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vol.26 no.2 • February 2018

Where will regulatory updates take physician offices?

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FEBRUARY 2018 • VOLUME 26 • ISSUE 2

PUBLISHER’S LETTER News You Can Use..........................................................6

PHYSICIAN OFFICE LAB The Case for Complexity

How to help your physician office customers go from waived to moderate complexity lab.................8

CONTRACTING EXECUTIVE PROFILE

Where will regulatory updates take physician offices?

14

Raymond Davis, Vice president supply chain Universal Health Services, Inc., King of Prussia, Pa...................... 12

POST-ACUTE POST-ACUTE CARE: HIDA INSIGHTS

Home Care in 2018 26

Slightly bruised by regulations, home care agencies can use help from their distributors.

And they’re getting it.

Patients, Payers Cut Costs with ASCs

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page

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.

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FEBRUARY 2018 • VOLUME 26 • ISSUE 2

QUICKBYTES

HEART DISEASE

Coronary artery disease: The facts................... 34

Technology news

46

WINDSHIELD

HEALTHY REPS Health news and notes.......................................... 42

HIDA GOVERNMENT AFFAIRS UPDATE States Move Ahead with Medicaid as Lawmakers Consider Reform...................... 49

REP CORNER

Dan Blom: Pay it Forward

Automotiverelated news 44 4

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50 INDUSTRY NEWS News........................................................................................... 54

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PUBLISHER’S LETTER

News You Can Use For about the past 18 months, I have been talking about content selling in this column

and during many of your national sales meetings. Each month we try to bring you content that will help you as well as your customers. For about the past year we have been covering the following topics: •H EDIS, a tool used by more than 90 percent of America’s health plans to measure providers’ performance on important dimensions of care and service. Because so many plans collect HEDIS data, and because the measures are so specifically defined, HEDIS makes it possible to compare the performance of health plans on an “apples-to-apples” basis.

•M ACRA, which replaces the Medicare Sustainable Growth Rate (SGR) methodology for updates to the Physician Fee Schedule with a new approach to payment called the Quality Payment Program. The program was designed to encourage the delivery of high-quality patient care through two avenues: The Merit-based Incentive Payment System, or MIPS, and Alternative Payment Models, or APMs.

Scott Adams

Please take the time to read this month’s cover story with the current updates on both of these reimbursement tools. Leading with content like this when you are cold calling or working with existing customers is what will set you apart in the 80/20 rule.

On another note, it’s the month of love, and given Bama’s amazing win last month I am still full of cheer, so Happy Valentine’s day to the industry I love! This is the start of my 22nd year in med/surg sales and throughout my career I have met some people that I am so grateful to call lifelong friends. We are truly blessed to work in such a great industry.

Dedicated to Distribution, R. Scott Adams PS: We have some new exciting features coming to RepConnect during Q1: • 2018 Updated CPT Codes • A favorite’s button • End-User 3 minute product sales videos PSS: I am launching a free bi-monthly newsletter called MedRepInsights. This will be filled with content pertinent to your career. Things like press releases, articles, podcasts, and survey questions.

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; www.sharemovingmedia.com

editorial staff editor

Mark Thill lthill@sharemovingmedia.com managing editor

Graham Garrison ggarrison@sharemovingmedia.com editor-in-chief, Dail-eNews

Alan Cherry acherry@sharemovingmedia.com art director

Brent Cashman bcashman@sharemovingmedia.com

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vice president of sales

Jessica McKeever

jmckeever@sharemovingmedia.com (800) 536.5312 x5271 director of business development

Alicia O’Donnell

aodonnell@sharemovingmedia.com (800) 536.5312 x5261 sales executive

Tyler Moss

tmoss@sharemovingmedia.com (800) 536.5312 x5279 sales executive

Lizette Anthonijs Lizette@sharemovingmedia.com (800) 536.5312 x5266

publisher

Scott Adams sadams@ sharemovingmedia.com (800) 536.5312 x5256 founder

Brian Taylor btaylor@ sharemovingmedia.com

Subscriptions

www.repertoiremag.com/ subscribe.asp or (800) 536-5312 x5259

2018 editorial board Bill McLaughlin Jr. : IMCO Bob Miller : Gericare Medical Supply

circulation

Laura Gantert lgantert@ sharemovingmedia.com

Linda Rouse O’Neill : HIDA Brad Thompson : NDC Chris Verhulst : Henry Schein

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PHYSICIAN OFFICE LAB

The Case for Complexity

By Jim Poggi

How to help your physician office customers go from waived to moderate complexity lab

One of the customer situations distributor account

managers struggle with is taking a customer from a waived lab to a moderate complexity lab. Even though this move can help customers with office efficiency, better patient outcomes and the opportunity for additional revenue, it’s scary. Why? Mostly because it can be a complex process and, if not done well, can put the customer’s current business at risk. For a well-established account manager, loss of a big account can have major financial implications. For a new account manager, getting off on the wrong foot by messing up this customer transition can erode confidence and damage the new account manager’s reputation.

Dodging this opportunity may reduce risks and anxiety, but it also limits rewards for the account manager and the customer as well. The distributor account manager who establishes himself as a valuable consulting resource

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is more likely to gain the trust needed to be called in for major customer initiatives and opportunities.

There is a simple, repeatable approach to taking a customer from waived to moderate complexity testing. It requires planning, open dialogue with the customer and attention to detail in the implementation process. Underpinning it is knowing that going moderate complexity is always a team selling process with the account manager as quarterback and using supplier, corporate and other resources to create a compelling customer proposal and a well thought out implementation plan.

The following is a roadmap to take your customer from waived to moderate complexity testing: Explore/uncover needs and motivation. Learn their practice objectives and current situation. How do they

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PHYSICIAN OFFICE LAB plan to improve patient outcomes and patient satisfaction?

Which tests do they believe have value in patient treatment plans?

Is there a physician in the practice qualified or interested in being the lab director? Are they on friendly terms with any of your customers who have implemented CLIA moderate testing?

Marshall your resources. Analyze the tests the customer wants to perform and their motivation to create a proposal that covers their needs. Confirm best fit solutions with trusted suppliers and internal company resources including lab category managers and lab specialists.

Top causes for failed CLIA moderate complexity testing implementations • Under planning; Not setting proper expectations about implementation (timing, activities that need to be managed, roles, responsibilities, financial and test menu outcomes) • O ver emphasizing the speed and ease of the transition or revenue opportunities • Taking on too much at one time: typical practices cannot absorb the time and effort to implement multiple instruments (chemistry, hematology and immunoassay) at the same time • Staff turnover/staff dissatisfaction • Neglecting to plan for the future: • Staff training and management of on-going lab administration • Failure to keep good records • Not planning for staff turnover

Do a sanity check on their requirements. Going too far too fast typically leads to problems and concerns. Create an initial proposal of the systems that will meet the customer’s testing needs in writing with products, cost, implementation details and timing

Smooth the path to a successful implementation.

Organize your supplier’s and company’s resources to plan implementation and communicate the plan in advance.

Assure frequent communication and progress reports during implementation

Set up an appointment to deliver the proposal with your team, including trusted suppliers and internal resources. Be prepared to answer questions about the process of going moderate complexity. Your supplier or company lab specialist can help, and your company’s lab category team should also be able to offer expert guidance.

Provide referrals if possible. Set up follow up appointments to showcase and demonstrate the systems appropriate to the testing they want to do if necessary

Own the solutions

Get a commitment. Present the final proposal and leasing agreements for signature and ask for their agreement to move forward. Don’t forget the two forgotten solution elements: •L IS/EMR connectivity •P roficiency Testing Consider leasing terms that provide a three-month delay in making payments to take pressure off of implementation timing. Also, offering a range of leasing options creates confusion. Go with your best solution only.

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Using the resources of your supplier partner, your company and publicly available information will go a long way to assuring smooth implementation. Communicating transparency and setting expectations that there will be “speed bumps” during the process is a key first step to manage implementation. Rapidly acknowledging and addressing difficulties during implementation will build credibility and confidence in your planning and leadership. Own the solutions and quarterback the team at your disposal to get things back on track quickly. Hold weekly meetings to assess progress and address issues as they are uncovered.

The successful account manager creates effective and efficient customer lab solutions. Customers gain value from increased office efficiency, having needed lab tests on hand to create or modify patient treatment plans and creates customer convenience by avoiding needless trips to reference laboratories. Better patient outcomes and satisfaction will result.

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IDN OPPORTUNITIES

Contracting Executive Profile Raymond Davis, Vice president supply chain Universal Health Services, Inc., King of Prussia, Pa. Editor’s note: Raymond Davis was selected as one of the “Ten People to Watch in Healthcare Contracting” by the Journal of Healthcare Contracting, a sister publication of Repertoire.

UHS operates through its subsidiaries more than 350 acute care hospitals,

behavioral health facilities and ambulatory centers in the U.S., Puerto Rico, the U.S. Virgin Islands and the United Kingdom. More than 81,000 employees treat over 2.5 million patients each year.

Raymond Davis joined UHS in May 2017 as vice president, supply chain.

He brought with him over 15 years of healthcare industry and supply chain management experience in vendor selection, supply formulary (item master) management, contract management, procurement, distribution center operations and logistics, and sterile processing. Immediately prior to joining UHS, he served as senior director of supply chain, medicine division and non-acute, for a large integrated network on the West Coast.

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?

Raymond Davis: One of the most rewarding projects I have been a part of is “Cost to Serve,” an approach that leverages calculation and analysis of the profitability of products, customers and routes to market, and provides a metrics-based focus for decision-making based upon service mix and operational variables.

Raymond Davis

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Davis’ work experience includes support for academic medical centers, community hospitals, physician medical group practices, home care and surgery centers. He holds an MBA and is a certified Six Sigma Black Belt.

He is also credentialed as an Associate Certified Coach (ACC) by the International Coach Federation.

At UHS, Davis oversees end-toend supply chain functions across the entire UHS network, including contracting, strategic sourcing, value analysis, distribution, logistics, purchasing, and capital equipment purchasing. The UHS supply chain team is responsible for over $1 billion in supply and purchased services spend across the company’s 350 facilities.

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The intent of Cost to Serve is to bring cost visibility, define value across all service lines, and improve outcomes for the healthcare provider industry.

This approach will drive healthcare to a retail model, allowing providers to be more consumercentric in price modeling and patient outcomes data. This level of transparency will improve the current model within the industry and allow for rapid innovation through consumer alignment.

11/30/17 11:27 AM

Many leaders have taught me the value of creating understanding of the supply chain function within a healthcare system.

JHC: Please describe a project on which you look forward to working in the next year.

Davis: The UHS supply chain team is currently working on development of a supply chain strategy map, functional plan, and demand management queue.

This project will allow the team to identify and actualize customer needs and demands while continuing to drive toward a strong margin and create value for all whom we serve.

JHC: How have you improved the way you approach your job or profession in the last 5-10 years?

Davis: One of the larger shifts in my approach as a supply chain leader has been to build awareness for the value of the supply chain function as a strategic differentiator for the organization. Many leaders have taught me the value of creating understanding of the supply chain function within a healthcare system.

JHC: What do you need/want to do to become a better supply chain executive in the coming year(s)?

Davis: To continue to evolve as a supply chain executive, I challenge myself to look across industries to identify potential best practices, determine whether they are relevant in the healthcare space, and incorporate the newest successful approaches. Challenging myself to learn from others and continuing to focus on strategic partnerships helps me to create success for my organization and team members.

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Where will regulatory updates take physician offices?

E

nsuring a smooth continuum of care for discharged hospital patients, curbing opioid usage, and telehealth were all on the minds of the National Committee for Quality Assurance (NCQA), as it issued new technical specifications for the 2018 edition of the Healthcare Effectiveness Data and Information Set, or HEDIS. The specifications include seven new measures, changes to several existing measures and two cross-cutting topics, which address issues across multiple measures.

HEDIS is a tool used by more than 90 percent of America’s health plans to measure providers’ performance on important dimensions of care and service.

Because so many plans collect HEDIS data, and because the measures are so specifically defined, HEDIS makes it possible to compare the performance of health plans on an “apples-to-apples” basis.

First established in the late 1980s, HEDIS measures address a broad range of health issues, such as persistence of beta-blocker treatment after a heart attack, controlling high blood pressure, comprehensive diabetes care and breast cancer screening.

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Included in HEDIS is the CAHPS® 5.0 survey, which measures members’ satisfaction with their care in areas such as claims processing, customer service, and getting needed care quickly. “CAHPS” is an acronym for “Consumer Assessment of Healthcare Providers and Systems.”

Health plans use HEDIS results to see where they need to focus their improvement efforts. In addition, many health plans report HEDIS data to employers or use their results to make improvements in their quality of care and service. Employers, consultants, and consumers use HEDIS data, along with accreditation information, to help them select the best health plan for their needs. Many plans commonly include

HEDIS compliance targets into payment contracts with providers, reports America’s Health Insurance Plans, or AHIP. HEDIS results are included in Quality Compass, a web-based comparison tool that allows users to view plan results and benchmark information.

5. Use of opioids from multiple providers. This measure assesses the rate of health plan members 18 years and older who receive opioids from multiple prescribers and multiple pharmacies. According to NCQA, high dosage, multiple prescribers and pharmacies are all risk factors for dangerous overdose and death.

New measures The newest additions to HEDIS are designed to address emerging health needs and evolving processes in care delivery, according to NCQA. 1. Transitions of care. This measure is designed to improve care coordination during care transitions for at-risk populations, including older adults and other individuals with complex health needs, according to NCQA. It assesses percentage of inpatient discharges for Medicare members 18 years and older who had each of the following during the measurement year: • Notification of inpatient admission.

• Receipt of discharge information.

• Patient engagement after inpatient discharge.

• Medication reconciliation post-discharge.

6. Depression screening and follow-up for adolescents and adults. This measure assesses the percentage of health plan members 12 years and older who were screened for clinical depression and, if screened positive, received follow-up care. It completes a set of three measures that address the needs of patients receiving care for depression: screening, ongoing monitoring, and response to treatment.

7. Unhealthy alcohol use screening and follow-up.

This measure assesses the percentage of health plan members 18 years and older who were screened for unhealthy alcohol use and, if screened positive, received appropriate follow-up care within two months.

Changes to existing measures 2. Follow-up after emergency department visit for people with high-risk multiple chronic conditions. This measure assesses the percentage of ED visits for Medicare members 18 years and older with multiple high-risk chronic conditions and follow-up care within seven days of the ED visit. This follow-up should ensure better coordination of diagnoses, medications and follow-up needs, says NCQA. 3. Pneumococcal vaccination coverage for older adults. This measure assesses the percentage of health plan members 65 years and older who received the recommended series of pneumococcal vaccines: 13-valent pneumococcal conjugate vaccine and 23-valent pneumococcal polysaccharide vaccine. The measure is designed to track more closely to updated guidance from the Advisory Committee on Immunization Practices (ACIP) The measure also uses electronic data, and will one day supplant the current survey-based metric.

4. Use of opioids at high dosage. This measure assesses the rate of health plan members 18 years and older who receive long-term opioids at high dosage (average morphine equivalent dose >120mg).

1. Immunizations for adolescents. NCQA revised the human papillomavirus (HPV) vaccine rate to align with the updated Advisory Committee on Immunization Practices guidelines, which now permit a two-dose, rather than three-dose vaccination schedule for adolescents.

2. Breast cancer screening. NCQA added digital breast tomosynthesis (DBT) to the list of acceptable tests for breast cancer screening.

3. I nitiation and engagement of alcohol and other drug abuse or dependence treatment. NCQA updated this measure to include medication-assisted treatment (MAT) as an appropriate treatment for people with alcohol and opioid dependence. The measure also adds telehealth to treatment options. Additionally, alcohol, opioid and other drug dependencies are added as subgroups for reporting (rate stratification) and the engagement timeframe is extended from 30 to 34 days.

4. Identification of alcohol and other drug services.

NCQA updated this measure to include MAT as an appropriate treatment for people with alcohol and opioid

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Regulatory update dependence, and reporting of measure rates by alcohol, opioid and other drug dependence diagnosis as subgroups; and for more granular reporting, it separates outpatient, ED and telehealth services. NCQA says the measures will give providers, consumers and plans better insight regarding access to treatment services, and add clinically useful information about utilization of services for those with substance dependence diagnoses.

5. Plan all-cause readmissions. NCQA developed a strategy to extend the existing Plan All-Cause Readmission (PCR) measure to the Medicaid population, essentially becoming a new measure for Medicaid.

NCQA expects the measure will especially useful to states as they assess quality.

Cross-cutting topics 1. Telehealth for behavioral health measures.

Telehealth is an effective, efficient way of delivering healthcare, and is becoming widely reimbursed by payers such as health plans, states and CMS, says NCQA. That’s why NCQA introduced telehealth in seven behavioral health measures for HEDIS 2018.

2. Excluding members in institutional care settings.

NCQA is excluding Medicare members enrolled in Institutional Special Needs Plans (I-SNPs) or who live long-term in institutional care settings from the following measures: • Breast cancer screening.

• Colorectal cancer screening.

•O steoporosis management in women who had a fracture.

• Controlling high blood pressure.

The listed HEDIS measures are appropriate for the age-defined general population but not always for people who are frail or have mobility or other functional limitations, according to NCQA.

Transitions of care Mary Barton, vice president performance measurement, NCQA, discussed the importance of the “Transitions of care” measure during a video chat on the organization’s website.

For the patient, the days and weeks following discharge can be a vulnerable time, she said. “We’re concerned about

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medical errors. Maybe the patient’s medications were changed in the hospital; maybe tests had been ordered during the hospital stay, but the results were incomplete by the time of discharge.

There is a lot of opportunity for things to get dropped.”

To ensure what Barton referred to as a “clear connection between sites of care,” NCQA will be measuring how frequently – or if – primary care physicians are notified of an inpatient admission of one of their patients. The organization will also measure how complete the patient’s information is on the discharge record, so the next provider (primary care physician, long-term-care facility, etc.) knows what “ EDs are excellent has been done and what at taking care of needs to be done. the first thing that And finally, NCQA will brought the patient measure how promptly the in. But they’re not discharged patient’s physician necessarily trained contacted him or her after or staffed to do the discharge, to make a followkind of in-depth up appointment, if necessary. communication “We have to close the loop on that patient’s care,” she that a primary care said. After a hospital stay, with team should do.” its steady stream of caregivers, a patient can feel alone. He or she needs a primary care support team to guide him or her through the next stage of recovery.

Similarly, the measure “Follow-up after emergency department visit for people with multiple high-risk chronic conditions” is designed to address the continuum of care, said Barton.

“We know there is a subset of patients in Medicare who are over 65, who have multiple chronic conditions,” she said. “They are vulnerable; they may be frail; they often have functional limitations; and when they go to the ED, they may experience a change in their medication, which needs to be followed-up.”

Also, there may be a multifactorial set of events that led to that ED visit. “EDs are excellent at taking care of the first thing that brought the patient in,” said Barton.

“But they’re not necessarily trained or staffed to do the kind of in-depth communication that a primary care team should do.” For example, the patient may face socioeconomic forces that led him or her to the ED, such as an eviction from their house or apartment.

“We’re looking for evidence that an ongoing care team took note of that ED visit and circled that patient back to the primary care setting.”

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Regulatory update

Quality Payment Program: YEAR 2 Physicians facing some changes in MACRA

Physicians caring for highly complex patients will re-

ceive some relief in Year 2 of the Quality Payment Program, established by the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA). In addition, say the feds, the program will offer: • Meaningful measures and activities.

• A reduction in clinician burden (part of the Centers for Medicare & Medicaid Services’ recently launched “Patients Over Paperwork” initiative).

• New incentives for participation.

• Better care coordination.

• An easier way for clinicians to qualify for incentive payments by participating in Advanced Alternative Payment Models (Advanced APMs) that begin or end in the middle of a year.

Not all physician practice groups were pleased, however.

MACRA replaces the Medicare Sustainable Growth Rate (SGR) methodology for updates to the Physician Fee Schedule with a new approach to payment called the Quality Payment Program. The program was designed to encourage the delivery of high-quality patient care through two avenues: the Merit-based Incentive Payment System, or MIPS, and Alternative Payment Models, or APMs. The Merit-based Incentive Payment System consolidates components of three prior programs: the Physician Quality Reporting System (PQRS), the Physician Valuebased Payment Modifier (VM), and the Medicare Electronic Health Record (EHR) Incentive Program for Eligible Professionals.

For MIPS, physicians earn a payment adjustment based on evidence-based and practice-specific quality data. To

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show evidence that they provided high-quality, efficient care supported by technology, they must send in information in the following categories: • Quality.

• Advancing care information, which replaces the Medicare EHR incentive program, also called Meaningful Use. • Improvement activities, such as expanding practice access, improving care coordination and promoting patient safety.

• Cost. (New for 2018.)

Alternative Payment Models, or APMs, are payment approaches that provide added incentives to deliver highquality and cost-efficient care. APMs can apply to a specific clinical condition, a care episode, or a population; and they allow the provider to earn an incentive payment for participating in an innovative payment model. Advanced APMs

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Regulatory update are a subset of APMs, and let practices earn more for taking on some risk related to their patients’ outcomes.

Year 2 changes Released in November, the final rule for Year 2 of the Quality Payment Program offers up to five bonus points on the physician’s final score for treatment of complex patients, based on a combination of the Hierarchical Condition Categories (HCCs) and the number of dually eligible patients treated.

The final rule also weighs the MIPS “Cost” performance category to 10 percent of the total MIPS final score. The Centers for Medicare & Medicaid Services is including the Medicare Spending per Beneficiary (MSPB) and total per capita cost measures to calculate practices’ cost performance scores for the 2018 MIPS performance period. CMS will calculate cost measure performance; no action is required from clinicians.

“CMS has yet to extensively test new episode-based measures, reform the patient attribution methodology, and implement risk- and specialty-adjustment to avoid penalizing physician practices who treat the country’s most vulnerable patients,” says McLaughlin. “We are also concerned CMS will not provide feedback about costs and patients who are attributed to groups during the performance period, so groups will have no way to track their resource utilization.”

To accommodate small practices (that is, groups of 15 or fewer clinicians), Year 2: • Excludes individual MIPS-eligible clinicians or groups with less than or equal to $90,000 in Part B allowed charges or less than or equal to 200 Part B beneficiaries.

• Adds five bonus points to the final scores of small practices.

• Gives solo practitioners and small practices the choice to form or join a Virtual Group to participate with other practices. A Virtual Group is a combination of two or more Taxpayer Identification Numbers (TINs) made up of solo practitioners and groups of 10 or fewer eligible clinicians who come together “virtually” (no matter specialty or location) to participate in MIPS for a performance period of a year.

• Continues to award small practices three points for measures in the Quality performance category that don’t meet data completeness requirements.

• Adds a new hardship exception for the Advancing Care Information performance category for small practices.

In addition, the final rule: Allows the use of 2014 edition and/ or 2015 Certified Electronic Health Record Technology (CEHRT), and gives practices a bonus for using only – Jennifer McLaughlin, senior associate 2015 CEHRT. director, government affairs, for MGMA •A utomatically weighs the Quality, Advancing Care Information, and Improvement Activities performance categories at 0 percent of the final score for APMs and Advanced APMs clinicians affected by hurricanes Irma, Harvey and CMS says that Year 2 offers more details on how the agency Maria, and other natural disasters. (In other words, will incentivize clinicians who participate in APMs offered clinicians in affected areas who do not submit data by payers other than Medicare, starting in 2019. This stanwill not have a negative adjustment.) dard allows a non-Medicare payment arrangement to meet • Continues a phased approach to public reporting the financial risk criterion to qualify as an Other Payer AdQuality Payment Program performance informavanced APM if participants are required to bear total risk tion on Physician Compare. of at least 8 percent of their revenues from a given payer.

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Regulatory update The agency has also updated its policies to further encourage and reward participation in Advanced APMs in Medicare.

Specific policies include: •E xtending the 8 percent generally applicable revenue-based nominal amount standard that allows APMs to qualify as Advanced APMs for two additional years, through performance year 2020.

• Exempting Round 1 Comprehensive Primary Care Plus participants from the 50-clinician limit on organizations that can earn incentive payments by participating in medical home models.

• C hanging the requirement for Medical Home Models so that the minimum required amount of total financial risk increases more slowly.

• M aking it easier for clinicians to qualify for incentive payments by participating in Advanced APMs that begin or end in the middle of a year.

MGMA perspective CMS says that it worked with more than 100 stakeholder organizations and over 47,000 people, and reviewed over 1,200 stakeholder comments to finalize its Year 2 rule. But not all of those stakeholders are pleased with the result. The Medical Group Management Association is one. MGMA represents more than 40,000 medical practice administrators in more than 12,500 organizations.

In response to the association’s 2017 Regulatory Burdens survey, more than half of respondents reported they were participating in MIPS in 2017, and 72 percent said they planned to exceed the minimum reporting requirements, says Jennifer McLaughlin, senior associate director, government affairs, for MGMA. “However, 73 percent view MIPS as a government program that does not support their practice’s clinical quality priorities, and the vast majority are very concerned about the clinical relevance of MIPS to patient care.

MGMA supported the MACRA legislation, but the association believes that, as implemented: • MIPS is burdensome and incompatible with the intent of Congress to improve the quality of and reduce the cost of healthcare.

• P hysicians have limited opportunities to move into an eligible APM, in large part because the regulations establish a restrictive risk standard.

• T he Center for Medicare & Medicaid Innovation – a part of CMS charged with supporting the development and testing of innovative healthcare payment and service delivery models – has taken a top-down, government-driven approach to developing APMs. “MACRA was implemented seemingly to reduce physician practices’ regulatory burden, but MIPS is largely a continuation of … legacy programs,” that is, the Physician Quality Reporting System, or PQRS; and Meaningful Use (of certified electronic-health-record technology), says McLaughlin.

MGMA also takes exception with CMS’ decision to limit the pool of APMs to those developed by the Center for Medicare and Medicaid Innovation. “There is a much larger pool of innovative alternative payment models out there,” including those in the Medicare Advantage program and the Patient-Centered Medical Home care delivery model, says McLaughlin.

MGMA expressed disappointment with CMS’ decision to measure cost in 2018 even though that information is still incomplete, she continues. “CMS has yet to extensively test new episode-based measures, reform the patient attribution methodology, and implement risk- and specialty-adjustment to avoid penalizing physician practices who treat the country’s most vulnerable patients,” says McLaughlin. “We are also concerned CMS will not provide feedback about costs and patients who are attributed to groups during the performance period, so groups will have no way to track their resource utilization.”

Editor’s note: For an easy-to-read chart pointing out the differences in Year 2 of MACRA, go to this CMS website: www.cms.gov/Medicare/Quality-Payment-Program/resource-library/QPP-Year-2-Final-Rule-Fact-Sheet.pdf

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Cardiologists are ready for MACRA The American College of Cardiology is confident its members will fare well under MACRA’s pay-for-performance approach.

“We expect positive quality measure performance to carry through under MIPS and help many of our members not only avoid a penalty, but potentially also have a shot at the payment incentives available to high performers,” says Christine Perez, associate director, Medicare payment and quality policy, American College of Cardiology.

In the College’s 2017 practice census, over half of practices surveyed stated that they have in place an implementation plan for the Quality Payment Program, says Perez. “We believe that this number may be higher, as there are many practices where clinicians may be unaware that their administrative team, quality team, or clinical leadership [are] taking the lead on MIPS and APM activity on behalf of the group.

“Historically, cardiologists have performed well in reporting quality measures under [the Physician Quality Reporting System], so we expect this to carry over under MIPS. We have heard of several practices aiming for a full year performance this year since they have already established much of the reporting infrastructure and expertise with measure reporting under the previous Medicare programs.”

“The ACC agrees that quality should be a major part of new payment methodologies, as long as it is measured appropriately,” says Perez. And ACC believes MACRA is headed in the right direction.

“Unlike PQRS, which was pay for reporting, MIPS is now pay for performance, so we have been encouraging our members that it is not only important to participate, but also to continue to review their performance and continuously improve the quality of care they provide to patients.

“Looking to future and more robust years of the program, the ACC will continue to advocate that CMS allow cardiologists to report measures that are clinically meaningful to the patient population they treat.”

Most ACC members plan to report their performance measures via ACC’s qualified clinical data registry, EHR, or a qualified registry, says Perez. “We have heard concerns regarding the availability of CMS’ attestation portal for Advancing Care Information and Improvement Activity reporting. There were hopes that this portal would be available earlier in the year so practices would have a chance to become familiar with it and know that they had a solution available for reporting these categories.”

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POST-ACUTE CARE

Home Care in 2018 Slightly bruised by regulations, home care agencies can use help from their distributors. And they’re getting it.

With an estimated 10,000 to 11,000 Baby Boomers

turning 65 every day, it’s a safe bet that home care will play a growing role in the future of U.S healthcare.

For one thing, surveys indicate that aging Boomers prefer home care to institutional care. For another, the federal government can hardly ignore the potential cost-savings of home care. (Together, Medicare and Medicaid made up 77 percent of home health spending in 2016, according to the Centers for Medicare & Medicaid Services.) A recent study published in the American Journal of Medicine (Nov. 24, 2017) maintains that home health care can reduce 365-day post-discharge costs by more than $6,000 per patient, and reduce readmissions and deaths.

But home care providers face challenges as well, including reimbursement cuts (both real and threatened), competitive bidding, and fraud and abuse, to name a few.

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Repertoire asked three distributors (and distributor groups) to share their perspectives on the market: • Cardinal Health.

• Medline Industries.

• IMCO Home Care.

Cardinal Health at-Home “Post-acute is a critical part of Cardinal Health’s focus and mission,” says Luke Whitworth, vice president of Home Healthcare Solutions, a Cardinal Health company.

“As care continues to shift to the home, we will continue to look at opportunities that enable us to best serve our customers (patients, caregivers, clinicians, and commercial) and our strategic growth initiatives.”

Cardinal Health at-Home supplies home care patients with more than 40,000 products from more

A CUT ABOVE

Abby (Messermann) Helton Abby Altergott Adam Davidson Adam Knepper Adam Smith Al Piland Alan Feldman Alan Rosenberg Albert Frere Alex Fernandez Alex Palermo Alex Rad Alexandria Nicholas Alix Mayo Amanda Minor Amanda Myers Amy Goodspeed Andrew Plattner Andy Carellos Andy Dierenga Andy Marshall Andy McKeague Andy Pancratz Angelo Magliocca Ann Kittrell Anne Weissman Annie Malecheck Anthony Agosto Anthony Celesia Anthony Maiorano Anthony Toppin April Dutton Ashir Wilkerson Ashley Bertot Ashley Brangers Ashley Howard Ashley Johnson Ashley Kirk Ashley Rachadi Azalea Gonzalez Barbara Hunnell Beau Pierce Bertha Tamayo Bes Swetnam Beth Selfe Betsy Day Bill Bischoff Bill Brockett Bill Chase Bill Newman Bill Norwood Bill Way Billie Choquette Birdie Sudhichitt Blair Riedel Bob Hall Bob Patney Bob Sabatini Bobby Lewis Brad Fosmore Brad Hankey Brad Hupe Brad Macrorie Brad Murrell Brad Petker Braden Pritz Brandie Edwards Brandon Davidson Brandon Young Brandy Whitlow Brent Depperschmidt Brett Gorra Brett Myers Brian Cooper Brian Crowell Brian Cugliari Brian Katz Brian Ruppert Brian Whitlock Britt Hastings Britt Jones Bruce Brown Bruce Penning Bruce Salvani Bruce Stock Bryan Colbert Bryan Forester Bryan Hayes Candice Mueller Carlo Pissani Carlos Delgado Carol McGee Carole DeLong Cathy Lamberti Cathy Whitt Chad Durr Chad Harris Charles Johnson Charles White Chelsey Martinez Cherrie Gadman Cherry Arney Cheryl DiVita Cheryl Turpin Chip West Jr Chris Barry Chris Hanenberg Chris Kinney Chris Kozarits Chris McDougald Chris Pacheco

Chris Poole Chris Selin Chrissy Casanta Chrissy Kivita Christopher Aarsvold Cindy Dufrene (Spence) Clint Chaney Clint Harris Clint Mahle Cody Nasir Colin Connelly Corey Geatz Curran Hoover Curt Collier Curt Tisdell Daisy Vasquez Dan Coll Dan O’Connell Dan Quas Dan Woods Daniel Evans Daniel Fischer Daniel Walsh Danielle Rahn Danielle Thomas Danna Brightwell Danny Zepeda Darla Bird Darrell Hodges Dave Massi David Broomberg David DeRosa David Graves David Harlan David Vandeven David Wellman David Wiley Dawn Hepner Dawn Thompson Debbie Gutowski Debra McCarthy Dee Akers Delta Atkinson Denise Dillow Denise Mckeon Dennis Aldridge Dennis Feldman Derek Smith Dionn Avant Dirk L. Miller Domenic Fraone Don Schlatter Doug Anderson Doug Christenson Doug Huffman Dylan Eschete Dylan Walker Earl Freeman Ed Hitzel Ed McAnally Eddie Martinez Edward Colwell Eli Argueta Ellie Buckalew Elliott James Hays Eric Anderson Eric Petersen Eric Sanchez Eric Yonkers Ericka Hazelett Erin Huffman Fran Imwalle Francis Lanni Frank Barger Frank Rivas Fred Cook Fred Shorter Gary Nance Genine Barker Gilbert Martinez Gilda Kingsbury Gina Brooks Glen Olofson Greg Brown Gregg Schneider Gunnar Brown Gustavo Rodriguez Hal Crowe Harrison Jones Heather Thomas Heather Webber Helen Boga Henri Antebi Henry Swann Jr Holly Moore Hope Quinn Howard Kohut Ian Hutton Ian Silber Indhira Aragon Ira Silverman Isabel Ortiz Isaiah Haller Ivette Lugo Jack Pressly Jackie Ames James Barnes James Buxton James Chiacos James Cowen, Jr. James Gonsalves

James Liotta James Mann James Mayer James Miller James Nardini James Snella Jamie Iuliano Jamie Trail Jan Widger Janea Hickson Janet Toland Janna Malicoat Jasmine Bennett Jason Graham Jason Lerandeau Jason McCommon Jason Moninger Jason Rulney Jason Yunker Javier Lozano Jay Comer Jay Rennirt Jayson Orgill Jean Labanowski Jeff Baumtrog Jeff Bowman Jeff Corson Jeff Hirsh Jeff Kremer Jeff Schoenhals Jeff Traub Jeff Zlabis Jeffrey Cohen Jeffrey Lipson Jenna Carapazza Jennifer Olsen Jennifer Schecter Jerad Miller Jeremy Hanright Jerry Bishop Jerry Fairchild Jesse Dandrea Jessica Humprhrey Jill Galgano Jill Putman Jim Lovelace Jim Lynch Jo Dixon Jodi Mann Joe Antenucci Joe Clark Joe Coffman Joe De Bona Joe Lopes Joe Read Joe Romero Joey Rodriguez John Burkley John Cole John Downs John Howell John Ilvento John Kropf John Morrison John O’Neil John Pacelt John Schmertzler John Totten Johnny Santos Jon Comon Jon Dang Jon Leask Jose Valdes Joseph Alfano Joseph Lutz Josephine Musacchia Josephine Rose Joshua McCreary Jovo Jovanovic Judith Lundy Judy Clark Julie Grissom Julie Lanasa Juliette Williams Julio Gonzalez Justin Laupert Justin Smith Justin Trail Kamila English Kamilah Rumjahn Karen Collins-Lashley Karen Goody Karen Macias Kathleen Tuccillo Kathy Cramer Kayleen Jaynes Kaylene Hindman Kef Louis Keith Brady Keith Klump Keith Valley Kelli Woody Kelly Brake Kelly Enmon Kelly Muncy Kelly Schaut Kelly Stubblefield Ken Darst Ken Devault Ken Mason Kendra (Kagey) Leslie

Kenneth Przybyla Kenneth Wormell Kenny Beehler Keriann DeRosa Kerry Heneage Ketti McBride Kevin Gordner Kevin McCarthy Kevin Penelerick Khalid McClure Kianna Langston Kim Hagan Kimberly Cardon Kris Olsen Kristen Seneca Kristi Burns Kristina Haas Kristina Wearne Kurt Hoffman Kyle Fairchild L.A. Wong Lainey Ratliff Lance Osler Larry Hohs Larry Luftig Larry St.Lawrence Laura Henshaw Laura Sizemore Lauren Erlichman Lauren Figueroa Lauren Thomas Cole Laurie McGratty Laurie Nayer Laurie Taffner Lee Cook Lee Mahle Lelia Ennis Linda Nichols Linda Walters Lindsey Laskowski Lisa Campbell Lisa Keenan Lisa Young Liz Jaques Liz Mason Lloyd Anderson Lori Podd Lorraine Golding Luanne Nestasia Lynn Rushton Malcolm Phillips Marc Brier Marci Howser Marcia Gunnigle Margie Main Marguerite Boyle Maria Pinto Marie Woods Marilyn Hornsby Mario Damas Marisa Payne Mark Christopher Mark Dunn Mark Edwards Mark Hoyer Mark LoPorto Mark McKenna Mark Phillips Mark Robertson Mark Weeks Martin Anderson Mary Long-Sisto Mary Ramirez Maryann Cresser (Bancroft) Matt Arkison Matt De Stefano Matt Hurst Matt Kaplan Matt Murby Matthew Breznick Matthew Davis Matthew Mackay Matthew Robertson Maureen Yearwood Megan Shadduck Melanie Turner Melinda Mohan Melissa Ciullo Melissa Grant Melissa Humphreys Melissa Lambert Mic Wespinter Michael Seisdedos Michael Cole Michael Diaz Michael Kuszmaul Michael McKenna Michael Mucciacciaro Michael Paley Michael Polo Michael Vaughn Michele Huston Michele Morse Michele Rowland Michelle Chalcraft Michelle Feiler Mike A France Mike Adams Mike Clawson Mike Gomber Mike Ludwig

Mike Luxton Mike McGoldrick Mike Molloy Mike Nolan Mike Petrone Mike Pezonella Mike Schramm Mindy Eckhart Mitch Spector Mitze Reid Moe Taghavi Molly Hornick Moses Odria Nancy Ratliff Nancy Resnick Nathan Adler Nathan Harrington Nathan Higgins Neal Kennedy Neal Silverstone Neb Malcolm Neil Kaplan Nick Fasolina Nick Iadanza Nick Lisa Nick Ropp Nick Wolfgram Norbert Jovero Open Open Open Open Owen Lawson Paige Brown Pam McDaniel Pat Herlihy Patricia Rodriguez Patrick Nolan Patti Megan Paul Campbell Paul Mees Pepsi Parker Pete Czarnecki Pete Rewolinski Peter Farwick Peter Kukulich Phillip Brown Phillip Cervantes Price Pearson Rachel Kaye Randy Kawata Randy Larrison Randy Whale Ray Walker Rayanna Jones Rene Favela Reva de Leon Rhonda Jarvis Rhonda Knight Rich Bilz Rich Dwyer Richard Daley Richard Earls Richard Gherardi Richard Lapsley Richard Pencosky Richard Scherr Rick Howard Robbie Cato Robert Cook Robert D’Ambrosio Robert Foulke Robert Izen Robert Roche Robin Sweeney Robyn Rasmussen Rocky Rodriguez Ron Baker Ron Janzen Ronnie Fugger Rose Wood Rosie Rials Ross Conner Russell Nichols Ryan Crothers Ryan Edwards Ryan Hannigan Ryan Hetzel Ryan Nance Ryan Pereira Sal Chavez Sam Boyd Sam Durham Sam Hess Sam Shalaby Sam Zambardino Sandra Happes Sandra Simmons Sandra Small Sandy Palmer Sarah Boswell Sarah O’Brien Scot Shannon Scott Dekeyzer Scott Gluckstern Scott Jacko Scott Patton Scott Smith Scott Yardley Sean Donahue

Sean O’Leary Seth Klein Shan Zalotrawala Shane Cook Shane Teat Shaniya Forde Shannon Hall Shari Conley Sharon Borek Sharon Pacelt Sharon Wilburn Shawn Kruer Shawn Lopez Shawn Sherman Shawna Berry Sheila Ferrel Sheila Manganella Sheila Rivera-Haskins Spencer Leslie Stan Coss Stephanee Tyler Stephanie May Stephanie Mays Stephanie McNamara Stephanie Silva Steve Jackson Steve Kreditor Steve McNeal Steve Sharp Steve Taylor Steve Weil Steven Ward Stuart Byrne Sue Pappas Suzanne Johnson Suzanne Tribout Swain Sherman Sydnie Landers Sylvia Mota T Overton Taylor Lyon Teresa Ollestad Teresa Taylor Teri Schultheis Terri Beidle Terri Groseclose Terri White Terry Clarke Terry Linville Terry Picicci Terry Wilson Thomas Bigold Thomas St. Marie Thomas Turnage Tiffany Wagner Tiffiny Cisko Tim Alderman Tim Dwyer Tim Maroda Tod Poneleit Todd Adams Todd Krehmeyer Todd Marshall Todd Van Duyn Tom Lenihan Tom Maseth Tom O’Donnell Tom Rosol Tom Sharpe Tom Small Tom Torchia Tommy Gatewood Tona Jacques Tonia Bradley-Booker Tony Amason Tony Arditi Tony Baratta Tony Falco Travis Meekins Trevor Carr Troy Gale Troy Watson Tyler Brown Vanessa McCoy Vanessa Rojas Venus Robinson Vicki Krouse Victoria Archer Victoria Wilson Vincent Scalici Vinny Mongiovi Wendy Kahn Will Taylor Yaremy Bustamante Zack O’Rourke

From Repertoire’s EOL and the 21 manufacturers who provided product training, thank you for your outstanding compliance rate for the 2017 modules. As salespeople, we always hear about the 80/20 rule. The 647 reps listed here far outdo that rule!

POST-ACUTE CARE than 700 manufacturers, says Whitworth. The company’s businesses ship disposable medical supplies and durable medical equipment from eight distribution centers in Ohio; New Jersey; Texas; California; Florida; Illinois; North Carolina; and Oregon. Together they comprise more than 800,000 square feet of inventory space, and enable one-to-two-business-day shipping to 99 percent of the U.S. Cardinal Health at-Home operates through three channels: Home Healthcare Solutions (acquired by Cardinal Health in 2015), Edgepark Medical Supplies (acquired in 2013) and Independence Medical (acquired in 2013).

Home Healthcare Solutions serves home care and hospice agencies with utilization management tools

Independence Medical provides more than 12,000 commercial customers (primarily suppliers of home medical equipment, durable medical equipment and pharmacy) a direct-to-consumer medical supply program. Independence Medical offers customers analytics through the Growth Essentials™ technology platform, a suite of interactive dashboards to help customers better understand their patient population.

“As a medical supply distributor to home health and hospice agencies, we’ve found that agencies are looking for partners and scaled solutions rather than a partner who simply distributes product,” says Whitworth.

“Their world is becoming more complex with higher acuity patients, a changing reimbursement landscape, and increased regulatory requirements.”

CAREessentials can help, says Whitworth, as it “helps customers identify spend outliers, monitor clinical practices, and benchmark agency performance, which can truly help them identify opportunities to reduce spend, optimize product use, and improve patient outcomes.

“The home health and hospice agencies deploy a field-based staff.

This can naturally result in inconsistencies from clinician to clinician.

These inconsistencies drive up cost, and pose some risk to clinical out– Pam Wedow comes. CAREessentials provides visibility to these inconsistencies, allowing them to act.”

“ Home care companies may have to be more expansive and creative in their offerings, perhaps by generating more cash sales of items not necessarily reimbursed by Medicare.” and shipping supplies directly to consumers at home, says Whitworth. “Beyond products, Home Healthcare Solutions provides customers with scaled solutions and interactive dashboards, known as CAREessentials™,” he explains. “Our mission is to work with our customers as a true partner in managing medical supply spend to improve patient experience, staff productivity, clinical practice and business profitability.

Edgepark Medical Supplies works with more than 1,300 health plans, including Medicare and select state Medicaids, to support billing efficiencies, patient compliance, and shipping supplies directly to the home. Its products include diabetes testing/ insulin therapy, insulin pumps/CGM, ostomy, urological, incontinence, respiratory, wound care, and breast pumps.

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Medline Industries Medline Industries began shipping home-direct about 20 years ago, says Chris Nave, senior vice president of homecare sales. Today, the company delivers more than 5 million orders annually to home health, hospice and on behalf of dealers, he says. More than 300 post-acute reps – both inside and outside – call on the post-acute market, which includes agencies, dealers, pharmacy, long-term care, etc.

Home care will continue to grow for several reasons, he says: • Technology will continue to play a large role in home care due to its ability to reduce readmissions, increase patient engagement and outcomes, as well as reduce nursing labor costs.

• The aging population continues to grow.

• Shifts in Medicare Advantage, managed care organizations and other alternative payment models are driving reimbursement.

Despite the strong indicators of growth, home care agencies, dealers and pharmacies face their share of challenges, says Nave. Medicare reimbursement, such as alternative payment models through managed care organizations, is one. A second is the increased retail presence in the market, as well as significant market changes, such as CVS Health’s recently announced intention to acquire Aetna.

“Because Medline is a privately held company, we have the ability to be flexible and nimble when it comes to customers’ needs, allowing us to take on risk to ensure success for our customers,” says Nave. “Medline believes in the importance of bringing value beyond shipping supplies.

Our value-add programs allow us to offer customers alternative programs to help reduce readmissions, increase star ratings, and improve patient and clinician satisfaction.”

Home Care was a natural for IMCO, says Wedow.

Yes, there is a learning curve for physician or long-term-care distributors, she says. “If you’ve met one home care customer, you’ve met one.” The call point at one pharmacy, for example, might be a busy pharmacist/owner who fills scripts and talks to patients all day, she says. The next customer might fit a very different profile. “It’s a matter of getting to know the customers and helping them with delivery of products (perhaps home delivery), or expansion of their business into other cash sales or retail products that may fit with whatever patient modalities they deal with.”

Reimbursement reductions and competitive bidding – a system whereby Medicare selectively contracts with a limited number of homecare providers based on the lowest bid prices – have put a squeeze on margins, and have forced home care companies to change, says Wedow.

“They may have to be more expansive and creative in their offerings, perhaps by generating more cash sales of items not necessarily reimbursed by Medicare.” (An example might be a basket or backpack to be used in conjunction with a rollator.)

For many IMCO members, making the move into home care comes naturally, she continues. “Many of the products are the same as those in the physician and long-term-care markets,” she says. “And we know the manufacturers.”

IMCO members understand the value of distribution, and they are skilled at communicating – and demonstrating – it to existing and prospective customers, including home care clients, says Wedow. Setting up drop ship programs for their customers’ patients is just one way they do so. What’s more, IMCO members have existing relationships with physicians and other providers in the area, and can help connect those providers with their home care customers to bolster their referral network.

IMCO Home Care’s strategy is to recruit members, then introduce them to an IMCO distributor. In some cases, reps from IMCO distributors actively recruit new members themselves.

IMCO Home Care Daytona Beach, Florida-based IMCO made a decision to create IMCO Home Care about five years ago as a way to help its distributor members get better entrenched in that market, says IMCO Home Care Managing Partner Pam Wedow. Most IMCO Home Care members are retailers, such as home medical equipment stores and independent pharmacies. “We have upwards of 500 member locations, and we’re still a fledgling group,” she says IMCO Home Care’s strategy is to recruit members, then introduce them to an IMCO distributor. In some cases, reps from IMCO distributors actively recruit new members themselves.

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POST-ACUTE CARE

Where’s the money going?

Home healthcare, while growing, still accounts for just about 3 percent of U.S. healthcare spending, according to the Centers for Medicare & Medicaid Services.

Spending for freestanding home healthcare agencies decelerated in 2016, increasing 4 percent to $92.4 billion (compared to 5.8 percent growth in 2015). Slower growth in Medicaid spending (4.6 percent in 2016 from 7.7 percent in 2015), out-of-pocket spending (0.5 percent in 2016 from 3.1 percent in 2015) and private health insurance spending (2.8 percent in 2016 from 6.6 percent in 2015) contributed to slower overall growth in 2016. Medicare and Medicaid together made up 77 percent of home health spending in 2016.

The bigger picture Total U.S. healthcare The stronger spending increased growth in 2014 4.3 percent to reach and 2015 was $3.3 trillion, or $10,348 due in part per person in 2016, according to CMS. to the initial Spending growth impacts of the decelerated in 2016 ACA’s expansion after the initial impacts of Affordable Care of Medicaid Act coverage expanenrollment during sions and strong retail that period. prescription drug spending growth in 2014 and 2015. The overall share of gross domestic product (GDP) related to healthcare spending was 17.9 percent in 2016, up from 17.7 percent in 2015.

Spending by type of service or product in 2016 looked like this: Hospital care (32 percent share). Spending for hospital care increased 4.7 percent to $1.1 trillion in 2016, slower than the 5.7 percent growth in 2015. The slower growth in 2016 was driven by the slower growth in the use and intensity of services, reports CMS. Hospital care expenditures showed mixed trends across the major payers, with slower growth in Medicaid and private health insurance spending, stable growth in Medicare spending, and faster growth in out-of-pocket spending.

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Physician and clinical services (20 percent share).

Spending on physician and clinical services increased 5.4 percent to $664.9 billion in 2016. Although growth for physician and clinical services decelerated slightly in 2016 (from 5.9 percent in 2015), it outpaced the growth in all other goods and services categories. The growth in the use and intensity of physician and clinical services was a driving factor in the overall growth in physician and clinical services, accounting for nearly three-quarters of the 5.4 percent increase.

Prescription drugs (10 percent share). Growth in retail prescription drug spending slowed in 2016, increasing 1.3 percent to $328.6 billion. The slower growth in 2016 follows two years of strong growth in 2014 and 2015, – 12.4 percent and 8.9 percent, respectively. This strong growth reflected increased spending on new medicines and price growth for existing brand-name drugs, particularly for drugs used to treat hepatitis C, says CMS. Growth slowed in 2016 primarily due to fewer new drug approvals, slower growth in brand-name drug spending as spending for hepatitis C drugs declined, and a decline in spending for generic drugs as price growth slowed.

Other professional services (3 percent share).

Spending for other professional services reached $92.0 billion in 2016, an increase of 4.7 percent.

This was a deceleration from the 5.9 percent growth in 2015. Spending in this category includes establishments of independent health practitioners (except physicians and dentists) that primarily provide services such as physical therapy, optometry, podiatry, or chiropractic medicine.

Dental services (4 percent share). Spending for dental services increased 4.6 percent in 2016 to $124.4 billion, a slight acceleration from 4.4 percent growth in 2015. Private health insurance (which accounted for 46 percent of dental spending) increased 4.8 percent in 2016, the same rate of growth that occurred in 2015. Out-of-pocket spending for dental services (which accounted for 40 percent of dental spending) increased 4.3 percent in 2016, faster than the 3.4 percent increase in 2015.

Other health, residential, and personal care services (5 percent share). This category includes expenditures for medical services that are generally delivered by providers in non-traditional settings such as schools, community centers, and the workplace; as well as by ambulance providers and residential mental health and substance abuse facilities. Such spending grew 5.3 percent in 2016 to $173.5 billion after increasing 8.7 percent in 2015. The slowdown was driven by the slower growth in Medicaid spending, 57 percent of all spending in this category, which slowed to 5.7 percent in 2016 after 10.8 percent growth in 2015.

4.9 percent in 2014. The slower growth in 2016 was due to slower growth in spending for both the Medicare fee-for-service (2.2 percent in 2015 to 1.8 percent in 2016) and Medicare Advantage (11.1 percent in 2015 to 7.4 percent in 2016) portions of Medicare.

• Medicaid (17 percent share): Total Medicaid spending decelerated in 2016, increasing 3.9 percent to $565.5 billion. This was much slower growth than in the previous two years, when Medicaid spending grew 11.5 percent in 2014 and

Nursing care facilities and continuing care retirement communities (5 percent share). Spending for freestanding nursing care facilities and continuing care retirement communities decelerated in 2016, growing 2.9 percent to $162.7 billion, compared to 3.7 percent growth in 2015. The slower growth in 2016 was largely attributed to slower spending growth in both Medicare (1.2 percent in 2016 from 4.0 percent in 2015) and private health insurance (5.9 percent in 2016 from 14.3 percent in 2015).

Durable medical equipment (2 percent share).

Retail spending for durable medical equipment, which includes items such as contact lenses, eyeglasses and hearing aids, reached $51.0 billion in 2016 and increased 4.9 percent, which was faster than the 4.1 percent growth in 2015.

Other non-durable medical products (2 percent share).

Retail spending for other non-durable medical products, such as over-the-counter medicines, medical instruments, and surgical dressings, grew 4.4 percent (about the rate of growth in 2015, 4.6 percent) to $62.2 billion in 2016.

Who’s paying?

Meanwhile, CMS reports 2016 spending by major sources of funds: • Medicare (20 percent share): Medicare spending grew 3.6 percent to $672.1 billion in 2016, which was lower than growth in the previous two years when spending increased 4.8 percent in 2015 and

9.5 percent in 2015. The stronger growth in 2014 and 2015 was due in part to the initial impacts of the ACA’s expansion of Medicaid enrollment during that period. State and local Medicaid expenditures grew 3.2 percent, while federal Medicaid expenditures increased 4.4 percent in 2016.

•P rivate health insurance (34 percent share): Private health insurance spending increased 5.1 percent to $1.1 trillion in 2016, which was slower than the 6.9 percent growth in 2015. The deceleration was largely driven by slower enrollment growth in 2016 after two years of robust enrollment growth due in part to ACA coverage expansion.

• Out-of-pocket (11 percent share): Out-ofpocket spending grew 3.9 percent in 2016 to $352.5 billion, faster than the growth of 2.8 percent in 2015. This was the fastest rate of growth since 2007 and exceeded the average annual of growth 2.0 percent from 2008-15.

Source: Centers for Medicare & Medicaid Services, www.cms.gov/Research-Statistics-Data-and-Systems/ Statistics-Trends-and-Reports/NationalHealthExpendData/downloads/highlights.pdf

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POST-ACUTE CARE: HIDA INSIGHTS

Patients, Payers Cut Costs with ASCs The cost of medical procedures performed at ambula-

tory surgery centers (ASCs) is generally lower than that of procedures performed at hospital inpatient departments.

Both the number and range of procedures performed in ASCs has grown substantially in recent years, leading to lower costs for both public and private payers, as well as patients. By one estimate, consumers could save up to $5 billion if more care was shifted to existing ASCs. HIDA’s new 2018 Ambulatory Surgery Center Market Report offers an in-depth look at ASC market conditions, as well as factors affecting demand and utilization.

The following is a look at some of the key trends and data points collected for this new report.

ASCs handle the majority of outpatient surgeries Last year, ASCs handled approximately 58 percent of outpatient surgeries, up from 41 percent in 2005. This figure will continue to grow, with ASCs handling 60 percent of outpatient surgeries by 2020. At the same time, more surgeries are shifting from inpatient to outpatient settings.

In 2005, 58 percent of surgeries were performed in an outpatient setting, and this figure is expected to reach 64 percent by 2020.

ASCs to treat more surgeries of all types The Centers for Medicare and Medicaid Services is focused on paying the same amount for certain medical procedures, regardless of setting. Currently, hospital outpatient departments are paid more than ASCs for outpatient

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surgery. Beginning this year, hospitals will be paid 40 percent of the amount specified in the outpatient prospective payment system for certain procedures that can be performed at an ASC or a physician office.

Publicly-owned ASCs experience steady revenue growth HIDA analysis contained in the report shows that publicly-owned ASCs’ revenue grew steadily between 2014 and 2016. These companies’ per-procedure revenue increased by 52 percent, on average, during this period.

Key drivers of this growth include surgical and anesthesia advances that allow more complex procedures to be performed at ASCs. Publicly-traded ASCs also have seen rising profits during this period, though the share of their budget devoted to supplies is also rising. With their experience and unique perspective, distributors can bring a unique value to these fast-growing providers by offering supply chain solutions.

While these are some of the key growth trends affecting market conditions for ASCs, these providers also face a number of risks and constraints. Certificate-of-need programs, quality reporting requirements, and industry consolidation are among the (challenges, or something else, for which these facilities need to account). For an in-depth look at this rapidly changing healthcare segment, visit www.HIDA.org/MarketReports to purchase your copy of HIDA’s 2018 Ambulatory Surgery Center Market Report.

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HEART DISEASE

Coronary artery disease: The facts Heart disease is the leading cause of death for both men and women, re-

ports the Centers for Disease Control and Prevention. About 610,000 people die of heart disease in the United States every year – that’s one in every four deaths.

Coronary artery disease (CAD) is the most common type of heart disease in the United States, killing more than 370,000 people annually. For some people, the first sign of CAD is a heart attack.

CAD is caused by plaque buildup in the walls of the arteries that supply blood to the heart. Plaque is made up of deposits of cholesterol and other

substances in the artery. Too much plaque buildup and narrowed artery walls can make it harder for blood to flow through the body. When the heart muscle doesn’t get enough blood, the result can be chest pain or discomfort, called angina.

Over time, CAD can weaken the heart muscle. This may lead to heart failure, a serious condition where the heart can’t pump blood the way that it should. An irregular heartbeat, or arrhythmia, also can develop.

High blood pressure, high cholesterol and smoking are key risk factors for heart disease. About half of Americans (47 percent) have at least one of these three risk factors. Several other medical conditions and lifestyle choices can also put people at a higher risk for heart disease, including: • Diabetes • Overweight and obesity • Poor diet • Physical inactivity • Excessive alcohol use

For more information, visit the CDC website at www.cdc.gov/heartdisease/facts.htm

Cardiac troponin is the biomarker of choice A recent article in JAMA Internal Medicine evaluated re-

cent literature as well as a report by the American College of Cardiology and the European Society of Cardiology, all of which demonstrate that cardiac troponin is the biomarker of choice, reports COLA, the lab accreditation organization.

“The research shows that cardiac troponin alone is adequate in the evaluation of patients with suspected heart muscle damage because of its nearly absolute myocardial tissue specificity and high clinical sensitivity in the detection of myocardial injury,” says John Daly, M.D.,

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chief medical officer for COLA. “The reports conclude that CK-MB [Creatine Kinase-MB] provides no additional diagnostic or clinical value in diagnosing heart attacks and can safely be eliminated in the evaluation of a patient for a diagnosis of myocardial infarction.”

In fact, adds Daly, CK-MB performed with cardiac troponin can even cause clinical confusion when the results are contradictory. Because many laboratories offer a default order set that includes both cardiac troponin and CK-MB, it is recommended that order sets be eliminated.

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HEART DISEASE

Four legs good Regular screenings, a proper diet and plenty of exer-

cise all have their place in helping prevent heart disease.

Dog ownership is another.

In a population-based study with 12 years of follow-up, researchers in Sweden showed that dog ownership is associated with a lower risk of cardiovascular disease in single households and with a reduced risk of cardiovascular and all-cause death in the general population. The results of the study were published in the journal Nature.

“One mechanism by which dog ownership could reduce CVD risk and mortality is by alleviating psychosocial stress factors, such as social isolation, depression and loneliness – all reportedly lower in dog owners, the researchers write. “These factors have been linked to increased risk of coronary heart disease, cardiovascular death and all-cause mortality.

Apart from the social support, it has consistently been shown that dog owners achieve more physical activity and spend more time engaged in outdoor activities.

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“Dog ownership has also been associated with elevated parasympathetic and diminished sympathetic nervous system activity, lower reactivity to stress, and faster recovery of blood pressure following stressful activity. Apart from the social support, it has consistently been shown that dog owners achieve more physical activity and spend more time engaged in outdoor activities.”

Of course, more study is needed to establish a direct causal relationship between dog ownership and better cardiovascular health, the researchers say.

“Although careful attention was paid to adjusting for potential confounders in a set of sensitivity analyses, it is still possible that personal characteristics that we did not have information about affect the choice of not only acquiring a dog, but also the breed and the risk of CVD.”

Health screenings are up By reducing out-of-pocket costs for preventive treat-

ment, the Affordable Care Act appears to have encouraged more people to have health screenings related to their cardiovascular health a UCLA study found. Comparing figures from 2006 through 2013, researchers found that more people were screened for diabetes, high cholesterol, cigarette use and high blood pressure – all risk factors for heart disease – after the ACA was implemented than before.

The research, published in the peer-reviewed American Journal of Managed Care, found that from 2006 to the fourth quarter of 2013, the percentage of doctor visits during which diabetes screening was performed increased to 7.6 percent from 3.9 percent; during which people talked to their doctors about smoking, to 74.5 percent from 64.4 percent; and during which screening for high blood pressure, or hypertension, was performed to 76.4 percent from 73.2 percent.

But the research also revealed a disparity between men and women in one key area. Although more men who are at risk for heart attacks and stroke take daily doses of baby aspirin, the number of women taking baby aspirin each day is unchanged since before the ACA became law.

Baby aspirin is commonly prescribed to people at risk for heart attack and stroke.

“There has been a lot of concern about women receiving poorer quality cardiovascular care, and our study reinforces this concern,” said Dr. Joseph Ladapo, the study’s lead author and an associate professor of medicine in the division of general internal medicine and health services research at the David Geffen School of Medicine at UCLA. Data for the study was drawn from the National Ambulatory Medical Care Survey and National Hospital Ambulatory Medical Care Survey data from 2006 to 2013.

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HEART DISEASE

Vitamin B7 may interfere with lab tests The U.S. Food and Drug Administration issued a “Safety

Communication” in November, alerting the public that taking biotin – also known as vitamin B7 – can interfere with certain lab tests, including tests for markers of cardiac health, such as troponin.

Biotin in blood or other samples taken from patients who are ingesting high levels of biotin in dietary supplements can cause clinically significant incorrect lab test results. The FDA has seen an increase in the number of reported adverse events, including one death, related to biotin interference with lab tests.

Biotin in patient samples can cause falsely high or falsely low results, depending on the test. Incorrect test results may lead to inappropriate patient management or misdiagnosis. For example, a falsely low result for troponin, a clinically important biomarker to aid in the diagnosis of heart attacks, may lead to a missed diagnosis and potentially serious clinical implications. The FDA has received a report that one patient taking high levels

of biotin died following falsely low troponin test results when a troponin test known to have biotin interference was used.

The FDA is aware of people taking high levels of biotin that would interfere with lab tests. Many dietary supplements promoted for hair, skin, and nail benefits contain biotin levels up to 650 times the recommended daily intake of biotin. Physicians may also be recommending high levels of biotin for patients with certain conditions such as multiple sclerosis (MS).

Patients and physicians may be unaware of biotin interference in laboratory assays. Even physicians who are aware of this interference are likely unaware as to whether, and how much biotin, patients are taking. Since patients are unaware of biotin interference, they may not report taking biotin supplements to their physicians, and may even be unaware they are taking biotin (e.g., when taking products generally labeled for their benefits to hair and nails).

To view the FDA Safety Communication, go to www.fda.gov/MedicalDevices/Safety/AlertsandNotices/ucm586505.htm

CPR training will demand feedback devices The American Heart Association will require the use of

an instrumented directive feedback device in all courses that teach adult CPR skills, effective Jan. 31, 2019. The devices provide real-time, audiovisual and corrective evaluation and instruction on chest compression rate, depth, chest recoil and proper hand placement during CPR training.

The Association reports that studies reveal that this technology, which can be integrated into or serve as an accessory to a manikin, helps students master CPR skills and reduces the time between training and demonstration of competence in a training environment. This new requirement impacts the AHA’s Basic Life Support (BLS), Advanced Cardiovascular Life Support (ACLS), ACLS for Experienced Providers and Heartsaver® adult CPR training courses taught in the United States and internationally.

When CPR is taught and performed according to the American Heart Association’s CPR and ECC Guidelines, chest compressions are delivered at a rate of 100 to 120 compressions per minute and a depth of at least 2 inches.

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To comply with the new course requirement, feedback devices must, at a minimum, measure and provide realtime audio and/or visual feedback on compression rate and depth, allowing students to self-correct or validate their skill performance immediately during training.

On ZOLL’s AED Plus® and the AED Pro®, rescuers hear – and see – “Push Harder” or “Good Compressions,” as well as encouragement to “Start CPR” if needed, according to the company. On the R Series® and the X Series®, Real CPR Help provides numeric displays of both rate and depth, as well as verbal feedback, if desired, to “Push Harder” or “Good Compressions.”

Each year, more than 350,000 cardiac arrests occur outside the hospital and over 200,000 occur in a hospital setting, according to the American Heart Association.

Only 46 percent of people who suffer an out-of-hospital cardiac arrest receive bystander CPR before professional help arrives. CPR, if performed immediately and correctly, can double or triple a victim’s chance of survival.

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Ansell has a rich library of online and hard-copy resources to help you guide your customers to the right glove. Easy-to-read charts spell out the pros, cons and applications for all kinds of gloves. Our professional white papers, which go into greater detail, will appeal to a subset of your customers as well.

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HEALTHY REPS

Health news and notes Overweight, obesity and cancer Overweight and obesity are associated with increased risk of 13 types of cancer. These cancers account for about 40 percent of all cancers diagnosed in the United States in 2014, according to the latest Vital Signs report by the Centers for Disease Control and Prevention. Overall, the rate of new cancer cases has decreased since the 1990s, but increases in overweight- and obesity-related cancers are likely slowing this progress. About 630,000 people in the U.S. were diagnosed with a cancer associated with overweight and obesity in 2014, according to CDC. About two in three occurred in adults ages 50 to 74. The rates of obesity-related cancers, not including colorectal cancer, increased by 7 percent between 2005 and 2014. The rates of non-obesity related cancers declined during that time.

Other findings: • 5 5 percent of all cancers diagnosed in women and 24 percent of those diagnosed in men are associated with overweight and obesity.

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• Non-Hispanic blacks and non-Hispanic whites had higher incidence rates compared with other racial and ethnic groups. Black males and American Indian/Alaska Native males had higher incidence rates than white males.

• Between 2005 and 2014, colorectal cancer decreased 23 percent, due in large part to screening. Cancers not associated with overweight and obesity decreased 13 percent.

•C ancers associated with overweight and obesity, excluding colorectal cancer, increased among adults younger than age 75.

Slow down with the yoga The number of yoga practitioners in the United States has more than doubled to 36.7 million over the last decade, with health benefits the main reason people practice, according to the Yoga in America study conducted last year on behalf of Yoga Journal and the Yoga Alliance, as reported

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by the Washington Post. While yoga enthusiasts are often pictured as young and bendy, the reality, according to the Yoga in America study, is that 17 percent are in their 50s, and 21 percent are age 60 and older. Along with this upsurge of interest has been an upsurge in injuries, particularly among older practitioners. “Participants aged 65 years and older have a greater rate of injury from practicing yoga when compared with other age groups,” researchers wrote last year in a study of nearly 30,000 yoga-related injuries seen in U.S. hospital emergency departments from 2001 to 2014. Suggestions: Start where you are, not where you think you should be; recognize that some yoga classes are vigorous and athletic, and others are intended to be relaxing and restorative; find a well-trained, experienced teacher.

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The Alzheimer’s collision course There is no proven intervention for preventing late-life dementia, report researchers from the Minnesota Evidencebased Practice Center (EPC). The researchers reviewed published studies to determine if physical activity, prescription medications, over-the-counter vitamins and supplements, or cognitive training interventions could help to prevent dementia in patients who did not have it at the time of the studies. The vast majority of research showed that none of the interventions worked. According to the researchers, the reasons these interventions fail is not entirely clear. It is possible that they simply do not work to improve cognition, or it could be that the studies started the interventions too late in life, didn’t use them long enough, or because of shortcomings in many of the studies. Researchers note that while there was no evidence about whether an intervention to practice a healthy lifestyle earlier in life protects against cognitive decline or dementia in later life, it is unlikely to worsen cognition and may have other, noncognitive benefits.

Meanwhile, the National Institutes of Health reports that approximately 6 million American adults have Alzheimer’s disease or mild cognitive impairment, which can sometimes be a precursor to the disease. NIH also forecasts that these numbers will more than double to 15 million by 2060, as the population ages. For the first time, scientists have attempted to account for numbers of people with biomarkers or other evidence of possible preclinical Alzheimer’s disease, but who do not have impairment or Alzheimer’s dementia. People with such signs of preclinical disease are at increased risk to develop Alzheimer’s dementia.

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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.

Automotiverelated news

In-n-out car rental Avis Budget Group, Inc. is offering travelers in the Kansas City area a chance to test a completely mobile rent-a-car experience that features keyless entry and ignition. Under the agreement, selected vehicles in the Avis Car Rental fleet are enabled with Continental’s Key-as-a-Service (KaaS) technology, which allows Avis customers to use the Avis app to lock/unlock the car and start the engine.

and eating supper – a late night meal – at least once a week is now nearly twice as common as brunch; 2) at least half of U.S. adults have at some point eaten food that they know is expired or food that has fallen on the floor; 3) nearly 90 percent of millennials admit to texting while dining out; and 4) 43 percent of Americans say they are picky eaters. The survey was conducted online by Harris Poll on behalf of Uber Eats within the United States between Oct. 26 and Nov. 6, 2017, among 1,019 US adults aged 18+.

Tires for Bitcoin London-based Zenises announced it will be the first tire company in the world to accept Bitcoin for off-line and online transactions. Zenises has been working to develop the technology at its newly launched technology center in Madrid, and reports it has been working with several experts in the Blockchain world. CEO Harjeev Kandhari stated that “We have already received our first payment in Bitcoin and all systems are go! We are now working on the platforms to accept other cryptocurrencies in the near future.”

Brunch is dying!

Uber Eats – Uber’s standalone meal delivery app – released findings from its first-ever “How America Eats” survey. Some key takeaways include: 1) Brunch is dying,

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Driverless choppers Aurora Flight Sciences conducted a successful demonstration of the company’s autonomous helicopter system developed under the Office of Naval Research’s Autonomous Aerial Cargo Utility System (AACUS) program.

Held at Marine Corps Base Quantico’s Urban Training Center, the AACUS-Enabled UH-1H (AEH-1) conducted multiple flights, showcasing its ability to autonomously execute re-supply missions in relevant and austere settings. AACUS is a hardware and software suite that enables a Marine on the ground to request a supply delivery via helicopter from a handheld tablet, requiring no advanced training to operate the system. AEH-1 is fitted with onboard lidar and camera sensors that enable it to detect and avoid obstacles and evaluate the landing zone.

Hang on tight WardsAuto announced the winners of the annual Wards 10 Best Engines Award program, and for the first time, four electrified powertrains made the cut. The new list is also notable for its lack of winners from German automakers for the first time in the award’s 24-year history.

And while luxury brands are typically well-represented on the Wards 10 Best Engines list each year, only two – Infiniti and Jaguar – made the cut for 2018. This year’s winners are: • 1 50-kW Electric Propulsion System (Chevrolet Bolt EV) • 3.6L Pentastar DOHC V-6/PHEV (Chrysler Pacifica Hybrid) • 2.7L Twin Turbo DOHC V-6 (Ford F-150) • 5.0L DOHC V-8 (Ford Mustang GT) • 130-kW Fuel Cell/Electric Propulsion System (Honda Clarity) • 2.0L VTEC Turbocharged DOHC 4-Cyl. (Honda Civic Type R) • 3.0L Turbocharged DOHC V-6 (Infiniti Q50) • 2.0L Turbocharged DOHC 4-Cyl. (Jaguar XF) • 3.3L Turbocharged DOHC V-6 (Kia Stinger) • 2.5L Atkinson DOHC 4-Cyl./HEV (Toyota Camry Hybrid) Vehicles must have a base price no higher than $63,000.

DieHard on Amazon The DieHard brand announced that it is celebrating 50 years of performance by launching DieHard products on Amazon.com. An assortment of DieHard jump starters, battery chargers and maintainers are available for purchase. Passenger car tires and automotive batteries will be added to Amazon.com in early 2018. “As we have previously stated, we want to diversify the revenue streams of our iconic brands, and launching on Amazon.com will significantly expand the distribution and availability of the DieHard brand in the U.S., building on the success of our recent Kenmore appliances launch on Amazon. com,” said Tom Park, President of Kenmore, Craftsman and DieHard brands at Sears Holdings,

Best family cars Kelley Blue Book’s KBB.com editors named their recommendations for the Best Family Cars of 2018, based on safety ratings, overall value, versatility, amenities, comfort,

drivability and technology. Most of the SUVs and minivans on the list offer smart cruise control and automatic braking. A smaller number offer teen-driver monitoring, wireless phone charging and lane-keeping assist. Two models – the Honda Odyssey and Chrysler Pacifica minivans – offer built-in vacuum cleaners. In addition, more and more are protecting families with crash-avoidance and collision-mitigation intervention. Among the best cars: Chevrolet Equinox, Honda CR-V and Subaru Outback (best two-row SUVs); Chevrolet Traverse, Honda Pilot, Toyota Highlander and Volkswagen Atlas (best three-row mid-size SUVs); Chevrolet Tahoe and Ford Expedition (best three-row full-size SUVs); and Chrysler Pacifica, Honda Odyssey and Toyota Sienna (best minivans).

Fully electric Toyota coming up Twenty years after Toyota introduced the first Prius in Japan and 17 years after it arrived in the United States, hybrids are practically synonymous with Toyota, writes Motor Trend. But as demand for electrified vehicles increases, Toyota needs to be able to use newer, better batteries. To achieve this goal, the company announced plans to collaborate more closely with Panasonic, the company it has worked on batteries with for the past two decades.

Bloomberg reports that Panasonic and Toyota are developing prismatic cell batteries, as well as solid-state batteries.

Assuming that Toyota and Panasonic don’t experience significant setbacks in their development of solid-state batteries, expect to see a fully electric Toyota on the road in the early 2020s, says Toyota.

A silent, dark gray sedan…

“While the world’s most famous automakers were pulling the covers off their latest, shiniest offerings at the Los Angeles Auto Show, a dark gray sedan circled the convention center, almost silently,” Wired magazine recently reported. “Riding on 21-inch wheels, the Lucid Air cuts a muscular stance, its door handles flush with the body of the car, one thin bar of light bars stretching across its front, another along the slightly boxy rear. Fully electric, it offers a tempting vision of the future.” But a cool preproduction car does not necessarily make a practical production vehicle, points out the magazine. Ask Elon Musk. Still, Menlo Park, Calif.-based Lucid “has one big advantage Tesla didn’t have when it was getting started a decade ago: Electric cars are no longer an odd, ignored corner of the market.”

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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

Private label, Amazon style AmazonBasics leads Amazon’s private brand sales, with over $400 million (as of Dec. 20, 2017) in estimated sales, or 85 percent of total Amazon private brands sales in the United States, according to e-commerce analytics firm One Click Retail. Due to a strong performance of both Pinzon (bath, bedding goods, etc.) and AmazonBasics, Amazon’s Home product group – which was expected to achieve over $80 million in 2017 sales – surpassed its Electronics product group, estimated at less than $70 million. The Amazon Elements line of baby wipes continues to be a success, nearly doubling its 2016 estimated sales with a growth of 94 percent yearover-year. The estimated >$15 million sold in 2017 in baby wipes alone makes up the majority of the Amazon Elements brands, supplemented by just over $1 million

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in estimated sales of vitamins and supplements. Since September 2017, Amazon has launched several new private brands, according to One Click Retail: Rivet (consumer rugs and living room furniture); Stone & Beam (premium rugs, sofas, lamps and fixtures); and Goodsport, Peak Velocity and Rebel Canyon (activewear and sports apparel).

A new term to learn: Blockchain Though typically associated solely with bitcoin and cryptocurrency, blockchain technology is becoming increasingly important for a wide range of industries – from oil & gas to security and sports betting, according to NetworkNewsWire. Blockchain technology was initially developed to facilitate the exchange of cryptocurrencies without the need of a middleman, like a bank, to make a transaction. In this

Blockchain technology was initially developed to facilitate the exchange of cryptocurrencies without the need of a middleman, like a bank, to make a transaction.

state guidance advises consumers to, among other things, keep cellphones away from their head and bodies during the day and their beds at night, as well as avoid using cellphones when streamlining audio or video or downloading or sending large files.

Very best apps of 2017

A sampling of comments from the editors of Mashable on what they believe are some of the year’s very best apps: Astro: The app has all the organizational features you’d expect from an email client: multiple inboxes, gesture-based controls, message scheduling, and the ability to “snooze” emails for later. What makes Astro stand out, though, is the built-in assistant that learns your habits and can help remind you to stay on top of your messages. Send it a few commands and it can unsubscribe you from annoying newsletters, remind you to get back to people, and manage your VIP list.

Datally: Worrying about how much mobile date you’re using seems like one of those problems we should be able to easily avoid by now, but too often that’s just not the case. And, depending on where you live, cellular data can quickly add up to a costly investment. That’s why Google’s data-saving app Datally is so dang useful. The app not only breaks down exactly how you’re using your data; it helps you prevent apps from accessing it when you don’t want them to. Meaning: No more surprise overages.

system, every transaction is represented online as a block, which is distributed to a network of computers for approval before being added to the chain to complete the transaction. Blockchain uses cryptography to secure exchanges and provides a digital ledger of transactions that are transparent, reportedly reducing the risk of fraud and preventing transactional duplication.

Cellphone radiation California’s new cellphone safety guidelines for adults and children are being welcomed by the public health, environmental and First Amendment advocates. The guidelines echo a Berkeley City Council action in May 2015, which approved a cellphone disclosure ordinance that obligates vendors to warn buyers that carrying the devices close to the body could expose them to excessive radiation. The

Halide: Most camera apps aren’t worth using simply because it’s just so much easier to stick with iOS’s default camera. Halide is an exception worth making, though.

The app gives you full manual control over exposure, focus, ISO, white balance, and shutter speed with easy gesture-based controls that are meant to emulate old-school film cameras.

Ikea: One of the breakout augmented-reality (AR) apps of the year came not from a tech giant, but from Ikea. The furniture company’s AR app, which lets you preview how certain pieces of furniture will look in your home, isn’t just clever – it’s actually useful.

A decentralized ISP Open Garden wants to make it easy for anybody with an Android phone to share their Wi-Fi connections with anyone who is nearby, reports TechCrunch. To incentivize people to do so, the company plans to launch its own Ethereum token in early

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QUICK BYTES

While Open Garden argues that this is a totally new concept, the likes of Fon and others have long enabled W-Fi sharing without the need for Ethereum tokens and mesh networks.

2018. The company bills this as the launch of a “decentralized Internet Service Provider (ISP).” The rationale is that most people use only a small amount of their broadband connection’s bandwidth cap.

So why not share this access with others and earn some OG in the process? While Open Garden argues that this is a totally new concept, the likes of Fon and others have long enabled W-Fi sharing without the need for Ethereum tokens and mesh networks. Most have done so with mixed success, likely because few people actually want to share their Internet access. Open Garden is trying to jumpstart the process of building participation by using its FireChat app to bootstrap this process. The company says its messaging service has over 5 million registered users and they will form the basis for seeding this network. Over time, Open Garden also plans to add apps for iOS, Mac, Windows and set-top streaming boxes.

Hey, pirate. Yeah…you Tom Rutledge, chief executive officer of Charter Communications Inc., which sells cable TV under the

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Spectrum name, is leading an industrywide effort to crack down on password-sharing, reports Bloomberg.

It’s a growing problem that could cost pay-TV companies millions of subscribers – and billions of dollars in revenue – when they can least afford it. “There’s lots of extra streams, there’s lots of extra passwords, there’s lots of people who could get free service,” Rutledge said at an industry conference in December. The CEO has said that one unidentified channel owner had 30,000 simultaneous streams from a single account. Charter, which operates in cities including New York and Los Angeles, isn’t the only company tackling the issue. Researchers at Walt Disney Co.’s ESPN network recently asked a group of about 50 millennial sports fans how many of them shared passwords. Everyone raised their hand, said Justin Connolly, executive vice president for affiliate sales and marketing for ESPN and other Disney networks. “It’s piracy,” he said. “It’s people consuming what they haven’t paid for.”

HIDA GOVERNMENT AFFAIRS UPDATE

States Move Ahead with Medicaid

as Lawmakers Consider Reform

Leaders in the House of Representatives have expressed interest in en-

titlement reform this year. Changing Medicaid will likely be a key element of any entitlement reform effort, as the program comprises a large portion of federal spending. Since 2018 is an election year, it is unlikely entitlement reform legislation will advance, but it is important to be mindful of potential cuts.

In addition to potential cuts, many states will face new Medicaid budget pressures this year. Federal funds for states that expanded Medicaid under the Affordable Care Act are decreasing, even though enrollment and spending continue to grow.

Every year, HIDA publishes a comprehensive outlook on Medicaid. This month’s column highlights some of the key insights from our most recent update, factoring in the Trump Administration’s intentions to reform Medicaid, ongoing trends, and market implications.

State Medicaid spending accelerates in 2017 States’ Medicaid grew by 3.5 percent in FY 2017, up from 2.4 percent in FY 2016. The primary driver of this accelerated growth is an ACA provision that required states to pay 5 percent of enrollees’ costs in January 2017.

According to the Centers for Medicare and Medicaid Services, the provision of long-term care through MCOs is growing more rapidly than overall Medicaid long-term care spending.

Managed care enrollment and spending grows in many states States are increasingly using managed care organizations (MCOs) to provide care. As of March 2017, there were a total of 275 Medicaid MCOs in the U.S., with over 48.3 million enrollees nationwide. Between March 2016 and March 2017, 14 states experienced growth in MCO enrollment, while only six states experienced a decrease.

According to the Centers for Medicare and Medicaid Services, the provision of long-term care through MCOs is growing more rapidly than overall Medicaid long-term care spending. The cost of long-term care provided through MCOs rose by 24 percent in FY 2015 (the most recent available data) to $29 billion. This cost accounted for 18 percent of all long-term care spending.

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

Insurers continue to offer plans to nearly all U.S. consumers on ACA exchanges While some counties struggled with the possibility of having no insurers on their marketplaces in 2018, ACA health plans will be sold in nearly every county in 2018. Based on the latest data, most of the 12 million people who obtained health insurance through the individual marketplaces will have the same number of insurers to choose from as they did last year.

These are just some of the insights contained in HIDA’s Medicaid 360: State-by-State Medicaid Report. In addition to an overview of national trends, the report details provider reimbursement changes in each state, and provides a granular look at Medicaid expenditures across the country. To learn more about this report, or other resources from HIDA Government Affairs, email HIDAGovAffairs@HIDA.org.

www.repertoiremag.com

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Pay it Forward As a Paramedic, Dan Blom saved lives. As a sales rep, he helps others do so.

There are many cool things in life.

For Dan Blom, having a loving family tops the list. But there is a close second: Bringing clinically deceased people back to life. Helping others do the same is right up there as well. Blom is the Mid-Atlantic regional director for Bound Tree Medical.

His interest in emergency medical services goes way back. Growing up in Fairfax County, Virginia, he had a friend in high school with an interest in emergency services. “He told me the fire department would let you join when you were 16,” explains Blom. “My mom would tell the story this way: ‘Danny came home from school one day and announced, ‘Today I joined the fire department, and there’s nothing you can do about it.’”

Whether it happened exactly that way or not, Blom did indeed spend the next year attending the Fire and EMT academy, and though he could not do any hands-on work, he learned much in the classroom and on ridealongs. He became an EMT at age 16.

For college, he attended Rochester Institute of Technology in Upstate New York, where he began studying film and video. But he changed his major to criminal justice and emergency management. It was at RIT that he became a Paramedic, and he worked part-time at the job. He was also a member of the RIT Ambulance Corps, a student-run emergency

Dan Blom

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Blom family

medical services volunteer organization, which responds to the medical needs of the RIT community 24/7. It was there that he met another member of the Corps, Tiffany Chapin.

The two married 19 years ago, and have four children.

Food sales Though he had anticipated a career in criminal justice or emergency medical services, another opportunity arose at graduation – selling food to restaurants on behalf of Kraft Foodservice.

“I loved the people aspect of calling on restaurant customers and helping them to create and serve their patrons with quality menu offerings we had developed together,” he says.

“But over time, I would find myself

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“As an EMT and Paramedic, I learned that life can be fragile and can change in an instant.

I learned to make every day count.”

daydreaming at my Kraft job. I had a hard time calling on restaurants when my heart and brain were always thinking about my next shift as a Paramedic and how much fun it was going to be.

“Tiffany – who was still my girlfriend at the time – could see that I was much more passionate about being a Paramedic, and she told me I should leave Kraft Foodservice and become a full-time Paramedic. At first, I did not want to make that decision, knowing well that Kraft paid much better than being a Paramedic.

As time passed, it was clear to both of us that I was meant to be in an EMS role as a Paramedic more than I was meant to sell food to restaurants.” So in 1992, he joined Henrietta Ambulance in Henrietta, N.Y.

Hands-on

“ There is something magical and hard to describe about a patient who is clinically deceased, without a pulse, when you arrive, but who, after some interactions, is back breathing and with a beating heart again.”

“I for sure enjoyed hands-on patient care,” he says. “As a caregiver, a special feeling occurred for me whenever we had a CPR save happen in the field.

There is something magical and hard to describe about a patient who is clinically deceased, without a pulse, when you arrive, but who, after some interactions, is back breathing and with a beating heart again. That is a truly cool feeling, and one I will never forget.”

Seven years later, he was named chief of career staff at Henrietta. “I was in charge of payroll and benefits all the way down to the operations, staffing, and day-to-day decisions of the entire organization.

All of a sudden, I had not only patients to care for, but also over 35 employees and more than 70 volunteer members counting on me. That was a big responsibility and one that I took very seriously. It helped me to become a stronger coach, for sure.”

In 2005, Dan and Tiffany made a decision to move closer to family in Virginia and North Carolina. So he started searching for EMS/Fire jobs in that area.

Back to sales “Then Tiffany asked me what I would think about being a sales rep again. I told her I liked selling, but I did not really want to sell food again. She asked me if I would be interested in selling medical supplies to Fire and EMS customers.” It was the right question.

It turns out that Henrietta bought its EMS supplies from Tri-anim (which merged with Bound Tree in 2008).

After making inquiries, Blom was given the opportunity in an expansion sales territory in Virginia and the District of Columbia. Three years later, shortly after Tri-anim and Bound Tree merged, he was named manager for the mid-Atlantic region.

Being a Paramedic is a challenging job – one best done by the young.

“When you carry patients in and out of homes every day, the job becomes a healthy workout on most days,” he says. “The emotional stress mainly came from seeing things during traumatic calls, the kind of stuff

that no person should ever need to see in a lifetime. But the emergency services industry is a large, extended family, and having an outlet to talk as a family is what always gets people through those harder days and calls.”

Selling to Fire and EMS agencies can be strenuous too.

“In my first year, I traveled a lot within the territory and found it harder to catch up with my customer contacts in person then I had originally anticipated. This was especially true at the busier and larger Fire and EMS agencies within the territory. Many times, this happened because they were out on emergency calls when I would arrive. I had to become very good at making localized travel plans around a particular area of the state each day. This way, I could maximize my efforts to circle back and catch up later in the day with customers when they would returned from being out on life-saving calls.

“As an EMT and Paramedic, I learned that life can be fragile and can change in an instant. I learned to make every day count. This skill set was important to help me show customers quickly how, as a distribution company, we could help them save more lives with our products offerings while also saving them some money.”

“ The emergency services industry is a large, extended family, and having an outlet to talk as a family is what always gets people through those harder days and calls.” www.repertoiremag.com

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Industry news Bovie Medical appoints Goodwin as CEO Bovie Medical Corporation named Charles D. Goodwin as CEO. He also joined the company’s board of directors effective December 15, 2017. Goodwin succeeds Robert L. Gershon, who has resigned to pursue other opportunities. Previously, as Vice President of Olympus Corporation’s global surgical energy group for five years, Goodwin was responsible for the group’s global commercial strategy, managing a team of over 500 employees.

Midmark announces changes to executive leadership team Midmark Corp. announced the promotion of three executive team members. Effective Jan. 1, 2018, Eric Shirley has been promoted to chief commercial officer (CCO), Mike Walker has been promoted to chief Mike Walker operations officer (COO) and Jon Wells has been promoted to vice president of marketing.

Starting his career with Midmark in 2004, Eric Shirley most recently held the title of vice president and general manager of the dental and animal health divisions. In his new role, Eric Shirley Shirley is responsible for overseeing all marketing and sales functions for the company, exclusive of Midmark India.

Mike Walker has been with Midmark since 1986. He has held a variety of positions at Midmark and most recently served as vice president and Jon Wells general manager of the medical division. He will lead the manufacturing, engineering and quality teams as well as research and development.

Jon Wells joined Midmark in 1990. His most recent position was vice president, medical marketing.

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Ventyv hires Ken Spence as Director of Distributor Relations, Diana Baker as Territory Business Representative Ventyv™, a provider of infection prevention products, has hired industry expert Ken Spence as its director of distributor relations. Spence will ensure the delivery of superior infection prevention products that Ken Spence are consistently available to meet the demands of workers in the industries Ventyv serves. Spence has 38 years of experience in the healthcare industry, primarily in the infection prevention field. His previous positions include working in sales executive distribution at Provista; as a national account Diana Baker leader at Sempermed USA Inc.; and as a mid-Atlantic sales manager at Clorox Healthcare.

Spence earned degrees from University of South Carolina and from the Business Administration School of Darla Moore. Outside of work, he enjoys spending time with his children and grandchildren, and boating and golfing.

Ventyv also announced the has hiring of local area sales leader Diana Baker as its Territory Business Representative for Central Florida. Baker will be responsible for growing the company’s sales throughout the territory, and will focus on ensuring that customers’ needs are met with superior and consistent hand protection products. Baker has 13 years of sales and marketing experience, including 9 years as a senior surgical sales representative for Medline Industries, selling various types of latex, nitrile, and vinyl synthetic exam gloves and other infection prevention products. Baker earned degrees in International Business and Spanish from The College of Charleston in South Carolina, and also has a Broadcasting Certificate from The Connecticut School of Broadcasting.

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