requirements for critical incidents after completing an ongoing review. State Medicaid agencies in 48 states that covered assisted living services reported spending more than $10 billion (federal and state) on such services in 2014, according to the GAO. These 48 states reported covering these services for more than 330,000 beneficiaries through more than 130 different programs.

Editor’s note: The GAO report – Medicaid Assisted Living Services: Improved Federal Oversight of Beneficiary Health and Welfare Is Needed – is online at

April 2018



High-tech Home Care Catholic healthcare delivery system Trinity Health said it

will test the efficacy of Internet and video technologies combined with home visits by secondary caregivers, to determine how the technologies may increase access to primary care physicians and advance people-centered care. Based in Livonia, Michigan, Trinity Health includes 93 hospitals as well as 120 continuing care programs, which include PACE, senior living facilities, and home care and hospice services. The Internet technology from Glass Enterprise Edition is a very small computer with a transparent display that clips onto glasses or industry frames. It brings information into the secondary providers’ field of view so they


April 2018

don’t have to switch focus between what they are doing with their hands and the content they need to see to do their job, according to Trinity Health. The telehealth provider will be swyMed. With the combination of Glass and swyMed, secondary providers should be able to do assessments of recently released and chronic care patients – in real time and in the patient’s home – without the burden of having to hold a video camera or a tablet, says Trinity Health. Clinical simulation of the technologies was scheduled to begin in late summer at the Loyola University Health System in Maywood, Illinois.

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Surgical Wound Monitoring from Home A smartphone app called WoundCare is successfully

enabling patients to remotely send images of their surgical wounds for monitoring by nurses. The app was developed by researchers from the Wisconsin Institute of Surgical Outcomes Research (WiSOR), Department of Surgery, University of Wisconsin, Madison, with the goal of earlier detection of surgical site infections and prevention of hospital readmissions. The study results appeared on the website of the Journal of the American College of Surgeons. “Patients cannot identify [infections] and frequently ignore or fail to recognize the early signs of cellulitis or other wound complications,” study authors wrote. “This drawback leads to the common and frustrating scenario where patients present to a routine, scheduled clinic appointment with an advanced wound complication that requires readmission, with or without reoperation.”

Forty vascular surgery patients were enrolled in the study. Each was provided an iPhone 5S and an accompanying visual reference guide to assist in using the phone and app. During the study, seven wound complications were detected and one false negative was found. Study authors note that the success and sustainability of a postdischarge wound-monitoring protocol requires a dedicated transitional care program and not simply adding a task to the current staff workload. This protocol also has a costsavings component, in addition to the patient safety and satisfaction aspects, study authors noted. Surgical site infections are the most expensive hospital-acquired infection, costing an average of nearly $30,000 per wound-related readmission and an estimated $3 billion to $10 billion annually.

“Patients cannot identify [infections] and frequently ignore or fail to recognize the early signs of cellulitis or other wound complications.”


April 2018


Aging Population, Hospital Partnerships

to Drive SNF Patient Growth

Acute care providers face increasing pressure from

payers to lower readmissions, and a rising number of patients require post-acute care. As a result, hospitals and acute care facilities are increasingly working together. These partnership have tremendous potential as the U.S. population ages, especially since the number of patients seeking acute care is projected to grow from 8 million in 2012 to 27 million by 2050. HIDA’s 2017 Post-Acute Market Report offers an in-depth look at the post-acute care market, as well as factors affecting demand and utilization. Among the key data points and trends gathered for this report:

Skilled nursing facilities and health systems anticipate collaboration, not consolidation

Patients 85 and older are a close second, and this segment is projected to grow substantially faster than the 65-75 and under-64 segments.

Medicare to remain largest SNF payer through 2021 Medicare paid $40 billion to SNFs in 2016 and this figure is projected to reach $50 billion by 2021, a 25% increase.

Discharges to post-acute facilities from hospitals and health systems are expected to rise from 5 million to over 8 million in 2035.

Neither health systems nor skilled nursing facilities (SNFs) anticipate an uptick in hospital ownership of nursing facilities. SNF providers report just 3% ownership by health systems and predict this figure will fall to 2% in the future. Similarly, only 2% of health systems target SNFs for acquisitions. In lieu of outright acquisition, SNF providers expect to work more closely with hospitals. More than 40% of SNF leaders believe they will be the primary recipient of hospital discharges, and half of SNFs anticipate future partnerships with hospitals.

Discharges from hospitals to post-acute facilities to jump by over 60% Discharges to post-acute facilities from hospitals and health systems are expected to rise from 5 million to over 8 million in 2035. Penalties for hospital readmissions, along with new payment models that promote coordination (such as within accountable care organizations), contribute to post-acute providers’ collaboration with hospitals. Patients aged 75 to 84 currently make up the largest segment of acute discharges to post-acute settings.

By comparison, out-of-pocket payments are expected to increase by 14%, while both private insurance and Medicaid payments are expected to rise by 11%.

Growing demand a key topic at HIDA’s upcoming post-acute channel strategies conference Provider, distributor, and manufacturer leaders will meet to discuss these trends and others at HIDA’s upcoming Post-Acute Channel Strategies Conference (May 1-2, Chicago IL). Topics on the conference agenda include: • Shifting settings for care • Changing decision-makers amid reimbursement changes • New provider needs as value-based payments take hold • The impact of these shifts on manufacturerdistributor relationships To learn more, or to register for this conference, please visit And to purchase your copy of HIDA’s 2017 Post-Acute Market Report, visit

April 2018



Health news and notes CHIP is stroke risk Why is it that most people who have heart attacks or strokes have few or no conventional risk factors, such as high cholesterol and blood pressure, a history of smoking or diabetes, or a family history of cardiovascular disease? Scientists may have figured it out, reports The New York Times. They have learned that a bizarre accumulation of mutated stem cells in bone marrow increases a person’s risk of dying within a decade, usually from a heart attack or stroke, by 40 or 50 percent. They named the condition clonal hematopoiesis of indeterminate potential, or CHIP. CHIP has emerged as a risk for heart attack and stroke that is as powerful as high LDL or high blood pressure but it acts independently of them. And CHIP is not uncommon. The condition becomes more likely with age. Up to 20 percent of people in their 60s have it, and perhaps 50 percent of those in their 80s.

Expecting the unexpected Excel Medical, Jupiter, Florida, launched the first FDAcleared patient surveillance system, an always-on remote monitoring platform that displays near real-time clinical views of physiologic and medically relevant data including


April 2018


waveforms and alarms for at-risk patients across hospital workstations, mobile devices and inside electronic medical records. The WAVE Clinical Platform automatically calculates risk, giving an at-a-glance early warning of patient deterioration up to six hours in advance of when clinicians would otherwise notice – and while there is still time to prevent further deterioration. There are more than 400,000 unexpected deaths in U.S. hospitals annually, says Excel.

Blood sugar levels and cognitive decline Increasing blood sugar levels are associated with cognitive decline, a long-term study has found, reports The New York Times. Researchers assessed cognitive function in 5,189 people, average age 66, and tested their blood sugar using HbA1c, a test that accurately measures blood glucose levels over a period of weeks or months. They followed the group for up to 10 years, tracking blood glucose levels and periodically testing cognitive ability. The study is in the journal Diabetologia. There was no association between blood sugar levels and cognition at the start of the study. But consistently over time, scores on the tests of memory and executive function declined as HbA1c levels increased, even in people without diabetes.

Treatment for ischemic stroke The physical removal of a blood clot in the brain, called a thrombectomy, was recently approved for use up to six hours after a stroke in research funded by the National Institutes of Health’s National Institute of Neurological Disorders and Stroke. “Although stroke is a medical emergency that should be treated as soon as possible,” said researcher Dr. Gregory Albers, Stanford University, “[this finding] opens the door to treatment even for some patients who wake up with a stroke or arrive at the hospital many hours after their initial symptoms.” NIH ended the study early because of overwhelming evidence of benefit from the clot-removing procedure.

Benefits of gastric bypass surgery For obese people with diabetes, doctors have increasingly been offering gastric bypass surgery as a way to lose weight and control blood glucose levels. Short-term results are often impressive, but questions have remained about the long-term benefits of such operations. Now, a large, international study funded by the National Institutes of Health has shown that about 50 percent of folks not only lost weight, but they also showed well-controlled blood glucose, cholesterol, and blood pressure. The good news is that five years later about half of those who originally showed those broad benefits of surgery maintained that healthy profile. The not-so-good news is that the other half, while they generally continued to sustain weight loss and better glucose control, began to show signs of increasing risk for cardiovascular complications.

needed to better understand how dental treatment can reduce stroke risk, according to the researchers.

Who’s best at treating sleep apnea? Patients with obstructive sleep apnea (OSA) can achieve similar outcomes receiving care from a sleep specialist or a non-sleep specialist, such as a primary care physician. The findings of a systematic review are published in Annals of Internal Medicine. Researchers from the Minneapolis Veterans Affairs Health Care System Evidencebased Synthesis Program and the University of Minnesota, School of Medicine reviewed 12 published studies to evaluate the effectiveness and harms of care by nonsleep specialists versus sleep specialists for patients with suspected or diagnosed OSA. The data showed low-strength evidence that OSA management outcomes are similar whether provided by primary care physicians, sleep specialist nurses, or sleep specialist physicians.

Patients with obstructive sleep apnea (OSA) can achieve similar outcomes receiving care from a sleep specialist or a nonsleep specialist, such as a primary care physician.

Dental care for stroke prevention Regular dental care may significantly lower patients’ stroke risk, according to a January 15 study published in the journal Stroke. This research furthers the scientific evidence that cardiovascular health is deeply connected to oral health, reports Dr. Biscupid. The study, which included thousands of U.S. adults, found a significant association between inflamed gums and ischemic stroke incidence. Inflammation may be the link between periodontal disease and stroke, and further studies are


Some studies have suggested that, in infants who are genetically susceptible, early exposure to complex foreign proteins, like those in cow’s milk, may increase the risk for an immune system reaction to beta cells and development of type 1 diabetes. It’s not true, says an international group of researchers, who tested this idea in a study of infants in 15 countries. Funded in part by NIH’s Eunice Kennedy Shriver National Institute of Child Health and Development (NICHD) and National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK), the researchers enrolled more than 2,000 infants with a known genetic susceptibility to type 1 diabetes (in the gene for human leukocyte antigen, or HLA) and a close relative with the disease. The infants were randomly assigned to receive either a cow’s milk formula or an extensively hydrolyzed formula, in which the complex milk proteins have been broken down into small pieces. The researchers found that weaning with the hydrolyzed formula did not significantly decrease the incidence of type 1 diabetes compared to conventional formula after a median of 11.5 years.

April 2018


WINDSHIELD TIME Chances are you spend a lot of time in your car. Here’s something that might help you appreciate your home-away-from-home a little more.

Automotive-related news

Heads-up Navdy has introduced a new portable head-up display (HUD) that can be added to almost any car, reports PC Magazine. The $299 Hudly is a solid way to safely display navigation directions and other information while you drive, according to the magazine. But for the time being, the device can only project content from your connected smartphone. Hudly measures 7 inches by 5.3 inches, and is easily removed from the dashboard. The unit is powered by a USB charging port and comes with a power cord that plugs into your car’s 12-volt outlet. Getting a HUD in most cases still means having to buy a new car, according to the review. So aftermarket alternatives like Hudly offer a low-cost option for everyone else.

The Takata recall continues (with good reason) The largest and most complex automotive recall in U.S. history gets more complicated all the time, reports Consumer Reports. About 3 million vehicles were added to the campaign to replace Takata airbags in about 37 million vehicles, which can malfunction and kill drivers and passengers. Ford expanded a do-not-drive order for its 2006


April 2018

Ranger small pickup, a particularly problematic model year for the airbags. GM petitioned the government to get out of recalling some of its most widely sold SUVs and trucks. And a deal in bankruptcy court could make it difficult for consumers to sue. It has been nearly 10 years since automakers began recalling vehicles for exploding Takata airbags and four years since regulators began to investigate the defect. And it has been more than two years since NHTSA took over its management. Even so, this recall is not close to being over, reports Consumer Reports. Waves of vehicles are scheduled to be added in each of the next two years, and officials expect it to take a couple more years for all the airbag repairs to be completed. Here’s the issue: Ammonium nitrate used in Takata airbags can become unstable over time, especially after exposure to temperature fluctuations and periods of constant high humidity. That can lead to inflators exploding with an unexpectedly violent force and spraying metal shrapnel. At least 15 drivers and passengers in the U.S. have died from blunt force trauma, from injuries to the head and neck, and from massive bleeding from lacerations caused by the flying metal.

Revenge of the carmakers

Voice-enabled virtual assistant

How do you get someone to pay hundreds of dollars for an inferior product, when most people already have a better one in their pocket? That’s the problem facing carmakers trying to sell built-in navigation systems when superior alternatives, such as Apple’s Maps, Google Maps and Waze, are available for free to anyone with a smartphone, points out The New York Times. Most in-dash navigation systems aren’t as smart as your phone, perhaps lacking traffic data or point-of-interest information, and stuck with clunky update procedures. But improvements are on the horizon. In-dash navigation systems will be getting smarter, not just learning your preferences and using data connections for timely updates, but crowdsourcing sensor information from connected vehicles to assess traffic problems and road conditions – even guiding you around a newly formed pothole. Even with their limitations, in-dash systems have some advantages, the paper says. They’re convenient and uncluttered. There’s no need to find a way to suspend a smartphone and its dangling charge cable; they use a vehicle’s built-in controls, and there’s no danger of running out of power.

Hyundai will introduce its “Intelligent Personal Agent,” a voice-enabled virtual assistant system, in models set to roll out as early as 2019. Co-developed by Hyundai and SoundHound Inc., Intelligent Personal Agent is said to allow drivers to use voice commands for many With the Google different operations and real-time data. In fact, it Assistant’s recent acts as a proactive assisintegration into tant system, predicting Android Auto, the driver’s needs and providing useful infordrivers with mation, such as an early Android Auto will reminder of an upcomsoon be able use ing meeting, or sugSpotHero and the gested departure times that account for curGoogle Assistant rent traffic conditions. to find and pay for These personal features parking on the go, combine with an array completely hands- of driver conveniences, such as the ability to free, in more make phone calls, send than 50 major text messages, search destinations, search markets across music, check weather North America. and manage schedules. It also allows drivers to voice-control frequently used in-vehicle functions, such as air-conditioning, sunroofs and door locks. The Intelligent Personal Agent supports a “Car-to-Home” service, enabling the driver to control electronic devices at home with simple voice commands.

The grisly stats In 2016: • 3 7,461 people were killed in motor vehicle crashes – a 5.6 percent increase from the previous year. This follows an 8.4 percent increase from 2014 to 2015, which was the largest percentage increase in nearly 50 years. •A  utomobile crashes remain a leading cause of death for Americans age five to 34. •A  lmost half (48 percent) of passenger vehicle occupants killed were unrestrained. •A  total of 5,286 motorcyclists died, totaling 14 percent of all crash fatalities. • 1,233 children aged 14 and younger were killed in motor vehicle crashes, including 311 children age four through seven and 228 children age 2 and younger. •C  rashes involving young drivers (age 15-20) resulted in 4,853 fatalities, accounting for almost 13 percent of all crash deaths. •T  here were 10,585 fatalities in crashes involving a drunk driver. • I n crashes involving a distracted driver, 3,450 people were killed. Source: “2018 Roadmap of State Highway Safety Laws,” Advocates for Highway & Auto Safety

‘Hey Google, Book parking’ Parking reservation service SpotHero has launched a new integration that enables drivers to book parking with the Google Assistant using voice commands. With the Google Assistant’s recent integration into Android Auto, drivers with Android Auto will soon be able use SpotHero and the Google Assistant to find and pay for parking on the go, completely hands-free, in more than 50 major markets across North America. Drivers can book parking with the Assistant on eligible devices, including Android phones and iPhones, simply by saying “Hey Google, book parking.”

April 2018


QUICK BYTES Editor’s note: Technology is playing an increasing role in the day-to-day business of sales reps. In this department, Repertoire will profile the latest developments in software and gadgets that reps can use for work and play.

Technology news About a decade ago, when Amazon introduced its first

Multi-gig connectivity

e-reader, publishers panicked that digital books would take over the industry, the way digital transformed the music industry, reports The New York Times. And for a while, that fear seemed totally justified. At one point, the growth trajectory for e-books was more than 1,200 percent. Bookstores suffered, and print sales lagged. But in just the last couple of years, there has been a reversal: Print is holding steady – even increasing – and e-book sales have slipped. One possible reason is that e-book prices have gone up, so in some cases they’re more expensive than a paperback edition. Another possibility is digital fatigue; people spend so much time in front of screens that when they read they want to be offline. Another theory is that some e-book readers have switched to audiobooks, which are easy to play on your smartphone while you’re multitasking.

Road warriors with thin, light laptops will be able to experience multi-gig connectivity by using the suite of Thunderbolt™ 3 solutions to multi-gig Ethernet adaptors for PCs and MACs from Aquantia Corp. The Thunderbolt adapters connect to the Thunderbolt port on the laptop to provide an RJ45 Ethernet port that supports 5GbE and 10GbE networks. It is also backwards compatible to support legacy 10/100/1000BASE-T networks.

Print is holding steady – even increasing – and e-book sales have slipped.

What’s in store? Western Digital unveiled new devices that address what the company describes as “today’s personal content explosion,” including voice-activated media streaming via popular Smart Home devices, the “world’s smallest” 1TB USB flash drive, and a portfolio of “ultra-mobile, high-performance, wireless and high-capacity flash storage products.” The “world’s smallest 256GB USB flash drive” – the 256GB SanDisk Ultra Fit™ USB 3.1 Flash Drive – can store 14,000 photos, 10 hours of full HD video and 16,000 songs, with 64GB still available for files.


April 2018

Keep an eye on Fluffy Pebby announced that its smart robotic pet sitter system, said to allow pet owners to monitor, interact with and entertain their pets remotely, was set to ship starting late Q1 2018. The Pebby “ball,” which can be remotely controlled via the Pebby companion app (for iOS and Android), houses a 1080p wide-angle video camera and four lithium-ion batteries to allow pet owners to watch, interact with and capture their pet’s cutest, candid moments in real-time (live footage streams to the Pebby app). Made in a pet-friendly size (80mm in diameter), Pebby features an interchangeable/ multi-design inner casing, built-in LED lights for “night vision” mode and LED glow rims. It also houses built-in speakers and a laser toy that is safe for humans and pets.

Free charge “Free Wi-Fi” at your favorite coffee shop is great. But how about “Free Charging.” Wi-Charge’s wireless-charging technology uses infrared beams to transfer power between a charging hotspot and client devices within a 10-meter range. The hotspot easily mounts on a wall or ceiling, providing full room coverage, so your cellphone can recharge automatically while you’re drinking your coffee, without any user intervention. Says the company, “Similar concepts have been attempted by others, but so far no one could offer a solution that is powerful enough to charge a phone, have sufficient reach to cover a room, and be radiation-safe. Wi-Charge is the first company to achieve the power/range/safety level required for a commercial wireless power solution.”

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Save a Victim

Drunk-driving tragedy spurs Sarah Alasya to help others avoid making a fatal mistake Don’t drink and drive. It’s life-saving advice, which Sar-

ah Alasya takes seriously. In fact, over the past four years, she has helped around 500 people avoid making that mistake. Alasya is Midwest division manager, physician office division, for Medline. For Alasya, it’s personal. Her younger brother, Matthew, is serving a 6 1/2-year prison term for drinking while driving, and killing another driver. It happened in June 2013, when Matthew was 22. “He was just out partying with friends at local bars and chose to drive home,” she says. “He blacked out and ended up getting on the freeway going the wrong way. He hit Vincent Canzani head-on less than a mile onto the freeway. Vincent died at the scene.” Matthew was in the hospital for several days after the crash, she explains. “Our family didn’t leave his side. We


April 2018

were sure, though, he would be arrested after leaving the hospital. He came to my house to recover, and every day we waited for police to show up.” But they didn’t. For three months, Matthew’s life was at a standstill. “He didn’t know what to do,” says Alasya. “The guilt ate him up.” During those three months, Matthew found via social media an organization called “Because I said I would,” a nonprofit dedicated to the betterment of humanity through promises made and kept. The group does so through “Promise cards,” chapters of volunteers, character education in schools, and awareness campaigns. “I believe it was over a few weeks that he spoke with the founder, Alex Sheen, and together they decided to do a PSA,” says Alasya. “Matthew wanted to prevent others from making the same decisions. He felt that it was his


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corner duty to do so, but didn’t know the best way to get that message out. He wanted the help of someone who just wanted to make a difference. “‘Because I said I would’ has unique social media strategies for getting messages out to followers, and the organization helped Matthew create a message and spread it.” That message came in the form of a 3 1/2-minute video titled “I Killed a Man,” in which Matthew tells his story. It went live on YouTube Sept. 3, 2013.

(L to r) Sarah Alasya’s sisters Paige Cordle and Grace Etter, mom Kari Cordle, Sarah and Matthew Cordle

Grace Etter, Yellow cab employee Creighton, Ilker Alasya and Sarah Alasya (kneeling)

“My family wasn’t aware he was doing this,” says Alasya. “We found out right before ‘Because I said I would’ posted the video on YouTube. We begged him not to release it, because we just wanted to protect him. The video put it all out there and took away some options as far as the court system goes, but he had never been so sure of anything. “He said it was like a weight had been lifted. I had mixed feelings when I first saw it. It was powerful, but it was also my little brother. Today I am beyond proud of him, and share the video as often as I can. For him, and later what I realized for many others, it was the right thing to do.”


January 2018

Shortly after the video went viral – receiving a million hits in just a couple of days – a warrant was issued for Matthew’s arrest. He turned himself in on Sept. 10, 2013. On Oct. 23, he was sentenced to 6 1/2 years mandatory in prison. He will be released on March 7, 2020.

Response “I remember being worried to tell my manager and coworkers at the time,” says Alasya. “I was afraid that because the story had so much attention, it could create backlash for me personally and professionally. But they were extremely supportive.” Most of the online responses were positive as well, she says. “Many that reached out didn’t know us personally, but I think they could feel that Matt was genuine, and most could relate in some way. Many people wanted to tell us their own stories. Some were offenders and some had been victims. A lot of people wanted to know more about Matt in general. They were supportive of him and our family. “Social media connected us to all kinds of people. Harold Dennis, a survivor of the nation’s deadliest drunk driving crash – 27 people were killed when a drunk driver hit a school bus in Carrollton, Kentucky, in 1988 – reached out to our family. Many people had sent him the video, and I think he just wanted to know more. He had wanted the offender in his story to do exactly what Matthew was doing – take responsibility. “Ultimately, he ended up meeting Matthew in jail, and today he and I still talk regularly. He has become someone I admire, and I am thankful to have him in my life. There were some negative comments too, of course. They were hard to read, and I had to stop myself from commenting back.”

Save Your Victim “It was hard not to be totally wrapped up in it all since the story had gone worldwide,” she recalls. “I didn’t sleep much, and my mind raced. With people reaching out, telling us stories, sharing pictures of those they had lost to drunk drivers, it felt overwhelming.” She threw herself into her work to keep busy, but she knew she needed something else to channel all that energy. “It started with the idea of a website, where all those stories could be shared publicly, in hopes of helping others

and bringing light to the issue,” she says. “From there we started having local groups contact us, and I had the opportunity to join a local DUI taskforce. A local cab company, Yellow Cab, also sat on the taskforce, and they have been an amazing resource for us. “My brother had all these ideas in prison to help people, but of course implementing them is the tough part, so we created the nonprofit – Save Your Victim – in hopes of making those things happen. Today, together with Yellow Cab, we host safe ride events, typically around busy weekends or big social events. These events are run solely by volunteers and nonprofit dollars. “We will give anyone – no questions asked – a ride home with Yellow Cab, paid for by Save Your Victim. If we can prevent one person from driving drunk – which we have! – it is all worth it. “To date, we have given out over 500 rides. It also helps bring awareness, as the local and national news have covered the events. I have also had the opportunity to speak at local schools, to prison groups, DUI offender groups, and to collaborate with other nonprofits around the U.S. I was asked to speak at an event that was held at Ohio University, as part of Prom Promise, to over 600 high school students. It was surreal being back at my alma mater, but if you are willing to share your story, there are people willing to listen …. and hopefully learn.”


“At first, it was scary, because we were facing such a huge unknown. We all experienced a lot of questions and worrying about how Matthew would adjust and, really, survive. He was going through a lot and I visited him – and still do – almost every Sunday. I always left in tears. “It was emotional for about the first year as he figured it out, but fortunately, he did. Now I look forward to seeing him, because he has grown up so much and appreciates

Matthew Cordle (from the video “I Killed a Man.”)

things in a much different way. I don’t worry now about him being in prison – although my parents still do! He has missed a lot, though, in this time, the hardest being the passing of both of our grandparents, whom he was extremely close with. My sister got married in 2016, and of course he wasn’t there. But he will get to come home and for that I am grateful. “We are lucky. He is a completely different person. He is emotionally stable, mature and healthy. It’s funny – now HE gives ME advice, and sometimes even worries about me. I do feel he deserves to be there, and I am relieved he has used the experience to better himself and even graduate from Ohio University. It is hard to describe, but also painful, because we are missing out on that person. “I am unbelievably proud of the person he has become. He is truly living for two people now.”

“I never ever could have guessed my brother – or anyone I know, for that matter – would have caused something like this, and I would be visiting them in prison, let alone that my family would be sharing that story with the world.”

This experience changed Alasya’s life. “My husband always says that after the crash, I became someone different, that I see the world with new eyes,” she says. “I never ever could have guessed my brother – or anyone I know, for that matter – would have caused something like this, and I would be visiting them in prison, let alone that my family would be sharing that story with the world.” But there has been growth.

Editor’s note: View Matthew Cordle’s video, “I Killed a Man,” at In addition, Sarah Alasya encourages readers to visit or find them on Facebook, and share how drinking and driving has affected their lives. “We’re always looking for new stories and voices to help expand the conversation,” she says.

April 2018



Congress Tackles Vital Public Health Legislation While the delay of the medical device tax and recent cuts to the corporate tax rate

have been top-of-mind for healthcare distributors and manufacturers, lawmakers will soon take up another piece of vital healthcare legislation. The Pandemic and All-Hazards Preparedness Act (PAHPA) is up for its third reauthorization this fall and shapes the way key public health agencies respond to outbreaks and natural disasters.

By Linda Rouse O’Neill, Vice President, Government Affairs, HIDA

This legislation is vital for ensuring medical products are available when and where they are needed during a crisis, but it needs to contain the right provisions. HIDA and the Healthcare Products Coalition have developed a set of principles that, if included in the reauthorization, will strengthen the healthcare supply chain and ensure federal experts will be able to draw on private sector expertise. Below is a summary of these principles:

1. Formalize public/private partnerships to ensure continuity during times of disaster. Medical products are key to any emergency or pandemic response. To address the supply of these needed goods, the healthcare supply chain must be more elastic. Supply chain leaders and the Strategic National Stockpile have developed a model that can ensure a commercial “cushion” of key products can be maintained and ready to deploy when needed. The law should take steps to formalize and implement this model. 2. Create a ‘national contingency healthcare system’ which would allow suppliers to divert needed products to where they are needed most. During the Ebola outbreak in 2014, the CDC worked with state and local emergency response stakeholders to create a three-tier hospital system. Acute care facilities were designated as either “Frontline Healthcare Facilities,” “Ebola Assessment Hospitals,” or “Ebola Treatment Centers.” Building and formalizing this approach so it could be used during any public health crisis would allow distributors and manufacturers to direct critical medical products to the facilities and patients who need them most.


April 2018

3. D  evelop transparent communication pathways between public and private partners. Providers and federal officials at the local, state, and federal level all rely on the healthcare supply chain. Thus, these parties, along with healthcare distributors and manufacturers, must consistently communicate their capabilities and expectations so all can efficiently respond to emergencies. 4. C  reate an emergency response fund and pass necessary appropriations measures. Preparing for a public health emergency requires training and investment. Creating multi-year funding and an emergency contingency fund would allow a faster response to aid those affected by disaster. These funds would also provide stability during the recovery period. Be sure to tell your representatives that you care about PAHPA and the vital role healthcare distributors and manufacturers play in emergency preparedness. If you would like to learn more about the legislation and how you can get involved, please contact us at

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Industry news Alfa Wassermann announces 2017 President’s Club winners Alfa Wassermann Diagnostic Technologies (West Caldwell, NJ) announced its 2017 President’s Club winners, Frank Pollock (Business Development Manager of the MidAtlantic region) and Jennifer Kennedy (Business Development Manager of the West region). President’s Club is the highest honor awarded to the top sales representatives in the 2017 calendar year.

Owens & Minor makes changes to board Owens & Minor Inc (Richmond, VA) announced that its board of directors elected Mark F. McGettrick to the board of directors, effective March 1, 2018. McGettrick currently is the EVP and CFO of Dominion Energy. In addition, McGettrick also is CFO and director on the board of Dominion Energy Midstream Partners LP, a Master Limited Partnership operating a portfolio of natural gas assets. In addition, two board members have announced they will not stand for reelection at the company’s 2018 Annual Meeting of Shareholders to be held May 8, 2018. James E. Rogers, former chairman of BackOffice Associates LLC, will retire from the board effective May 8, 2018. Also, David S. Simmons, chairman & CEO of Pharmaceutical Product Development LLC, announced that he will not stand for reelection due to competing business demands associated with his chairman & CEO position. His service on the board will cease May 8, 2018.


left to right: Les White, Director of Sales; Frank Pollock; Jennifer Kennedy; Mark Gnagy, Vice President of Sales; Peter Napoli, COO & President


April 2018

The March issue of Repertoire incorrectly identified editorial advisory board member Doug Harper as president of IMCO Home Care. Doug is president of NDC Homecare. (Pam Wedow, also an incoming board member, is vice president and general manager of IMCO Home Care.) We regret the mistake.

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