Repertoire - May 22

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vol.30 no.5 • May 2022

repertoiremag.com

How Quidel Navigated COVID-19 A conversation with Quidel President and CEO Doug Bryant.


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We know it’s been a challenging year, and it matters that we made it through together. That’s what trusted partnerships are all about. Our experienced sales and service teams are always here to help ensure your success, providing diagnostic products that deliver the highest quality results. Because for you, for us, and for your customers, every result matters. POINT-OF-CARE READER

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MAY 2022 • VOLUME 30 • ISSUE 5

How Quidel Navigated COVID-19 A conversation with Quidel President and CEO Doug Bryant. PUBLISHER’S LETTER

TRENDS

The Art of Pre-Selling........................ 2

PHYSICIAN OFFICE LAB When the POL Customer Has Stopped Testing How to safeguard your lab business by anticipating your physician office customer’s needs and challenges................... 4

Clinic vs. Clinic Retailers won’t give up their quest for primary-care market share. Neither will independent physician practices.......... 38

The Job of a Lifetime Cancer survivors are growing in numbers, and increasingly, primary care physicians are accompanying them on their lifelong cancer journey................................. 42

SUPPLY CHAIN

18

HEALTH NEWS Health News and Notes................... 54

MARKETING MINUTE Content Marketing Insights for Healthcare Brands.................... 55

REP CORNER A Custom Connection As dedicated sales reps, Cardinal Health’s Jeff Ledbetter and Taylor Graffeo share a common goal to connect with their customers and provide the best possible solutions.......................................... 56

Inflation and the Healthcare Supply Chain: What You Need to Know...............................................8

HIDA

IDN NEWS

Transportation Delays and Inflation Woes Persist in Medical Supply Chain..................... 59

IDNs in the News................................... 10

IDN OPPORTUNITIES

TRENDS

Collaboration for the Win Yankee Alliance President and CEO Larry Kaufman believes there’s more value for healthcare stakeholders in working together than remaining insular.................................. 14

Breaking the Rules of Healthcare: Restoring the Value of Primary Care

TRENDS

SUPPLY CHAIN Operation Warp Speed Paul Mango, Former Deputy Chief of Staff for Policy HHS, discusses the success of the public-private collaboration to deliver COVID-19 vaccines..................... 28

No Surprises Act is Flawed: Doctors They support the concept but not the proposed resolution process for payment disputes........................................... 48

If status in medicine were determined by saving lives, primary care physicians would quickly re-ascend the hierarchy....... 60

NEWS Primary Care News.............................. 63 Industry News........................................... 64

Subscribe/renew @ www.repertoiremag.com : click subscribe repertoire magazine (ISSN 1520-7587) is published monthly by Share Moving Media, 1735 N. Brown Rd. Ste. 140, Lawrenceville, GA 30043-8153. Copyright 2022 by Share Moving Media. All rights reserved. Subscriptions: $49.00 per year for individuals; issues are sent free of charge to dealer representatives. If you would like to subscribe or notify us of address changes, please contact us at the above numbers or address. POSTMASTER: Send address changes to Repertoire, 1735 N. Brown Rd. Ste. 140, Lawrenceville, GA 30043-8153. Please note: The acceptance of advertising or products mentioned by contributing authors does not constitute endorsement by the publisher. Publisher cannot accept responsibility for the correctness of an opinion expressed by contributing authors. Periodicals Postage Paid at Lawrenceville, GA and at additional mailing offices.

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May 2022

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PUBLISHER’S LETTER

The Art of Pre-Selling “April showers bring May flowers.” I heard that quote while watching the Masters this

past Sunday and it made me think of one of the pearls of wisdom Billy Harris taught me back in my exam glove selling days. Billy always believed in the art of pre-selling everything, whether it was a new pay plan to the sales team or a new nitrile glove to a client. About three to six months before we would be asking for orders on something new, Billy would say “Time to start pre-selling.” We would come up with a game plan to casually get a ‘yes’ from whoever the target audience was. Why did we do that? Because when it came time to ask for an actual order we could say, “Remember when we talked about ‘X’ and you mentioned you’d be interested in it? Well, it’s here and we are ready to rock and roll.” This approach also allowed us to temperature check ideas before we launched them. For example, by pre-selling a pay plan change we would get feedback from the team and we could tweak the new program accordingly. There are countless benefits to pre-selling your ideas, products and services. Think of it like “April showers bring May flowers.” The next time you know something new is coming, try pre-selling it with you clients. It’s such a casual way to get an early ‘yes.’ We’ve recently been placing QR codes with end-user videos in our advertiser’s ads. This issue has one in the Symmetry Surgical ad on page 39. If you scan the QR code it will auto populate an e-mail for you, so you don’t even have to write it yourself. All you have to do is add in a client e-mail and BOOM – you’re pre-selling the Bovie® Smoke Shark® III. My challenge for you this month is to scan that code and send the video to 5 potential clients. Who knows, maybe you will sell some equipment you never planned to sell this month. Good luck, and always be closing!

Scott Adams

Dedicated to the industry, R. Scott Adams

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

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PHYSICIAN OFFICE LAB

When the POL Customer Has Stopped Testing How to safeguard your lab business by anticipating your physician office customer’s needs and challenges. One of my more questionable personal outcomes related to COVID social isolation is that I

have watched more television lately. On the positive side, I’ve noticed a clever way some programs are using “current time” and doing flashbacks. They start with a dramatic moment in current time and then flashback to the events leading up to it. Let’s see how it relates to your lab business.

By Jim Poggi

4

May 2022

Your phone rings and you see it is one of your largest customer’s office managers. When you answer, you are shocked to hear, “Bill, this is Yolanda from the community group practice. The medical director has decided to stop testing immediately and is asking you to arrange removal of all the instruments. She let me know that this decision is final and not subject to negotiation.” You are in a state of shock and can only mumble “let me get back to you” before you hang up. Yolanda reminds you “we need this done ASAP.”

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You flash back to your typical customer visit. You quickly dodge past the lab where two techs are apparently working hard on chemistry and hematology systems. You wave hello but head to the relative safety of the business office to check in. No real pressing issues, but you have a couple of new products to share and a back order or two to manage. Besides, the lab SEEMED OK, busy but OK. When business is done, you skirt past the lab, hoping not to get engaged in a technical discussion. You made it and with a sign of relief, settle into your car to get to the next customer visit.


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PHYSICIAN OFFICE LAB What you do not know is that the lab staff is struggling with technical issues on two chemistry tests and has not been able to resolve them on the phone. You also did not know that one of the techs quit in frustration and they are down to two techs, rather than the three that normally staff the lab. The techs have been “hoping for the best” on the technical issues and have not alerted the management or medical staff yet. That ugly moment happens when they fail a proficiency test on their chemistry system six weeks later. Oh, and there was that recall letter you filed, assuming that the vendor would contact them and come to the rescue.

Keep your finger on the pulse Moral of the story? Every important element of your business needs to be actively managed, including the lab business. After all, it is only an asset if the customer is satisfied, confident, well trained and receives meaningful meetings with you. As the account manager and quarterback, you do not have to be the technical resource, but you need to keep your finger on the pulse of the personnel running the lab. Your commitment to follow up and desire to assure the satisfaction of the customer will help you to have a satisfied customer, a safe and secure lab business and the possibility of future referrals to other prospects.

Every important element of your business needs to be actively managed, including the lab business. After all, it is only an asset if the customer is satisfied, confident, well trained and receives meaningful meetings with you. Let’s step back in time and try to change the past to improve the future. Back then, you actively call on the lab and learn from the lab manager “Barb is just not getting chemistry. We have worked closely with her but can’t seem to get her on track.” You ask a few questions and learn she is not confident in herself and the new lipid tests she has recently begun performing. You suggest an onsite vendor training visit. The vendor’s technical representative can identify issues and coach a willing tech on how to resolve them and move on. As her confidence grows, she will be more 6

May 2022

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able to take on new tests and more able to consistently turn out high quality results. Her ability to troubleshoot will also improve. As a significant additional benefit, she will also be more willing to reach out to technical service with questions in the future. Training takes place and makes the expected improvements in Barb’s performance and confidence level. Barb stays on the job and performs well. Two weeks later you learn of a recall on two lots of quality control material. You check in with your vendor and learn there are new lots now available to replace the recalled product. You immediately call the customer and ask them to provide you with the lot numbers of QC material they’re using. They also got the recall letter and confirm they have one of the recalled lots in the lab refrigerator. You arrange a replacement of the recalled product and then personally deliver new QC material with the vendor. You assure the customer that the new product will perform properly and ask them to set up a run to test the performance of the new material before switching to it. Your vendor assigns a technical specialist to follow up. As a result, the next QC run performs properly, the customer has data to assure themselves and any inspector that their tests are performing correctly and knows their patient results will be accurate and consistent. A potential crisis is averted and customer confidence is restored. The medical director has the office manager call you to let you know “Bill, we were really concerned about the QC recall since we never had one before. You and the manufacturer stepped in, helped us manage a concerning situation, and the medical director asked me to thank you on behalf of the staff and our patients. We appreciate you and all you do.” Of course, these situations do not occur frequently and do not always have the same happy endings I have proposed. But, I can assure you of one thing: if you do not hold meaningful lab meetings and pay careful attention to the satisfaction of the lab staff and management you may be setting yourself up for the kind of unfortunate outcome Bill experienced when Yolanda called to deliver the bad news that they had decided to stop testing and move on. Secure your customer’s satisfaction, work along with your key manufacturer to assess the overall performance of the lab and make sure your business is safe. Check in early and often. Ask questions. Probe for issues before they get out of hand and continue to focus on the benefits of in office testing and even expansion of needed testing. Ten minutes on every visit will pay dividends for you and your customer. Check in and check up on your customer and business. Your customers perform check ups every day. So should you.


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SUPPLY CHAIN

Inflation and the Healthcare Supply Chain: What You Need to Know

There’s no getting around it. Inflation has permeated every aspect of the economy – including the healthcare

supply chain. Raw materials, energy, labor and logistics have all been affected, said Margaret Steele, Vizient senior vice president, med/surg.

Indeed, over the 12 months from February 2021 to February 2022, the Consumer Price Index, which measures the average prices of consumer goods and services, increased 7.9% to a four-decade high. Labor costs rose 4% to 8% with manufacturers and freight companies struggling to attract workers and drivers. In the healthcare sector, escalating labor costs have been particularly painful. In its February National Hospital Flash Report, Kaufman Hall found that from December to Janu8

May 2022

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ary labor expense per adjusted discharge climbed 14.6%. Through the last year and a half (since fall 2020) energy, resins, cotton and most metals have all surged in excess of 30%. “With the recent upturn of oil prices, the rate of inflation will continue this upward trend,” Steele said. “These levels of inflation are impacting manufacturers and service providers significantly and they have begun raising prices on the supplies, equipment, and services they deliver to hospitals.”


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Global events hit home Steele said the healthcare supply chain has been significantly impacted over the last several years due to many factors including world events. As a result, timely and accurate information is critical to minimize impact and determine risk mitigation strategies. “Supply chain leaders use various tools, such as budget impact projection reports, market supply updates and category specific insights, to understand the impact of changes affecting raw materials, labor and logistics as they look to understand cost and risk for supply disruption,” Steele said. Now, supply chain leaders are utilizing these same sources to monitor the impact of the recent events that also have an impact on raw materials, manufacturing and transportation. Steele projects the most impactful and of most interest will likely be oil as so many products contain some form of plastic or resin (a derivative of oil). In mid-March, resin prices remained higher than preCOVID levels and were expected to remain so as long as oil remains near or above $80 per barrel and producers continue struggling to get resins moved through the supply chain. Both issues are anticipated to remain through most of 2023. Oil price fluctuation, trucker shortages and port backups will also impact the costs for transporting products to the provider locations. “Many products have not yet been impacted as the situation is affecting raw materials,” Steele said. “That said, impact mitigation strategies vary by location and provider type. Providers are sharing conservation strategies in efforts to reduce usage as appropriate, pre-qualifying alternative products in the event of a disruption, increasing product on hand (or at a distributor/partner location) and ensuring product is sourced from a variety of locations. Several suppliers have medical teams that will work with the providers directly to discuss alternative uses. And, many are also participating in commitment programs, wherein suppliers and providers agree on a longer, committed supply and in some cases pricing.” While GPO and self-negotiated contracts are keeping prices fairly stable at the moment, supply chain leaders fully expect to see significant price increases in the next series of contracts, said Mike Schiller, senior director of supply chain at the Association for Health Care Resource & Materials Management (AHRMM) of the American Hospital Association (AHA). “Many are anticipating high single to low double digit price increases and have begun to include these into their budgetary considerations.”

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IDN NEWS

IDNs in the News

1 North: UPMC launches first tele-emergency department in Pennsylvania UPMC is leveraging its clinical expertise and innovative technology to launch the first tele-Emergency Department (Tele-ED) in Pennsylvania at UPMC Kane in McKean County. In line with the Pennsylvania Department of Health guidelines announced on March 2 to increase patient access to care through innovative delivery models, UPMC created a first-of-its kind in Pennsylvania rural health care approach that will allow access to excellent emergency medical care at UPMC Kane. UPMC Kane is partnering with UPMC Hamot in Erie to create 10

May 2022

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an emergency medicine collaboration using advanced telemedicine technology. Board-certified emergency medicine physicians located at UPMC Hamot, 94 miles away in Erie, partner with on-site, trained advanced practice providers (APPs) at UPMC Kane, 24 hours a day, seven days a week, to provide the best care for all who seek it. “Bedside care is delivered by physician assistants (PAs) and certified registered nurse practitioners (CRNPs) at UPMC Kane using advanced video, audio and examination technology to connect patients seamlessly and quickly with board-certified emergency medicine physicians at UPMC Hamot,” said Mark Papalia, UPMC

Kane president. “Together, the APP and physician diagnose and care for the patient.” UPMC Kane is an acute care hospital located in a remote, rural community with an average daily inpatient census of five to six hospitalized patients and approximately 6,000 total emergency department visits each year. UPMC Hamot is the advanced tertiary care regional hub for UPMC in northwest Pennsylvania and southwest New York caring for nearly 70,000 patients in the emergency department annually. UPMC Hamot provides high-level specialized care and is a Level II trauma center, the only accredited trauma center in the Erie region.


ʯ ʯ

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Cleveland Clinic Hillcrest Hospital – 125 Cleveland Clinic Avon Hospital – 312

The rankings are based on three data sources: online surveys of more than 80,0000 medical experts from around the world; results from publicly available patient experience surveys; and medical key performance indicators, including patient safety, infection prevention measures, and doctor-to-patient ratios.

3 South: Baptist Health South Florida launches startup

3

2 Midwest: Cleveland Clinic ranked number two hospital in the world Cleveland Clinic is ranked as the number two hospital in the world again by Newsweek’s World’s Best Hospitals 2022 list. Cleveland Clinic Abu Dhabi, Cleveland Clinic Fairview Hospital and Cleveland Clinic Florida are also recognized among the Top 250 hospitals in the world. The rankings are based on surveys and data from more than 2,200 hospitals in 27 countries. “(W)hat has set the world’s leading hospitals apart is their continued ability to deliver the highest-quality patient care and conduct critical med-

ical research even as they focused on battling COVID,” said Newsweek Global Editor in Chief Nancy Cooper. “Indeed, as the fourth annual ranking of the World’s Best Hospitals by Newsweek and Statista shows, consistency in excellence is the hallmark of these institutions …” Newsweek also ranked six Cleveland Clinic locations among the best hospitals in the United States: ʯ Cleveland Clinic – 2 ʯ Cleveland Clinic Fairview Hospital – 38 ʯ Cleveland Clinic Florida-Weston – 45 ʯ Cleveland Clinic Akron General Hospital – 86

Baptist Health South Florida announced an agreement with Rehab Boost, a pioneer in artificial intelligence (AI) to develop an innovative platform to diagnose movement abnormalities. The body motion recognition technology being developed under the name Gait Boost, LLC is a first-of-its-kind platform, which also marks Baptist Health Innovations’ first startup company. Gait Boost, will focus on a person’s gait, better known as a person’s manner of walking. Abnormalities in movement may provide early indicators of severe sicknesses or medical conditions. “Gait Boost is intended to work at the intersection of technology and medical knowledge, ultimately offering a new way to identify abnormalities,” said Mark Coticchia, Corporate Vice President, Baptist Health Innovations. “The opportunity and ability to diagnose patients sooner than currently available with new medical approaches, advancements and innovation is precisely why Baptist Health Innovations was created – to commercialize novel ideas for patient benefit.” www.repertoiremag.com

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SPONSORED

GOJO

Using Technology to Renew the Focus on Hand Hygiene Post Pandemic Healthcare facilities are faced with the difficult challenge of convincing patients that it’s safe to return to critical and elective care. Patients are seeking assurances that their healthcare provider has made their personal well-being a

priority from the moment they enter the facility. Hand hygiene is a critical and foundational aspect of patient safety that spans across all hierarchies and disciplines.

What makes hand hygiene so challenging? First, it is a simple task performed in a complex environment. Second, the sheer volume of hand hygiene that is and should be performed by healthcare workers makes it difficult to manage and improve. Automated hand hygiene monitoring systems have shed new light on this.1 No other task comes close and involves so many healthcare workers. With the pandemic came unprecedented challenges to healthcare facilities, and some quality metrics like hand hygiene performance were difficult or impossible to obtain. Published reports of hand hygiene performance during the pandemic showed that initial performance increased

followed shortly thereafter by a return to baseline or below.1,2 Quality metrics like hand hygiene are essential during both times of stability and times of crisis.3 The goal of any quality metric is to obtain reliable data to improve patient safety, yet hospitals relying on direct observation alone are likely insufficiently allocating and deploying valuable resources for improvement efforts based on the scant information obtained. Quality and safety leaders readily acknowledge that a gap exists between reported compliance rates and hand hygiene behaviors taking place on a 24/7 basis. The next step for many hospitals is to implement a more accurate, efficient, and reliable measurement system. Over the past decade, healthcare facilities have been introduced to automated hand hygiene monitoring systems that have been designed to provide standardized collection of data across multiple units and facilities on a 24/7 basis.4,5 PURELL SMARTLINK™ AMS was developed to serve as a metric for capturing hand hygiene data and managing risk associated with hand hygiene behaviors. As SARS-CoV-2 becomes a less formidable disruptor and there is a renewed focus on quality in healthcare, implementing technology to efficiently generate large volumes of standardized hand hygiene data can provide a more complete picture of hand hygiene practices leading to better resource allocation and improved patient care.

oore LM et al. The impact of COVID-19 pandemic on hand hygiene performance in hospitals. Am J Infect Control. 2021;49(1):30-33. M Makhni S et al. Hand hygiene compliance rate during the COVID-19 pandemic. JAMA Int Med. 2021;181(7):1006-1008. 3 Austin M & Kachalia A. The state of health care quality measurement in the era of COVID-19. JAMA. 2020;324(4):333-334. 4 Boyce JM. Measuring health care worker hand hygiene activity: current practices and emerging technologies. Infect Control Hosp Epidemiol 2011;32:1016-28. 5 Boyce JM. Electronic monitoring in combination with direct observation as a means to significantly improve hand hygiene compliance. Am J Infect Control 2017;45:528-35. 1 2

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IDN OPPORTUNITIES

Collaboration for the Win Yankee Alliance President and CEO Larry Kaufman believes there’s more value for healthcare stakeholders in working together than remaining insular. By Daniel Beaird

Larry Kaufman

Larry Kaufman has been president and CEO of Andover, Massachusetts-

based Yankee Alliance, a national GPO and certified sponsor of Premier, Inc., for a little over a year, taking the helm last February, after former president and CEO Cathy Spinney retired. He has a demonstrated history of creating patientfocused cultures for serving health systems, most recently as president and CEO of Trivergent Health Alliance MSO in Maryland and 35 years with HCA Healthcare and HealthTrust, the HCA-initiated national GPO. 14

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After more than 20 years running hospitals at the C-suite level for HCA, Kaufman moved into the CEO role for the eastern U.S. for HealthTrust and his responsibilities expanded to non-HCA facilities. “That gave me exposure to a lot of organizations from Miami to Maine that had their unique challenges,” he said. “And states in between like Georgia that suffered from a large number of critical access facilities closing over the last several years and that was pre-COVID. Just challenges upon challenges, and then COVID hit.” Trivergent gave him the opportunity to work with a group of hospitals in Maryland to centralize some of their enterprises like supply chain, pharmacy, and laboratory operations. “The idea being that we are better together. That gets more important over time,” Kaufman said. “It was doubly important in Maryland because Maryland is the only state in the U.S. that has a capitated approach to healthcare. That kind of population health focus drew me there.” Maryland operates the nation’s only all-payer hospital rate regulation system. Under a 36-year-old Medicare waiver that exempts Maryland from the Inpatient Prospective Payment System (IPPS) and Outpatient Prospective Payment System (OPPS) and allows the state to set rates for these services, all third parties paid the same rate. CMS and Maryland partnered to modernize the state’s unique all-payer rate-setting system for hospital services that aimed to improve patients’ health and reduce costs, and updated the waiver to allow Maryland to adopt new policies that reduced per capita hospital expenditures and improved health outcomes. “Finally, Yankee Alliance was an opportunity to work with an


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IDN OPPORTUNITIES organization established a long time ago with the idea of working together,” Kaufman said. “Yankee has done well since its beginnings in 1984 given how many changes have affected the healthcare industry.” “Yankee’s members are always looking to take it to the next level to drive out unnecessary cost. I like being around people who are inspired to do better and are openminded to work with organizations that could be identified as competitors,” he said. “There’s more value in working together than being insular.” Kaufman classifies group purchasing as a service industry serving a service industry. “My previous employer HCA had – at any given time – north of 250 hospitals, but

they still needed all the friends they could get. Hospitals will continue to look to each other to improve. CEOs are looking for real ways to work together like they never have before, not just sharing information over a cup of coffee but structuring components of operations,” he said. That’s where GPOs like Yankee Alliance come in. They have a tremendous amount of information but they’re not the source of it. “We’re kind of like a good point guard in basketball. We get the ball, and we pass it,” Kaufman said. “We’re making sure we’re plugged into the industry and connected with our members.” Whether it’s access to PPE, a value analysis function or contracting,

Kaufman says the common theme of sharing information is all the same. Yankee Alliance runs comparative analytics to show its members where they stand relative to each other. That creates interest, positive peer pressure and motivation to members to do better.

Larry Kaufman, FACHE, joined Yankee Alliance as its president and CEO on Feb. 1, 2021. He most recently served as president and CEO of Trivergent Health Alliance MSO in Maryland and has held various hospital administration and GPO leadership positions. He has more than 35 years of experience in labor and non-labor cost reduction, physician and clinical integration, and the development of strategic initiatives – both operational and clinical – to reduce variation, cost and improve quality. Yankee Alliance has grown to more than 18,000 members in all classes of trades across all 50 states. It is a member-driven national healthcare GPO with a two-fold mission: to collaborate with members to reduce supply and operating expenses through aggregation of data, purchasing, ideas and knowledge, and to excel in strategic innovations that continually assist members in reducing their cost while recognizing their individual needs.

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Yankee Alliance provides the environment for its membership to interface with each other for solutions. “Everything we do is in a glass house with the lights turned on,” Kaufman explained. “Everything we’re tackling should be something that has been a problem or an opportunity for our membership. We’re flexible to whatever is slamming our facilities that week.” Yankee Alliance is a certified sponsor of Premier, Inc., and its group purchasing program combines the Yankee Alliance portfolio of contracts with those negotiated by Premier. Yankee Alliance’s contract managers assist with implementation, troubleshooting problems with suppliers or contract service issues and answering questions. “From the start, we’ve focused on contracting, whether it’s commodities or other supplies that a hospital uses, we look at what our members are purchasing and identify opportunities for aggregation to increase our negotiating strength,” Kaufman said. Yankee Alliance’s contract portfolio includes 2,641 Premier contracts, 456 Yankee Alliance aggregated Premier contracts and 191 Yankee Alliance specific contracts. “We create our own contracts for what our members are buying that aren’t Premier contracts,” Kaufman added. “Things like purchased services and other areas. It’s a matter of us paying attention to what’s happening within our membership and using that data to tell us what we need to be contracting for and not.” Yankee Alliance also offers support and assistance in clinical areas with a large focus on value analysis. “Our job there is to see where our members are relative to the best demonstrated practices in the value analysis process,” Kaufman said.


“We use evidence-based practices to help them move from where they are to where they’d like to be.” Kaufman says the common theme of sharing information is all the same. Yankee Alliance runs comparative analytics to show its members where

they stand relative to each other. That creates interest, positive peer pressure and motivation to members to do better. “It’s all about operational excellence,” Kaufman concluded. “You never know where a solution is

going to come from. This industry is always changing, and hospitals will collaborate in ways they haven’t before to benefit from speed to learning, strength in numbers and functioning more effectively to drive out unnecessary variations.”

Labor shortages, technology, critical supplies and sourcing Labor Shortages Hospitals are being forced to shelve services because of staffing shortages. Boston’s Tufts Medical Center announced recently it is closing its Boston children’s hospital, known as the Floating Hospital for Children (due to its founding as a ship in the 1800s to bring sick children into the Boston Harbor for fresh air and medical treatment). Tufts plans to continue operating its pediatric primary care services and neo-natal intensive care unit, but the closure announcement has caused concern among Massachusetts’ pediatrician offices. Representatives for Tufts Medical Center have stated that the children’s hospital has been in question for a while and the hospital faces high demand for beds as more adult patients require specialized care. “Right now, people are looking at two things,” Kaufman said. “They’re looking at the pain they’re feeling – there are nursing units closing across the U.S., among other negative things. Then, they’re looking at the future and how to get out of these predicaments.” Kaufman says there’s nobody rushing to the forefront with the solution, but that it will be a combination of many different things. “First, it’s about creating environments in which the staff wants to be there, in spite of having gone through a pandemic,” Kaufman said. “You want to make sure the world you’re putting your employees in is as good as it can possibly be, so when they’re thinking about ‘do I stay or do I go,’ they stay. You also have to make sure you’re using those employees as efficiently as possible.” “And finally, hospitals and health systems are trying to reinvigorate some things they’ve been doing for years and looking at the work that needs to be done in higher education and teaching institutions to produce more labor,” Kaufman said. After the pandemic, Kaufman says the challenge of attracting more labor lies in the perception of what the healthcare industry is about. “We need a serious makeover on the value and quality of life you can have by working in a hospital,” Kaufman said. “Working in

healthcare used to be seen as an awesome thing to do. But the question today is do people want to do something they feel like puts them in harm’s way? We have to work on that.”

Technology Technology is advancing in every way in the healthcare and supply chain industries. “It’s going to advance with or without us,” Kaufman said. “We don’t have a choice of taking advantage of AI (artificial intelligence) or machine learning. There are applications in every area, certainly within supply chain.” “Healthcare is going to follow every other industry. We won’t turn into the auto industry with robots running assembly lines, but we’ll have robots functioning in hospitals in one form or another – whether it’s in the pharmacy, roaming the halls or cleaning the patient rooms with a UV scan. It’s going to continue to be a disruptor,” Kaufman said.

Critical Supplies and Sourcing “Our members have critical supplies now that they wouldn’t have been carrying two or three years ago,” Kaufman said. “Everything was just-in-time back then and now with all of this inventory sitting around, there has to be an efficient way of keeping it.” “It’s similar to looking at hospitals on the Gulf Coast. I spent most of my career in Florida being ready for the next hurricane. There was always a part of the warehouse that was just hurricane supplies – everything from water to plywood to cots. Now, we have hurricanes hitting everywhere and supply chain issues still going on,” Kaufman said. Yankee Alliance works in coordination with Premier on sourcing. “We support onshore and near shore manufacturing as much as we can, and diversifying sourcing so it’s not all coming from China,” Kaufman said. “We’re also advocates for the industry, making sure our members and ourselves are speaking to Congressional representatives on the importance of developing a database to know where critical supplies are.”

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Doug Bryant

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How Quidel Navigated COVID-19 A conversation with Quidel President and CEO Doug Bryant.

The pressures were immediate, and daunting. Early in

the pandemic, Quidel, a leading manufacturer of diagnostic solutions, was being asked to go from manufacturing 50 to 60 million tests per year, to producing 16 million a week. “That does not happen overnight,” said Quidel President and CEO Doug Bryant. Fortunately, the company was up to the task, and in the span of two plus years has transformed its capabilities in servicing the U.S. healthcare industry during a crisis. In a wide-ranging conversation with Repertoire Publisher Scott Adams, Bryant discussed Quidel’s mobilization amid the pandemic, how its relationships with distribution partners have helped in the past couple of years, and how the organization’s unique culture has contributed to its transformation in a severely disrupted marketplace. Repertoire: How have your distribution partners contributed to be as quick and efficient as they can at getting COVID testing and solutions in the hands of labs, hospitals, and physician offices? Doug Bryant: We have had tremendous relationships with all the major distributors and each one of them could tell you about their travails along the way in supporting us. We’ve had a couple of transformational events in recent years following the acquisition of the Alere assets and in our presence in the cardiovascular space. www.repertoiremag.com

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How Quidel Navigated COVID-19

In March 2020, we were thrown off a bit when we were asked to go to the White House to have a conversation around COVID testing. From that point onward, our company mobilized and did several things that were surprising and exceptional. At the same time, our distribution partners equally were stepping up and handling a lot of issues simultaneously. The consumer market didn’t start until early 2021 when a significant demand was beginning to build. The folks at McKesson were especially helpful with that market in terms of giving us access to thousands of independent pharmacies and also helping with the relationship with Amazon and others. But truthfully, we could not have done any of this without all our distribution partners. We are super thankful for those relationships. Repertoire: What measures has Quidel taken to meet some of this increased demand for COVID-19 testing? Bryant: When you reflect on it, it’s a bit daunting. And just the pressures that we were under immediately to go from a company that had been manufacturing about 50 to 60 million tests per year, to a company that last week manufactured 16 million tests during a week. That does not happen overnight. I mentioned the meeting at the White House on March 4, 2020. By March 17, we had a PCR product in market. By May, we had the Sofia SARS product, the first global rapid antigen test. Later in the year, we had other tests, but then we also introduced a combination assay.

Sofia® 2 analyzer

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It was a lot of work on the R&D side. Because of what has happened to our company, we have gone from developing about 20 products at one time – 20 products in our portfolio – to managing about 50 product programs across our organization. The R&D folks stepped up the clinical regulatory folks running the studies to get the Emergency Use Authorizations that we ended up with. I believe the number is seven products that are Emergency Use Authorized and available to be shipped here in the United States. So, there’s that side. We improved our distribution capacity. You can make a lot of tests, but if you can’t get them shipped, it doesn’t really matter. We had to stand up another 110-120,000 square feet of distribution capabilities just to get trucks in and out to move the product. In addition, in a nine-month period, we stood up from the studs of a building to a fully-fledged manufacturing facility in Carlsbad, California, which is where we now manufacture the Quickvue products. At the same time, we were dramatically leveraging our footprint in our facility where we manufacture Sofia and we increased manufacturing lines there. Along the way, you can imagine that each program and each product that we manufactured had significant supply chain issues. Those supply chain issues created the delay in getting our partners the product they needed to supply their customers. As a result, I think we did a lot for the country, and a lot for communities across the United States. We could not have done it without our distribution partners. Repertoire: What were some of those supply chain issues, and what were some of the measures you took to address those challenges? Bryant: One of the things that we have done because of the major supply chain issues we faced was to build redundancies across the system. For example, for the extraction vials (where you put your swab in to get the cells off the swab and then take that liquid and use it to run the test) we had one manufacturer that we relied on for years. We’re now employing seven, all in the United States. We needed that redundancy. We needed partners that were flexible in terms of their ability to ramp up and down, and do so comfortably without suffering extreme economic problems. Cashflow is a big thing for smaller companies. Our ability to work with them, to make all that happen, was an important part of it.


We do not have to have five out of five decisions that were absolute winners. I am OK if we have eight out of 10. I would rather have two mistakes and 10 decisions rather than five perfect decisions. Our company has always done well financially. Our cash flow has been extraordinary. We were able to weather all that, but I would say the supply chain issues were a really big challenge. And the other thing that our partners and distribution would tell you is that while we were making a lot of COVID products, we were not making a lot of other products. Sometimes it was the other things that were creating the most heartburn for our distribution partners who were trying to take care of customers who needed things other than just COVID tests. I would imagine that would be true across all my colleagues in the industry on the manufacturing side, but those are the two big challenges. Repertoire: Let’s shift gears a little bit. Can you talk about the unique company culture at Quidel? Bryant: We try to be nimble, quick, and decisive. We do not have multiple layers of decision-making. I tend to like to hire people that have the technical background to do the job that we are asking them to do. Of course, we also like to have people who can take their raw intellect and combine that with their sets of experiences over time to give them what I would call a “gut feel.” If a person has that technical skill to do whatever it is that we are asking them to do and they also have that “gut feel,” they tend to be able to make good decisions. So, we have a culture that says, “It’s OK to make a mistake, but it’s better to make more decisions and to move quickly.” We do not have to have five out of five decisions that were absolute winners. I am OK if we have eight out of 10. I would rather have two mistakes and 10 decisions rather than five perfect decisions. That’s a part of our culture that is a bit unique. We insist on having people that have a positive, can-do attitude who are willing to take the risk, make a decision, move forward, live with the outcome, and be accountable. We also spend a lot of time on our company’s happiness. It sounds a bit altruistic to say that we believe as an executive team that the happiness of our employees is the most important thing to us. But people who are happy tend to be more productive, and people who are more

Sofia® SARS Antigen FIA manufacturing

productive have better outcomes, which in turn makes them happy. So it’s this circular thing that we have in our company where we have a bunch of people that are just genuinely happy and productive. I don’t spend a lot of time worrying about the unhappy people. Unhappy people do not like to be around happy people. What happens is over time, we don’t really have to manage that. They tend to go leave and go to work for some other company where they have more unhappy people to hang around with. I ask all the time when I interview people, “Do you have friends at work? Do you have people that you like www.repertoiremag.com

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How Quidel Navigated COVID-19

to hang around with on the weekends who happen to be also in our company or in your former company?” That’s the type of people we have. And now with this recent acquisition of Ortho, I think it’s super important that we take this philosophy, what we call the Quidel Way, and we figure out how to imbue that same philosophy in that organization. We almost need cultural ambassadors to continue to tell the story. Imagine if we can get all 6,000 of us together to be super happy in our endeavors and to be thinking about what we can do, not just for ourselves, but for others in the company and our communities. If I can pull that off, it would be the achievement of my career. Repertoire: How have you been able to balance some of the urgency of Quidel’s mission, which has been incredibly important to our country and to the wellness of the population, with the well-being of your team members? Bryant: We tried to balance it, but at the end of the day, you are asking people to put themselves at risk to come to work. My HR team made a recommendation, saying, “Doug, you need to communicate with these folks very routinely.” We set up weekly video calls where I talked about whatever was going on at the time and where we were in terms of processes and accomplishments. I spent a lot of time recognizing people who had stepped up and made things happen. And I did that routinely. I also shared a bit of my personal life. It just became more of a family situation where we created this weekly dialogue where we kept everybody up to speed. And then I thanked them, honestly, for stepping up and rising to the challenge of the pandemic. We did videos of folks in our factories and throughout the organization and took people’s comments. The positive comments that we were getting back from team members was quite impressive and rewarding, honestly. But balance? I don’t know about balance. For about the first 18 months, I don’t think we took a day off. We came in every morning early and had a meeting, first on the molecular side with those products, which would then go into the other products. We had a daily meeting about what was going on and what we needed to do to get product out the door. We did our best to make sure that people felt like we were doing the right thing and that we were making good choices. 22

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The decisions we made were not always easy: the way we decided to go to market, the way we decided to protect the interests of our current customer base, to protect the relationships that we had with distribution partners. When we had a fall-off in demand as COVID seemed to be abating for a brief period, one of our competitors shut down one or more of their factories. We never did that. We continued to ramp up. We continued to do what we felt was the right thing, and that helped with the balance.

I spent a lot of time recognizing people who had stepped up and made things happen. And I did that routinely. I also shared a bit of my personal life. It just became more of a family situation where we created this weekly dialogue where we kept everybody up to speed. Repertoire: What are some positives you’ve seen in the supply chain in these last two years that might not have come to light had we not been forced to take a pause? Bryant: That’s an interesting thought. I would say that from the business side of things, we were not really the size of a company that could compete with these larger companies before. And it wasn’t because we weren’t innovative enough or didn’t have the technical talent. It’s because we did not have the scale. Now that we have gone through this exercise, we certainly have scale, and we can compete with these other larger companies as we enter new markets. We are not going to be held back by our inability to supply product relative to what they are doing. That’s a big deal for us. The increased manufacturing capability sounds simple on the surface, but it is multifaceted. We hired 400 people up in Carlsbad for the new factory. It is a significant enough number of people that even the mayor of Carlsbad recognized. That is one aspect. The R&D capabilities, the brand strength that we now


Delivering a difference, together When we come together, we do great things for patient care. Thank you to our valued suppliers for supporting customers when they needed us most.

©2022 McKesson Medical-Surgical


How Quidel Navigated COVID-19

Quidel San Diego, California headquarters

have enables us to hire the talent that we need in the R&D and engineering side. These are the things that from a business perspective have really been transformational for us. The other aspect is we have generated a lot of cash. By the middle of this year, we will still be sitting on a billion and a half or so in cash. The ability to access capital markets and to have cash coupled with cash on the balance sheet has enabled us to look at other things that we might do, investments that we might make. Certainly, the Ortho acquisition, which is signed but not yet closed, that could not have happened had we not gone through the exercise that we just did over the last couple of years. Repertoire: Is there someone who helped mentor you and invested their time into your career journey? Bryant: I really don’t have somebody that pops into my mind because I’ve had the opportunity to be around 24

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a number of people that I could observe and emulate. I’ve had some folks that were pretty good at what they did, and they were worth observing and patterning myself after. When I think about it, I never really planned a career. I just did the best I could and everything that I was asked to do. As a result, I would be asked to do other things. That was what motivated me – the opportunities to take on positions of increasing responsibility over time. So for me, it’s never been about a series of job titles. It’s been more about a series of accomplishments. I would say to those folks who are trying to manage their career, who might be a little bit earlier in the process, be self-reflective. Everything that you do, try to think, “How well did I do it? Could I have done it better? What are the things that I did that were useful? What makes people successful? Is there something that I can learn there?” I would say the most important thing about having a long and prosperous career is to be observant, but also self-reflective.


How can you help distribution reps sell more while improving outcomes and taking care of the caregivers?

Share Moving Media is committed to providing the med/surg community with timely, important content to help reps thrive during a crucial point in the industry’s history. Reps are turning to Share Moving Media platforms for content in record numbers. Consider the following:

Repertoire’s Web traffic is up 180% over 2021

2-Minute Drills taken are double in 2021 verses 2020

Repertoire Podcasts are up 265% over last year

Repertoire being read digitally is up 225% over 2021

Contact Amy Cochran to learn how Share Moving Media can be your content resource for 2022. 770-263-5279 acochran@sharemovingmedia.com

Share Moving Media is dedicated to providing our customers with the tools to increase their market-share through our publications, educational services and associations for providers, manufacturers and distributors in the business of healthcare.


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SUPPLY CHAIN

Operation Warp Speed Paul Mango, Former Deputy Chief of Staff for Policy HHS, discusses the success of the public-private collaboration to deliver COVID-19 vaccines. Paul Mango, the deputy chief of staff for policy for the U.S. Department of Health and Human Services (HHS) from

2019 to 2021, joined Publisher Scott Adams for a Q&A on Operation Warp Speed (OWS), a public-private partnership to facilitate and accelerate the development, manufacturing and distribution of COVID-19 vaccines, therapeutics and diagnostics. Mango served as the formal liaison for OWS and has written a new book called Warp Speed: Inside the Operation That Beat COVID, the Critics, and the Odds.

They also discussed the Strategic National Stockpile (SNS) and Project Airbridge, a program created to shorten the amount of time it took for U.S. medical supply distributors to bring PPE and other critical medical supplies into the U.S. during the initial COVID-19 pandemic response. Scott Adams: It was really unique to watch our industry come together, even competitors working side by side (during the initial COVID-19 pandemic response). Your team had a ton to do with that. Talking about the Strategic National Stockpile, in

those early days of the pandemic when you were developing strategy on how to collaborate, you worked specifically with medical and supply chain distributors. What were the potential shortages during that time? Paul Mango: All hell was breaking loose. But exceedingly early in the pandemic, in February 2020, when we started experiencing hospital admissions and then some of the initial fatalities here in the U.S., I called six or seven large health systems that were treating these patients because we wanted to know what the supply consumption was associated with a

COVID patient in the early days. It was a 10-day length of stay on average. Providence in Seattle had some of the first cases, and the clinical medical director said they were going through 350 N95 masks per patient over a 10-day length of stay. We started doing the math. Our Strategic National Stockpile had 12 million N95 masks. You can start to figure out that after about 40,000 patients the cupboards were going to be bare, and we were expecting a lot more. We had to develop a strategy quickly on how we were going to get supplies to those hospitals and health systems that needed them most. We put a team together to understand where the PPE was manufactured. You had masks, gowns, booties and Nitrile gloves. What we learned was the vast majority of these were manufactured outside of the U.S. Nitrile gloves were 98% outside of the U.S. N95 masks – we actually made quite a few. But when it came to gowns, they were sewn in Mexico or in South America. We developed a strategy with four major components: 1. Acceleration 2. Reallocation 3. Preservation 4. Repatriation

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Thanks for your partnership To our distribution partners across the country, our sincerest thanks. You have been instrumental in helping Quidel provide access to crucial diagnostic tools, improving human health for millions in need. Together we faced unforeseen obstacles, from supply chain disruptions to emerging variants, all while never losing sight of our customer’s needs during the urgency of COVID-19 test distribution. Our shared efforts have empowered individuals to take charge of their health and removed barriers to testing access for communities across the country. For this and so much more, the entire Quidel Team thanks you. We look forward to continuing to work alongside you, instilling health confidence in millions.

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SUPPLY CHAIN Acceleration (Project Airbridge) was a function of us working with these great medical supply company distributors. It was McKesson, Henry Schein, Quidel, Abbott and Owens & Minor. Cardinal was very instrumental. Great, iconic American companies that had rights to much of the PPE in China. Wuhan, China, ironically, was where a lot of PPE was manufactured and they had to shut down their factories for six weeks during the early days of COVID. When they resumed production, they had been filling up their warehouses with stuff these medical supply companies owned. If they put them on the normal transportation route on large container ships coming back to the U.S., it would’ve taken 45 days to get here, unloaded and put on trains or trucks from the West Coast. It could be 55 or 60 days – two months. We decided to send 747 cargo jets over to the warehouses in China and this was the fundamental nature of the Airbridge. The medical distributors would still own 100% of the product we picked up, but in return for us financing the transportation, the companies permitted us to direct the allocation of 50% of whatever we picked up. Our ability to take a constrained supply base and redirect it to the hotspots was crucial to the long-term success. These medical suppliers and distributors were patriots. They exhibited no selfinterest and were all a team. We used the Defense Production Act (DPA) Title VII, which permitted normal competitors to collaborate during this time of a public health emergency. One of the ways they collaborated was, along with Palantir Technologies, which is a great information technology company, creating an information technology system 30

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giving us line of sight into each N95 mask, gown and booty from factory to warehouse to where it was being shipped in the country. This decision support system was phenomenal. Distributors had never had that on their own, and now we have one. It’s really a national asset and that permitted us to reallocate. Again, the first principle was Acceleration. That was getting things here overnight that would normally take two months. Once we did that, it shifted around using this IT system to send more gowns to Mount Sinai in New York, for example, because New York was blowing up with cases. That meant these suppliers would have to short some of their other customers, but those would be customers that didn’t have the same need at that time. The third part of our strategy was Preservation. We decided to get hospitals and health systems on the phone and the American Hospital Association helped us. We had 2,000 participants from hospitals around the U.S. listening to those leaders in the hospitals that were treating COVID patients. This is where COVID wings came about. Hospitals created COVID wings to put the COVID patients together. The last part of our strategy was called Repatriation to bring production back to the U.S. Close to $500 million worth of grants were issued to expand domestic manufacturing capacity of masks, gloves and other things. A lot of this was offshored 20 years ago when labor arbitrage opportunities were significant. Two things have happened in the interim period. One is worldwide labor costs have normalized a bit. It’s not equal, but it’s normalized a bit. Secondly, after we offshored a lot

of this manufacturing, Asian countries applied automation techniques and equipment to manufacture it. We learned that the U.S. was actually a cost advantaged place to manufacture it 20 years later, particularly Nitrile gloves. The base raw material for Nitrile gloves is petroleum, and it’s much cheaper in Louisiana, Mississippi and Texas than it is in Vietnam. There was a potential cost advantage in bringing this manufacturing back, but an initial capital investment in the equipment was necessary to automate it, and that’s what we funded. Adams: Talk about Defense Production Act Title VII that allowed national distributors to work together early on. Mango: Early in the pandemic, HHS collaborated closely with FEMA, which is an expert at responding to disasters – floods, hurricanes or tornadoes. They had representatives distributed across 10 regions in the U.S. as logistical hubs. I was at FEMA at 7:30 a.m. every morning and we had our initial call with these distributors at 8 a.m. The CEOs were on the phone calls. They were committed. The private sector knows best what to do. We needed to elicit their input and ideas. Our role was to coordinate, not tell them what to do. These calls were them informing us on how to get this done. We’d have morning calls and late afternoon calls every day. We had the right leadership at the table, and it was realtime problem solving. We got into a rhythm, and once there, it was fantastic. FedEx, UPS and others helped us with the Airbridge. Great, iconic American companies stepped up. In Fall 2020, we were prioritizing for vaccinations and there was a debate about vaccinating the elderly


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SUPPLY CHAIN and most vulnerable first or vaccinating the healthcare workers first. Deborah Birx said that out of 20 million healthcare workers in the U.S., only 200,000 had been infected at that time. People who are in contact with COVID patients every day weren’t infected. That’s because of the success of Airbridge and these companies. We got PPE to the right place at the right time. Adams: Give us a couple lessons you learned and some things that we might be able to avoid if we face this again, which we probably will. Mango: Coming back to the Strategic National Stockpile, we were fundamentally unprepared for what hit us. The mission of that stockpile had a lot to do with chemical, biological and nuclear warfare. In the early days of the Trump administration, the biggest threat to this country in 2016 through early 2018 was North Korea. Many resources went into antidotes that would protect America against nuclear threats. We weren’t prepared for a biological threat like this. But when I left, we had close to 300 million N95 masks in the stockpile. I hope we don’t repeat the mistakes of the past, but the government dramatically increased demand for certain supplies during the pandemic. Unfortunately, we saw this with testing too, and once that demand goes away, the supply goes away. Then it’s exceedingly difficult to respond to the next pandemic. The federal government needs to continue to fund the presence of idle capacity that is warm and can be hot very quickly. Collaboration needs to take place between the Strategic National Stockpile, medical supply distributors and 32

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manufacturers to ensure it’s in place and pressure test it multiple times a year. The federal government is going to have to pay for that, but it’s significantly cheaper than the trillions of dollars of lost economic growth because we weren’t prepared. Lastly, the federal government’s role in an emergency like this is to enable the private sector to be successful. It depends on the private sector to deliver success. The government enables, the private sector delivers. Adams: I want to shift gears and move to Operation Warp Speed. Please tell us how it started. Mango: In the early days of the pandemic, even in January 2020, the initial stages of Operation Warp Speed had begun. Moderna was working with the NIH before the pandemic broke out on using mRNA technology to develop cancer therapies. When the viral sequence – the DNA sequence of the coronavirus – was posted on Jan. 10, 2020, Moderna and the NIH collaborated on using mRNA technology to develop a vaccine very quickly. It had never been done before. mRNA is a new vaccine technology. In about 10 days, they had a good vaccine, unbelievably. They didn’t know it. We didn’t know it. But what was developed in those first 10 days is basically what Moderna eventually distributed. At the time, there were about 95 vaccine candidates that were being developed around the world. We started funding a number of companies to accelerate that development. Secretary Alex Azar and I sat down with the FDA and the Office of the Assistant Secretary for Preparedness and Response (ASPR). Secretary Azar mapped out the strategy for Operation Warp Speed,

and everything that used to be done in series would now be done in parallel. The financial risk associated with that, like starting manufacturing even though we didn’t know whether the vaccine would be authorized by the FDA, would be assumed by the federal government. It had a number of principles around governance, doing things in parallel and assuming financial risk, and spreading our investment risks across three technology platforms – mRNA, viral vector and protein subunit. Another especially important principle was bringing in private sector expertise as our manufacturing lead. That’s how it started, and the rest is history. Adams: March 28 and March 29, 2020, is when this was outlined? Mango: That’s correct. Now, there’d been some early work done on screening the world for vaccines and investment in Moderna, but it wasn’t a coherent initiative. It didn’t have a governance structure or strategy. Secretary Azar got it right away and said, this needs to change dramatically. Adams: Talk about some of those guiding principles that help with the effort of doing that. Mango: The most important one was performing activities in parallel as much as possible. The typical approach for a pharmaceutical company is going through a phase one trial, examining those results, starting a phase two trial a couple of months or even a year later, examining those results, then going into phase three, large scale human trials, and finally taking it to the FDA. The FDA could take six months to evaluate data. But Peter Marks (with the FDA) made a pledge of having an answer


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SUPPLY CHAIN in 14 days on any data he received and any application he received from EUA. He had his staff working in three shifts, eight-hour shifts, 24 hours a day. Typically, after authorization from the FDA is when a pharmaceutical company starts manufacturing because they don’t want to put a lot of effort and resources into it before they know it’s going to be approved. We took as much of that as possible. Phase one, phase two and phase three clinical trials were measured in days, not months. We used a lot of the NIH’s clinical trial sites. We helped recruit individuals for trials that weren’t necessarily patients. A lot of them were healthy. Then, we began manufacturing in the Summer 2020. Remember, the first EUA was granted on Dec. 11. We were already manufacturing, and it’s the first time in history that there were millions of doses of vaccines available and being shipped 24 hours after the FDA authorized use. That was one principle. When it came to governance, it was fascinating. I spent 25 years at McKinsey & Co. leading transformational efforts in large corporations,

and it’s a remarkably similar principle. When you have an emergency like this in any organization, you can’t let the bureaucracy bog you down. What we did was set up an Operation Warp Speed board co-chaired by Secretary Mark Esper at the Department of Defense and Secretary Alex Azar. We had a number of physicians and some White House representatives on it. We met every Friday morning to make decisions. If we needed any support beyond that board, we had a direct line to the Oval Office. That took weeks and months off of contracting issues and defense product act use issues. It was all action. That was an especially important principle. The third one was the venture capital mindset from Moncef Slaoui. He’s the most successful vaccine developer of our generation. He brought 14 vaccines successfully to market at GlaxoSmithKline. But he’s a strategist at heart and he laid out the candidate investment portfolio. Some people in the scientific community were saying, ‘get every horse you possibly can in the race.’ Invest in 20 of these things. However, what those scientists didn’t understand and

Moncef Slaoui and General Gus Perna did was that the more you invest in, the less probability you have of getting through clinical trials. You need 30,000 people in each clinical trial. If you had 20 different trials going on, that’s 600,000 Americans. You have potentially a shortage of raw materials. You would add to the complexity of distribution. These vaccines took different size needles and syringes. They had to be stored and distributed under different conditions. The complexity of the supply chain issues would grow exponentially as you added vaccine candidates. We limited ourselves to six, and potentially seven, but we said no more than that across three technology platforms and two candidates in each platform. In August 2020, we performed ‘trust but verify.’ Moncef had laid out his candidates, syndicated it with the board, and we evaluated each candidate on three dimensions – the probability they could get EUA before year’s end, their ability to scale up manufacturing and their effectiveness in those over age 65. We knew in Summer 2020 this virus

Warp Speed: Inside the Operation That Beat COVID, the Critics, and the Odds A powerful story of how our nation’s leaders overcame the odds, saving the American people from the throes of a deadly pandemic. The prior record for vaccine development and distribution was approximately 4.5 years. Operation Warp Speed got the COVID-19 vaccine to the American people in less than 10 months. Operation Warp Speed did not happen by accident. It was the result of exceptional leadership, explicit strategy, and unprecedented teamwork. Author Paul Mango, one of the key leaders of Operation Warp Speed and the former deputy chief of US Health and Human Services,

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chronicles the challenges of developing the vaccine. In this harrowing, behind-the-scenes account of the most successful public-private partnership since World War II, we learn how the nation’s biggest leaders accomplished the impossible. Through sheer will and commitment, a small group of leaders fulfilled its mission, making the United States the only country in the world which could offer a vaccine to any citizen by April 2021, scarcely 14 months after the genetic identification of the virus. The electronic version is available for download. The hard cover version will be out in early to mid May 2022.


Meet some of the team members of Operation Warp Speed: ʯ ʯ ʯ ʯ

President Donald Trump Health and Human Services Secretary Alex Azar Dr. Robert Kadlec, Assistant Secretary for Preparedness and Response (ASPR), an agency within HHS Carlo de Notaristefani, Lead Advisor, Manufacturing and Supply Chain

disproportionately affected those with certain underlying conditions and the elderly. We used those criteria and performed a cumulative probability analysis. The cumulative probability analysis suggested a 75% probability of having at least one safe vaccine manufactured at scale and effective in those over age 65 before year’s end. There was a 32% chance we’d have two and less than a 10% chance we’d have three. We wound up with two. We were considering a seventh candidate, and every candidate we invested in was about $2.5 billion. We ran the seventh company through our probability analysis, and it only took the 75% probability to 78%. It wasn’t worth the leadership dilution and the complexity in the supply chain. We used that tool successfully to help us make decisions. The CDC had a strong preference for using the public health infrastructure to distribute and administer vaccines. But General Perna in the Army Material Command said, ‘we prefer CVS, Walgreens, Walmart, UPS and FedEx,’ and that won out because America’s public sector infrastructure is dilapidated at best. They don’t have electronic scheduling

ʯ ʯ ʯ ʯ ʯ

Dr. Moncef Slaoui, Chief Scientific Officer General Gustave Perna, Army Material Command Dr. Peter Marks, Director of the FDA’s Center for Biologics Evaluation and Research Matt Hepburn, Vaccine Lead Dr. Francis Collins, Director of National Institutes of Health

of patients and don’t know how to call patients back for their second doses. We looked into all of that, and we had an underlying belief in the private sector. Adams: McKesson was the exclusive distributor of the vaccine. What role did McKesson play in Operation Warp Speed? Mango: We quickly concluded that given McKesson’s relationships with the government, knowledge of how the government operated and their own stellar reputation that we would go with McKesson for this broader role. One of the federal government’s roles was to ensure that when these vaccines went out, all the needles, syringes and PPE accompanied them. If the vaccine required a booster, it would be put into kits sent out with the vaccines. If we were sending out 100 doses of vaccine, we’d send out 110 needles in syringes because we didn’t want someone dropping a needle or syringe to preclude that vaccine from being used, and these had short shelf life, so they had to be used. McKesson reorganized its warehouses and kitted hundreds of millions of needles and syringes, and got them to distribution hubs in

Kentucky with UPS and FedEx. They went out to the 70,000 vaccine administration sites we had in our IT system, and they did it flawlessly. Adams: Kudos to McKesson. What were some lessons learned through this? Mango: This is an uplifting story about America. Amid all this divisiveness, intolerance and political divisions, hopefully Americans are proud of how exceptional America is. It’s the only country in the world that offered vaccines to each of its citizens by April 2021. It’s an extraordinary level of innovation, industrial dexterity and nimbleness, and the talent and capability that we have. A lot of people disparage large corporations. But in times of need, there’s no better place to be than within American industry. Without the development that had taken place decades before mRNA technology, warehouse management, distribution management, information technology, and tens of thousands of clinics, we never would’ve gotten through this. Let’s not disparage our large corporations for being profitable because they developed unprecedented capabilities.

Editor’s note: To listen to the complete conversation, visit http://repertoiremag.com/paul-mango-podcast.html. www.repertoiremag.com

May 2022

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The Baby Boomer generation (1946-1964) was the first to be affected by HCV following its emergence in the 1940s, and initial discovery in the 1970s. The Boomer generation was also the first to be stigmatized by the virus. Not unlike the HIV epidemic, HCV has often been culturally associated with “risky behavior.” Many of the Boomers diagnosed with HCV were unfairly maligned at the time by societal impulses to blame their diagnosis on their own behaviors. This stereotype ensured that HCV would proliferate hidden by stigma, remaining undetected and untreated for many. Spread of HCV in the Boomer generation can also be attributed to other factors such as unsafe medical practices related to blood screening during organ transplant or blood transfusion procedures prior to 1992.1 The enduring stigma of HCV has had disastrous effects on all generations. In fact, current growth in HCV prevalence is primarily experienced in younger generations, despite advancements in screening and treatment which can result in cure. Most recent data from 2018 indicates that Millennials (most adults in their 20s and 30s) make up 36.5% of newly reported chronic hepatitis C infections,

the highest rate of prevalence ahead of Baby Boomers with 36.3% and Generation X (adults in their late 30s to early 50s) with 23.1%. More than half of the 2.4 million americans living with HCV don’t know they have the virus.2 In response to this growing epidemic, the CDC updated its HCV screening guidelines in April 2020, recommending one-time HCV testing of all adults (18 years and older) and all pregnant women during every pregnancy. The CDC also recommends people with risk factors, including people who inject drugs, be tested regularly. In addition, The

United States Preventive Services Task Force (USPSTF) recommends that clinicians consider HCV screening high-risk patients younger than 18 and older than 79, as well as younger pregnant patients.3 Detection is the first step to prevention, and the best way to stop the spread of HCV is early diagnosis. Our OraQuick® HCV Rapid Antibody Test is the only CLIA-waived point-of-care HCV test on the market today. It detects HCV antibodies in fingerstick and venipuncture whole blood in individuals 15 years and older with three easy steps (collect, insert, read*), and provides results in 20 minutes. A crucial tool in the fight against HCV, the OraQuick® HCV Rapid Antibody Test helps health care providers reach more people where they are, anytime, anywhere. If we are to see an end to this HCV epidemic, it is important that all generations routinely be screened for HCV. Undetected HCV can become chronic, and if left untreated can lead to serious health impacts such as cirrhosis of the liver and liver cancer. It’s time to end the HCV epidemic and ensure that future generations know a world without HCV. For more information about the OraQuick HCV Test and how it can help healthcare providers fight the HCV epidemic, please contact us at endtheepidemics@orasure.com.

https://www.health.harvard.edu/blog/baby-boomers-and-hepatitis-c-whats-the-connection-2019050116532 https://www.cdc.gov/nchhstp/newsroom/2020/hepatitis-c-impacting-multiple-generations-press-release.html 3 https://www.cdc.gov/hepatitis/hcv/guidelinesc.htm *For complete testing instructions, please refer to package insert. 1 2

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TRENDS ʯ

CVS: MinuteClinic® clinics are in 1,100 CVS Pharmacy and Target stores. In 2021 CVS announced it would convert as many as one thousand existing stores into HealthHUBs, offering treatment for common illnesses, chronic care management, telehealth, pharmaceutical consultation and medical products.

ʯ

Dollar General: Established a partnership in 2020 with London-based Babylon, a telehealth provider which, in March 2021 acquired Fresno, California-based FirstChoice Medical Group, with 180 primary care and 1,000 specialty providers. In July 2021 Dollar General hired its first chief medical officer, Albert Wu, M.D.

ʯ

Walgreens: In October 2021 agreed to invest $5.3 billion in VillageMD to accelerate the opening of at least 600 Village Medical primary care locations – staffed by primary care physicians and pharmacists – in more than 30 U.S. markets by 2025. (VillageMD remains independent, but Walgreens has a 63% ownership stake.)

ʯ

Walmart: As of September 2021, provides healthcare services (including primary care, x-rays, labs, wellness classes) in 20 health centers, called Walmart Care Clinics, in Arkansas, Georgia and Illinois. Walmart Health is building seven primary care clinics in Northeast Florida.

Clinic vs. Clinic Retailers won’t give up their quest for primary-care market share. Neither will independent physician practices. Not long ago, big health systems appeared to be the biggest challenge for

independent physician practices. And truth be told, they probably still are. A December 2021 study published in Health Affairs showed that from 2014 to 2018, hospital and health system ownership of physician practices increased by 89%, from 24% to 46%. But increasingly, health systems are competing for the physician market with health insurers, drugstore chains and other retailers.

They’re not new to the game. They’ve tried many approaches before. But they’re persistent. Here’s a rundown on what’s happening among some of the big retail players.

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Amazon Care: Works with Care Medical, an independent practice based in Seattle, to deliver healthcare to Amazon Care members, and plans to expand the program across the United States. The company provides telehealth as well as “mobile care RNs” (the latter in a handful of locations). Best Buy: Acquired Current Health for $400 million in

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November 2021. According to Best Buy, Current Health “integrates patientreported data with data from biosensors – including their own continuous monitoring wearable device – to provide healthcare organizations with actionable, real-time insights into the patient’s condition.” Meanwhile, Best Buy’s Geek Squad installs personal emergency response systems, medication management devices, remote patient monitoring, and “Senior Living Safety Systems” in the home.


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TRENDS Along with these retailers add UnitedHealth’s Optum unit, which Bloomberg says has more than 60,000 employed or “aligned” physicians, about half in primary care; and Humana, which is reported to be bringing its primary-care footprint to about 250 locations in 2022.

Austin Regional Clinic All that said, independent practices, such as Austin Regional Clinic, based in Austin, Texas, remain strong. “Our advantage is being local,” says CEO Anas Daghestani, M.D. “Healthcare is still local, and there are pieces you can solve by providing a digital experience or applying [artificial intelligence]. But at the end of the day, patients seek the relationship, local access and market knowledge.” Austin Regional Clinic is a 42-year-old multispecialty group with 380 physicians, nurse practitioners and physician assistants. The Clinic cares for 580,000 patients in 33 locations in the Austin and Central Texas area. It represents 19 specialties, but 65% of its physicians and advanced practice providers focus on primary care. It’s true that independent practices lack the scale and access to the infrastructure or financial solutions that national companies enjoy, says Dr. Daghestani. “But we respond by investing in the future and looking for strategic partnerships, whether with large organizations or with local and regional ones.” Another advantage that independent practices have over many retailer-based clinics is their ability and desire to solve for total care, not pieces of it, he says. “People need a quarterback to guide their care, and we can be that quarterback.” Chief Medical Officer Manish Naik, M.D., says, “One of the biggest challenges companies such as 40

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Amazon, Walmart and the others face is that they’re addressing one piece of the puzzle, such as an urgent care issue or something from a menu of common minor ambulatory conditions.” That approach exacerbates the fragmentation of healthcare, he says. “You may address the sore throat, but you haven’t addressed things like blood pressure or blood sugar. You’re not caring for the whole patient. An organization like Austin Regional Clinic supports patients in managing all aspects of care, and if we do a good job of that, the total cost of care is less.”

doctors aren’t the only ones who are mastering these skills at Austin Regional Clinic. “Some of our most senior doctors have contributed significantly to the progress we’ve made with cutting-edge digital solutions.”

‘Unfair advantages’ Retailers and insurers are trying to solve for the same issues that all physician practices are, including access, patient satisfaction, and recruitment and retention of patients, says Dr. Daghestani. And they have significant and impressive tools to address those issues. But the challenge they

‘ People need a quarterback to guide their care, and we can be that quarterback.’ Conventional wisdom has it that young people prefer the perceived simplicity and speed of dealing with a retail clinic rather than a family physician or practice. “It may be harder to attract [young people], but it’s doable,” says Dr. Naik. “You have to provide a digital front door, whether it’s a patient portal, telemedicine or digital access, like online scheduling and text reminders, and we’ve had success doing that. “Still, there’s a limit to what you can accomplish digitally. AI or a patient portal are tools like any other tools. But how do you connect that digital care with in-person care?” After all, AI is only as good as the input fed into it, and that should be based on feedback from clinicians taking care of patients in their offices, he says. Young doctors coming into practice today were brought up in the digital world and find it easy to adjust to electronic medical records and patient portals, says Dr. Naik. But young

face is that they are fragmented from the larger healthcare ecosystem. If retailers are to maintain a presence in the healthcare market, they would be well-advised to partner with local practices, such as Austin Regional Clinic, he says. Insofar as competition from bigger players goes, Dr. Daghestani sees “unfair advantages” every which way. “Yes, national companies have access to capital and technology, and they have a new way of looking at things, because healthcare is new to them. But our unfair advantage at Austin Regional Clinic is this: We think of ourselves as organized medicine. We are local, we have relationships with patients and employers, and for us, healthcare is a career, not a project. “If we can figure out how to channel our respective ‘unfair advantages’ so that independent practices and national companies can both be successful, that’s where the magic can happen. And if we can’t figure that out, we risk further fragmentation.”


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TRENDS

The Job of a Lifetime Cancer survivors are growing in numbers, and increasingly, primary care physicians are accompanying them on their lifelong cancer journey.

As of January 2019, there were 16.9 million cancer survivors in the United States. That’s 5% of the population.

The number was projected to increase to 22.2 million, by 2030, and to 26.1 million by 2040. The number of people expected to live five or more years after their cancer diagnosis was projected to increase 33%, to 15.1 million. In 2019, 64% of survivors were age 65 or older, and it was estimated that by 2040, 73% of cancer survivors in the United States would be age 65 or older. 42

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TRENDS Five-year and 10-year survival rates for those with childhood cancer now exceed 80%. In 2020, there were an estimated 500,000 survivors of childhood cancer in the United States. It’s all good news. But being a survivor doesn’t mean patients or their healthcare providers can leave cancer behind. Patients with a history of cancer live with the threat of recurrence and late effects of treatment. Both they and their primary care doctors need to keep an eye out for treatment-related effects and cancer-related medical issues and comorbidities, even years after the cancer occurrence.

tor, Cancer Survivorship Section and co-leader, Cancer Control & Survivorship Program, St. Jude Children’s Research Hospital, Memphis, Tennessee. “Cancer treatment also plays a large role, and toxicities are related to specific modality, dose, and therapy combinations.” Dr. Hudson is part of The Children’s Oncology Group (COG), a National Cancer Institute-supported clinical trials group, and she is co-author of “Long-term Followup-Care for Childhood, Adolescent, and Young Adult Cancer Survivors,” a September 2021 clinical report from the American Academy of Pediatrics. The report

‘ Every healthcare professional – primary care physicians, orthopedists, dermatologists and others – will have cancer survivors in their panel.’ There are approximately 18 million cancer survivors in the United States, says Lidia Schapira, M.D., FASCO, professor of medicine at Stanford University School of Medicine, and director of Cancer Survivorship at the Stanford Comprehensive Cancer Center and Cancer Institute, Stanford, California. “When you look at it like that, you can see that every healthcare professional – primary care physicians, orthopedists, dermatologists and others – will have cancer survivors in their panel.”

Risk People with a history of cancer can experience impairment in function due to organ loss (i.e., surgical removal) or infiltration with cancer, says Melissa Hudson, M.D., direc44

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is based on care guidelines developed by the COG. “Health behaviors and genetics play an important role, and understanding mechanisms that make a survivor more or less vulnerable represent a focus of ongoing research,” she adds. “Comorbid health conditions can increase vulnerability, and social determinants of health – which can determine a survivor’s access to care – can impact outcomes.”

Burden of late effects In general, cancers that typically require intensive multimodality therapy (e.g., radiation and chemotherapy) carry a higher burden of late effects, says Dr. Hudson. Examples include brain tumor survivors, high risk/advanced stage solid malignancies (e.g., sarcomas),

Hodgkin’s lymphoma, and solid and hematological malignancies treated with hematopoietic cell transplantation. “The prevalence of health conditions increases with aging and with increasing time from cancer diagnosis and treatment. Multimorbidity is common.” In many ways, primary care physicians approach their patients who have had cancer similarly to those who have not, says George Abraham, M.D., MPH,, MACP, FIDSA, president of the American College of Physicians and chief of medicine at Saint Vincent Hospital, Worcester, Massachusetts. “We watch lipid counts, diabetes risk and risk of infection, much as we do with any of our patients,” says Dr. Abraham, who is professor of medicine at University of Massachusetts T.H. Chan School of Medicine. But there are differences. For example, people with premenopausal breast cancer may be at risk for early heart failure depending on the type of chemotherapy used, and those with a history of breast cancer are strongly encouraged to get annual mammograms. Peripheral neuropathy – numbness of the feet – can be a sign of chemotherapyinduced nerve injury. Similarly, liver dysfunction could be related to radiation-induced lung toxicity. Promoting overall wellness – e.g., healthy eating, plenty of exercise – is particularly important for patients with a history of cancer, as it can reduce the risk of recurring cancer and secondary infections, says Dr. Abraham. “We are especially mindful of making sure cancer patients give up potential risk factors. Someone who had lung cancer is encouraged not to smoke; someone who had liver cancer shouldn’t drink.”


Comorbidity Adult cancer survivors are especially susceptible to comorbid illnesses, according to the American Cancer Society. People who are treated for cancer, even those treated in childhood, tend to have a higher prevalence of chronic illness later in life. Age-related health conditions appear earlier and with greater severity than might otherwise be expected. Using 2002-2018 National Health Interview Survey data, among 30,728 cancer survivors, increasing trends were observed in the prevalence of hypertension, diabetes, kidney disease, liver disease and morbid obesity. Cancer survivors with multiple chronic conditions increased from 4.7 million in 2002 to 8.1 million in 2018. The increase was more pronounced among survivors aged 18 to 44 years. Among adults without a cancer history, the prevalence of multiple chronic conditions also increased, but more slowly than among survivors.

The long-term plan Primary care providers – pediatricians, family practitioners, internists, practitioners trained in internal medicine and pediatrics, and advanced practice providers – are likely to have an increasingly vital role in caring for this rapidly growing population, according to The Childhood Cancer Survivor Study, the largest and most extensively characterized cohort of five-year survivors of childhood cancer in North America. But there are hurdles to jump. “We consistently hear about longterm consequences of treatment that aren’t well managed by the care team,” says Shelley Fuld Nasso, CEO of the National Coalition for Cancer Survivorship, which conducts an annual cancer survivorship survey.

While receiving treatment, the cancer patient is closely monitored by a team of oncologists, she says. But when treatment ends, patients may feel they’ve been left on their own to deal with the fatigue, depression and anxiety, which are common. That’s not to mention longer-term effects, such as cardiotoxicity or heart damage due to chemotherapy, or monitoring for recurrent or additional primary cancers.

and primary care, with potentially harmful results for the patient. “I’ll confirm the disconnect, and I’ll confirm it’s not good for the patient,” says Dr. Schapira. Survivorship care plans have been recommended for almost 20 years, but implementation by medical professionals remains uneven, she says. “The problem is, the early versions of care plans were long, laborious, and not helpful to primary

Patients who have been treated for cancer need more than a piece of paper or PDF to guide themselves and their physicians through long-term care plans. Cancer survivors often need special help during the first year after treatment, she continues. “You may be seeing your care team daily, then you’re told, ‘Your treatment is done; come see us in three months.’ But their lives don’t necessarily go back to the way they were before their diagnosis. Survivors are dealing with collateral damage, and they lack regular support and communication. It’s emotionally challenging.” Survivorship care plans – which spell out diagnosis, therapy, potential late effects and long-term surveillance guidelines – can help the patient and primary care doctor navigate survivorship. “Part of what we do is empower survivors to be advocates,” she says. “But not everyone can or will be able to advocate for themselves. And they shouldn’t have to. Having a cancer diagnosis is hard enough.”

The disconnect Advocates for cancer survivors speak of a disconnect between oncology

care doctors.” Furthermore, they were paper-based and difficult for care providers to access and share with colleagues. But today, clinical specialists and generalists have access to easy-to-complete forms, such as those available online from the American Society of Clinical Oncology and other groups. Dr. Abraham says that because large healthcare systems and multispecialty practices share common electronic platforms, secure messaging among providers is more doable today. “There’s less of a disconnect than what we saw with paper-based systems, which relied on dictated notes and passing paper.” Technology is not the only barrier to effective communication between oncology and primary care, according to experts. Putting together individualized treatment summaries and care plans isn’t easy, says Fuld Nasso. It calls for cooperation among medical oncologists, surgical oncologists, radiological oncologists and others. Nor is there www.repertoiremag.com

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TRENDS adequate reimbursement for their time spent doing so. “As one expert said, ‘If it were easy, it would be done all the time,’” she says. What’s more, studies show that patients who have been treated for cancer need more than a piece of paper or PDF to guide themselves and their physicians through longterm care plans. “It’s about communication and discussion,” she says. “It’s helping people use the care plan, share it with physicians, see that it is updated over time, and make sure it remains tailored to the individual.” “Care planning is a process where individuals involved in the care of the patient anticipate their healthcare needs and surveillance, and make plans to coordinate ongoing care, share responsibilities about education and risk mitigation, and help the survivor gain access to the care they need,” says Dr. Hudson. “Hospitalized patients routinely get a discharge summary upon discharge, but cancer patients don’t necessarily get a survivor care plan. “It just makes good sense that they do.”

before. They want a concise plan with all their treatment information. “At St. Jude, we strive to educate our patients and families about why the care plan is so important. Some people embrace it; others don’t so much. Some of it is cultural, some relates to health literacy. But we need them to understand how their cancer history during childhood can affect long-term health.” Similarly, primary care physicians need to appreciate that they are caring for a cancer survivor who may have unique health risks.

Ownership Dr. Schapira’s research has focused on improving communication between

The prevalence of health conditions increases with aging and with increasing time from cancer diagnosis and treatment. Furthermore, the mere existence of a care plan doesn’t mean the survivor or their provider knows what to do with it, she continues. People who were treated for cancer in their youth might have forgotten they even received such a plan. “Years after their treatment, they may develop breast cancer or a heart problem,” she says. “They can request their records, but they don’t need information on what their blood counts were 20 years 46

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patients and physicians. The Stanford team has opened a faculty-embedded primary care practice specifically for cancer survivors and offers a free online CME course on the care of patients with a history of cancer. “It’s a great resource for primary care doctors and nurses,” she says. Last fall, CRC Press published “Essentials of Cancer Survivorship: Guide for Medical Professionals,” edited by Dr. Schapira, for cancer

clinicians as well as generalists and specialists who meet cancer survivors in their practices. “A 25-year-old software engineer, who was treated for leukemia when she was four, moves to Silicon Valley and looks for a primary care doctor. But she is not a typical healthy 25-year-old, and we need her primary care doctor to assess her health risks to make sure she gets good advice and care. A 75-year-old man treated with radiation for early-stage prostate cancer when he was 65 may develop a urethral stricture at age 75 and come to his primary care doctor with symptoms of urinary frequency. A woman treated with radiation to the chest as a college student is at risk for developing breast cancer, and we recommend screening with mammograms and MRIs, if possible, eight to 10 years after treatment. And the cardiac health of someone whose treatment included exposure to cardiotoxic drugs may be affected.” Cancer survivors need to understand their risks and what they need to do to stay healthy. “If they were treated as a child, they may need to learn enough about the disease and treatment to ‘own’ their history,” says Dr. Schapira. Similarly, primary care doctors need to understand the protocol those patients underwent years before and how the exposures to cancer treatments can affect the health of the patients in their office. “It’s about co-managing,” she says. “How can we include the patient in their continuing health in a way that is empowering but not overly burdensome?” Several organizations and associations, including the National Coalition for Cancer Survivorship, have developed care guidelines for patients and primary care physicians. “The whole idea is to become more proactive with these tools.”


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TRENDS

No Surprises Act is Flawed: Doctors They support the concept but not the proposed resolution process for payment disputes. The No Surprises Act of 2020 has gotten off to a rocky start since it went into effect on January 1. Few people op-

pose the concept, that is, protecting patients from receiving bigger-than-anticipated bills from their provider following a procedure, or totally unanticipated bills from out-of-network providers (e.g., emergency room physicians, orthopedists, radiologists) who participated in their care.

Rather, the primary point of contention has been the process by which payment disputes between out-ofnetwork providers and commercial payers will be resolved regarding claims filed on behalf of people covered by group and individual health plans. The No Surprises Act protects people covered under group and individual health plans from receiving surprise medical bills when they receive most emergency services, non-emergency services from out-of-network providers 48

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at in-network facilities, and services from out-of-network air ambulance service providers. (People covered by Medicare and Medicaid already have these protections.) It establishes an independent dispute resolution (IDR) process for payment disputes between plans and providers. It also provides dispute resolution opportunities for uninsured and self-pay individuals when they receive a medical bill that is substantially greater than the “good faith estimate” they receive from their provider.


Before the No Surprises Act, people with health insurance who received care from an out-of-network provider or an out-of-network facility, even unknowingly, would often be on the hook for the difference between the billed charge and the amount paid by their health plan. (This practice, called “balance billing,” is banned in some states.) An unexpected balance bill from an out-of-network provider is now considered a surprise medical bill. For people without insurance or who self-pay, the No Surprises Act assures they will get a good faith estimate of how much their care will cost prior to delivery of the service. For services provided in 2022, patients can dispute a medical bill if final charges are at least $400 higher than the good faith estimate, but they must file a dispute claim within 120 days of the date on their bill. Enforcement of the “good faith estimate” requirement will expand over time, according to legal firm Reed Smith. In the current first phase, providers must provide such an estimate inclusive of their own charges. Effective Jan. 1, 2023, however, they will have to include co-provider estimates, such as out-of-network emergency services. In “Phase 3,” whose effective date has yet to be determined, good faith estimates – including provider and co-provider estimates – will be required for all patients regardless of their insurance status.

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Doctors object Under the law, once a patient with insurance initiates a dispute over payment, the matter is paused pending resolution. Generally, the IDR process will follow a “baseball-style” approach, following these steps, according to the American College of Emergency Physicians:

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2. Physician/group can dispute the amount during a 30-day open negotiation period.

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3. If that fails, either party can take the dispute to IDR using an online portal. They select an arbiter from a pre-vetted list of IDR entities. Both parties must pay the IDR fee upfront – $200 to $500 for one claim; $268 to $670 for “batched” claims of

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TRENDS similar services with the same insurer. (The “winner” of the dispute will be refunded its fee.) 4. Each party submits offer for reasonable payment within 10 days. Those offers must include the Qualified Payment Amount (calculated as the median innetwork rate), information on the physician’s training and experience, and a description of the complexity of the procedure or the medical decision-making associated with it. 5. The impartial reviewer evaluates submissions from provider and insurer, then chooses one of the two payment amounts within 30 business days. 6. The “loser” makes the other side whole and pays for the IDR fee within 30 calendar days.

“ Physicians will have little to no leverage to negotiate contracts above whatever an insurer calls the ‘median,’ which itself is subject to manipulation by the insurers.” The regulations as implemented allow arbiters to assume that the correct amount for an insurer to pay the doctor is the median amount usually paid for that service in that geographic area. Doctors’ groups argue that the text of the law precludes such a presumption and that other factors must be given equal weight, including the provider’s training, quality of outcomes, patient acuity or complexity of services provided, and teaching status and case mix of the facility where services were provided. In February 2021, a federal judge in Texas ruled in favor of the Texas Medical Association, deciding that the No Surprises Act implementation did indeed give unequal weight to the Qualified Payment Amount (QPA), tilting the process unreasonably in favor of insurance companies. While a relief to doctors’ groups, several are still jittery.

Physicians’ stance Repertoire received e-mailed comments about the No Surprises Act from the American Association of 50

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Orthopaedic Surgeons (AAOS), American College of Emergency Physicians (ACEP) and American Society of Anesthesiologists (ASA). Douglas W. Lundy, MD, MBA, FAAOS, Advocacy Council Chair, American Association of Orthopaedic Surgeons “AAOS believes that the patient protections afforded by the No Surprises Act are vital to improving access to care. While the manner in which the law was interpreted and subsequently finalized by the Departments is beyond the scope of the legislation that was passed with the support of AAOS, we remain committed to ensuring that our patients have access to the care they need and are held harmless for financial burdens that extend beyond their in-network cost-sharing.” Despite the February ruling in favor of physicians in the Texas Medical Association’s lawsuit, Lundy said that AAOS remains concerned with aspects of the IDR process. For example, the four-business-day time frame for initiating IDR following the end of the open negotiation period may be unreasonable should circumstances beyond the control of the physician to meet the deadline arise, he said. “Likewise, we are concerned that the timeline for the parties to jointly choose an IDR entity may not be sufficient to determine the appropriate IDR entity to oversee a payment determination. Underlying these matters is a concern that there needs to be disclosure of the IDR entity’s record if the Departments detect a pattern of consistently favoring one side or the other. “We encourage the Departments to consider the long-term impacts that the Provider-Patient Dispute Resolution process may have on self-pay and uninsured patients, particularly the underrepresented communities it is, in part, intended to serve. While the monetary threshold to access the provider-patient dispute resolution process was carefully considered during rulemaking, the time patients will have to spend going through the process may prove prohibitive or exclusionary.” Laura Wooster, senior vice president, advocacy and practice affairs, American College of Emergency Physicians “Emergency physicians have consistently advocated in support of solutions to stop surprise bills, promote transparency, and protect patients since earnest discussions about this issue began in Congress four years ago,” she said. “The ruling in Texas is a strong step in the right direction and one of the clearest indications


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TRENDS to date that policy granting unequal weight to the qualified payment amount (QPA) directly contradicts the language in the No Surprises Act. It also reaffirms the congressional intent of the law as noted in a November 2021 letter to the Administration signed by more than 150 members of Congress. “As HHS assesses its legal options and revises its guidance on IDR implementation, ACEP is hopeful that the department changes the policy permanently so that insurers are discouraged from narrowing networks, canceling contracts and pursuing tactics that make it harder for patients to access lifesaving emergency care.” Randall M. Clark, M.D., FASA, president of the American Society of Anesthesiologists “The ASA has long maintained that patients should be held harmless when there are disputes between physicians and insurers,” he said. “We have had the ability to put that into effect in many states for more than

20 years.” However, even with the favorable outcome of the current lawsuits, “the overall process will likely drive down physician payment over time. Insurers will have the ability to eliminate any contracts above the median, creating an immediate effect on at least half of physician contracts. “It won’t matter in the future if physicians are in network or out of network. Health insurers will be able to treat both groups exactly the same. Physicians will have little to no leverage to negotiate contracts above whatever an insurer calls the ‘median,’ which itself is subject to manipulation by the insurers.” The public should recognize that “the federal government is now regulating contracts between private parties in a way that has never been done before. This extends beyond asserting the parameters of how contracts should be managed, which one could argue is very appropriate, and now extends into what one private party pays another. This is unprecedented, in our opinion, and fraught with hazard.”

Hospitals wary of No Surprises Act Doctors aren’t the only ones who are disgruntled with the No Surprises Act. The nation’s hospitals have their own beef, citing the potential burden they face providing “good faith estimates” for services provided people without insurance or who self-pay. In a March 7 letter to Kathleen Cantwell, director, Office of Strategic Operations and Regulatory Affairs, Centers for Medicare & Medicaid Services, AHA Senior Vice President Ashley Thompson wrote, “Many hospitals already delivered pre-care estimates to uninsured and self-pay patients, but the new timeline and format

requirements necessitated workflow and other operational changes, including from even the most sophisticated hospitals. While these efforts have generally allowed hospitals to meet the requirements in place today, our members report that the ongoing burden is significant. The estimates regularly take between 10-15 minutes to produce, and though hospitals are looking at ways to introduce additional automation, it will be difficult to fully automate given the individualized nature of the estimates.” AHA expressed further concern about yet-to-be-implemented rules for good faith estimates set to

‘ There is currently no method for unaffiliated providers or facilities to share good faith estimates with a convening provider or facility in an automated manner.’

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become effective on Jan. 1, 2023. At that time, providers will be expected to include projected charges from unaffiliated providers or facilities. “There is currently no method for unaffiliated providers or facilities to share good faith estimates with a convening provider or facility in an automated manner,” wrote Thompson. “In order to share this information, billing systems would need to be able to request and transmit billing rates, discounts and other necessary information for the good faith estimates between providers/ facilities. This is not something that practice management systems can generally do, since billing information is traditionally sent to health insurers and clearinghouses, not other providers/facilities. “We urge HHS to refrain from enforcing the comprehensive good faith estimate requirement until a technical solution for exchanging this information is developed and implemented across all providers.”


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HEALTH NEWS

Health news and notes Survey: Pandemic creating far-reaching and negative impacts on those with chronic back or leg pain A new survey commissioned by Medtronic and conducted by public opinion research firm The Harris Poll, finds nearly half (44%) of current chronic back and leg pain sufferers have experienced care delays during the COVID-19 pandemic, despite 87% reporting that their pain has not improved or even worsened since the pandemic began in March 2020. The national survey, “Painful Pandemic: How a Healthcare System Under Strain Impacts Chronic Pain Patients,” of 810 U.S. adults who currently experience chronic back or leg pain finds far-reaching impacts of this debilitating condition on patient lifestyle, everyday activities, and mental state, further exacerbated by the pandemic’s impact on stressed health systems and the ability of patients to seek timely care.

Of those who report worsening chronic pain during the pandemic, more than half (52%) cite challenges in receiving appropriate medical care as a contributing factor. Additionally, 44% say since the pandemic began, they have experienced care delays, including postponed, rescheduled, or canceled appointments or procedures for their pain. Of those who proactively postponed their medical care, more than half (55%) cited COVID-19 fears as a contributing factor. Most people currently living with chronic back or leg pain report numerous detrimental physical and mental impacts. When listing physical challenges associated with chronic pain, sleep, exercise habits, sense of mobility/function, and ability to enjoy hobbies are aspects of life most negatively impacted. Chronic back or leg pain sufferers under age 55 are more likely than those 55+ to report that their ability to work has been impacted (36% vs. 22%, respectively), while those over age 55 are more likely than those age 35-54 to say their sense of mobility/ function has been impacted (58% vs. 46%, respectively).

UPMC study suggests malaria drug could combat chemo-resistant head and neck cancers A new study suggests that the malaria drug hydroxychloroquine inhibits pathways that drive resistance to the chemotherapy agent cisplatin in head and neck cancers and restores tumor-killing effects of cisplatin in animal models. The findings, published in Proceedings of the National Academy of Sciences by University of Pittsburgh and UPMC scientists, pave the way for a clinical trial that combines cisplatin and hydroxychloroquine to treat chemotherapyresistant head and neck cancers. “When caring for patients with head and neck cancers, I often see chemotherapy fail. Cisplatin is a very important chemotherapy drug, but tumor resistance to cisplatin is a huge problem,” said co-senior author Umamaheswar Duvvuri, M.D., Ph.D., head and neck surgeon at UPMC Hillman Cancer Center and professor of otolaryngology in Pitt’s School of Medicine. “My lab is interested in understanding the mechanisms of resistance so that we can find better ways to treat these patients.” Previous research showed that a protein called TMEM16A is linked with cisplatin resistance in patient tumors. Overexpression of this protein, which occurs in about 30% of head and neck cancers, is also associated with decreased survival. 54

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MARKETING MINUTE

Content Marketing Insights for Healthcare Brands Staying ahead of today’s trends will help you address

your audience’s challenges as they occur. Your content is one of the most powerful tools for accomplishing this. Thankfully you don’t have to guess what those trends will be because experts have already shared some of the most valuable content marketing insights for healthcare manufacturers and other B2B companies. Today we will look at the most relevant insights from experts for healthcare content marketing in 2022.

Why is content marketing important for healthcare? About 50% of B2B marketing content is focused on creating brand awareness and interest. That means your content shouldn’t be a lengthy sales pitch. Instead, it should be empathetic and authentically connect with healthcare workers. However, healthcare is changing very quickly, affecting how facilities connect to distributors and manufacturers. As their needs change, your content should also shift to continue to meet their new needs. You can use content marketing insights to: ʯ Understand your audience and their needs ʯ Connect to healthcare facilities using the most effective channels ʯ Remain relevant in 2022 through innovative strategies ʯ Make more accurate budget forecasts for resource allocation

Top content marketing insights for healthcare suppliers and manufacturers The Content Marketing Institute (CMI) provides annual reports and predictions about content marketing by consulting the leaders in the industry. Here are some of the most significant insights healthcare manufacturers can use to improve their healthcare content marketing strategy in 2022 based on the advice of over 100 content marketing experts. 1. Connect to Your Audience Make 2022 the year you ditch your transactional mentality. Instead, exchange it for a relationship-building focus. One

report showed 87% of B2B marketers today prioritize their audience’s needs over their sales message. Your content is a way to connect in unique ways with your audience to include them in your marketing process. For example, consider using a live stream to let your customers ask questions about your company or products. 2. Use Data to Build your Content Data should be the building blocks of your healthcare marketing guidelines. The internet is filled with valuable data on your customers and their typical behavior, such as common searches, pain points, needs, and more. Your content team should use that data to create content based on actual numbers instead of guessing what healthcare facilities want. 3. Stay on Top of Trends B2B marketing doesn’t have to be stiff and formal – you and your audience are both humans. That’s why you shouldn’t be afraid to use current trends to help promote your business and products. Consider sharing memes, using filters, and embracing social media campaigns to mix fun trends with your professional content. 4. Keep Your Content Empathetic Today healthcare workers face more challenges than in the past and require a higher level of empathy. Your content can be a safe space for them by showing you recognize their struggles and feel for their situation instead of only focusing on your brand and agenda.

Create an effective content marketing strategy Are you ready to create quality and valuable content for your healthcare supply business? You shouldn’t settle with content that blends in with your competitors. Instead, take your content marketing strategy into the new age of technology and authentic customer interactions using the latest healthcare marketing insights. To view the complete article with more strategies, visit https://sharemovingmedia.com/category/blog www.repertoiremag.com

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REP CORNER

A Custom Connection As dedicated sales reps, Cardinal Health’s Jeff Ledbetter and Taylor Graffeo share a common goal to connect with their customers and provide the best possible solutions. When your solution impacts the medical care of thousands of patients, Jeff Ledbetter is adamant: “You need to

get it right.” Fifteen years of sales experience and the support of some great mentors have certainly set him on the right track. In spite of how the industry has changed since he got his start in 2007, he remains confident that being a successful salesperson still requires connecting with the customer. That means asking probing questions to better understand their business and personal objectives, he adds.

“Selling is in my genes,” says Ledbetter. “My father was an entrepreneur and sold real estate for many years.” Later, when he began his first sales position in the healthcare industry, he was fortunate to work for a terrific manager, he points out. So, when she left that company and joined HLS MedFreight, he jumped on the opportunity to

join her a few months later. HLS MedFreight was acquired by Cardinal Health in 2010 and became part of Cardinal’s OptiFreight® Logistics business unit. While the transition from a small-company environment to that of a Fortune 20 company took some adjustment, he recalls immediately feeling at ease given the welcoming Cardinal Health work

culture that embraced a healthy work-life balance. “I’ve never even thought about leaving Cardinal Health,” he says.

The day-to-day Each customer has a unique set of circumstances and processes, and the challenge is to develop the optimal delivery solution, notes Ledbetter.

Jeff Ledbetter

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“OptiFreight® Logistics focuses on getting customers’ packages to the destination as efficiently as possible. Some providers need their packages within hours, while others can wait several days for it to arrive. This variance means bringing an open mind and a blank slate to the initial conversation. What the customer is doing today may be far different from their optimal solution. My role as their trusted advisor is to guide them to the best solution. Doing so is my greatest personal reward. “Cardinal Health is very good at educating its employees and ensuring that each of us understands the impact of what we do, every day,” he continues. “OptiFreight® Logistics is a trusted and premier total healthcare logistics solution built on three pillars: Tailored Solutions, Committed Experts and Innovation and Insights. Regardless of the size or complexity of the provider, we can create a customized solution that solves their shipping issues. Being part of Cardinal Health enables me to provide a one-stop partnership for all of my healthcare provider customers.” In turn, Ledbetter and his OptiFreight® Logistics colleagues depend heavily on local couriers, regional and national parcel carriers and ocean barge companies for the timely delivery of products. “We need them to perform flawlessly in order for us to excel for our customers,” he explains. However, the growth of eCommerce businesses over the last five years, as well as pandemic-related shipping challenges, has placed an extreme strain on the overall supply chain, including shipping and mail services. “Our challenge is to create a solution for our customers that works in today’s market, and is flexible enough to be adjusted as future market conditions

Taylor Graffeo

dictate. We can’t simply be a set-andforget solution when it comes to our customers or our partners.”

Smarter and smarter Over the past 15 years, Ledbetter has watched customers – from hospitals to health systems, pharmacies, ambulatory surgery centers, clinical laboratories and physician offices – become increasingly adept at navigating the healthcare marketplace independently of their sales rep’s guidance. “Today, customers have the online tools to do more marketplace research ahead of engaging their sales rep,” he says. “They are smarter and know more about what they want, earlier in the typical sales cycle. Sales reps must

bring value and demonstrate their expertise early on in order to stay engaged with potential customers. This environment makes it that much tougher to earn customers’ trust, and then remain a trusted advisor to them. “Throughout my time in sales, it has always been about making a personal connection to support the trust my customers have placed in me and to deliver a solution that meets or exceeds their expectations,” he continues. “Ten years ago, I made that connection through phone conversations and personal visits.” Today, in addition to traditional means of connecting, he must reach out through social media. “Sales reps are expected to communicate with their customers via online www.repertoiremag.com

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REP CORNER platforms, such as LinkedIn, and through messages and videos.” While his approach to sales has evolved, however, the pleasure Ledbetter receives from providing his customers with the best possible solutions has remained constant through the years. “I follow two guiding principles,” he says. “Be authentic and have fun.” Indeed, this attitude has enabled him to exceed his sales quota year after year, as well as become a Cardinal Health Champions Club member. “I am a humble person whose goal is to solve the needs of my customers and always provide maximum value to them. I strive to ensure that authenticity shows through every solution we create.” This isn’t something you can fake, he adds. “My friends and family would say that same authenticity carries over to my personal relationships outside of work.” Enjoyment and fun are essential in life, he points out. “And it’s possible to find them, even when you are dealing with the delivery of lifesavings medical products.”

A big difference Taylor Graffeo is a newcomer to healthcare sales, with 2 ½ years in the business. “I joined the healthcare industry in 2019, when I started as an inside sales rep for Cardinal Health OptiFreight® Logistics,” he says. Prior to this role, he gained experience in energy supply sales and 3PL sales as a freight broker. And while he technically sells a service, rather than a product, as with his medical product sales counterparts, the challenges keep him on his toes and make his work all the more interesting. “The day-to-day challenges are what keep my role exciting,” says Graffeo. Working across different markets means he must consider a 58

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variety of nuances. “If you work in the healthcare industry, you likely are motivated to provide a better quality of life for patients. This looks different with each role. With OptiFreight® Logistics, we provide more visibility, control and analytics to the logistics side of healthcare, which ultimately leads to products and supplies getting to the right place faster at a lower cost. I think that makes a big difference.

he is in a key position to provide his customers with Cardinal Health’s versatile tools and team of committed experts.

More important than ever Staying connected with customers is more important than ever before, notes Graffeo. “With new businesses starting every day, it is imperative to be part of the reason my customers want to stay with OptiFreight®

Today’s customers are smarter and know more about what they want, earlier in the typical sales cycle. “What makes OptiFreight® Logistics unique is our comprehensive, custom approach to each customer,” he continues. “While other companies may ship similarly, we look at every aspect of our customers’ logistics operations, taking a consultative approach to process improvement and cost savings, while focusing ultimately on the patient.” That said, Graffeo will be the first to admit there will always exist the possibility of error. “My previous role as a freight broker has prepared me for my current role by helping me understand it’s possible for anything and everything to go wrong in the world of shipping.” His experience communicating directly with carriers, working through their issues and understanding their frustrations, however, helps him be more proactive. “Because I understand what happens at an operational level, I can ask the right questions early in the sales cycle.” Additionally, as an energy supply consultant who sold a savings and value opportunity, rather than a tangible product, he believes

Logistics,” he says. “The strategy for connecting with customers has changed over the years as technology has advanced.” Whereas he once might have flown across the country for a business meeting, today it’s standard to set up a video call. “That means less time away from my family. Video calls are much quicker, less expensive and arguably more effective than in-person meetings. In the course of a day, I can exchange a smile in meetings all over the world and still be home with my family for dinner.” He is also a fan of online tools such as LinkedIn for connecting with his customers. “LinkedIn is a powerful and useful tool that has paid relational dividends to me over the years. “In my short career, I have discovered that relationships are one of the most important things in this world,” says Graffeo. “As a result, I’ve slowed down and taken time to connect with others as a colleague, friend and husband. I believe there is something to learn from everyone if we just connect.”


HIDA

Transportation Delays and Inflation Woes Persist in Medical Supply Chain Since December 2021, the Health Industry Distributors Association (HIDA) has monitored

delays in the healthcare supply chain. We’ve canvassed our member companies to get their first-hand experience in how their goods are moving by sea, by rail, and by truck. Unfortunately, transportation delays persist, and they have been compounded by increases in shipping and raw material costs. By Linda Rouse O’Neill, Vice President, Supply Chain Policy and Executive Branch Relations, Health Industry Distributors Association

The latest research from HIDA has found persistent delays in the healthcare supply chain. ʯ Despite a modest drop in delay times since December 2021 (from 37 to 27 days), transportation times are still 440% longer than they were before the pandemic. ʯ The volume of medical supply containers awaiting delivery has increased 13% in the last three months. Approximately 9,000 to 14,000 containers remain delayed. ʯ As West Coast ports remain congested, the volume of medical supply containers at East Coast ports has skyrocketed. The ports of New York (+124%) and Charleston (+84%) seeing the greatest increase in container volume of medical supplies. ʯ When surveyed about the trend in transportation delays, 61% of medical distributors have seen no appreciable improvement, while 21% say delays have worsened.

Transportation issues in healthcare products distribution aren’t just a matter of days and delays. It is also a matter of dollars and cents as transportation costs are rising quickly worldwide. ʯ Shipping Costs: Container freight rates between Asia and the U.S. West Coast exceeded $15,000 in January 2022, more than a 250% increase. ʯ Trucking Costs: A lack of available drivers, trucks, and trailers is increasing costs for shippers and making it more difficult for carriers to haul more freight. ʯ Parcel Freight: Higher annual rate increases and expanded surcharges will make 2022 an even more expensive year for unprepared parcel shippers. Furthermore, volatility in commodity markets is a key factor putting pressure on the cost of producing medical supplies. While transportation

costs impact the cost of distribution, commodity price spikes impact the cost of manufacturing medical supplies. ʯ Aluminum shortages have raised prices to their highest point in over a decade. A lack of crutches, walkers, and wheelchairs have forced providers to ask for donations. ʯ Nickel is key to the manufacture of medical instruments. Russia is the world’s third-largest producer of nickel. Market volatility following the Russian invasion of Ukraine has caused nickel prices to spike. At one point, nickel prices doubled in a matter of hours to over $100,000 per ton. ʯ Chromium is a component of stainless steel surgical probes. War in Ukraine has disrupted shipping routes from key suppliers of chromium in Central Asia. In the first three weeks of March, prices for ferrochrome ore increased more than 40%. ʯ Silicon chip shortages have been exacerbated by rising demand for medical devices used to treat COVID-19 in emergency rooms and intensive care units. These issues aren’t going away. The healthcare supply chain should remain top of mind for policymakers. At HIDA, we are advocating for solutions like a “fast pass” that would prioritize the handling of medical supplies at our nation’s ports. Shipments of critical medical products cannot wait for supply chain congestion to resolve itself. As long as these supply chain disruptions persist, HIDA will continue to stress the importance of getting life-saving medical supplies into the hands of front-line healthcare providers. www.repertoiremag.com

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TRENDS

Breaking the Rules of Healthcare: Restoring the Value of Primary Care If status in medicine were determined by saving lives, primary care physicians would quickly re-ascend the hierarchy. By Dr. Robert Pearl

In most professions, the pecking

order is clear, even when there’s no formal designation. Take pro football. Although nothing in the rulebook grants status or authority to certain players, everyone knows the starting quarterback is the most valuable person on the field. That’s because no other player can do more to win (or lose) a game.

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You might assume the same type of logic applies to medicine. If saving a life is the most valuable thing a doctor can do, then surely the physicians who save the most lives would garner the most esteem. That’s not the case. Instead, the relative rank of specialties is decided by an unwritten and outdated rule – the fourth such rule highlighted in this series, “Breaking the Rules of Healthcare.”

Rule No. 4: Doctors achieve high status by doing the impossible Throughout history, desperate patients have come to doctors hoping for a miracle. Physicians responded with incredible acts of healing – at times seeming to possess supernatural powers that defy known science. Doing the impossible not only elevated the prestige of the medical profession, it has also become the criterion for ranking people within it. This explains why, for most of the 20th century, primary care (internal medicine) doctors were held in highest esteem. Their superpower, which set them apart from colleagues, was the ability to unravel medical mysteries. When cardiologists, pulmonologists or orthopedists couldn’t diagnose an ailment, they turned to primary care for expertise. Time and again, these brilliant diagnosticians did the impossible and, in doing so, held their position atop medicine’s hierarchy. However, this unwritten rule – the one that enshrined primary care in the 20th century – is the same rule that sent the specialty crashing down in the 21st.

The rise of the specialist, the fall of primary care The 20th century ended with an eruption of medical innovation.

This period brought about the widespread use of MRIs and CT scanners, along with improvements in the quality of ultrasounds. These tools digitized diagnosis and radically improved medical practice. But they also turned a renowned skill of primary care doctors into an average and unremarkable ability. Meanwhile, surgeons and interventional subspecialists had embarked on a period of relentless innovation – boosting their status in medicine by doing what was once thought impossible.

The unwritten rule of status makes no sense today As medicine evolved in modern times, so did the needs of patients. Today, our nation now faces a growing epidemic of chronic diseases (heart disease, diabetes and asthma). These lifelong illnesses account for 7 in 10 American deaths and have caused the relative flatlining of life expectancy over the past two decades. This deadly healthcare crisis won’t be solved with surgeries and procedures of ever-greater complexity. It will be solved by doctors who

Primary care’s focus on preventive medicine and chronic-disease management may not inspire awe quite like cutting into the heart or brain, but these approaches can and do save more lives. Orthopedists, whose 20th-century job was to reset and cast broken bones, could suddenly replace hip and knee joints with space-age implants. Ophthalmologists, who historically wrote prescriptions for eyeglasses, invented a way to restore the vision of patients with cataracts by removing the opaque lens. And incredibly, interventional cardiologists could now reverse myocardial infarctions by passing catheters into the heart, unblocking the occluded blood vessels. These unbelievable advancements flipped the healthcare hierarchy on its head. Specialists were now seen as heroes, capable of impossible feats, while primary care physicians were demoted in both status and pay. Today, specialists earn two to three times more than internal and family medicine doctors.

can prevent disease, improve overall health and preserve life. To make it happen, physicians must first break the outdated rule of status.

Breaking the rule: Achieving high status by saving lives If status in medicine were determined by saving lives (rather than doing the impossible), primary care physicians would quickly re-ascend the hierarchy. Consider the results of a study by Harvard and Stanford researchers in 2019. The team found that adding 10 specialists to a population of 100,000 people correlates with an average life-expectancy increase of 19.2 days. But when adding an equal number of primary care physicians, longevity increased by 51.5 days. That’s an increase of 250%. This happens because primary care doctors don’t just treat medical www.repertoiremag.com

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TRENDS problems as they arise. They also help patients avoid heart attacks, cancer and strokes in the first place. Primary care’s focus on preventive medicine and chronic-disease management may not inspire awe quite like cutting into the heart or brain, but these approaches can and do save more lives.

Restoring the value of primary care In any profession, those with power and privilege are slow to cede either. But hierarchical change is possible. Returning to football, there was a time when offensive linemen were as undervalued as primary care physicians are today. Sometime in the last century, some smart coaches realized that a skilled left tackle was central to a team’s success. After all, this player’s job is to protect the quarterback’s blindside and prevent a potentially season-ending injury. With this realization, offensive tackles were soon being selected in the first round of the NFL draft. Today, they’re the highest paid players on offense. Once the basis for status in medicine shifts to saving lives, primary care will receive the esteem and income it deserves.

How to break the rule To update the rule of status for the 21st century, health insurers and doctors will need to institute two important changes: 1. Adequately fund primary care To effectively prevent and battle chronic disease, doctors need more

resources. Today, however, only 6% of healthcare spending goes to primary care. Bumping the total to 9% (a 50% increase) would allow these physicians to hire more support staff, spend more time with each patient and help people manage their chronic illnesses. The resulting improvements in patient health would drive down overall healthcare costs.

programs) failed to lower mortality rates. The incentive structure forced doctors to focus on only a few clinical areas; usually the ones with the highest incentives. A better approach ties incentives to improvements in longevity and overall health. Artificial intelligence (AI) could help with that. AI apps can analyze

This deadly healthcare crisis won’t be solved with surgeries and procedures of ever-greater complexity. It will be solved by doctors who can prevent disease, improve overall health and preserve life. The hard part will be convincing public and private insurers to foot the bill. Payers will demand reliable performance data that tie their financial investment directly to lives and dollars saved. This brings us to the second change. 2. I dentify and reward the physicians who save the most lives Not all primary care doctors achieve the same life-saving outcomes. In fact, some U.S. physicians are 30% more effective at preventing deaths from stroke, heart attack, or cancer than others. Because of this gap in outcomes, insurers won’t be willing to increase primary care payments across the board. They’ll want to reward doctors who achieve the best results. Unfortunately, past attempts at this (via “pay for performance”

tens of thousands of medical journals to identify approaches that most effectively increase life expectancy. It could then compare the performance of physicians against these opportunities. And instead of rewarding doctors for testing for high blood pressure or enrolling people in diabetes-management programs, AI would assess whether the patient’s blood pressure and blood sugar were normalized. Over time, AI will develop greater predictive accuracy: tying lifesaving approaches to lives saved. As more patients participate – and fewer people develop complications from chronic disease – insurers will see fit to invest more in primary care. Over time, with better pay and greater recognition, primary care’s status will increase – and so will the life expectancy of all Americans.

Dr. Robert Pearl is the former CEO of The Permanente Medical Group, the nation’s largest physician group. He’s a Forbes contributor, bestselling author, Stanford University professor, and host of two healthcare podcasts. Pearl’s newest book, “Uncaring: How the Culture of Medicine Kills Doctors & Patients,” is available now. All profits from the book go to Doctors Without Borders. For more information or to sign up for his newsletter, visit robertpearlmd.com. 62

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NEWS Primary Care News How does U.S. primary care stack up? International research group examines Among high-income countries, U.S. adults were the second least likely to have a regular doctor or place to go for care, ahead of only Sweden, according to the Commonwealth Fund data. The majority of adults in all 11 countries reported having a regular doctor or place of care, but adults in the U.S. and Sweden reported this at significantly lower rates than adults in most of the countries, Commonwealth reported in a recent examination of how the U.S. compares in primary care. Some of the other findings: ʯ U.S. adults are the least likely to have a longstanding relationship with a primary care provider. ʯ Access to home visits or after-hours care is lowest in the U.S. ʯ U.S. primary care providers are the most likely to screen for social service needs. ʯ One-third of U.S. primary care physicians have mental health providers in their practice, compared with nearly all in the Netherlands and Sweden. ʯ Half of U.S. primary care physicians report adequate coordination with specialists and hospitals – around the average for the 11 countries studied. “While there is a shortage of health workers globally, our analysis demonstrates that the U.S. primary care system trails far behind those of other countries in many areas, particularly when it comes to health care access and continuity,” The Commonwealth Fund said in its conclusion. To read the full report, as well as several policy option suggestions for U.S. policymakers to consider as they work to improve primary care visit www.commonwealthfund.org/ publications/issue-briefs/2022/mar/primary-care-highincome-countries-how-united-states-compares.

areas, where either the proportion of family physicians and primary care physicians is too low or there are no primary care physicians whatsoever, according to Kaiser Family Foundation data, said Dr. Jennifer Aloff, a family physician at Midland Family Physicians.

Expanding access to care in Indiana The United Health Foundation has launched a partnership with HealthNet, a nonprofit health care provider serving Indiana, to expand access to primary and behavioral health care in Morgan and Monroe counties in Indiana, as well as low-income areas in Indianapolis. The $2 million, three-year grant will allow HealthNet to bring medical professionals and a mobile health vehicle to neighborhoods in Indianapolis, and Morgan and Monroe counties four days a week. The program will address health disparities by: ʯ Bringing primary care, preventive services and mental health screenings to underserved communities. ʯ Providing high-risk patients with at-home monitoring devices to track their own health. ʯ Making referrals to dental care, substance use disorder treatment, specialty care and other health supports for patients.

Michigan experiencing primary care decline According to the Detroit Free Press, Michigan is experiencing a decline in the number of primary care physicians, with more shortages expected by 2030, particularly impacting residents in underserved areas. The shortages can be curbed, in part, by beefing up state funding for existing programs to recruit, train and retain physicians in that field, a group of family medicine physicians told the Free Press. Michigan has 269 health professional shortage

The HealthNet-United Health Foundation partnership is expected to improve adult and child immunization rates, breast cancer screenings and colorectal cancer screenings by 15% as well as improve cervical cancer screenings by 20% over baseline, according to a release. Additionally, the partnership aims to improve health outcomes of individuals with chronic conditions such as diabetes and hypertension. www.repertoiremag.com

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NEWS Industry News PWH announces John Sasen Memorial Scholarship Recipient PWH announced the recipient of the 2022 John Sasen Memorial Scholarship, Saran Ross, Sr. ManSaran Ross ager, RX Sales Administration at McKesson. She is dedicated to improving, diversifying and providing equity in the health experience of others and is excited to join the PWH network. Congratulations Saran, on your well-deserved scholarship. Several women were considered for this award that honors someone in the healthcare industry that is an inspiring individual, demonstrates leadership and is an ambassador to the industry. The scholarship is awarded to one woman each year and includes a one-year PWH membership as well as attendance to the HIDA Executive Conference.

Yankee Alliance and The Claflin Company establish exclusive distribution agreement Yankee Alliance and The Claflin Company have established an exclusive distribution agreement to provide Yankee Members access to Claflin’s wide range of logistics programs along with enhanced savings opportunities for Yankee aggregated contracts. The agreement, which will continue to add aggregations opportunities, will aim to provide Yankee members with the most aggressive customized contracting options in the industry. “This agreement will allow Yankee Members to achieve further savings opportunities and explore 64

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sourcing diversity in the post pandemic supply chain. Claflin is very excited to be partnered with such a forward-thinking organization like Yankee.” Alex Caldwell, Claflin VP Sales & Marketing.

Midmark evolves and expands training program with new leadership hire Midmark Corp., the only clinical environmental design company providing medical, dental and veterinary Jaclyn Smith solutions that enable a better experience at the point of care, announced the hiring of Jaclyn Smith as director of education and development. The hiring signals an evolution of the current program, which will expand and take on a larger role within the company, advancing Midmark’s clinical and non-clinical training for Midmark teammates and customers. Capitalizing on her robust understanding of the market landscape and educational programming, Smith will develop and provide oversight of Midmark’s clinical education, sales, training, and customer engagement resources. She will also work to ensure Midmark stays current with industry best practices and develop a network of external resources, including industry leaders and peer groups, to build content that augments the curriculum. Additionally, Smith will support the investment in team member development to strengthen this critical component of the organization’s

continued success by partnering with business leaders and Human Resources to proactively identify and respond to organizational development opportunities with solutions based on best practices in organizational development. With more than 20 years of experience in leading and implementing training and learning programs, Smith most recently designed the first enterprise learning strategy aligning learning with strategic outcomes for the 711/Human Performance Wing at Wright-Patterson Air Force Base. Before that, she led a 32-member performance consulting group responsible for the design and delivery of corporate university programs and services, which in 2019, was ranked 16th nationally, for approximately 5,000 staff members at CareSource. Smith will join a well-established professional education team that has been transforming Midmark’s training offering into a program that is informative, engaging and encourages attendees to apply what they have learned. The program takes a blended approach that features many informative and interactive components, including video, e-learning modules, live presentations, Q&A sessions, hands-on training and gamification modules. The program is used to ensure Midmark teammates understand the patient and provider experience and how medical, dental and animal health customers can use certain equipment and technologies to enhance the quality of care. For Midmark customers, the training program is focused on helping them understand how best to integrate our offerings into their facilities and workflows to ensure a better care experience and better patient outcomes.


Better BP is Better Care ®

Set the stage for better care and set yourself apart with this Midmark approach. We designed the only fully integrated point of care ecosystem to help promote a more consistently accurate blood pressure measurement by targeting 3 key areas using 3 unique products. 1

Proper Patient Positioning

The Midmark® 626 with Patient Support Rails+ is designed to promote AMA-recommended patient positioning for BP capture.1 The barrier-free low chair height allows most patients to place their feet flat on the floor while the accessory rails support the arm at heart height.

Midmark 626 Barrier-Free® Examination Chair with Patient Support Rails+ and IQvitals® Zone™ Vital Signs Monitor shown.

1

Proper Patient Positioning

+

2

Accurate, Consistent BP Capture

+

= Better BP Contact your Midmark Representative to start the conversation. midmark.com/consistentBP

1 https://www.aafp.org/afp/2005/1001/p1391.html © 2022 Midmark Corporation, Miamisburg, Ohio USA

3

EMR Connectivity


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