REP Jan 2020

vol.28 no.1 • January 2020

Sales in 2020 Are you up for a challenge?

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JANUARY 2020 • VOLUME 28 • ISSUE 1

Sales in 2020 18 PUBLISHER’S LETTER

Sales

Questioning Strategies to Help You Close the Sale

16

How to uncover the emotional gap between where your prospect is right now … and where he or she really wants to be.

Seeing Clearly in 2020................. 4

PHYSICIAN OFFICE LAB Eye Health and Lab

What is the distributor rep’s role?.............. 6

IDN OPPORTUNITIES Supply Chain Executive Profile Sparkle Barnes, Executive Vice President, CNECT Chief Strategy Officer, Health Center Partners of Southern California, San Diego, California..............................10

Reimbursement

Physician Payment What you need to know about physician payment changes

28

Sparkle Barnes

repertoire magazine (ISSN 1520-7587) is published monthly by Share Moving Media, 1735 N. Brown Rd. Ste. 140, Lawrenceville, GA 30043-8153. Copyright 2020 by Share Moving Media. All rights reserved.

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JANUARY 2020 • VOLUME 28 • ISSUE 1

TRENDS Decision Point for Retail Clinics..............................38

WINDSHIELD TIME Automotive-related news........42

QUICK BYTES Technology News...........................43

HIDA GOVERNMENT AFFAIRS Taking a Thoughtful Approach to Medical Device Sterilization.........................................46

INDUSTRY NEWS News ........................................................47

Trends

Room for One More?

Are non-acute providers ready for one more e-commerce marketplace for healthcare and business supplies?

Do med/surg distributors need another sales outlet?

Premier is betting ‘Yes.’

36

Healthy Reps

Health news and notes

39

Health Focus

One Discussion that Calls for a Gentle Touch Discussing weight management with their patients calls for sensitivity on the part of your physician customers 2

January 2020

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40

Rep Corner

The Opportunity to Shine Solving problems brings out the best in Michael Watson.

44

Visit OnGuardEdge.com to learn more.

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An Important Piece of the USP <800> Puzzle USP <800> mandates the use of a CSTD (Closed System Transfer Device) for the administration of hazardous drugs1, which makes OnGuard® CSTD an important part of USP <800> compliance planning. OnGuard is designed to help prevent accidental worker and patient exposure to hazardous drugs during compounding and delivery. Plus, it is the only CSTD tested for vapor containment using actual chemotherapy drugs.

©2019 B. Braun Medical Inc. Bethlehem PA. All rights reserved.

1. General Chapter <800> Hazardous Drugs—Handling of Drugs in Healthcare Settings Published February 1, 2016.

PUBLISHER’S LETTER

Seeing Clearly in 2020 In 2017, my business partner recommended I check out Warby Parker, a manufacturer

of eyeglasses. At first, I shrugged the suggestion off. What could be so different about one company to the next – they’re readers, for Pete’s sake. Since that time, I’ve grown to love this company. Not only do they make a great product, they stand behind it.

Like many of you, I’m on the road every week, so I’m hard on my glasses. They get scratched, broken, and need adjustments regularly. No matter where I am in the country, I can always go into a Warby Parker store and they take care of any issues I may have. In fact, on more than one occasion, they’ve taken my glasses back without questions and sent me a brand-new pair.

The icing on the cake happened this morning. I needed to have my glasses replaced due to multiple scratches. So, I called their 1-800 number, and with a sigh, awaited the eternal hell of automated systems. To my pleasant surprise, Amanda answered and said, “Good morning, this is Warby Parker, how may I help you?” Within 4 minutes I had my problem solved and was on my way.

Scott Adams

Add this service level to the fact they tell their company story in 100 words, and you can see why they have set themselves apart in an otherwise commodity-based category.

Warby Parker in 100 Words: Once upon a time, a young man left his glasses on an airplane. He tried to buy new glasses. But new glasses were expensive. “Why is it so hard to buy stylish glasses without spending a fortune on them?” he wondered. He returned to school and told his friends. “We should start a company to sell amazing glasses for non-insane prices,” said one. “We should make shopping for glasses fun,” said another. “We should distribute a pair of glasses to someone in need for every pair sold,” said a third.

Eureka, Warby Parker was born.

In many ways, we can be classified as a commodity-based industry. Selling distribution services can become mundane,

and we may find ourselves just going through the motions.

Think back to when you first started in this industry, your excitement and enthusiasm to take care of your customers’ biggest problems. The little things you did to earn their business in the early years are the same things that can set you apart today.

It’s a new year with a fresh start for all of us, so my challenge to myself and to you is, how do we become more like Warby Parker in 2020? What are some simple things we can do to set ourselves apart? It starts with each of us individually.

Here’s to seeing clearly in the new year!!!

Dedicated to the Industry, R. Scott Adams Publisher

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

vice president of sales

Katie Educate

keducate@sharemovingmedia.com (800) 536.5312 x5271

mthill@sharemovingmedia.com managing editor

Graham Garrison ggarrison@sharemovingmedia.com

sales executive - East

Lizette Anthonijs

Lizette@sharemovingmedia.com (800) 536.5312 x5266

editor-in-chief, Dail-eNews

Alan Cherry acherry@sharemovingmedia.com art director

Brent Cashman bcashman@sharemovingmedia.com

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sales executive - West

Amy Cochran

acochran@sharemovingmedia.com (800) 536.5312 x5279

publisher

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

Brian Taylor

Subscriptions

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2020 editorial board Richard Bigham: IMCO Eddie Dienes: McKesson Medical-Surgical

btaylor@ sharemovingmedia.com

Joan Eliasek: McKesson Medical-Surgical

circulation

Doug Harper: NDC Homecare

Ty Ford: Henry Schein

Laura Gantert

Mark Kline: NDC

lgantert@ sharemovingmedia.com

Bob Ortiz: Medline Keith Boivin: IMCO Home Care

PHYSICIAN OFFICE LAB

Eye Health and Lab What is the distributor rep’s role?

By Jim Poggi

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As we enter 2020, what could be more ap-

Testing needs

propriate than an overview of eye testing and how lab relates to eye care and overall health?

In this month’s article, I intend to explore these issues and give you some things to think about as a well-informed consultant. It should come as no surprise that the fit for lab varies dramatically between ophthalmology and primary care practices.

When it comes to ophthalmology practices, lab is usually not a front-line sales opportunity. But, there are some developments in technology that are changing the picture somewhat, especially for acute onset symptoms such as conjunctivitis and dry eye.

Currently it is my experience that patients suffering from acute onset eye symptoms usually present in primary care, urgent care or retail convenience clinics. As a result, I expect that most of the new testing technology will be adopted in our core market rather than ophthalmology practices. Time will tell.

Where to begin? The med/surg side of things is where most of the action has been historically for us in ophthalmology practices. Since eye examination equipment, exam room equipment and accessories are typically specialty products often sold on a direct basis, the med/ surg distribution business has been a limited source of products and solutions to ophthalmology practices. For the most part, the med/surg account management professional has been content to provide gloves, disposable items, some eye drops and the occasional ophthalmoscope to these clients. Our calls on these specialty practices tend to be few and far between, with focus on higher spend internal medicine and specialty practices more focused on our core product lines. I expect this trend to continue in the near term, but with some notable exceptions.

Primary care practices have very different needs for testing and treating eye problems than

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PHYSICIAN OFFICE LAB ophthalmology practices and are more focused on acute onset of symptoms conditions. Most of the time that primary care practices see patients with eye disease as their primary complaint, these patient visits are associated with conjunctivitis (pink eye) or dry eye. New technology is improving diagnostic capabilities for both pink eye and dry eye disorders. While we usually associate adenovirus with respiratory illness, adenovirus is also the primary reason for conjunctivitis symptoms that result from an infection.

Interestingly, primary care practices should test for pink eye for the same good reasons they test for respiratory diseases. First of all, an adenovirus infection of the eye causing pink eye can occur at the same time a patient presents with a respiratory adenovirus infection. Secondly, for both pink eye and respiratory infections, viruses are far more often the cause than bacteria. Testing for respiratory and pink eye conditions to verify whether the patient has a bacterial or viral cause makes sense from an antibiotic stewardship perspective. During the height of respiratory infection season, adenovirus infections of the eye and respiratory tract may lead to two different sources of patient symptoms and care needs. Even when it presents alone, viral causes vastly outnumber bacterial ones.

Dry eye is a very different story. It is more often a chronic condition and has a fairly wide variety of causes.

Rheumatologists have known for years that dry eye can present as an early symptom of an autoimmune disease referred to as Sjogren Syndrome. Patients who present with dry eye and dry mouth will require further testing typically with autoimmune panels we commonly sell in primary care to help confirm this diagnosis. While Sjogren Syndrome may not be a disease we all think of every day, it is estimated that 3 million patients are diagnosed with it annually in the United States. It is often associated with either rheumatoid arthritis or lupus. New dry eye tests help present a broader range of lab diagnostic options to the rheumatology practice. As consultants, it pays to keep up to date with the latest developments our customers need to be aware of and to help them solve the diagnostic challenges they encounter on a daily basis.

There are other causes of dry eye as well, and they are important to diagnose accurately and on a timely basis.

Chlamydia is regarded as the most common sexually transmitted infection and is asymptomatic in over 25% of men and up to 70% of women. Despite screening programs in primary care and public health, chlamydia continues to be a public health issue. Children born to a mother with previously undiagnosed chlamydia often present with dry eye and/or conjunctivitis. Symptoms of dry eye and conjunctivitis typically occur from 5 to 12 days after birth for children born with this infection. The CDC recommends chlamydia testing for infants who present with conjunctivitis symptoms within 30 days of birth. So, testing for both conditions can lead to faster more appropriate treatment.

Zika disease also presents with symptoms of conjunctivitis. For patients suspected to have been exposed to Zika virus carrying mosquitoes, it is also important to rule out Zika virus as a cause of conjunctivitis. In addition to patient history and physical, there are a number of serology and molecular tests available to diagnose Zika virus.

While ophthalmology practices and primary care practices rarely share the same patients, diabetes management is probably the best current model for ophthalmologists and primary care physicians to work collaboratively. Since diabetic retinopathy is directly related to lack of diabetic control and can lead to blindness, annual eye exams frequently include an examination of the retinal area to assess whether the retinal vasculature is being damaged by the progression of diabetes. These physical findings help to round out the clinical picture of the diabetic patient and point to the prognosis for future vision issues. On the primary care side of things, diagnosis and monitoring of glucose levels by way of hemoglobin A1c and serial glucose measurements provide the lab side of things.

As the linkage between the expanding variety of infections and eye disease and general health conditions continues to be understood, I expect there will be a new range of tests that complement diagnosis and treatment in both practice areas. Keep an eye out for new developments.

While Sjogren Syndrome may not be a disease we all think of every day, it is estimated that 3 million patients are diagnosed with it annually in the United States.

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IDN OPPORTUNITIES

Supply Chain Executive Profile Sparkle Barnes, Executive Vice President, CNECT Chief Strategy Officer, Health Center Partners of Southern California, San Diego, California Editor’s note: Sparkle Barnes was selected as one of the “Ten People to Watch in Healthcare Contracting” in 2019 by the Journal of Healthcare Contracting, a Share Moving Media publication for healthcare supply chain executives. We are reprinting that article for Repertoire readers with her permission.

About Sparkle Barnes: As executive vice president of CNECT, Sparkle Barnes serves as the principal leader and strategic driver of the national group purchasing organization (GPO). She is responsible for developing and executing long-term strategies, annual business initiatives, and regionally deployed tactics. In January 2016, she was selected for the role of chief strategy officer, an enterprise-wide position with Health Center Partners of Southern California. In this role for Health Center Partners and its Family of Companies, she balances strategy formulation and execution to create sustaining innovations that support member organizations and the 800,000+ patients they serve across 135 sites of care.

Barnes started her work in healthcare in 2002 in sales and member services with CNECT (then Council Connections), providing supply chain solutions for members.

She returned to school and received a master’s degree in human relations, then performed casework for the Sparkle Barnes

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IDN OPPORTUNITIES Navy-Marine Corps Relief Society, which provides assistance and financial/budgeting information to sailors and Marines who face financial difficulties. (She still volunteers and teaches classes for the Relief Society.)

Before her return to CNECT in 2010, Barnes worked for the Department of the Navy in Public-Private Ventures, overseeing the performance of private management companies that are selected to construct, renovate, operate and professionally manage housing for military service members and their families.

About CNECT and Health Center Partners: Affiliated with Premier, Inc, CNECT offers contracts covering all aspects of purchasing, from large construction projects to IT equipment and cyber security services, telecommunications and cellular services, pharmaceuticals and vaccines, reference laboratory services, med/surg supplies to office furniture, and more. CNECT is a wholly owned subsidiary of Health Center Partners of Southern California, a 501(c)(3) consortium of primary healthcare organizations and an advocate for its members, who serve the fundamental health needs of patients in communities across southern California.

Most challenging/rewarding project in the past 12-18 months: “Positioning our GPO to serve our members in a valuebased reimbursement (VBR) environment. As providers increase their contracts in risk-based arrangements and take responsibility for population health and patient care occurring outside of their own four walls, CNECT has aligned itself with supplier partners that can meet the needs of our members in a VBR model.”

In addition to supporting the GPO members, Barnes assisted Health Center Partners in the establishment of a clinically integrated network – Integrated Health Partners of Southern California – in June 2015, which is designed to help its community health center members be successful in a value-based model by managing population health, improving efficiencies and performances in managed care and care transitions, integrating data and improving clinical performance, and providing high-quality care to lower income and uninsured patients.

Looking forward to: CNECT is completing the second year of a three-year strategic plan that will position the organization to serve

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an estimated doubling of its membership to more than 10,000 organizations by June 30, 2020.

How are you better at practicing your profession than you were 5-10 years ago?

“Taking on an enterprise-wide role as chief strategy officer for the Family of Companies was transformational in how I lead CNECT. In the CSO role, I am on the front lines of policy, operational, and clinical decision support discussions in transitioning a care model from a feefor-service environment to value-based reimbursement, enabling me to bring a perspective and experience from the front-line into CNECT to better position our members.”

What are the challenges or opportunities facing the next generation of supply chain executives?

“The transition to value-based care is not slowing down.

If anything, it is accelerating. The future generation of supply chain professionals will need to be both experts in their fields and partners with their management teams as those organizations are more and more challenged to improve care quality and [achieve] cost reductions through value-based reimbursement models.

CNECT is completing the second year of a three-year strategic plan that will position the organization to serve an estimated doubling of its membership to more than 10,000 organizations by June 30, 2020.

“There is a real opportunity for supply chain professionals to partner with their GPO and become a part of the process.

Sit on committees, engage in the available tools and resources, and bring this market intelligence, market awareness to their teams to use the information in managerial decision making.

“Systems are accelerating consolidations, budgets are getting tighter, keeping a check on costs is what makes the margin. Partnering with a GPO will become that much more imperative to leverage the market intelligence and keep abreast of industry standards and advancements in care. There is real power in coming together. The collective can produce data driven insights that cross market segments and create disruptions that improve supply chain efficiencies and quality outcomes.”

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SALES

Questioning Strategies to Help You Close the Sale How to uncover the emotional gap between where your prospect is right now … and where he or she really wants to be.

By Sandler Systems, Inc.

Are you a salesperson who has been hearing too many

“We’ll think it over,” “Get back to me,” and “We’ll let you know” responses? If so, you’re in good company.

The key to closing more sales is uncovering pain – that is, uncovering a level of emotional discomfort on the prospect’s part that’s sufficient to inspire action to change what isn’t working. Notice that you’re not creating this discomfort. You’re shining a spotlight on something that already exists.

In the following two-part series, we will examine questioning techniques that will help you uncover the emotional gap between where your prospect is right now … and where he or she really wants to be.

Reversing Reversing is an extremely simple and effective way to uncover a prospect’s pain. It’s simply answering a question with a question … with a purpose. Your goal in reversing is to dig deeper, toward the root of the prospect’s pain. Reversing helps you find out if prospects actually have pain or not!

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Let’s look at an example in a selling situation so you can see how it works. Assume you’re a contractor selling residential roofing to long-time homeowner Jasmine Washington. Jasmine says to you, “Can you tell me a little bit about the roofing products that you would recommend for my house?” Most roofing salespeople would instantly jump at this opportunity to list all the products that they offer – what colors are available, how long material lasts, and so on and so forth.

We recommend that you do not do that. Instead of listing features and benefits, we recommend you respond to Jasmine’s question with something like, “That’s a very good question. We offer a wide variety of roofing products, and it would probably take me four hours to go over all of it. Can you be a little bit more specific as to what you might be looking for?”

In response, Jasmine says, “Well, we’ve had the house re-roofed three times over the past 25 years. Every single time, it didn’t last as long as they said it would.”

Would you be tempted to explain why your company is different? We recommend that you don’t. Instead, answer her implied question with a question of your own – which is another reverse.

“Wow, I’m sorry that happened to you. Would you be kind enough to tell me a little bit more about that?”

After a couple rounds of reversing, Jasmine starts to share a story based on her personal experience. Her story involves water leakage into her home that damaged kitchen appliances as a result of the roof ’s failure. She was

forced to make an insurance claim and thought that was a big hassle. Now that she’s explained her circumstances, you dig for pain and start posing questions like, “How did that impact you?”

She says, “Well, that year we had offered to host Thanksgiving, and the leak ruined the stove and fridge just days before the holiday. So, it was a very annoying situation. I would have been so embarrassed if it didn’t get fixed. Not to mention my husband flipped out that we had to spend money we didn’t have for a new roof.”

Notice that in this scenario, several reverses were used to uncover how the prospect really felt about the difference between where she is right now and where she wants to be – her pain. It’s quite common for the salesperson to have to ask multiple questions in order to uncover the real pain of the situation. In fact, it typically takes three or more reverses before prospects reveal their pain!

Use the Pain-O-Meter The Pain-O-Meter is a simple, powerful process that consists of four main questioning areas: A. Surface-level problem B. Impact on family/team C. Personal impact D. Emotional pain/buying zone The first two levels of questioning focus on the pain indications, while the last two levels are the true emotional pains. As you can see in the illustration, there is a needle as if on a meter (like a speedometer). If a question you ask leads the prospect or customer to share a surface-level problem, then the needle is on the far left of the Pain-OMeter: “First-Level pain.”

Examples of First-Level pains you can ask about include: prospects are getting late deliveries, no one picks up the phone when they call their suppliers, their computers are running slow, their investments are not performing well, or they have no college fund.

These problems touch on several different solutions, products, or services that might be needed. Good news? Well … maybe. At this point in the interaction with prospects, it is good to recognize that this person might need a solution that you can provide. But it is also important to understand that surface problems are not pains!

You are not ready to present anything. You still need to move the needle further to the right, if possible. If you try to present at this point, you’ll get trapped in the prospect’s system for buying things, and end up with a “let-me-think-over.” So be careful, and don’t get emotionally involved too soon.

In part two of the series, we’ll examine how to advance the needle to the “Second-Level pain.”

Learn more about increasing sales and success with a proven, systematic approach to selling. Contact us at salestips@repertoiremag.com.

About Sandler With over 250 local training centers around the globe, Sandler is the worldwide leader for sales, management, and customer service training. We help individuals and teams from Fortune 500 companies to independent producers dramatically improve sales, while reducing operational and leadership friction. © 2019 Sandler Systems, Inc. All rights reserved. S Sandler Training (with design) and Sandler Selling System are registered service marks of Sandler Systems, Inc.

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Sales in 2020

Are you up for a challenge?

The year 2020 promises to bring a mix of the

old and the new. Yes, there will be challenges – quotas, competition, customers who are squeezed by reimbursement cuts. But there also will be opportunities for medical sales representatives to hone their craft, improve their service, and simply get better. Repertoire posed questions about the year ahead to the following panel of experts:

ʯʯ John Cook, vice president of sales, NDC. ʯʯ Mina Rezk, vice president, Medline Physician Office Midwest Region. ʯʯ Jos Roach, senior account manager, Concordance Healthcare Solutions. ʯʯ Richard Bigham, vice president, primary care markets, IMCO. ʯʯ Ben Roberts, Medline division manager, Texas. ʯʯ Elizabeth Hilla, senior vice president, HIDA Educational Foundation executive director. ʯʯ Thomas DeCarlo, PhD, Ben S. Weil Endowed Chair of Industrial Distribution, The Charles & Patsy Collat Industrial Distribution Program, The University of Alabama at Birmingham. ʯʯ Ashley Brust, physician office corporate sales, Medline.

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Sales in 2020 What automated tools should reps be exploring to be more efficient and productive?

Mina Rezk: Social media continues to be the primary John Cook: An effective CRM is the most productive tool form of communication today. We will continue to see a salesperson can invest time in. This is a critical compoan increase in marketing and social media presence to nent of any automation, as it typically drives a salesperson’s capture new business and validate current customers’ next-step action items. While most times this is driven by buying decisions. the organization they work for, it is their responsibility to embrace and utilize CRM to the fullest potential. In today’s fast-paced and response-driven world, a salesperson You never want to automate every aspect cannot afford to forget to follow up of your sales process, as it can begin to feel with an opportunity or potential clirobotic and soulless to your customers. ent. A salesperson should also look to automate mundane daily tasks by creating email templates, developing In an Amazon world, we are seeing more online workflows and utilizing software platforms to generate ordering than ever. Most consumers today don’t own proposal documents, just to name a few. Now I will add a a computer or laptop; instead, they pay $1,000 for a word of caution when it comes to automation: You never phone because it doubles as their PC. We will see more want to automate every aspect of your sales process, as it apps and platforms that will probably focus on ordercan begin to feel robotic and soulless to your customers. As ing platforms, CRM/account management, route planhumans, salespeople add critical and irreplaceable elements ning, virtual meetings, etc. to customer interactions and relationships.

How will the rep of 2020 and beyond balance work and life?

Jos Roach: This is a question and challenge faced by myself and every successful rep I’ve ever known. How do you balance work and life in such a demanding environment? Each rep’s definition of success varies. For myself, I try and look at it from a perspective of priorities rather than balance. There are days and months where my balance is inconsistent based on the need of the customer. I always hold tight to my priorities, and it seems to have worked well over the last 15 years. Will the reps of 2020 and future be more or less successful than our mentors? Maybe we can be more successful if we listen and apply their experience.

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Tom DeCarlo: As a business professor teaching college students and researching salespeople for over 25 years, one trend I have noticed recently is that more and more young people emphasize the importance of a work-life balance as compared to students a decade ago. While today’s young people value work and are willing to work hard, they also would likely forgo the corner-office position and more salary to gain more flexibility in their schedules. This is likely an extension of growing up with access to technology and being connected 24/7. They recognize the capabilities of new technology and the potential that working remotely provides more flexibility and the possibility of a better work-life balance.

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Sales in 2020 Is it the rep’s job to sell or demonstrate change management to their customers? If so, how?

Tom DeCarlo: I believe it is the rep’s job to demonstrate change management to customers. Not only are reps closer to new product and management breakthroughs than medical professionals, but they have the business experience to identify how these new ideas can benefit customers. The key question is how?

As a business professor, I teach a creative solutions course to business professionals and students in which they learn how to develop and present new solutions in a way to maximize the chance of implementation.

an action, we experience personal and social pressure to behave consistently with it. Those pressures will cause us to respond in ways that justify our earlier decision. As a result, once doctors/hospital managers have committed to the research or pilot project, it becomes difficult for them not to support the implementation that naturally follows from its success.

Finally, these decisions do not take place in a vacuum.

Often there is an incumbent (or competitor) supplier that may also provide a potential solution (even after you have identified the issue!). In those instances it’s in the best interests of the rep to create an opportunity to be able to demonstrate how his/ her new idea is superior. This helps break the resistance or bias that may occur due to the incumbent’s relationship with the customer.

Mina Rezk: Advancement in technologies now allow us to integrate data from multiple platforms into one. An ECG, BP, and vitals can be directly entered into the EMR file and tracked more easily. The biggest Reps shouldn’t be required to be the advancement is telemedicine, and it expert but should understand the impact will continue to evolve. Much like on their customers and their patients. an Apple Watch can monitor your vitals, there will be hardware that can connect directly with your primary care physician and allow them to better monitor your vitals or manage a disease state.

There are a few principles to keep in mind when Reps shouldn’t be required to be the expert but influencing people to gain their support. For example, should understand the impact on their customers and when making a case for switching to a new product or protheir patients. There are responsibilities on both sides, cess, the chances of success increase if the idea is pitched as and the best reps know how to manage the details. It’s an incremental improvement rather than as a transformative critical to establish a partnership with our customers innovation (even if it has the potential to be). and ensure they are fulfilling their end of the agreeChances of success also increase when promoting ment to achieve our mutual goals; which is ultimately, a “trial” or “pilot” project for the new idea. Why? The patient care. “principle of consistency” states that once we have taken

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Face-to-face still counts, but how can reps integrate social media as well?

Elizabeth Hilla: Social media is an extremely valuable tool for connecting with customers, and reps who aren’t using it may be missing some opportunities. I personally use LinkedIn almost every day: ʯʯ It’s a great research tool for finding decision-makers. ʯʯ LinkedIn messages are very effective for getting in touch with folks I don’t know. I get a higher response rate from prospects on LinkedIn messages than I do through email or phone calls. ʯʯ It’s a strong (and free) marketing tool to get the word out about new resources or products. ʯʯ It’s a good way to establish your own personal brand and that of your organization. Sharing or even authoring articles, for instance, helps establish your areas of expertise.

Ashley Brust: Reps can’t forget to have a strong customer service mentality and show empathy to our customers. We

are moving so fast every single day, and we have access to so much technology … but that face-to-face meeting with our customers, and just listening to them, is really important. Sure, customers appreciate a quick email or text when they ask you something, but showing up and just enjoying a nice conversation with them helps build trust and brings your relationship to a much stronger point. Today I sat with a practice manager who said, “I know you can’t always fix all of our problems, but we just appreciate that you hear us out, because it shows you care.

Is it the rep’s job to help their customer improve patient satisfaction?

John Cook: One of the most important responsibilities of a medical sales professional is to understand the patient segment being served and make the most educated recommendation. Our landscape today is often, if not always, centered on patient satisfaction and the outcome of their treatments. As a healthcare representative, a salesperson needs to be more familiar with the products than the clinician so they can provide a recommendation that goes beyond the standard features and benefits. Everything needs to have the patients’ best interest and outcome in mind.

Tom DeCarlo: One way top distributor reps seem to be able to enhance patient outcomes and satisfaction is by providing the medical team with the support needed to be as efficient as possible. For example, for surgical products or equipment, the rep can pay a tremendous amount of attention to detail in preparing for a case, including providing multiple backup products and an understanding of what the surgery entails, as well as prepping the nursing team on the procedure, if needed.

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Sales in 2020 Do people in their 20s still look at medical sales as being the right place to be able to make real money, get professional satisfaction, and get ahead?

John Cook: When you look at what currently motivates the young professional, it is the ability to feel part of something and to make a difference. The healthcare segment allows them to capture this sense of contribution by directly impacting patients’ lives and better well-being. I believe that most individuals see a sales position as an opportunity to work autonomously, be in control of their earnings (which is typically uncapped earning potential) and [seize an] opportunity for a balanced approach to work and life.

Tom DeCarlo: Our unique medical distribution program at University of Alabama Birmingham provides students with an understanding of what it takes to be successful in today’s medical business environment. They learn about the regulations, the level of effort required and the different types of medical sales positions available. Many of them select companies that offer a career that meets their goals.

Ben Roberts: The opportunity still exists to make a great living for someone who is willing to roll up their sleeves

and work hard each day. But the 2020 rep needs to be smart and savvy about what they sell, how they sell, and who they sell to. They also need to use technology that keeps them active and not bogged down in the daily challenges.

I recently had lunch with a group of college students with big dreams. The thing that struck me is that while explaining their dreams, each had the intent to make money, but that was never mentioned as the primary reason. The overarching theme of each dream was doing something that makes a positive impact on their customers. They want purpose and to be passionate about what they do, how they do it and who they do it for. People buy from people they like, but also from people that care.

Regardless of industry, the generation we are referring to could be one of the greatest generations, because they see value in what actually matters to living a great life. They are willing to work hard to make that happen if they believe deeply that what they are doing matters.

And that isn’t necessarily driven by the number of 0’s in their bank account.

How does a rep stay relevant in a contract dominated industry?

Jos Roach: Exposure, commitment, and extreme ownership. To stay relevant in today’s industry, a rep needs exposure to GPOs, manufacturers, customers, and the needs of the patient. Commitment to the relationships the rep forms with the representatives from these organizations continues to drive relevance and the need for quality medical sales representation. Extreme ownership of an issue, followed through to successful completion, also creates relevance. It’s the voice inside that never wants to quit until a solution to an issue is found.

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Richard Bigham: Rep relevancy will be dictated based on their understanding of their customer and the customer’s strategic initiatives. As more providers move toward outcomes-based compensation, reps must understand the metrics that are important to their customers, as well as the tools reps have to support their customers’ goals. Reps should understand the end goal and work with customers to identify potential pain points and operational inefficiencies.

Once identified, the rep can provide solution options. While products will still be a crucial element, solutions that improve process workflows, outcomes and patient satisfaction will be drivers maintaining rep relevancy.

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Sales in 2020 What is the role of the rep in IDN-owned or -operated physician practices?

Elizabeth Hilla: IDNs have very few staff resources to devote to managing non-acute locations’ supply needs – and that’s something distributors can help with.

The primary non-acute distributor and the IDN customer will ideally work closely together to determine what level of “touch” is needed in these sites. The supply chain leader probably doesn’t want a rep pushing product at each practice, but they might well appreciate help in managing these locations. The rep’s role may

evolve to helping these practices improve their ordering practices, identifying opportunities for logistics improvements, and supporting contract compliance, for instance.

On the other hand, if I were a rep for a small or specialty distributor, my strategy would probably be different. I would probably continue calling on those practices to create demand for innovative products from my key manufacturer partners.

In an age of “value-based healthcare,” how can the rep help the customer validate the performance or value of a new product before the customer invests in it?

Tom DeCarlo: Historically, decisions for new med/surg products or equipment tended to be made using three basic principles: 1. Patient considerations.

(Is it a good solution for the patient?)

2. Cost. (Is it less expensive than what we already use?)

3. Ease of use. (How difficult is it for the doctor to learn how to use it?)

Most would agree that the recent trend has been for health administrators and purchasing committees to place

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a relatively greater emphasis on the cost principle than the other two. This may be due to the perceived parity of competitive products in the marketplace.

Nevertheless, it suggests that reps need to be prepared to make compelling arguments for why a new product will be better for the patient or easier to use, which may lead to lower overall costs (e.g., quicker patient recovery, less chance of complications, etc.). Ultimately, connecting perceived added value to a new product requires a thorough understanding of a customer’s operations and an ability to communicate that knowledge in developing a case for a new product.

REIMBURSEMENT

Physician Payment What you need to know about physician payment changes On Nov. 1, the Centers for Medicare & Medicaid Services

issued a final rule that includes updates to payment policies, payment rates, and quality provisions for services furnished under the Medicare Physician Fee Schedule effective on or after Jan. 1, 2020. Repertoire asked the American Academy of Family Physicians (AAFP) and the Medical Group Management Association (MGMA) for their reactions.

Repertoire: For 2020, CMS will maintain the weights of the cost (15%) and quality (45%) performance categories for the Merit-based Incentive Payment System, or MIPS. Background: Under the Medicare Access and CHIP Reauthorization Act of 2015, or MACRA, physicians earn a payment adjustment (up or down) based on evidence that they provided high-quality, efficient care supported by technology. To do so, they must submit information on “quality” (e.g., processes, outcomes), “promoting interoperability requirements” (e.g., electronic exchange of information), “improvement activities” (e.g., expanding practice access, promoting patient safety) and “cost” (i.e., the resources clinicians use to care for patients).

Gary LeRoy, M.D., president, AAFP: [Although the American Academy of Family Physicians had yet to formally

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respond to CMS’s final rule at press time] AAFP is likely OK with their decision to maintain the weights … given ongoing concerns with the cost category. One downside to maintaining the quality and cost weights is that there will be a more significant shift in those weights later, since – by law – they both must be 30% by the 2022 performance year.

Mollie Gelburd, J.D., associate director of government affairs, MGMA: MGMA is pleased to see that CMS maintained the category weights for 2020, particularly after originally proposing that the “cost” category be weighted at 20%. We have concerns about this category, because certain measures contain methodological flaws, which inappropriately hold physicians accountable for costs beyond their control. For example, the Total Per Capita Cost measure holds physicians responsible for the cost of a patient’s care even after that patient is no longer in the physician’s care, but in the care of another physician. In addition, because CMS has not yet provided feedback on cost measure performance, clinicians can’t change their clinical workflows in order to become more efficient and improve category performance. Until CMS fixes these performance flaws and provides feedback, MGMA believes the current MIPS category weights should be maintained.

Repertoire: Effective Jan. 1, 2020, CMS is increasing the performance threshold from 30 points to 45 points.

Background: Eligible Medicare Part B clinicians are scored on a 100-point MIPS performance scale. Payments are adjusted up or down based on the MIPS performance score. (These adjustments are applied to the Medicare payment for every Part B service billed by the clinician two years after the performance year.)

Mollie Gelburd: The performance threshold is critical, because if the physician’s score is lower than the threshold floor, then Part B payments are reduced; if the score exceeds it, payments are adjusted upward.

Repertoire: The 2020 Medicare Physician Fee Schedule introduces several changes regarding evaluation/management (E/M) services provided by doctors. Effective Jan. 1, 2021, changes to CPT codes will allow clinicians to choose the E/M visit level based on either medical decision-making or time.

Background: CMS is aligning its E/M coding with changes adopted by the American Medical Association Current Procedural Terminology (CPT) Editorial Panel for office/outpatient E/M visits. The CPT coding changes allow clinicians to choose the E/M visit level based on either medical decision-making or time, rather than on a combination of three variables: history, exam and medical decision-making.

They also revise the time and medical decision-making process for all of the codes, and require performance of history and exam only as medically appropriate.

Gary LeRoy: Focusing on medical decision-making (MDM) or time as a single variable for choosing the level of service simplifies code selection. That said, the revised CPT interpretive guidelines for medical decision-making represent a significant change in the way physicians and coders are accustomed to thinking about MDM. They will require some study and education before they become effective on Jan. 1, 2021.

Likewise, the time element is changing significantly.

Currently, it represents face-to-face time in the office or outpatient setting and can be used only to choose level of service when counseling and/or coordination of care dominates the encounter. In 2021 and beyond, the relevant time will be time on the date of service, not just face-to-face time, and it can be used to select level of

service for any encounter, not just those dominated by counseling and/or coordination of care.

Repertoire: Regarding E/M services, the CPT coding changes retain 5 levels of coding for established patients, reduce the number of levels to 4 for office/outpatient E/M visits for new patients, and revise the code definitions.

Gary LeRoy: Given that physicians will be allowed to choose the level of service on medical decision-making alone, deleting CPT code 99201 [i.e., office or other outpatient visit for the evaluation and management of a new patient] and reducing the number of levels of new patient office/outpatient visits makes sense. This is particularly relevant since CPT codes 99201 and 99202 have the same type of medical decisionmaking, i.e., straightforward. In some sense, this will simplify matters for physicians, because they’ll have only four rather than five levels from which to choose. The impact should not be significant, since new-patient visits are less numerous than established patient visits, and level-one new-patient visits are among the least frequent of new-patient visits.

Repertoire: CMS is implementing several changes for “care management” services (i.e., “transitional care management,” “chronic care management” and “principal care management”). Regarding chronic care management (i.e., services provided to beneficiaries with multiple chronic conditions over a calendar month), a Medicare-specific code will be assigned for additional time spent beyond the initial 20 minutes allowed in the current coding.

Gary LeRoy: CMS’s creation of a code for additional time spent beyond the initial 20 minutes is consistent with a proposal that the AAFP and others submitted to the CPT Editorial Panel. We are supportive of it until such time as a similar code can be incorporated into CPT. The code will more appropriately compensate AAFP members for the additional time they and their staffs spend in support of patients with chronic conditions.

Repertoire: “Recognizing that clinicians across all specialties manage the care of beneficiaries with chronic conditions,” CMS says specialists can now bill Medicare for providing principal care management to patients with one complex chronic condition while the patient is receiving chronic care management services from a primary care doctor.

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REIMBURSEMENT

Physician assistants get more responsibility Physician assistants may gain expanded responsibilities as a result of the final 2020 Physician Fee Schedule Rule, issued in November by the Centers for Medicare and Medicaid Services.

The rule loosens Medicare’s supervision requirements for PAs by largely deferring to state law on how PAs practice with physicians and other members of the healthcare team.

“In recent years, 11 states have replaced the outdated term ‘supervision’ with other terms, such as ‘collaboration,’ to better reflect current PA practice,” says Michael Powe, vice president of reimbursement & professional advocacy for the American Academy of PAs. “Another state, North Dakota, has eliminated the legal requirement for a specific relationship between a PA, physician, or any other healthcare provider in order for a PA to practice to the full extent of their education, training, and experience.”

“Deferring to states on how PAs work with other healthcare providers ensures that Medicare policy aligns with the direction many

Gary LeRoy: [In its response to the proposed rule, the American Academy of Family Physicians commented] the addition of new principal care management (PCM) codes would move away from the continuous, comprehensive, and coordinated value-based care and primary care CMS has otherwise been encouraging as a cost-effective way to care for Medicare patients.

To the extent most Medicare beneficiaries have two or more chronic conditions for which AAFP members are already caring in a continuous, comprehensive, and coordinated way via existing chronic care management, I do not expect the creation of PCM codes by Medicare to have a significant impact on how AAFP members care for these patients.

states are already heading when it comes to how healthcare is delivered,” David E. Mittman, PA, DFAAPA, president and chair of the Board of Directors for AAPA, said in a statement.

The final rule also: ʯʯ Authorizes PAs to prescribe medications in their role as “attending physicians,” similar to physicians and advanced practice registered nurses, under Medicare’s hospice benefit. ʯʯ Allows physicians, physician assistants, and advanced practice registered nurses (APRNs, that is, nurse practitioners, clinical nurse specialists, certified nurse-midwives and certified registered nurse anesthetists) to review and verify (i.e., sign and date) – rather than redocument – notes made in the medical record by other physicians; residents; medical, physician assistant, and APRN students; nurses; or other members of the medical team.

Repertoire: Taking a step back, what is your organization’s reaction to these changes?

Mollie Gelburd: MGMA would like to see MIPS become more clinically relevant. Currently, our members see it primarily as a compliance program, that is, a means to either avoid financial penalties or gain additional reimbursement. But as they stand, the MIPS measures don’t further clinical goals. We believe reporting requirements should be aligned with clinical improvement as well as cost efficiency. In a well-functioning program, an investment in a practice’s clinical program would also be an investment in MIPS. As it stands, those two things are separate.

Editor’s note: For an overview of the major policies finalized for calendar year 2020, see CMS’s Finalized Policy, Payment, and Quality Provisions Changes to the Medicare Physician Fee Schedule for Calendar Year 2020.

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REIMBURSEMENT Will MVPs bring a simpler future?

There’s nothing simple about the Medicare Physician Fee Schedule, including the Merit-based Incentive Payment System, or MIPS. But credit the Centers for Medicare and Medicaid Services for trying.

For 2021, CMS has proposed a next-generation MIPS program, called MIPS Value Pathways (MVPs). The goal is to move away from siloed activities and measures, and move toward an aligned set of measure options that are relevant to a clinician’s scope of practice.

Currently, MIPS-eligible physicians must submit information on a variety of measures in each of four categories: Cost, Quality, Promoting Interoperability, and Improvement Activities. The MVP framework would align and connect measures and activities across all four. A clinician or group would be in one MVP associated with their

specialty or with a condition, reporting on the same measures and activities as other clinicians and groups in that MVP. “We believe the MVP framework would help to simplify MIPS, create a more cohesive and meaningful participation experience, improve value, reduce clinician burden, and better align with APMs [Alternative Payment Models] to help ease the transition between the two tracks,” CMS said in a statement.

Simple, right? That remains to be seen.

“We recognize that this would be a significant shift in the way clinicians may potentially participate in MIPS,” says CMS. “Therefore we want to work closely with clinicians, patients, specialty societies, stakeholders, third parties and others to establish this new framework.”

How MVPs would change physician reporting and reimbursement Current state of MIPS (2020)

New MIPS Value Pathways Framework (in next 1-2 years)

Future state of MIPS (in next 3-5 years)

ʯʯ Cohesive ʯʯ Lower reporting burden ʯʯ Focused participation around

ʯʯ Simplified ʯʯ Increased voice

Overall direction of program

ʯʯ Many choices ʯʯ Not meaningfully aligned ʯʯ Higher reporting burden

pathways that are meaningful to clinician’s practice/specialty or public health priority

of the patient ʯʯ Increased CMS-provided data ʯʯ Facilitates movement to Alternative Payment Models (APMs)

Example: Diabetes

ʯʯ Endocrinologist chooses

ʯʯ Endocrinologist reports same

ʯʯ Endocrinologist reports on

from same set of measures as all other clinicians, regardless of specialty or practice area ʯʯ Four performance categories (Cost, Quality, Promoting Interoperability, Improvements Activities) feel like four different programs ʯʯ Reporting burden higher and population health not addressed

“foundation” of Promoting Interoperability and population health measures as all other clinicians, but now has a MIPS Value Pathway with measures and activities that focus on diabetes prevention and treatment. ʯʯ Endocrinologist reports on fewer measures overall in a pathway that is meaningful to their practice ʯʯ CMS provides more data; reporting burden on endocrinologist reduced

same foundation of measures with patient-reported outcomes also included. ʯʯ Performance category measures in endocrinologist’s Diabetes Pathway are more meaningful to their practice. ʯʯ CMS provides even more data (e.g. comparative analytics) using claims data and endocrinologist’s reporting burden even further reduced.

Source: Centers for Medicare and Medicaid Services 32

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Electrosurgical Units and High Frequency Desiccators Knowing the ABCs of electrosurgery will help position you as a trusted resource for your customers

Effective electrosurgery equipment is a key compo-

nent of today’s physician office. Electrosurgery is used in 80% of all surgeries performed in the United States, with each of these procedures requiring different types of disposable products.

A firm understanding of electrosurgical equipment and its clinical benefits enables you to be a consultative resource for your customers. Electrosurgical equipment is typically divided into two categories, either electrosurgical units (ESU) or high frequency desiccators, depending upon their ability to both cut and/or coagulate tissue. Versions within each category are consistently used in specific clinical specialties, which is important to understand as you focus on your account’s needs. An

ESU is designed to coagulate and cut tissue and can do so as effectively as a scalpel. A high frequency desiccator, on the other hand, can only coagulate tissue.

The following is a summary of the basic information required for fluency in electrosurgery.

Electrosurgical equipment: 1. E SUs are utilized for the cutting and coagulation of tissue with monopolar or bipolar energy.

2. High frequency desiccators are used to perform desiccation, fulguration and coagulation. They do not utilize a cutting waveform and need no patient grounding pad since the unit is a ground reference machine.

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Electrosurgical energy: 1. MONOPOLAR energy delivery requires a handpiece (pencil), an active electrode (blade, ball, needle or loop) and a return (dispersive) electrode (patient grounding pad). a. C UTTING is the primary monopolar mode of any modern ESU. Electrosurgical cutting requires less manual pressure than the sharpest scalpel.

There are two types of cutting: i. Pure cut mode is for dissection only and results in the electrode performing like a scalpel. ii. Blended cut mode adds hemostasis to cutting to seal off small bleeders. b. COAGULATION mode is the secondary monopolar mode of an ESU and is used solely for hemostasis. There are two types of coagulation: i. Standard coagulation is the result of an electrode being positioned in physical contact with the tissue. The duration of contact is also an important factor in stopping localized bleeding.

of cells in the bed where a lesion has been removed, and it will prevent possible migration of suspicious cells.

2. BIPOLAR energy is delivered only as a coagulation mode. Instead of using a patient grounding pad, the energy passes between the tips of an instrument and through the tissue they are grasping to stop the bleeding.

That’s it for the basics of electrosurgery, and it explains what you need to know about electrosurgical devices.

Choosing the appropriate device In order to be a valued resource, you will also need to know the correct electrosurgical generator for each specialty and site of care. Showing a customer the appropriate device is an important step in solidifying your credibility.

The typical user of a high frequency desiccator, such as the Bovie® DERM 942, is a dermatologist.

These cost-effective devices are usually placed in each dermatologist’s office exam room. For example, if the office has six exam rooms, the practice will require six Bovie® DERM 942 devices. Each of these high frequency desiccators require a single-use dermal electrode and certain procedures may require a second single-use electrode as well. The clinician may also require a single-use handpiece sheath. Given the volume of product used in the office, you can see how being a resource for the customer can translate into a long-term relationship with the practice.

If cutting is required in a clinician’s procedures, there is a strong possibility that there will be a need for a generator with more capabilities. The Bovie® Bantam PRO is essentially two machines in one, serving not only as a high frequency desiccator for simple dermatologic procedures, but also providing 50 W of cutting power. Using this electrosurgical unit also requires the use of a disposable return electrode (patient grounding pad).

For customers performing LEEP/LLETZ procedures, they may choose to move up a generator level.

Plastic surgery facilities and surgery centers typically find that the Bovie® Surgi-Center PRO provides everything they need in an ESU. This full function device can easily accommodate most surgical procedures performed at these facilities. ii. Fulguration (spray coagulation) is non-contact coagulation during which the current sparks or jumps from the active electrode to the tissue (like lightning arcing downward). It is quite effective for sealing hidden bleeders and for areas with large bleeders.

It can also be used to destroy surface layers

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®

The Specialist PRO is used in the classic LEEP (Loop Electrosurgical Excision Procedure) or LLETZ (Large Loop Excision of the Transformation Zone) procedures performed by the OB/GYN. The Specialist PRO-G system (ESU, Bovie® Smoke Shark™ II smoke evacuator, and mobile stand) is the perfect solution for the modern OB/GYN office. Accessories used with the Specialist PRO include an electrosurgical pencil, a patient grounding pad, a loop electrode, and a ball electrode – all of which are single-use products and are disposed of after the procedure.

Plastic surgery facilities and surgery centers typically find that the Bovie® Surgi-Center PRO provides everything they need in an ESU. This full function device can easily accommodate most surgical procedures performed at these facilities. As with the Specialist PRO, the Surgi-Center PRO also uses single-use accessories such as an electrosurgical pencil, electrodes, and a patient grounding pad in each procedure.

Patient grounding pads are available in two versions; a solid pad and a split pad. While both versions provide the system with a return electrode to close the electrical circuit, the split pad is considered much safer. Most ESUs (all Bovie® models that provide a cut mode) are designed to sense the grounding pad’s contact with the patient. If the grounding pad loses contact with the patient, these ESUs stop sending energy to prevent a potential patient burn. The ESU then displays an error message and will not provide energy until the grounding pad is properly repositioned. However, even with an ESU that has this sensing technology, the use of a solid grounding pad may prevent the unit from properly sensing a potentially dangerous event. Accordingly, the split pad is the most widely used and recommended.

That’s the ABCs of electrosurgery. As you can see, there are several electrosurgical generator options used by a considerable number of surgeons in countless procedures throughout the world. The result is numerous facilities needing to purchase high quality ESUs, with disposables being purchased on a continual basis.

What does that mean to you? If you are a consultative resource for a facility using electrosurgery, you will be able to provide the facility with critical, high-volume products needed to perform some of their most important procedures and establish yourself as a valued partner to their practice.

Optimal Control Better Protection A3350 This device offers 13 modes of surgical energy delivery in a 300 watt generator.

Special modalities include the advanced Bovie® Bipolar, Auto Bipolar options and special Laparoscopic modes tailoring to all electrosurgery needs.

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A1250S This device satisfies the physician’s surgical demands with safety, reliability and convenience. When paired with the Bovie® Smoke Shark™ II Smoke Evacuator, it is a total system solution for procedures and facilities that require smoke evacuation.

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TRENDS

Room for One More?

Are non-acute providers ready for one more e-commerce marketplace for healthcare and business supplies? Do med/surg distributors need another sales outlet? Premier is betting ‘Yes.’

On Oct. 21, Charlotte, North Carolina-based Premier announced it had launched its own e-commerce offering –

called stockd.™, designed to meet the needs of small- to medium-sized, non-acute healthcare businesses, including physician practices.

Premier is convinced there’s a need for an alternative e-commerce platform, and executives believe the company’s history in the healthcare supply chain makes Premier well-suited to provide it.

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“As an example of the needs raised by our members, Concordance Healthcare Solutions nearly four out of 10 alternate-site purchasers told us that “The model intrigued us for many reasons,” said Dave they utilize six online platforms or more for their busiMyers, president and chief operating officer of Concorness purchasing each month,” John Sganga, Premier’s dance Healthcare Solutions, in an email. “We concluded senior vice president of alternate site programs, told that the stockd. solution would be a powerful compleRepertoire in an email. “Going back mentary channel strategy for us and and forth between so many online our supplier partners. platforms takes significant resources “Concordance’s existing e-comand time out of providers’ schedules merce portfolio is more designed to to order supplies, compare pricing support existing customers or those and manage inventory. gained through a more outside-in mar“Taken as a whole, their responses keting effort – our feet on the street alluded to a hole in the marketplace for or telesales,” he continues. “We are a single, trusted online platform with continuing to develop better ‘inbound’ transparent pricing from which altermarketing solutions, tying in social and nate-site buyers could directly purchase direct marketing with our e-commerce healthcare and business supplies.” site, but our use of alternative channels Stockd. is separate from Prehad been limited.” mier’s GPO, said Sganga. “The platform is public-facing and open to “ As an example of the needs raised by our anyone … regardless of business or GPO affiliation.” Nor do sellers have members, nearly four out of 10 alternateto be Premier-contracted suppliers. site purchasers told us that they utilize six Each stockd. seller has its own online platforms or more for their business shipping policies, which are explained purchasing each month. Going back and forth on its brand page on stockd.com. between so many online platforms takes Stockd. users have access to significant resources and time out of providers’ med/surg, pharmaceutical, lab and physical therapy products and supschedules to order supplies, compare pricing plies; office supplies; food/beverage and manage inventory.” products; building maintenance and – John Sganga, Premier’s senior vice president of alternate site programs more. Among 32 vendors listed on its website (as of Nov. 1) as “Marketplace Sellers” are Concordance Healthcare Solutions, Brewer Company, Schiller AmeriFor its stockd. offerings, Concordance will focus on cas, Brandt Industries and Office Depot. its exclusive brand – DYAD – as well as Premier’s branded Users can register as stockd. members at no cost, product line, PremierPro™, said Myers. Concordance will granting them access to more favorable pricing and addialso offer stockd. users access to branded-supplier partners tional marketplace features, such as tax-exemption for “who want to leverage our logistics services to support their qualifying organizations and the option for validated phyposition on stockd.” sicians to purchase prescriptive medical devices.

“Stockd. has a healthcare foundation that can support For IDN supply chain executives concerned about multiple industries and consumer markets,” Myers said. “I rogue purchasing, stockd. offers the customer the abilthink they put some really good thinking into their positionity to have multiple representatives registered to purchase ing strategy, but like anything new, time will tell. Execution is on behalf of the organization, “which helps ensure alignkey. Competitive pricing is key – for the buyers and suppliers. ment across the supply chain about what’s being ordered, “This model does have strong potential to succeed, in by whom and how often,” Sganga said. my opinion.”

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TRENDS

Decision Point for Retail Clinics

By Mark Thill

Maybe it was inevitable that operators of retail clinics

would one day be forced to choose between expanding their healthcare offerings or scaling back their commitment to in-store clinics. Judging from developments in the latter half of 2019, that day may be at hand.

In October, Walgreens announced it would close all (157) of its company-managed Walgreens Healthcare Clinics, but continue to work with its network of local health system operators who own and operate approximately 220 clinic locations inside Walgreens today. (Of the 157 clinics that are closing, seven will transition to TriHealth, a Cincinnati, Ohiobased health system.)

In their stead, Walgreens and Jenny Craig will open 100 Jenny Craig weight-loss locations at Walgreens stores nationwide in January 2020. The locations will offer Jenny Craig’s program featuring one-on-one consultations, a customized menu plan and meal delivery.

Meanwhile, CVS Health announced plans last summer to bring its new HealthHUB store format to more U.S. markets in the first half of 2020 as part of its goal to operate up to 1,500 of the locations by the end of 2021.

On its website, CVS describes HealthHUB as “a firstof-its-kind community-based store concept focused on helping customers get well – and stay well – by offering a broader range of healthcare services, wellness products and services, trusted advice and personalized care, all with the ease of walking right into a local CVS Pharmacy.”

Diverging paths Walgreens is “clearly signaling an exit from providing traditional healthcare services that get billed through insurance networks,” Tom Charland, founder and CEO of Merchant Medicine, told Repertoire in an email. “CVS,

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however, is expanding into primary care more broadly, beyond the limited-scope retail clinic.”

Based in Roseville, Minnesota, Merchant Medicine is a management consulting firm in urgent care, retail clinics, telehealth solutions and consumer-driven healthcare.

“Until now, these retail clinics have avoided competing with primary care physicians in that they never took on a patient and followed them through a chronic condition,” he says. “That’s why we referred to them as acute episodic or limited-scope clinics.

“The HealthHUB concept from CVS goes all-in on primary care and is being tested in a number of markets.

So clearly there is a fork in the road between Walgreens and CVS, where one is no longer following the other.”

The fact is, operators of limitedscope clinics have always had a tough time achieving profitability, says Charland.

“Health systems don’t make money at these clinics either,” he says. Rather, “they view these clinics as a funnel to get new patients into their system; a way to create greater access in markets where primary care providers are in short supply; and a way to get their brand out into the community.”

Charland dismisses news reports that have suggested telemedicine may be delivering a knock-out blow to retail clinics.

The market forces at work are much broader than that, he says.

“These clinics struggled long before telemedicine became the topic of the day. The fact is, telemedicine platforms that are aimed at acute episodic illnesses are struggling even more than retail clinics.

“That being said, this whole acute episodic space suffers from too much capacity chasing a limited number of visits. The reason urgent care clinics continue to grow is they have an expanded scope of service, including suturing lacerations, X-ray for broken bones and the ability to handle more complex acute conditions.”

HEALTHY REPS

Health news and notes Stay agile Over time, everyone’s body ages and shows signs from natural wear and tear, says Mayo Clinic. Regular exercise helps delay the process. However, many people forget to include mobility exercises in their routine. Both flexibility and mobility are important to how your body functions.

Flexibility refers to the ability to move a joint through the full range of motion, or fully lengthen a muscle. Mobility involves a bit more. It includes flexibility, as well as strength, coordination and balance. Staying active and preserving mobility are important as you age. Here are three ways to do so: 1) Stretch every day; 2) use a foam roller for self-massage as a way to release tension in muscles and connective tissue; and 3) take advantage of your body’s natural movements by doing things like climbing, carrying, throwing, catching – even crawling.

Improved quality of life for adults with stroke Cardiorespiratory training, repetitive task training, and transcranial direct current stimulation (tDCS) may improve activities of daily living in adults with stroke, according to a systematic review for the 2019 U.S. Department of Veterans Affairs (VA) and U.S. Department of Defense Guidelines (DoD) for Stroke Rehabilitation, published in Annals of Internal Medicine.

Cognitive behavioral therapy, exercise, and selective serotonin reuptake inhibitors (SSRIs) may reduce symptoms of poststroke depression, but use of SSRIs to prevent depression or improve motor function was not

supported. Stroke is the fifth most common cause of death and a leading cause of long-term disability in the United States. Approximately 44% of younger individuals, aged 18 to 50 years, who have had a stroke experience moderate disability, and require some assistance with activities of daily living or mobility. Early rehabilitation after stroke is essential to help reduce disability severity and to address depression, which can often occur as a result of stroke.

Your lymph system: Take good care Your body relies on your lymphatic system to remove waste, like bacteria, viruses, toxins and abnormal cells that can lead to cancer, according to MD Anderson. And every step you take helps it do its job. That’s because the lymphatic system lacks an organ like the heart to pump fluid around your body. Lymph fluid relies on movement and the contraction of your muscles to make it flow. “The lymphatic system is stimulated by moving your muscles and getting your heart rate up,” says MD Anderson Senior Physical Therapist Sarah Cleveland.

“All these things stimulate the lymphatic flow.” The contraction of your muscles becomes the pump that helps the fluid get around your body. Exercise can help the lymphatic system flow more effectively and potentially help prevent infections and other diseases, like cancer.

“Any exercise is helpful for the lymphatic system,” says Cleveland. “Exercise under water is especially helpful because of the pressure from the water.”

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HEALTH FOCUS

One Discussion that Calls for a Gentle Touch Discussing weight management with their patients calls for sensitivity on the part of your physician customers Few people question the connection between excess weight and ill health. Even so, patients with weight manage-

ment issues aren’t necessarily eager to talk to their doctor about it. That means that if the physician believes the patient’s weight threatens his or her good health, it’s up to him or her bring it up. How they do so makes a difference, says Alan Schwartzstein, M.D., FAAAP, a family physician in Oregon, Wisconsin, and speaker of the American Academy of Family Physicians Congress of Delegates.

“I don’t know how other physicians address weight with their patients, but a common thing I hear from my patients is something along these lines: ‘I went to see Dr. Jones about my high blood pressure and all he wanted to talk about was my weight,’” says Schwartzstein.

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“That may not be the way doctor really approached it, but that’s what the patient hears.”

In his practice, Schwartzstein refrains from bringing up the topic of weight unless 1) the patient asks for assistance in weight management, or 2) Schwartzstein believes

the patient’s weight may contribute to or exacerbate a chronic condition.

“In the first case, the patient has brought it to my knowledge, so the issue is on the table,” he says. “But in the second case, while addressing a chronic issue such as osteoarthritis, I carefully share something like, ‘One of the contributors to the pain you’re experiencing might be weight.’ Then we talk about how the patient might benefit from weight management.”

Relationship is everything The stronger the relationship between primary care doctor and A common thing I hear from my patient, the easier it is to discuss patients is something along these lines: sensitive topics, including weight, ‘I went to see Dr. Jones about my high says Schwartzstein. blood pressure and all he wanted to talk “Some issues, like strep throat, can be addressed by any clinician, about was my weight.’ That may not be whether they’ve seen the patient the way doctor really approached it, but before or not,” he says. But with that’s what the patient hears. issues such as weight, the relationship can make all the difference.

“When I walk in the room, they trust that I will be sensitive to their issues. That’s why an ongoweight, let them know you are happy to work with ing relationship with a primary care doctor is so vital.” them as a partner. “I’m making it clear it’s not my problem to fix, but at the same time, I’m letting Years of experience have taught him other strategies them know we can work together as a team to about discussing weight with patients. address it.” ʯʯ Know when to stop. If a patient questions why ʯʯ Steer the discussion away from diets, even if the the office staff insists on taking his or her height patient asks for advice on which diet to follow. and weight prior to an exam, explain patiently. If “Rather than talk about diet, I emphasize habit he or she still resists, let it go. change,” says Schwartzstein. That’s because for many people, the amount and type of food they ʯʯ Seek context. Tie conversations about eat are actually habits from adolescence or early weight to the patient’s overall health, including adulthood. “I point out that when they were more chronic conditions. active and still growing as adolescents, they needed ʯʯ Watch for verbal or non-verbal clues as to how the calories. But later in life, you’re not always eatserious the patient is about weight management. ing to satisfy caloric needs.”

Even when addressing weight in the context of diabetes, arthritis or hypertension, if the patient is ʯʯ Watch your language. “When I talk to patients clearly not interested, let it go. “Pushing beyond in the office, I do not use the words ‘obesity’ or that point because I think it is better for them isn’t ‘weight loss,’” he says. “Instead I use the term being patient-centered,” says Schwartzstein. ‘weight management.’ It’s less confrontational.” ʯʯ If a patient asks for help managing his or her

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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.

Automotive-related news Watch out for bicyclists The National Transportation Safety Board is calling for a major policy overhaul to combat the rise in bicyclists killed in crashes with motor vehicles, after completing its first study of bicyclist safety since 1972. According to the National Highway Traffic Safety Administration’s most recent census of fatal motor vehicle crashes, 854 bicyclists were killed in collisions with motor vehicles in 2018. That’s a 38% increase since the low point in 2010 and the highest number of fatalities in 30 years. Including pedestrian fatalities, which are up 46% over the same period, people outside of motor vehicles now account for a fifth of all traffic deaths. Most motor vehicle collisions with bicycles occur at intersections. However, crashes are more often fatal at midblock locations, where vehicles are generally traveling faster, the board noted.

It called on the Federal Highway Administration (FHWA) to include protected bike lanes and safer intersection designs in its list of proven safety countermeasures.

Electric cars: Make some noise!

Starting September 2020, the United States will require all fully electric vehicles and hybrids operating in electric-only mode to make a sound at speeds below 18.6 mph, which is the number at which the electric motor and tires make enough noise to alert pedestrians in time to avoid a mishap, reports The New York Times. In the European Union, an alerting system that sounds like an internal combustion engine and generates noise at speeds below 20 kilometers per hour (about 12 miles per hour) must now be installed in every new electric vehicle. Existing electric vehicles are required to incorporate the device by July 2021. Equipping such vehicles with audible alerts is vital, Claire Stanley, an advocacy and outreach specialist for the American Council

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of the Blind, was quoted as saying. “As blind individuals, we learn to travel across streets and maneuver through cities by reading the sound of traffic around us,” she said. “But the silent nature of electric cars suddenly robs us of such clues.”

Don’t fear the cruise control Hyundai believes it can make the experience of using cruise control more intuitive by adding machine learning, reports Engadget. The South Korean automaker thinks drivers will be more likely to use its new machinelearning-based Smart Cruise Control (SSC-ML) because it will be able to match your own driving style. Hyundai says the feature adjusts for a couple of factors. First, it will mimic the distance you keep between your vehicle and the car in front of you. It also takes into account acceleration, as well as how you respond to changes in traffic.

Where Hyundai thinks its new cruise control will improve on any existing system is that it won’t take a single approach to every situation. The company claims SCC-ML will be smart enough to know that you don’t always keep the same distance from another car, and that you accelerate differently depending on your current speed.

Canceled!

Hyundai Motor Group announced the development of a Road Noise Active Noise Control (RANC) system, said to dramatically reduce noise within the cabin of a vehicle.

RANC builds on the Group’s current Active Noise Control (ANC) technology, which actively reduces noise by emitting soundwaves inverted to incoming noise. The new system can analyze various types of noise in real-time and produce inverted soundwaves. For example, there are different types of road noises that the new technology can process, such as resonant sounds created between tires and wheels or rumble sounds coming up from the road.

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 Google works to improve texting Google wants to catch up to the iPhone in the texting category, says CNET. The company is working with U.S. carriers to make text messaging more powerful, more consistent across Android phones and more fun to use.

Carriers will have to adopt a messaging protocol called Rich Communication Services, or RCS. When it’s widely available, RCS will replace SMS, the text messaging standard that’s been used since the 1990s. RCS messaging will let you share high-resolution photos, videos, GIFs and texts over Wi-Fi as well as over your phone’s data connection. You’ll be able to see if contacts are available, when they’re typing to you and when they’ve read a message.

Group conversations will also see improvements.

Play your emails Grab your headphones, press play, and groove to the sound of your email inbox, writes GeekWire, whose editors call Microsoft’s new “Play My Emails” feature for the Outlook app on Apple’s iPhone “a surprisingly useful and well-executed tool for keeping on top of your email.” The new feature uses Microsoft’s Cortana voice assistant to provide updates on appointments and events, summarize how many important messages have come in since last check, and say how long it will take to get through them, before reading them. With voice commands, users can flag messages for follow-up; archive, delete or skip messages; and dictate and send short replies. It is said to work smoothly with Apple AirPods and Microsoft Surface Headphones, pausing playback when you remove them, for example. It also works normally with other Bluetooth-enabled wireless audio devices, including in-car infotainment systems, integrating with basic media controls in the vehicle.

Not a keyword. A real key!

You probably keep a lot of sensitive information in your Google account – bank account numbers and balances, email addresses, photos of your face, your friends’ faces, your family. If you want the highest level of security you can get for your all that important data, you’ll want to check out the

Google Advanced Protection Program, says CNET. It relies on something very old but real: A physical security key, similar to the kind of dongle you use to start a car with keyless ignition. You don’t need to plug it into your phone, laptop or desktop, but you do need to keep it nearby whenever you access your Google account, like on a keychain or in your pocket. What’s the point? One of the common denominators among most data breaches is that attacks are carried out remotely, If you want the over the Internet. That’s why highest level physical security keys are said to of security be an effective defense against you can get online hackers. Even if a scamfor your all that important mer did steal your username and password, they still couldn’t get data, you’ll want to into your account without that check out physical key.

the Google Advanced Protection Program, says CNET.

Juice jacking

Travelers who need to charge their smartphones while on the go might want to avoid public USB charging stations, due to the security risk known as “juice jacking,” reports Digital Trends.

A Nov. 8 advisory from the District Attorney’s Office of Los Angeles County warned against the USB charger scam, in which hackers try to infect the smartphones and other electronic devices of unassuming travelers through the free USB charging stations in public places such as airports and hotels.

Juice jacking attempts see hackers loading malware into the charging stations, or in cables that they leave plugged in at the stations. The malware may either lock the smartphone and hold it as hostage, or forward sensitive information such as passwords to the attacker. The DA’s Office recommends travelers plug their own charging cables into AC power outlets. Portable chargers, which come in many different forms and price points, are said to be a safer alternative to public USB charging stations as well. Bottom line: Travelers should stick to the safe side and only consider public USB charging stations a last resort.

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REP CORNER

The Opportunity to Shine Solving problems brings out the best in Michael Watson.

Every medical distribution sales rep wants to shine

Needs-based selling

among his or her customers. It offers a competitive advanFor Miller, success in sales comes from simply acting as a tage and, more important, a sense of satisfaction in fillresource to the customer, explains Watson. The sales rep ing the customer’s needs. And if there is an opportunity to can keep focused on that goal by asking the customer shine, it’s not necessarily when things go right, but when four questions: they don’t, says Michael Watson, RN sales consultant, Geriʯʯ “What product are you using now?” care Medical Supply, in Gardendale, Alabama. ʯʯ “How do you like it?”

“Selling a glove is one thing,” says Watson, who calls ʯʯ “How would you improve on it?” on long-term-care facilities, hospices and community-based ʯʯ “Are you the decision-maker?” hospitals in northern Alabama. “But what if that glove tears during usage, or isn’t shipped when it was supposed to?

“It’s a very needs-based method of selling,” says Outstanding sales means meeting problems head-on, not Watson. “And it’s how I have been successful.” running away from them. That’s the opportunity to shine.”

Speaking of needs, his long-term-care customers Watson got a world of experience meeting problems have plenty of them – most related to reimbursement head-on while working retail. At age 16, he began workand staffing. ing for T.J. Maxx in shipping, receivTen years ago, long-term-care ing, even restroom duty. He worked facilities received adequate fundhis way up to department head and ing from Medicare and Medicaid, he assistant manager, and, at age 21, explains. But today, the feds are ratchbecame the youngest person in the eting down on reimbursement. At the company to manage a new store. same time, as baby boomer nurses The work was challenging, the hours and aides retire in greater numbers, long, and in the end, simply not what his customers are finding it tougher to Watson had in mind for a career. recruit and keep younger caregivers.

The Watson family: Will, Michael, Teresa, Meredith He met with career counselors, When things seem most chalone of whom suggested he pursue lenging while helping customers nursing. (His grandmother had been meet their needs, Watson keeps in a nurse, and his mother had an administrative job in the mind a favorite quote of his from former University of receiving/purchasing department of a local hospital in Alabama football coach Gene Stallings: “You can never Birmingham.) Nursing jobs were plentiful, and he could go wrong by doing right.” “It’s something Bob and I become a registered nurse with an associate’s degree – talk about all the time,” he says. “And it’s a point I try and pursue a bachelor’s degree later, if he wanted. “That’s to get through to my kids.” exactly what I did.”

Watson and his wife, Teresa, an attorney, have two Through his mother’s contacts, Watson got a job children, both at West Point – Will, who has an interest delivering medical equipment to hospitals and home in computer science; and Meredith, who has expressed health agencies. In 1998, he joined Progressive Therapy an interest in law.

Inc., which is Gericare’s rental company. It was there he To any young person thinking about medical sales, met Bob Miller (who holds executive management posihe offers these words of advice: “Know your products tions with Gericare and PTI.) “Bob came from Novartis and services, and to get to know your customers so Clinical Nutrition, which had an elite sales program,” says you can help identify their needs and be a resourceful Watson. “He taught me a lot about sales.” problem-solver for them.”

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HIDA GOVERNMENT AFFAIRS

Taking a Thoughtful Approach to Medical Device Sterilization

By Linda Rouse O’Neill, HIDA VP of Government Affairs

It’s well known across our industry that sterilized

medical products are critical to healthcare. Poor or incomplete sterilization can lead to transmission of infectious diseases, compromised patient health, or even death.

While there are a handful of sterilizing agents to choose from when it comes to medical devices, the most common is via ethylene oxide. The Food & Drug Administration recognizes that there are no viable alternatives currently available to replace EtO sterilization for certain medical products. EtO is used to sterilize 50% of all medical devices sold in the United States. That’s a total of more than 20 billion devices annually. EtO is often a device manufacturer’s top choice for sterilization because it’s toxic to microorganisms but non-corrosive to common materials used to make medical devices such as plastic, metal, glass, and rubber.

EtO sterilizes many life-saving items commonly used to treat patients across all care settings. It can effectively sterilize materials as diverse as polyurethane and gels for hydrocolloid wound care dressings, stents for heart surgery, and custom procedure packs for emergency Caesarean sections. It’s often the most effective sterilizing agent for devices that have many packaging layers or hard-to-reach areas such as with catheters. For example, the damaging effects of steam and radiation on anti-microbial coatings on single-use plastic devices make them unacceptable alternatives.

An FDA committee held a hearing on the matter to gather input from stakeholders so it could better understand the impact and importance of environmental, public health, and other factors related to the use of EtO. HIDA Government Affairs Director Josh Babb spoke at the

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meeting in Maryland, relaying to the panel that “HIDA recommends a thoughtful approach that considers the impact on the delivery of healthcare nationwide. Any changes to EtO policies must include a realistic and feasible plan to anticipate and address any potential product disruptions.”

Disruption at a single sterilization facility can have a magnified impact across the country and across all healthcare settings. Devices sterilized in one facility often support healthcare providers and patients in all 50 states. It’s important that policymakers understand the complexities of

device sterilization to protect patients, circumvent unintentional supply chain disruptions, and avoid product shortages.

HIDA has created a resource page outlining the issue, HIDA’s related activity, news updates, and links to government resources, including educational information from the FDA and Environmental Protection Agency on the use of EtO for medical device sterilization.

Please visit our page at HIDA.org/ETO. To learn more about HIDA’s Government Affairs efforts on this and other issues, please contact HIDAGovtAffairs@HIDA.org.

NEWS Concordance opens new Chicago location Concordance announced the opening of its newest distribution center in Chicago, Illinois. The new location opened for operation during the last week of September. Concordance first began servicing Rush University Medical Center in early spring 2019 from a smaller location which Rush University Medical Center had been using prior to Concordance’s arrival.

“Concordance’s business is built on a foundation of outstanding customers who value local and regional relationships, and we quickly determined that Rush, and other local organizations who share Rush’s mission, are a perfect fit for our company,” said Concordance COO, Dave Myers.

After establishing a presence in Chicago, Concordance leadership made the strategic decision to move and re-establish the location in a larger facility, allowing greater flexibility in servicing Rush and additional Chicago area customers. The newest location is a 175,000-square-foot facility, with over 100,000-square-feet of racked space and room for expansion. Concordance now operates 20 distribution centers serving the healthcare industry across the U.S. These strategic locations allow the company to provide supply chain services to the entire continuum of care.

Walmart to expand standalone health center model, open new clinics Walmart opened its first freestanding health center in September, and is planning to open several more, President and CEO Doug McMillon said in a commentary accompanying Walmart’s Q3 results. The company’s first standalone clinic, called Walmart Health, opened in Dallas, Ga. The 10,000-square-foot clinic offers a variety of services, ranging

from primary care to labs to dental, in one facility. McMillon also discussed the company’s plans to open more standalone health centers. “We’re opening a second location soon, and I know we'll continue to learn as we open several more and design the ideal model to provide customers with better and unique solutions for their everyday healthcare needs,” he said. The second health center will be in Calhoun, Ga.

Premier Inc. forms Contigo Health Premier Inc. (Charlotte, NC) announced it has formed Contigo Health, a new organization focused on optimizing care through clinically led partnerships with large, national employers and their health plans. Contigo Health is designed to be a clinically driven network of health systems collaborating with employers and their health plans to deliver the best care possible for their employees. Contigo Health plans to launch pilot programs with employers by partnering with health systems in select markets to eliminate unwarranted variation in care delivery. The goal is to avoid unnecessary invasive treatments and focus on delivering the most appropriate care to improve quality and reduce costs. A group of 35 leading health systems, representing more than 440 hospitals, have already signed letters of intent to participate in Contigo Health’s provider network. Contigo Health is also working with several large national employer partners, which it expects to announce in the coming months. Jonathan R. Slotkin, MD, will serve as Contigo Health’s chief medical officer to lead its clinical innovation, strategy and operations, while continuing to care for patients as a neurosurgeon at Geisinger.

Seattle Children’s closes three operating rooms due to mold, second time in 2019 In November, Seattle Children’s closed three operating rooms due to two new infections caused by the Aspergillus mold, the same reason that forced the shutdown of all hospital’s operating rooms earlier in 2019. The mold was discovered during a routine air test conducted this week. Seattle Children’s closed four operating rooms from May 18 to July 4 due to the presence of Aspergillus mold. And three surgical patients became sick from the mold in 2018, including one death. Aspergillus is a common mold found outdoors and indoors. It is breathed in daily by people without getting sick, but people with lung disease or weakened immune systems, and especially organ or stem-cell transplant patients, are at a higher risk of developing aspergillosis, a disease caused by the mold.

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NEWS GOJO announces next step in leadership transition plan GOJO Industries announced Carey Jaros as its president and CEO, effective Jan. 1, 2020. She will succeed Mark Lerner, who will become senior advisor and president emeritus. In her new role, Jaros will continue her years-long partnership with Marcella Kanfer Rolnick, who was named executive chair of GOJO in May 2018. Jaros joined GOJO in 2016 as chief strategy officer and transitioned to the role of COO in July 2018. In his new role, Lerner will sponsor key Enterprise project teams, working as an advisor, coach, and mentor to GOJO leadership team members. He will also continue to serve on the GOJO Board of Directors.

CMS approves behavioral health pilot in Washington, D.C. CMS has approved its first demonstration project to expand behavioral health treatment for Medicaid beneficiaries with serious mental illness living in Washington, D.C. The pilot is being launched with a Section 115 Medicaid waiver,

which will allow Medicaid to reimburse short-term residential stays in psychiatric hospitals for patients with serious mental illness, opioid use disorder or other substance use disorders. Federal law previously kept states from receiving the federal Medicaid match for Medicaid patient stays in psychiatric hospitals. With this approval, CMS anticipates that there will be measurable, verifiable and actionable outcomes for Washington, D.C.’s Medicaid recipients.

Health Cloud new features target medical device and pharmaceutical companies Salesforce has rolled out features for its Health Cloud, targeting medical device and pharmaceutical companies. It is part of Salesforce’s effort to compete with SAP and Oracle with industry-specific software. Health Cloud includes new sales agreement capabilities as well as account-based forecasting. This is aimed to help sales teams manage device sales, volume, price and revenue commitments, and to jointly track with operations teams if customers are meeting their commitments.

Statement of Ownership, Management, and Circulation PS Form 3526-R

1. Publication Title: Repertoire 2. Publication Number: 1520-7587 3. Filing Date: 10/01/2019 4. Issue Frequency: Monthly 5. Number of Issues Published Annually: 12 6. Annual Subscription Price: $49.00 US, $59.00 Canada 7. O ffice of Publication: 1735 N Brown Rd Ste 140 / Lawrenceville, GA 30043-8153 Contact Person: Laura Gantert 770-416-0071 8. General Business Office: 1735 N Brown Rd Ste 140 / Lawrenceville, GA 30043-8153 9. P ublisher: John Pritchard / 1735 N Brown Rd Ste 140 / Lawrenceville, GA 30043-8153 Editor: Mark Thill / 1735 N Brown Rd Ste 140 / Lawrenceville, GA 30043-8153 Managing Editor: Graham Garrison / 1735 N Brown Rd Ste 140 / Lawrenceville, GA 30043-8153 10. O wner: John Pritchard / 1735 N Brown Rd Ste 140 / Lawrenceville, GA 30043-8153 11. Known Bondholders, Mortgagees, and Other Security Holders Owning or Holding 1Percent or More of Total Amount of Bonds, Mortgages, or Other Securities: None 12. n/a 13. Publication Title: Repertoire 14. Extent and Nature of Circulation: Average No. Copies Each Issue During Preceding 12 Months 7721 4105

No. Copies of Single Issue Published Nearest to Filing Date Sept 2019 7661 4159

Total Number of Copies (Net Press Run) Outside County Paid/Requested Mail Subscriptions In-County Paid/Requested Mail Subscriptions Legitimate Paid and/or Sales Through Dealers and Carriers, Street Vendors, Counter Sales, and Other Paid or Requested Distribution 448 433 Requested Distribution Outside USPS. Requested Copies Distributed by Other Mail Classes The USPS 45 45 Total Paid and/or Requested Circulation 4597 4637 Outside County Nonrequested Copies 2594 2542 In-County Nonrequested Copies Nonrequested Distribution Nonrequested Copies Distributed Through the USPS by Other Classes of Mail 283 264 Nonrequested Copies Distributed outside the Mail 63 0 Total Nonrequested Distribution 2940 2806 Total Distribution 7537 7443 Copies not Distributed 208 191 Total 7745 7634 Percent Paid and/or Requested Circulation 61.00 62.30 Publication of Statement of Ownership will be printed in the January ‘20 issue of this publication.

Laura Gantert. Dir. Circulation & Admin. 11/1/2019 I certify that all information furnished on this form is true and complete. I understand that anyone who furnishes false or misleading information on this form or who omits material or information requested on the form may be subject to criminal sanctions (including fines and imprisonment) and/or civil sanctions (including civil penalties)

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January 2020

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