Round-up Magazine May 2015 by Maricopa County Medical Society (MCMS)

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Discover what the MCMS can offer you. Visit us at www.mcmsonline.com. Membership: 602-252-2015 Referral line: 602-252-2844 Governor Doug Doucey designated May 2015 as Hepatitis Awareness Month in Arizona. Join the Maricopa County Medical Society and the Arizona Department of Health Services as we bring awareness to hepatitis B and C. Encourage your patients to get screened!

For more information:

RANDY MCGRANE 602/912-8995

For more information or screening referrals, call the Arizona Dept. of Health Services at 602-364-3676 or visit http://www.azdhs.gov/ preparedness/epidemiology-disease-control/ hepatitis/index.php

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Number 4

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Page 4 Page 8

MCMS Board Meeting Minutes Page 33

From the Exec. Director In Memoriam

IN EVERY ISSUE:

Marketplace

April 2015

Page 34

•

Number 2 •

-2015 1955

60 Years

Celebrating

February 2015

Page 4 Page 10 Page 34 Page 36

You’re invited! “Philanthropy in Medicine”

To learn more visit www.mcmsonline.com

PUBLIC HEALTH: The causes of childhood obesity are many, and as such, more than one approach to treating it is important. Page 12

A CLOSER LOOK: We bring you a summary of a recent initiative led by the AMA to help improve the cumbersome EHR certification process for physicians. Page 25

FEATURE ARTICLE: Senator Bill Frist, MD shares his thoughts with Round-up readers on how our nation’s health IT framework needs to adapt. Page 26

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Number 3

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In Memoriam

New Members

From the Exec. Director

IN EVERY ISSUE:

Marketplace

March 2015

Page 4 Page 10

Page 9 Page 42

-2015 1955

60 Years

Celebrating

-2015 1955

60 Years

Celebrating

Save the date for “Philanthropy in Medicine” Details on page 13

MEMBER PROFILE: Meet Dr. Ryan Stratford, MBA, MCMS 2015 President. Learn more about what he believes are the challenges MCMS and organized medicine face, the opportunities that exist, and the commitment it will take from our members to truly make a difference. Page 8.

VIEWPOINT: Happy Anniversary to the SS, M&M, ADA & ACA! Page 41

MCMS OPEN HOUSE: On March 12, 2015 MCMS hosted an open house celebrating the Society’s building facelift. As you will see by the photos a great time was had by all! Page 36

A MEDICAL STUDENT’S PERSPECTIVE: An A.T. Still University and a University of Arizona College of Medicine – Phoenix student share their thoughts on Public Health. Pages 26 & 28

FEATURE ARTICLE: Senator Bill Frist, MD reflects on a trip to Cuba and compares its public health system to the United States. Page 20 A PARENT’S PERSPECTIVE: Dr. Tim Jacks takes off his Pediatrician hat and puts on his “Papa Bear” hat with an open letter to a parent of an unvaccinated child. Page 24

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Number 1

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January 2015

editorial of the new year he formally takes the reins from Dr. Miriam Anand and describes his vision to keep MCMS moving in a forward, positive direction. Page 14.

PRESIDENT’S PAGE: MCMS 2015 BOARD OF DIRECTORS: Meet the physicians that lead your Society. Page 16.

A CLOSER LOOK: Round-up sat down with Dr. Jeff Mueller, a MCMS member and ArMA’s President, and asked him about the role of physicians in the legislative process and what to expect during this year’s Legislature. Page 26

The Society received a much needed facelift to the building and courtyard, page 20.

Providing news and information for the medical community since 1955.

Volume 61

FEATURE ARTICLES: We asked Rep. Heather Carter and Sen. Kelly Ward to share their thoughts on the importance of physician involvement in the health policy-making process and how the physician community can get involved. Pages 28 & 30.

round-up

To learn more visit www.mcmsonline.com

PUBLIC HEALTH: The resurgence of measles transmission in the US after being almost eradicated several years ago provides a teachable moment to re-examine public health strategies and personal and community responsibilities. Page 16

Meet Diana Petitti, MD, MPH and learn about the path she has walked as an epidemiology researcher and public health advocate. Page 30

MEMBER PROFILE:

Providing g news and information for the medical community since 1955.

Volume 61

A Round-up Magazine subscription is one of the many perks of MCMS membership. Join today!

PRESIDENT’S PAGE: Technology has transformed a physician‘s ability to discover, diagnose and treat their patients. However, with great advancements come great responsibility. Page 8

Dr. Paul Berggreen is keeping pace with technology. Page 16

TECHNOLOGY: The legal pitfalls of documentation shortcuts when using EHRs and steps to take to ensure that your practice is properly securing electronic records. Pages 28 & 32

Details on Page 13

Event sponsored by Arizona Central Credit Union.

May 7, 2015, 6-8:30 pm at the Maricopa County Medical Society.

MCMS Members: Join us for cocktails and hors d’oeuvres as we celebrate the Society’s building facelift with an Open House on March 12. Details on page 3.

From the Exec. Director Announcements Marketplace Board of Directors Meeting Minutes

IN EVERY ISSUE:

A MEDICAL STUDENT’S PERSPECTIVE: A.T. Still University and University of Arizona College of Medicine – Phoenix medical students share their thoughts on how they plan on helping their patients feel empowered. Pages 22 & 24

FEATURE ARTICLE: A number of medical schools are adding coursework on clinical empathy into the curriculum. With the growing trend of hospitals incorporating patient satisfaction in their determination of physician compensation, clinical empathy looks to be a vital resource for better connecting with patients and improving the doctor-patient relationship. Page 18

Providing news and information for the medical community since 1955.

Volume 61

To learn more visit www.mcmsonline.com

PUBLIC HEALTH: See Me Smoke-Free — The first multi-behavioral smart phone app designed to empower women to quit smoking. Page 16

MEMBER PROFILE: Dr. Christine Harter’s dedication to patient empowerment and community outreach. Page 26

Providing news and information for the medical community since 1955.

Volume 61

round-up round-up

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About the Maricopa County Medical Society

The Maricopa County Medical Society (MCMS) is a professional association of physicians that provides advocacy, patient referrals, business and medical services programs, and networking opportunities to its membership for the betterment of all physicians and healthcare in Arizona.

Member Services - Advocacy. Working with the Arizona Medical Association (ArMA), MCMS strives to represent physicians in legislature to promote positive change in health policy.

- Physician Referral Line. To aid the community and help attract patients to our physician members, the MCMS offers a telephone and web-based physician referral service to connect the patient with a physician that best meets their medical needs. In 2014, the MCMS provided over 10,000 patient referrals to its members. - MCMS Business Services. MCMS offers business services through the Greater Arizona Central Credentialing Program (GACCP), a recognized leader in the primary source verification industry, and the Bureau of Medical Economics (BME), which provides specialized collection of delinquent medical accounts.

- Preferred Partner Program. MCMS provides its members references to our preferred business partners, who offer services and consumer goods that will benefit physicians professionally and personally.

- Engagement in the Medical Community. MCMS hosts social and educational events throughout the year, allowing members to network and learn from peers.

- Community Outreach. MCMS is dedicated to supporting the community and has been a proud supporter of the ACT Kids Health Fair for 16 years. This all-volunteer event addresses a full spectrum of health requirements for underprivileged children who otherwise do not have access to medical care.

- Round-Up Magazine and InforMED Society. Round-up, a monthly magazine, and bi-monthly e-newsletter, InforMED Society, focus on topics that are important to physicians and includes articles from experts in the medical field.

326 E. Coronado Rd., Ste 101 Phoenix, AZ 85004

Overview p: 602-252-2015 f: 602-256-2749

mcms@mcmsonline.com www.mcmsonline.com

On behalf of the Maricopa County Medical Society (MCMS), we wish to thank you for your dedication to the citizens of our community. Your commitment to providing high quality healthcare throughout the Valley of the Sun is what we stand for, and we aim to help you focus your time on doing what you do best.

The Society understands the needs of physicians and recognizes that not all physicians are alike. Those that deliver medicine in the private practice arena have a unique set of needs that the Society has long been poised to meet. Those practicing medicine in any of our region’s excellent hospitals or clinics have a different set of needs, and the Society is striving to adapt to this growing population of physicians. Despite the differences in what employed and self-employed physician want and need, medicine can only survive through a unified physician voice. The strength of medicine here in Arizona, especially throughout the Phoenix metropolitan area, is critically dependent upon the physicians of yesterday, today, and tomorrow working together. We recognize that physicians of tomorrow are a vital part of physician autonomy, and that the future of how healthcare is delivered rests firmly on their shoulders. But to get there they need the mentorship and lessons learned passed on by those still practicing and those who have since left a distinguished career in medicine behind.

The cost of membership in MCMS is one of the lowest in the nation. We know that with specialty societies and other organizational commitments, physicians have to be selective. We want to ensure that every member gets considerable value for the price of membership. Taking advantage of one or more of our business partnerships all but pays for your annual membership. We also run a physician referral line and referred over 10,000 patients to Society members in 2014. Depending upon your specialty, one or two referrals may well cover the cost of your membership.

So join us today. Let us help you continue deciding what care your patients need — and when they need care. Let us help you navigate the complexity of a changing national healthcare system that puts more and more pressure on our physicians.

JOIN US TODAY and discover how MCMS can assist you. Ryan Stratford, MD, MBA President Jay Conyers, PhD Executive Director/CEO

To learn more visit www.mcmsonline.com

IN EVERY ISSUE: From the Executive Director In Memoriam New Members Letter to the Editor Marketplace

Page 4 Page 8 Page 10 Page 11 Page 46

Celebrating 60 Years

- 015 1955 2

round-up Volume 61

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Number 5

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May 2015

Providing news and information for the medical community since 1955.

MEMBER PROFILE: Dr. John Couvaras How he’s made “the businesss of medicine,” including a robust social media campaign and marketing tactics, work to grow his private practice. Page 20

PRESIDENT’S PAGE: The business of medicine is the most important part of the “business” of medicine. Page 12 PUBLIC HEALTH: The promises and challenges of Precision Medicine. Page 16

PRACTICE MANAGEMENT: What’s your plan for success when opening a new medical office? Page 26 HUMAN RESOURCES: Recruiting top talent away from your competitors. Page 30

MALPRACTICE INSURANCE: The business of protection. Page 34 LEGAL: Surviving a claims audit: things to consider when (not if) your practice is audited. Page 38 REAL ESTATE: Innovation abounds in the healthcare industry. Page 42

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from the executive director from the executive director

What’s Inside? May 2015: The Business of Medicine By Jay Conyers, PhD

his month, we focus on the business of medicine, and what it takes for a physician to survive in today’s world. Given the importance of this topic to nearly every single physician throughout the valley, we have once again distributed Round-up to all practitioners in Maricopa County. If you’re not a member yet and want to become more active in protecting the practice of medicine, or simply want to stay apprised of what’s going on in the local medical community, then join the Maricopa County Medical Society. It’s easy to do — just complete the attached business reply card and send it in. We’d love to have you!

Jay Conyers, PhD MCMS, Executive Director Contact Information: E: jconyers@mcmsonline.com P: 602-251-2361

Back to the issue, and why we’re focusing on the business of medicine this month. Never before have physicians required a deeper understanding of the interplay between business and the practice of medicine than they do now. It doesn’t appear that a physician’s reliance on business is going away any time soon, and more and more physicians are opting to pursue business training to keep up.

The most common form of business training for physicians has come by way of joint MD/MBA programs, or through executive MBA programs that allow established physicians to complete the degree at night and on weekends. In 1990, roughly half a dozen medical schools offered joint MD/MBA programs, but that number ballooned by more than an order of magnitude over the last twenty years. Of the nearly 70 joint programs in the U.S. today, more than half were formed after the turn of the century. Last fall, it was estimated that more than 500 medical students are currently enrolled in joint programs nationwide.

That’s good news for the practice of medicine as it will help bolster the seemingly thin pipeline of physician leaders poised to run a hospital. Having worked a decade in the Texas Medical Center, I rarely came across a physician CEO. I’m sure there were more, but I only recall one, with John 4 • Round-up •May 2015 • A monthly publication of the MCMS

from the executive director Mendelsohn, MD manning the ship at MD Anderson Cancer Center from 1996-2011.

I thought that perhaps this was an anomaly specific to Houston, but after doing a little research (thanks, Google!), I was surprised to learn that less than 4% of our nation’s hospital CEOs are trained as physicians. With the number of hospitals in our country fast approaching 7,000, it’s amazing to think that less than 250 physicians sit at the top of leadership chain. Undoubtedly, the growing MD/MBA pipeline will provide more qualified physician leaders and put more in the critical CEO post.

articles that are intended to help you better navigate the business landscape of medicine. We bring you an article about how to recruit and retain top talent through the development of unique compensation packages. We also have an in-depth article on malpractice insurance, and what physicians should consider when buying coverage. A great article on how to defend your practice against a claims audit is part of this issue, as is an update on how the booming healthcare industry is having a dramatic impact on the medical real estate sector.

We’ve also included a panel discussion on what to consider when opening a medical practice and how these inAs expected, not all physicians who pursue an MBA dustry experts strive to assist physicians through the do so with the intention of becoming the next hospital process. And don’t miss the piece by Senator Bill Frist CEO. More and more physicians are enrolling in execuon how he sees President Obama’s recent Precision tive MBA programs to better prepare themselves to manMedicine Initiative playing out. Lastly, we profile a physiage a physician group, improve the efficiency of their own cian — John Couvaras, MD, of IVF Phoenix — and practice, or improve their understanding of how the health share his story of how he’s learned to adapt his business policy landscape will change the way they deliver care. model to a changing healthcare world. Today, nearly 20% of executive MBA students work in the healthcare field, with a good portion of those being physiNext month we bring you an issue focused on Employcians. And while many simply don’t have the time to take ment and follow it up with our Education issue in July. on even a part-time executive MBA program, they’re find- Until then, we hope you enjoy this issue and hope many ing time to take courses in finance or accounting so that of you non-members will reach out to us and join the they better understand how to read a balance sheet. Maricopa County Medical Society. ru

TY R PE O PR T EN M

246

SALE/LEASE-BACK /SQUARE FOOT SALE PRICE

IC AL

SO LD

In this issue, we’ve assembled a robust collection of

Rencor is pleased to announce the completed sale of Arrowhead Dermatology’s Avondale MOB.

Ryan Reynolds | 602-224-4502 EXT-2 | rencordevelopment.com A monthly publication of the MCMS • May 2015 • Round-up • 5

round-up

may 2015

Providing news and information for physicians and the healthcare community since 1955. Published monthly by the Maricopa County Medical Society.

4 12 16 20 26

what’s inside

president’s page The Business of Medicine is the Most Important Part of the “Business” of Medicine public health The Promises and Challenges of Precision Medicine

member profile A Customized Approach to Medicine in a Changing World: A Sit-Down with MCMS Member John Couvaras, MD

practice management What’s Your Plan for Success When Opening Your Medical Office

resources/benefits 30 human HR’s Daily Dilemna: Recruiting

Top Talent Away From Your Competitors

34 insurance The Business of Protection 38

legal Surviving a Claims Audit: Things to Consider When (Not If) Your Practice is Audited

estate 42 real Innovation Abounds in Healthcare Industry, Real Estate

In every issue

In Memoriam ....................................................................................................................................................................8 New Members ................................................................................................................................................................10 Letter to the Editor ..........................................................................................................................................................11 Marketplace ....................................................................................................................................................................46

Cover photo: Denny Collins Photography • www.dennycollins.com • 602-448-2437 6 • Round-up •May 2015 • A monthly publication of the MCMS

Round-up Staff

Editor-in-Chief Ryan R. Stratford, MD, MBA Editor Jay Conyers, PhD

Advertising, Design and Production Candice Scheibel Contributing Writer Dominique Perkins Advertising

To obtain information on advertising in Round-up, contact MCMS.

phone: 602-252-2015 advertising@mcmsonline.com Postmaster

Send address changes to: Round-up, 326 E. Coronado Rd., Phoenix, AZ 85004 mcmsonline.com

facebook.com/MedicalSociety twitter.com/MedicalSociety Periodicals postage paid at Phoenix, Arizona.

Volume 61, No. 5, May 2015.

Round-up (USPS 020-150) is published 12 times per year by the Maricopa County Medical Society, 326 E. Coronado, Phoenix, AZ 85004. To subscribe to Round-up Magazine please send a check for one-year subscription of $36 to Round-up Magazine, 326 E. Coronado Rd., Phoenix, AZ 85004 or visit mcmsonline.com/subscribe.

Connect with your Society.

MCMS 2015 Officers President

Ryan R. Stratford, MD, MBA

President-Elect

Adam M. Brodsky, MD Vice President

John L. Couvaras, MD Secretary

Kelly Hsu, MD Treasurer

Mark R. Wallace, MD

Immediate Past-President Miriam K. Anand, MD Board of Directors 2013-2015

R. Jay Standerfer, MD

Steven R. Kassman, MD Shane Daley, MD

Anthony Lee, MD 2014-2016

Lee Ann Kelley, MD May Mohty, MD

Richard Manch, MD Anita Murcko, MD 2015-2017

Ross Goldberg, MD

Jennifer Hartmark-Hill, MD Tanja L. Gunsberger, DO Marc M. Lato, MD

Letters and electronic correspondence will become the property of Round-up, which assumes permission to publish and edit as necessary. Please refer to our usage statement for more information.

Celebrating 60 Years

- 015 1955 2

Round-up is a publication of the Maricopa County Medical Society (MCMS). Submissions, including advertisements, are welcome for review and approval by our editorial staff at roundup@mcmsonline.com.

All solicited and unsolicited written materials and photos submitted to Round-up will be treated as unconditionally and irrevocably assigned to and the property of MCMS and may be used at MCMS’ sole discretion for publication and copyright purposes and use in any publication, website or brochure. MCMS accepts no responsibility for the loss of or damage to material submitted, including photographs or artwork. Submissions will not be returned.

The opinions expressed in Round-up are those of the individual authors and not necessarily of MCMS. Round-up reserves the right to refuse certain submissions and advertising and is not liable for the authors’ or advertisers’ claims and/or errors. Roundup considers its sources reliable and verifies as much data as possible, but is not responsible for inaccuracies or content. Readers rely on this information at their own risk and are advised to seek independent legal, financial or other independent advice regarding the content of any submission.

No part of this magazine may be reproduced or transmitted in any form or by any means without written permission by the publisher. All rights are reserved.

Editor: Ryan R. Stratford, MD, MBA rstratford@mcmsonline.com

Managing Editor: Jay Conyers, PhD jconyers@mcmsonline.com

A monthly publication of the MCMS • May 2015 • Round-up • 7

in memoriam in memoriam Bruce Dean, MD

Dr. Bruce Dean, 63, physician and professor of neuroradiology at St. Joseph Hospital/Barrow Neurological Institute passed away on April 22, 2015.

Dr. Dean was born in 1951 in Richmond, IN to Calvin and Geneva Dean. He received his undergraduate degree from Purdue University and his medical degree from the Indiana University School of Medicine. After graduating from medical school in 1978, he served in the United States Army as a Major, completing his residency at Tripler Military Hospital in Honolulu, HI. Two years after completing his fellowship in Neuroradiology at the Barrow Neurological Institute, he joined the staff where he has served for the last twenty-four years. He will be greatly missed by his family, friends, and the medical community. They remember him for his dedication to his profession, selfless giving, and humble attitude. He was a beloved husband, father, and brother.

Dr. Dean is survived by his loving wife of 25 years, Gail, sons Troy and Ryan (wife Shanna); brothers Gary, Alan, Rick, and Terry; and sisters Wanda and Patricia. ru

Betty Jo Grajeda MD

Betty Jo Grajeda, MD, 56, of Chandler, Arizona, died suddenly April 12, 2015, after a three month battle with lung cancer.

She is the beloved wife of Jeffrey Hrycko, and the loving daughter of Betty (Estrada) Burgett and Joseph Rodriquez Grajeda; and sister of Edna Caton (Brian Caton) and Norma Jean Grajeda. Dr. Grajeda graduated from Douglas High School, Cochise Community College, the University of Arizona, and the Medical College of Wisconsin. She was beloved by anyone who knew her. ru

Charles Edmond Basye, MD

Dr. Charles “Chuck” Edmond Basye, 80, of Scottsdale, Arizona passed away on May 8, 2015.

Dr. Basye was born to Paul and Margaret Basye in Kansas City, MO on August 28, 1934. He graduated from Burlingame High School in Burlingame, California and attended Stanford University, receiving his undergraduate and medical doctor degrees. After working a few years in Minneapolis as a physician on a Native American Reservation in Rosebud, SD, he settled with his family in Ft. Collins, Colorado, where he practiced medicine and directed a Family Practice Residency Program. He moved to Scottsdale, Arizona in 1981 and continued to teach Family Practice residents and work in private practice, including many years at the Mayo Clinic. He retired from medicine at the age of 76.

Dr. Basye loved to travel and tend to his flowers at home. He was especially proud of his beloved alma mater, Stanford, often travelling to Palo Alto to watch The Cardinal football team play their rivals. He was an active member of Desert Hills Presbyterian Church and his faith in God was the foundation of his life. He will be greatly missed by family and friends, as well as countless patients and families. He took special joy in providing superior medical care for the entire family from cradle to grave, in the fine tradition of the town doctor.

Dr. Basye is survived by his brother John Basye and his wife Barbara Hewitt. He is survived by his first wife, Rosalie Smith, and their five children/spouses, Ken (Debbie), Christie (Tom), Doug (Hong), Kathy (Shane), and Greg (Aimee). He was preceded in death by his second wife Lynda Saltz Basye, and is survived by his stepsons/spouses Steve (Ann) and Samuel (Wendy) Saltz. He is survived by his third wife, Glenda Basye, who lives in Scottsdale. He is also survived by 20 grandchildren and one great-grandchild. ru

8 • Round-up •May 2015 • A monthly publication of the MCMS

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new members The physicians highlighted on this page recently joined the Maricopa County Medical Society. Please reach out to one or more of them and welcome them aboard, and share with them your insight on how the Society can be of service.

ETHAN BINDELGLAS, MD Family Medicine Medical School: Sackler School of Medicine, NY Internship & Residency: Banner Good Samaritan Medical Center Practice: Arcadia Personal Physicians 4350 E. Camelback Rd., Ste. G-120, Phoenix, AZ 85018 Phone: 602-952-0625

ANDREW J. CARROLL, MD Family Medicine Medical School: St. George’s University School of Medicine Internship & Residency: Mid-Hudson Family Health Services Institute Practice: Renaissance Family Medical Care, 333 N. Dobson Rd., Ste. 15, Chandler, AZ 85224 Phone: 480-282-8336

PAMELA FRAZIER, MD Psychiatry Medical School: University of Pennsylvania, Philadelphia, PA Internship: Presbyterian – University of Pennsylvania Medical Center, Philadelphia, PA Residency: Hospital of the University of Pennsylvania, Philadelphia, PA Practice: Pamela T. Frazier, MD, 4300 N. Miller Rd., Ste. 142, Scottsdale, AZ 85251 Phone: 602-617-6854

TIM JACKS, DO Pediatrics Medical School: Midwestern University Residency: St. Joseph Hospital & Medical Center Practice: Gilbert Pediatrics, 4365 E. Pecos Rd., Ste. 123, Gilbert, AZ 85297 Phone: 480-892-3880

STAMATIS KANTARTZIS, MD Radiology Medical School: University of Pittsburgh School of Medicine Practice: Chandler Radiology Associates; 1955 W. Frye Rd., Chandler, AZ 85224 Phone: 480-728-3263

NAMITA KOTHARI, MD OB/GYN Medical School: Sawai Man Singh Medical College, Jaipur, Rajasthan Residency: Henry Ford Health Systems, Detroit, MI Practice: East Valley Women’s Medical Group, 10238 E. Hampton Ave., Ste. 212, Mesa, AZ 85209 Phone: 480-632-2004 CHRISTINE RAGAY – CATHERS, DO Family Medicine Medical School: Des Moines University/COM Residency: St. Joseph’s Hospital & Medical Center Practice: Luke Air Force Base

CYNTHIA STONNINGTON, MD Psychiatry Medical School: Mayo Medical School, Rochester, MN Residency: Stanford University Medical Center, Palo Alto, CA Practice: Mayo Clinic Arizona, 13400 E. Shea Blvd., Scottsdale, AZ 85259-5404 Phone: 480-301-8000

10 • Round-up •May 2015 • A monthly publication of the MCMS

letter to the editor Dear Dr. Conyers,

Your remarks in Round-up [Volume 61, Number 4, April 2015] concerning, “lack of agreement that Patient Empowerment is a good thing” struck a chord.

Take “informed consent” for example. I had difficulty on many occasions in giving the patient any information at all, for two reasons. The patient would frequently interrupt me with, “Please Doctor, don’t recite the list of horrors that might await me. I am upset and frightened enough without listening to a litany of complications that could be in store. I will sign the papers with your disclaimers.” Or, the patient testifies that, “Yes, I signed the consent form, but did not understand it.” The Jury says, “That is not informed consent.” There is no way that a patient can be taught four years of medical school and years of post-graduate training and experience in a few minutes.

I have been compelled to refuse to operate on patients who refused a colostomy when that is exactly what was

required. I do not question their right as long as I have an equal right to not accept them as a consultant.

Furthermore, does the advertising by drug firms directly to patients on television empower them to make a decision as to what medication is best for them? Do the incessant calls and time required to answer their inquiries about the new anticoagulant justify the need for “empowerment?”

Making the doctor the guarantor of safety as well as results when, “A little knowledge (on the part of the patient) is a dangerous thing,” is a truism, and not in the patient’s interest, nor the doctor’s. Why don’t clients dictate to their lawyers the legal language they wish the contract to contain? I am just getting started, but am reminded that, “Brevity is the soul of wit.” Warmly,

Paul B. Jarrett, MD MCMS Member since 1946

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A monthly publication of the MCMS • May 2015 • Round-up • 11

president’s page

The Business of Medicine is the Most Important “Business” of Medicine By Ryan R. Stratford, MD, MBA

ecently, I was discussing different surgical options for treating pelvic organ prolapse and urinary incontinence with a patient. After considering all of the options, she reticently said, “I think I need to wait for about eight months.”

MCMS President 2015 Ryan R. Stratford, MD, MBA Dr. Stratford specializes in Urogynecology/Pelvic Reconstructive Surgery. He joined MCMS in 2005. Contact Information: The Woman's Center for Advanced Pelvic Surgery 4344 E. Presidio Street www.TheWomansCenter.com P: 480-834-5111 E: rstratford@mcmsonline.com

We discussed issues of needing to adjust her work schedule to avoid heavy lifting and straining for a number of weeks, and she showed only enthusiasm for surgery until something crossed her mind – finances. As she thought it through, she realized that her deductible had not been met and that waiting until the new calendar year would allow her to meet the deductible in the same year that she had other planned health needs, thus helping her to save money.

The patient was embarrassed to explain to me why she wanted to wait. I quickly reassured her that she should not be embarrassed to do what each of us does when considering where to expend our limited resources. Truthfully, she was responding to what is at the core of every decision we make where we have to determine the value of one thing over another. After learning more about her situation, I learned why the decision to postpone surgery made perfect sense. Luckily, given the non-emergent nature of her condition, postponing treatment had little impact on her outcome.

Many would argue that medicine should not be a business, that the pure practice of medicine would allow patients to choose what options are best for their health based solely on

12 • Round-up •May 2015 • A monthly publication of the MCMS

president’s page availability of care and scientific understanding of what is best. Although enticing to consider, I believe that the business of medicine preserves the individual right of choice and thus produces the greatest level of health.

How does the need to pay for healthcare improve someone’s health? Through efficient and valuebased distribution of healthcare resources.

Whenever there are scarce resources, decisions have to be made on how to allocate those resources. I think society has long held an unfortunate misperception that there are unlimited resources in medicine to provide for all of our healthcare needs. Healthcare is limited by many constraints. If the distribution of that care is determined by individual payment, requiring each patient to pay some amount for their care, then the patient remains the primary distributor of the scarce resource. If patients are no longer required to make payment for their healthcare, then they lose the ability to choose how healthcare resources are distributed. Ultimately, whoever is responsible for payment becomes the distributor of the scarce resource. I strongly believe in the ability of each individual, with guidance from a healthcare provider, to best be able to determine where to allocate scarce resources. I have much less faith in a governing system, no matter how well-intentioned, to be better able to distribute the resources in healthcare than each individual.

To illustrate this idea, I can think of a few simple examples. The value or utility of correcting urinary incon-

tinence varies greatly among my patients. I have some patients who are not bothered by the need to use multiple heavy incontinence pads daily and other patients who are significantly bothered by leakage once a week. Even though the patient who

leaks high volumes daily would financially benefit from treating incontinence (average annual cost of hygiene products is over $900), she may not place as high a value on the treatment of her incontinence than the patient who leaks weekly, and resul-

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president’s page tantly not chose intervention. In this case, if the patient with less frequent incontinence chooses an intervention and the patient with more frequent incontinence does not, some would argue that aggregately fewer people are made better off. However, I would disagree because both patients were allowed to choose what they value and resultantly are happy with their choice and their health. In their eyes, they are both better off.

“...At the heart of the business of medicine are value judgments. Making value judgments requires more personal knowledge in order to make a decision, which in turn erodes the information gap between physicians and patients. Making value judgments requires personal responsibility, which in turn empowers patients to take greater responsibility for their own health. Making value judgments reduces unnecessary procedures and testing, which in turn redirects resources for things of greatest value. These value judgments are patient-centered and should remain patient-centered.” – Ryan Stratford, MD

Similarly, if the patient is no longer required to make payment for her care, the value she places on the care is no longer considered.

A few years ago, I saw a patient in consultation for urinary incontinence who was insured by state and federal funding. She was not, and could not be required to make any financial payment towards her healthcare, and she knew it. After the consultation, she was asked to keep a three-day record of her voiding frequency and voided volumes. On her way out of the office, she was offered a “voiding hat” (an upside down sombrero that sits underneath the toilet seat to collect the volume of her void) but asked to pay for the cost of the voiding hat: $3.00. I heard some yelling in the waiting room and then had a staff member come back to my office. She was nearly in tears, but explained that the patient yelled in disgust that she would have to pay $3.00 for the voiding hat when she was not required to pay anything for her healthcare. She was upset and demanded that we give her a voiding hat for free. My initial reaction was to acquiesce and tell my front office staff to just let her have a hat. The $3.00 meant little to me. However, I was struck by the patient’s behavior and realized that without some commitment it was highly unlikely that she would complete the voiding diary and make any improvements in her bladder symptoms. I told my staff to kindly explain to the patient that she did not need to have the voiding hat in order to complete the diaries, as she could use a measuring cup from home. If she valued the convenience of using the voiding hat enough to pay $3.00 then we would gladly give one to her.

Although the principle makes me feel like a scrooge knowing that this patient likely had very limited resources, I realize that I would be ineffective as her physician if I did not require her to put forth effort to improve her own health. Requiring payment for the hat was not a business decision but a value-based decision. I wanted the patient

to determine the value of her health and the distribution of her healthcare resources. I firmly believe that the responsibility of determining the value of healthcare should remain with the patient and not a governing body.

Because there are limited resources, we have to make decisions based on what we value most. At the heart of the business of medicine are value judgments. Making value judgments requires more personal knowledge in order to make a decision, which in turn erodes the information gap between physicians and patients. Making value judgments requires personal responsibility, which in turn empowers patients to take greater responsibility for their own health. Making value judgments reduces unnecessary procedures and testing, which in turn redirects resources for things of greatest value. These value judgments are patient-centered and should remain patient-centered.

Although many of my colleagues still feel uncomfortable with being required to consider the costs of medicine for their patients, I believe it is through the consideration of those costs that the rights of patients will be preserved and the best distribution of healthcare will be achieved. Truly, the business of medicine is the most important “business” of medicine. ru

14 • Round-up •May 2015 • A monthly publication of the MCMS

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public health

The Promises and Challenges of Precision Medicine By Senator Bill Frist, MD

hen President Obama announced the Precision Medicine Initiative in January, it was more of a broad goal than a specific action plan. In calling for a million-member cohort, he raised significant medical and technical challenges with costs that will far surpass the initial $215 million allotted for the initiative.

Sen. Bill Frist, MD Dr. Frist, senator from Tennessee from 1995-2007, is a nationally acclaimed heart and lung translplant surgeon, former U.S. Senate Majority Leader, and chairman of the Executive board of the health service private equity firm Cressey & Company. Connect with him through http://billfrist.com/

Nevertheless, Obama was absolutely right in calling for a focus on precision medicine, which proposes the customization of healthcare by implementing treatment models tailored to individual patients. I trained in surgery, a blunt tool compared to today’s targeted treatments. The future of medicine is in the specific, the less invasive, and often the more conservative approach. But less intervention requires more information. An area of healthcare that has recently become very important to me is community transformation projects focusing on the social determinants of health: environment, economic stability, access to care, education and community resources. Only 15 percent of our health is determined by the healthcare we receive, so paying more attention to the remaining 85 percent is not only imperative – it’s just good math.

16 • Round-up •May 2015 • A monthly publication of the MCMS

public health Precision medicine aims to take targeted genetic and molecular information and consider it in tandem with data about our environmental exposures and lifestyle choices. Integration of the smallest building blocks with the macro environment is exactly the direction in which medicine should be moving. Getting there will take some new habits, a new funding model, and new technologies.

This new medicine is fundamentally dependent on a team approach. When I did my medical training, doctors were not taught to work in teams. But precision medicine is by definition a multidisciplinary approach that includes physicians, researchers, computer scientists and bioinformaticians.

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As a former lawmaker, I think the president’s initiative responds to some important healthcare economics. The federal government currently funds about one third of all medical research and one third of delivered healthcare. But the economic health challenges facing us are still vast. For instance, the National Institute of Health (NIH) currently spends about $1.3 billion a year on Alzheimer’s re-

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A monthly publication of the MCMS • May 2015 • Round-up • 17

public health

“This new medicine is fundamentally dependent on a team approach. When I did my medical training, doctors were not taught to work in teams. But precision medicine is by definition a multidisciplinary approach that includes physicians, researchers, computer scientists and bioinformaticians.” — Sen. Bill Frist, MD

search, though the disease is estimated to cost Medicare and Medicaid $154 billion this year, and the total cost of care for Alzheimer’s disease and dementia is expected to be $20 trillion over the next 40 years.

Preventing or more efficiently managing diseases like Alzheimer’s, cancer, heart disease and diabetes could be a huge cost saver in the long run. The hope is that precision medicine offers some answers.

But collecting, coordinating and mining data from a million volunteers will present huge technological challenges. Data are likely to come from various public repositories and perhaps even for-profit databases. In order to be as useful as possible, those datasets need to include genomes, medical histories and biological samples. They’ll also need to harness ongoing data streams from wearables and other environmental inputs. There are many smart groups working to integrate all of that information, but the difficulty of combining what is now disparate data from varied sources is staggering. Once the data are collected, how will we use it? Clinical programs applying personalized medicine are already in place across the country. At Vanderbilt we have PREDICT (Pharmacogenomic Resource for Enhanced Decisions in Care and Treatment), which sequences patients for metabolism of clopidogrel, warfarin, tacrolimus and TPMT pathway drugs. But even these established programs haven’t fully answered whether sequencing based on risk factors results in long term cost savings and improved patient outcomes.

These are crucial questions to consider as we think about the impact of using federal dollars for scientific advancement. No one doubts that precision medicine is the future. However, use of public funds comes with huge responsibility. Obama’s initiative and the success of precision medicine across the country will depend on the leadership of many groups, both public and private, to help steward the use of funds and steer technology development efforts.

Today there are targeted oncologic therapies, areas of micro DNA testing such as non-invasive prenatal testing and tracking tumor DNA in peripheral blood, sequencing patients for genes that affect their health risks like PCSK9 for LDL metabolism, and sequencing for genes that affect drug metabolism like CYP2C19 for clopidogrel.

All of these uses are part of the future of precision medicine, but the key thing to impact here is the clinical encounter, the patient, the person. And that requires a multidisciplinary collaborative approach with eyes to innovation and new methods. I see precision medicine as a microcosm for the medicine of the future – and from where I stand the future is exciting. ru Reprinted with permission. First posted: May 5, 2015. To view original post, visit http://billfrist.com/promiseschallenges-precision-medicine/

18 • Round-up •May 2015 • A monthly publication of the MCMS

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member profile

A Customized Approach to Medicine in a Changing World: A Sit-Down with MCMS Member

John Couvaras, MD

Article photos: Denny Collins Photography www.dennycollins.com 602-448-2437

hen you walk into IVF Phoenix, Dr. John Couvaras hopes you will immediately notice something unique. “There is a different feel, I’m pretty sure,” he said. “It doesn’t feel like a doctor’s office. But it doesn’t feel like a Med Spa, either.”

This comforting environment is just one of the many things that are particular to Couvaras’ approach to private practice. “It keeps us very boutique: small, specialized,” he said.

Because personal interaction and connection are so important to the patient experience, Couvaras has established an environment where everyone is cross-trained, so they can flow easily between different tasks and roles.

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member profile This means that if a patient develops a particular connection with one individual in the office, they all have the capability to see the experience through to the end. Or, on the other hand, someone else can step in if the patient is feeling overwhelmed and they need to try a different communication approach. “You have to be tuned in to what the patient is experiencing,” he said. “Good communication is essential to patient comfort and compliance.”

With this communication in mind, IVF Phoenix does not have an answering service, and Couvaras insists the phone be answered within three rings. “When undergoing fertility treatments, a patient wants to talk to a person and we believe our individualized approach is key.”

The interchangeable office protocol also means that there are always two sets of eyes on any one procedure.

“Even me, I tell people: double-check my work. Participation, interaction, double-checking, it doesn’t make anybody’s ego bigger or smaller. Or, it shouldn’t. It should just be able to say, listen: this is so important. I want to try and take the mess-up rate and extinguish it to as little as possible.” The approach Couvaras’ practice takes is very individual, and highly customized.

Some of the successes he is the most proud of are the patients he has helped conceive without using In Vitro Fertilization (IVF). While it is certainly satisfying to achieve a high success rate with IVF, Couvaras feels that sometimes it is possible you are merely speeding up a process that may have taken place naturally if given a little extra time and attention.

The real challenge is with those who have seriously problems, and have perhaps failed multiple IVF attempts in the past.

“There’s a big difference here,” he said. With patients in these circumstances, Couvaras talks step by step through what has happened with each previous attempt, really identifying and analyzing those moments where things have gone wrong.

“And I’ll go through these lists of questions, and all of their answers, and then they’ll say, ‘no one has ever asked me these questions.” Instead of taking an all or nothing approach, he is able to make other adjustments that allow the patient to conceive without IVF. This problem-solving approach has truly defined Couvaras career. How Did We Get Here?

Couvaras was always good at science, and enjoyed the challenge of it. Medicine seemed like a good fit from a very early age.

“You kind of get older and you start realizing, what can I do with my life, and what am I best at doing? And what we are really good at doing is problem solving. In the profession of medicine, it’s all problem solving. Everything we do is problem solving.” He also liked the idea that doctors could be present at sacred moments in people’s lives birth, death, healing etc. “In other cultures, past and present, Priests or Shamans were allowed this same privilege.”

After graduating from the University of Texas Health Sciences Center, Couvaras completed his internship and residency at Baylor College of Medicine in Dallas, Texas, determined to become the best OB/GYN he could possibly be. He described the program as intense and demanding, at the very least. “They beat the patootie out of us over there,” he said. And although he claims you would have to wipe his memory to get him to do it all over from the beginning, he appreciates the difficulty now.

“There is something about spending 4 years, and squeezing 12 or 10 years into the 4. The more you squeeze in, the more you see, and the more you learn. So by the time you come out you are so much further ahead than anyone who hadn’t done what you have done,” he said.

After completing his OB/GYN training, Couvaras was ready to explore some sub-specialties, and wound up in reproductive endocrinology, automatically drawn to the challenges and possibilities presented by the field. “They didn’t know anything,” he said. “We know the basics, and then this is just a black box.”

A monthly publication of the MCMS • May 2015 • Round-up • 21

member profile “And I thought, Ah! This is the perfect environment for someone like me who wants to problem solve without being encumbered by someone telling me, here are algorithms.”

Couvaras has a large desk pad in his office, and as he talks he draws diagrams and uses analogies to illustrate his points.

He said sometimes a diagnosis can be compared to a car wreck. You know what that means, and you have an

On the Personal Side 1. Describe yourself in one word. Curious. 2. What is your favorite food, and favorite restaurant in the Valley? Ice Cream! Favorite Restaurant in the Valley? There are so many: Bink’s Midtown, Rancho Pinot, Chelsea’s Kitchen. 3. What career would you be doing if you weren’t a physician? I have always lived my life believing that “Obstacles are those things we see once we take our eyes of the goal” For this reason I have never contemplated doing anything else. But you never know! 4. What’s a hidden talent that you have that most wouldn’t know about you (play the guitar, sing, etc.)? I make amazing pizza from scratch. Dough flipping and all! 5. Best movie you’ve seen in the last ten years? Too many to mention! 6. Which would you say is the best day of your life? The day I married my wife and partner, Rhoda.

image in your head of what it looks like. But if you really want to know what caused it, fix the problem now and prevent it from happening again in the future, you have to dig deeper.

Couvaras approaches his patient cases with much the same mindset, and resists the urge to divide patient infertility into broad categories and then follow one or two solutions.

“We tend to react quickly and put everything under one diagnosis, when there are so many possibilities and factors. Instead of just looking at one outcome and choosing one of two solutions, we go deeper and look at all of the possibilities and try to determine the solution that is best for that individual,” he said. “You’re not just not getting pregnant; there are a whole bunch of other things that go along with this.”

Couvaras said the field of Reproductive Endocrinology has definitely come a long way from when he started out.

“Twenty-four years I’ve been doing this and we definitely know more.” And the business itself has changed just as much, if not more. The Business: A Changing Game

Couvaras feels it is radically harder to run a private medical practice these days, and less and less physicians are choosing that route. “A single doctor can’t survive because the reimbursement is so tight that you can’t afford to have one biller for you, you have to have one biller for three docs,” Couvaras said.

“I see it from a young person’s perspective going, ‘I don’t want to try to open my own practice; I can’t figure it out.’ I barely know my medicine, much less the business side and how to negotiate a contract.”

In fact, Couvaras said that the entire notion of contract negotiation is a fallacy.

“There’s no negotiation; it’s you, a little stick of a person, against this behemoth as the insurance company,” he said.

IVF Phoenix operates on a cash-basis, and so he avoids the “behemoth” in some ways, but still sees it take its toll.

22 • Round-up •May 2015 • A monthly publication of the MCMS

member profile “We used to talk about the old timers who were in the ‘golden age’ of medicine where we got paid, you know, x amount of dollars to do a procedure. Which now we get paid 1/5 of those dollars, and now currently we get paid 1/10.”

“We don’t do patient care this way, but we create a sort of family for our people,” he said. IVF Phoenix has such a unique approach, and their social media communities tell their story and allow their patients to share their as well.

Couvaras watched some private practices go entirely belly-up when the market got really bad between 2008 and 2012. He said for IVF the patient population is still coming back slowly, but they are managing to do alright.

“I see social media becoming a dedicated department for us as we look to the new generation of patients arriving at our practice.”

“And I’m realizing that people might look at me and think I was in the golden age, and it’s just not true.”

“We can still pay for medical benefits, we can still hire people,” he said. One of the myths of the medical industry is that every dollar a patient pays goes directly into the doctor’s pocket. But the space needs to be leased, and the office needs to be staffed and paid and the equipment is expensive. Another business change that could be viewed as both a challenge and a blessing is a more tech and business savvy patient base.

Couvaras said social media is definitely here to stay, and expanding daily.

What surprises him, however, is that more physicians don’t employ social media.

“Even though markedly younger doctors are supposed to have these incredible social media skills, I think the employed doc doesn’t see the relevance.”

He said this may be the case because they are caught in the grind of big medical groups who are not looking for

“Today’s consumer is born in the digital age with more information available to them. They arrive to us with more knowledge as a result of their findings on the web,” he said.

One of the ways to stand up against the amount of medical content on the internet is to make sure you are creating some of your own. IVF Phoenix is very active on social media, using Facebook, Tumblr, Instagram and Twitter to reach their audience. “I didn’t realize how powerful the darn thing was until my wife showed me,” he said. “It’s incredible.”

Couvaras describes his wife, Rhoda, who serves as Practice Manager and Marketing & Communications Director, as a “genius” with social media.

Dr. Couvaras reviewing a patient chart with a staff member. A monthly publication of the MCMS • May 2015 • Round-up • 23

member profile

Rhoda Rizkalla (Dr. Couvaras’ wife), sharing a laugh with the construction crew at IVF Phoenix’s new office location. continuity for their physician, but instead are creating exit strategies that move physicians through an administrative plan that does not benefit the patient or the physician.

“There are practices out there that will hire young doctors and then work them to death, and then take them and drop their salary down,” he said.

“Right now medicine has figured out that we are a commodity and you just plug us in and that’s it,” he said. But this model can’t last.

“I’m telling you, we are going to reach an end point. I think docs just need to wake up one day and recognize that together with a unified voice we have a markedly big voice and a big say in what goes on.” A Voice For Change

Couvaras is a definite believer in the power and voice of the physicians in Maricopa County, and getting them all together is one of his biggest goals. “Doctors should consider the power of numbers and aligning together to create change and foster business. Net-

working has been of tremendous value for me with the Society. I encourage members to become involved,” he said.

In addition to social media impacting the business of medicine, Couvaras also sees networking with other physicians through the Society as well. Couvaras said networking was not something he took advantage of when he was first starting out, and this is something he regrets.

“I think I could learn plenty from other people,” he said. “It’s not an advantage to practice in a vacuum. I’ve learned that over the years.”

“I used to say I didn’t play well with others, and I really didn’t because I had my own ideas. But as I’ve honed my ideas and they’ve proved themselves is that I have to learn to get out of the vacuum so that other people can see what I’m doing and they can get that perspective and curiosity that brings them in.”

Couvaras said that many physicians can get caught up in the rush between training and setting up practice without a lot of thought to socialization and involvement.

24 • Round-up •May 2015 • A monthly publication of the MCMS

member profile “I never socialized when I was younger,” he said.

“When I first joined the Maricopa County Medical Society, I paid my dues and came to 2 dinners in 20 some-odd years. And I just happened to come to a dinner 4-5 years ago and there was an opening for an officership and that’s when my wife said, you know, volunteer! You never volunteer!”

A view from the new medical office.

Couvaras volunteered, and at first wasn’t even quite sure what he had gotten himself into. However, he has now served in several capacities within MCMS, and is currently vice president of the board of directors.

He has also joined and participated in other organizations over the years. Couvaras serves as an IVF LAB Inspector for the College of American Pathologists (CAP), and is on the board for the Phoenix OBGYN Society. He also serves on the Credentials Committee for Paradise Valley Hospital, and is a member of the American Society of Reproductive Medicine (ASRM), the Society of Assisted Reproductive (SART), and the American Medical Association (AMA).

“It’s been an eye opener. The more I participate now, after all these years of doing nothing, the more I’ve started to realize, wow, I really did miss out.”

Much like the business of medicine, the nature of the Medical Society is changing as well. But Couvaras doesn’t believe that means we are losing our relevance. On the contrary. “I really think the relevance is key. We are all after the same thing.”

Something he does see changing, however, is the approach to communication. Like in his business model, he believes social media and technology are bound to take a bigger role.

“None of this mailing out stuff,” he said. We should be able to send out a question, have everyone click yes or no, and see an 80% response rate within 4 days.

This greater response and involvement, he said, would create a more concrete picture of where physicians stand, what they want, and what they are willing to fight for.

Couvaras feels that a truly unified physician group can have a huge impact on the medical business model, as well as legislation such as the Affordable Care Act. But it can also speed the progression of medicine itself.

It takes years of discussion for new ideas to really get put into practice, he said. New ideas can seem really far out of the box, or even a little dangerous at first. But the sooner discussion begins, the sooner medicine as a whole can advance, and networking is a really big part of that.

Another important component is continuing education. Couvaras says it is something he, like most physicians, usually dreads going into it. But, ultimately, after reading all the articles and sharing new ideas with other physicians, he has felt really grateful for the new information and perspective. ru

A monthly publication of the MCMS • May 2015 • Round-up • 25

practice management

WHAT’S YOUR PLAN FOR SUCCESS WHEN OPENING YOUR MEDICAL OFFICE? Ensemble Real Estate Solutions recently convened a roundtable discussion, moderated by Randy McGrane, around the topic of starting medical offices in today’s rapidly changing healthcare environment.

Contributing Authors: Michelin Abrahamsen Marina Hammersmith Randy McGrane Zandra L. O’Keefe Candace Hunter Wiest Jim Wolfe

practice management Why start a new medical office?

Randy: A great book that we like to refer to is “Start with Why” by Simon Sinek. I think we would all agree that the first step in helping medical professionals with a new office is to make sure you have explored the question of “why” they want to open a new office in the first place. To provide a solution, you have to know what problems you are solving.

Candace: We consulted with a medical practice a few years ago that was considering selling to a large healthcare chain. We asked them many “why” questions. The bottom line was there were no compelling reasons to sell at the price they were being offered. After that conversation, they decided not to sell, which turned out to be a good decision.

Zandra: A young orthopedic surgeon came to me for advice about setting up his own office. I asked him if he had considered partnering with others to leverage his overhead costs. He was young, was a high-producer in a good location, had the drive to do it on his own, and he had several other investments he could use to help start the practice without having to get a bank loan. For him, it was the right move.

Michelin: In our work with smaller medical practices, we see a strong desire among the physicians to help others. They may be unhappy with the current state of medical insurance but they still love medicine and want to have a direct influence on helping patients.

Marina: For some physicians, it’s ego—and I mean that in a good way. These doctors want to make their contributions to the patients and the practice, and they are driven to go in the direction of an opportunity that will best fit that desire. Jim: We don’t see many start-ups right now with doctors who have just completed their training. The ones that we’re seeing are disgruntled within a group and forming another group. Or, a group gets large and splits in two. Corporate employment models are changing, and that’s creating distress for some physicians. Many new practices are pretty small—one or two physicians—rather than the formation of larger groups.

How do you develop a business plan in an uncertain landscape?

Zandra: If you want to be successful, you need to work with professionals to help you develop a comprehensive plan that includes the various topics we’re addressing here—taxes, finance, insurance, real estate and banking.

Candace: We help clients take advantage of available resources. For example, once we realized that the Affordable Care Act (ACA) was going to be a reality, we offered to work with our physician clients to analyze the impact on their top line revenue by running a “shock test” based on estimates of a cut in future reimbursement rates. About a third declined the offer and ended up selling their practices to hospitals, a third chose to continue as is, and a third really spent a lot of time reviewing each scenario. They looked at the impact of a decline in reimbursements and realized they may need to diversify their payer mix, bring in other partners to diversify their practice services to create more revenue, or re-examine their overhead to reduce or share more expenses.

Marina: When they’re looking at their overhead, these costs include real estate. There is a perception that real estate is a large portion of overhead but it’s really not. However, they need to look at their payer mix and geographic factors. Is downsizing an option? They may also look at Class B space versus Class A, or buying versus leasing. Because real estate prices and interest rates are still low, buying may be a good option. Randy: On the leasing side, we’re also seeing shorter lease terms because of the uncertainty of the medical industry.

Michelin: We see physicians in their thinking-mode— when they are thinking of adding cash-based procedures and want to know if their insurance will cover those. It could be hearing tests, or weight management. For some physicians, these additions are helping financially.

Zandra: We’re seeing some physicians engaging in Joint Ventures (JV) with the hospitals to positively impact patient stays and care. We’re also seeing strengthening of affiliations to leverage what synergies they have. These JVs seem to be initiated by the hospitals but they have had a positive impact financially on the physicians, too.

A monthly publication of the MCMS • May 2015 • Round-up • 27

practice management

“...When we look at the value of commercial real estate, it’s never the physical building — it’s the desire and demand. The demand is the physicians’ need to practice but their desire can be affected by outside forces. For example, with a dental practice that’s built a business in a certain location, they’re not going to pick up and move locations. It may be better for them to own. If you can’t say with confidence that you will be there for the foreseeable future, it’s usually better to lease.” Jim: There are still some solo practitioners out there but they’re rare. It’s fairly difficult in this environment because of overhead costs so they sometimes share overhead. These are typically practitioners who want to remain independent and are satisfied with less income. How can we help solo practitioners and smaller practices succeed?

Jim: We can help them develop a comprehensive plan and benchmarks to measure their success. They’ll need that for a bank loan, too. It has to be a plan that they’re comfortable with because they’re the ones that have to implement it.

Michelin: With malpractice insurance, there are ways to educate them on risk management to keep costs lower. There are not huge insurance discounts until the group is more than 20 practitioners. Many insurance companies have hotlines that the physicians can call for their risk management questions.

Candace: We have industry guidelines that practices can utilize to see if their expenses are in line with industry averages. Having good risk management practices is huge, especially with solo practitioners.

Zandra: The first thing we do with clients is to help them understand their financial statements and how that affects their financial health. We can then help them identify tax advantages if they’re buying a building or big equipment as far as when to take deductions, particularly when it’s financed. We can also help them plan financially for physician owners coming and going, or buying versus leasing decisions.

Randy: For a small practice, we counsel caution when it comes to trying to own their own office. We introduce them to the concept of reversionary value of real estate.

How much is that asset worth in the future based on the marketplace? When we look at the value of commercial real estate, it’s never the physical building—it’s the desire and demand. The demand is the physicians’ need to practice but their desire can be affected by outside forces. For example, with a dental practice that’s built a business in a certain location, they’re not going to pick up and move locations. It may be better for them to own. If you can’t say with confidence that you will be there for the foreseeable future, it’s usually better to lease.

Candace: Two important questions to ask practices that are selling, merging or affiliating might be, “What have you signed away and who owns the receivables?”

Michelin: Sometimes groups send us their entire real estate lease to review, not just the insurance portion. We can’t help but notice at times that some groups are receiving better terms than others. We can advise them to have a professional help them review their lease terms before signing. With a claims-made malpractice insurance policy, there can be a tail payment of 200 percent of the current premium. Tail is what closes out the policy to cover any incident that happened while practicing. If you truly retire, the cost can be low or none. However, many physicians go on to be a medical director or have some other medical position. What is changing regarding location of practices? What are current factors that come into play?

Marina: Locations are strongly driven by hospital associations, JV partnerships, payer mixes and underserved populations. Providers want to be in the community – accessible to their patients and in proximity to the hospital if necessary. With the consumerism of healthcare increasing, retail store fronts are attractive options as well.

28 • Round-up •May 2015 • A monthly publication of the MCMS

practice management Randy: There is so much disruptive innovation that is impacting the industry such as retail sites, telemedicine, a new lower cost lab company, and viral immunology in cancer treatment. Another disruption is the shift from employer-based to private-based health insurance. An executive from a local healthcare chain recently predicted that by 2020, 100 million people will be purchasing individual insurance policies rather than employer based.

Candace: I believe there is a risk to relocations given the consumers’ desire to be in close proximity to their physicians. I also think as you consider a location, take a long view. What will your practice need in 10 years given the changes in technology, medical structure (hospitals changing the need to be close to a hospital) and your current patient base?

Jim: Individuals paying for their own health insurance are taking on larger deductibles and that trend is leading to more negotiated prices for healthcare services at the doctor’s office.

Zandra: Practices of all kinds continue to be engaged in various transactions, consolidating and splitting off. Some have quite a bit of value in the location, payer contracts, and leverage of their people and equipment. Practices will need experienced collaborative partners to work with management, their contracting consultants, legal counsel and physician owners to analyze what they have and help them get positioned for success. Candace: The pendulum is shifting. We’ll be seeing more partnerships come together. Physicians’ lives will be better and it’s better for healthcare.

Summary

If you’re looking to open a practice in today’s healthcare climate, it’s important to understand the “why.” Much like consumers of healthcare rely on a consortium of providers to map the road to health, physicians can create a team of trusted professionals to walk them through the process. ru

The following seasoned professionals who regularly work with those in the medical industry participated in the roundtable:

Michelin Abrahamsen, CPCU is the President of Desert Mountain Insurance Services, Inc., an Independent Insurance Agency specializing in healthcare accounts. She comes from an insurance family and began working in the insurance business as a teenager. After college, Michelin was a senior underwriter at a major insurance company specializing in malpractice insurance and earned the prestigious Chartered Property Casualty Underwriter designation. Contact her at michelin@desertmountaininsurance.com.

Marina Hammersmith, CCIM is a Senior Vice President, Healthcare Brokerage Services for Ensemble. She has more than 20 years of hands-on experience in healthcare asset management, property management, sales and leasing. During her 16 years at Ensemble, Marina has developed a widely known expertise in the field of healthcare real estate as a strong client advocate at numerous hospital campus and off campus locations throughout the valley. Contact her at mhammersmith@ensemble.net.

Randy McGrane is a Founding Partner, Managing Director and CEO of Ensemble. In addition to working extensively on business development, Randy oversees acquisition and disposition of property and manages long-term financing with the institutional debt markets. He has cultivated his vast operational expertise throughout his 30-year career, which began in the commercial construction industry in California. Contact him at rmcgrane@ensemble.net.

Zandra L. O’Keefe, CPA is a Managing Director for CBIZ and shareholder of Mayer Hoffman McCann, PC. She provides accounting, tax planning and compliance services as well as extensive business management consulting to a diverse group of closely held businesses, their owners and high net worth individuals for the Phoenix office tax division. She specializes in professional service businesses including physician owned medical group practices. Contact her at zokeefe@cbiz.com.

Candace Hunter Wiest is the President & CEO of West Valley Bancorp, Inc. and West Valley National Bank, the West Valley’s only locally owned and operated community Bank. She was recruited to organize the Bank in March of 2006. In addition to serving small business and medical professionals, in 2014 the Bank launched AZ Dental Bank, a specialty division of WVNB. Contact her at cwiest@wvnb.net.

Jim Wolfe is the President of Wolfe Consulting Group, Ltd. and has been a practice management business consultant for more than 30 years. Prior to forming Wolfe Consulting, he spent eight years in the real estate development and home building industries with a Fortune 500 company in Canada and the U.S. Contact him at jdw@wolfecon.com.

A monthly publication of the MCMS • May 2015 • Round-up • 29

human resources/benefits HRâ&#x20AC;&#x2122;S DAILY DILEMMA

RECRUITING TOP TALENT AWAY FROM YOUR COMPETITORS BY GIL ZEIMER

TIP #9: Provide employees with retirement and investment options.

TIP #3: Help your employees save time with direct deposit.

TIP #6: Give your employees free notary services. authenticate

TIP #8: Help your employees find great vehicles and auto loans.

TIP #2: Offer tax savings with a health savings checking account.

TIP #5: Volunteer together.

human resources/benefits In today’s ultracompetitive market and with the U.S. economy rapidly gaining momentum, the more benefits you can offer your prospective employees the more likely you’ll be able to hire them away from your competition. Don’t you wish there was a way that your HR & Benefits Department could offer your employees an incremental variety of valuable services for no extra cost? Credit unions may be able to help you out. As a Select Employee Group (SEG) partner of an existing credit union, consider the ways that your HR department can work together to discover unique and attractive employee benefits. Following are 10 tips to consider as you work on your recruitment and employee benefit strategy.

Tip #1: Install a Convenient Surcharge-Free ATM

Wouldn’t you love having an ATM right in your workplace? Can you imagine how much time that would save you on a weekly basis? Partnering with a credit union may bring benefits like these to your organization! It really does happen; recently a local Arizona credit union installed an ATM in the community room at Wickenburg Community Hospital. This not only deepened the credit union’s relationship with the hospital, but also provided the entire Wickenburg community with convenient access to their accounts; providing access for cash withdrawals, deposits, balance checks and fund transfers.

WE ARE PLEASED TO ANNOUNCE THE OPENING OF

A New State-of-the-Art Interventional Pain Management Practice Offering Treatments and Procedures to Manage Pain and Debilitating Conditions

THE REGIONAL PAIN INSTITUTE 21321 E. Ocotillo Road, Queen Creek, Arizona 480-636-1225 www.regionalpain.com Specializing in the safest and least invasive procedures to effectively treat more than 20 different disorders and diseases. The Regional Pain Institute is one of the early adoption sites in pain management medical practices nationwide trained to offer SI Bone Fusion -- an innovative new technology and a minimally invasive surgical option for patients who have failed non-surgical options for some causes of sacroiliac joint pain.

Dr. Kevin Henry

Dr. Glen Feather

The Phoenix location of the Regional Pain Institute is part of the Illinois-based Regional Pain Institute, a longtime leader in multidisciplinary interventional pain management. Founded nearly a decade ago and with office locations throughout Illinois, The Regional Pain Institute is launching new practice locations throughout the United States, which all share a common philosophy, treatment approach, and commitment to quality.

A monthly publication of the MCMS • May 2015 • Round-up • 31

human resources/benefits Tip #2: Offer Tax Savings with a Health Savings Checking Account

With escalating healthcare costs, who doesn’t want to save money on their healthcare expenses? Partnering with a Health Savings Account (HSA) provider gives your employees the opportunity to put up to $3,350 into a Health Savings Checking Account to save for future medical expenses. HSAs also offer a special tax-advantaged strategy for paying qualified medical expenses later on.

Any adult can have an HSA if they have coverage under an HSA-qualified “high deductible health plan” (HDHP), if they don’t have another health insurance coverage plan through a spouse or partner, if they’re not enrolled in Medicare, and if they’re not claimed as a dependent on someone else’s tax return.

Of course, we always recommend that you contact your tax adviser to answer any questions about an HSA. Tip #3: Help Your Employees Save Time with Direct Deposit

Credit unions let you pay your employees with the convenience of Direct Deposit. This convenient, safe and secure service saves your business time and money on employee payroll processing, and lets you avoid the hassle and expense of cutting individual employee checks. All transactions are processed online through a secure website. You’ll be their hero as well, saving them the trouble of dashing off to their financial institution to deposit their paycheck before closing time. It’s a win-win for you AND your team. Tip #4: Throw in Extra Vacation Days or Paid Time Off

A well-rested employee is a happy employee, so consider incenting them with extra vacation days or paid time off (PTO) to keep their minds sharp and loving their job. This is a great way to reward employees who are doing a terrific job – without having to pay them a cash bonus.

In fact, many firms have successfully incentivized employees by offering “summer” hours, that ask them to work four 10-hour days per week instead of five 8-hour days. In return, they get Fridays off during June, July and August and earn three-day weekends when they need them most during the dog days of summer.

Tip #5: Volunteer Together

Most employees take pride in improving the communities in which they live and work. If you and/or your team want to support a local charity, a shelter, or a church group, think about planning a weekend day when your employees can volunteer together to accomplish a certain task.

Have you ever thought about hosting a car wash, a bake sale or an art show as a fundraiser? Whatever you do, do it together with your employees. You can maybe even have a t-shirt design contest for the event – and reward the winner with a vacation day! Tip #6: Give Your Employees Free Notary Public Services

If you have a home loan, a title deed, a will or a trust to sign, or other important legal documents, why make your employees have to find someone to get it authenticated? By partnering with a local credit union your employees can arrange a free notary public service to get that paperwork signed, sealed and notarized.

Each document must be notarized, signed, and stamped in the presence of a notary. Notaries typically charge fees for their services, but free notary services are available through your local credit union. You can even have your documents notarized without a special appointment at a special customer service desk. Tip #7: Reward Them with Vacation & Travel Discounts

Everyone loves to travel while saving as much as they can while they do it. Many credit unions offer special discount vacation packages to places like Disneyland, Sea World, and San Francisco to the companies they partner with.

You can also qualify for discounts on hotel rooms, fantastic cruises and other exciting destinations, plus extra night free specials when you pre-book a vacation. If you purchase your package through your credit union, a portion of each sale also benefits the Children’s Miracle Network.

32 • Round-up •May 2015 • A monthly publication of the MCMS

human resources/benefits Tip #8: Help Your Employees Find Great Vehicles and Auto Loans

Since almost everyone needs a car at one time or another, offering your employees ways to find their new “ride” through known and safe channels can be an added bonus. Many credit unions offer online car buying programs such as AutoSMART.

You can access this convenient service from your desktop, laptop, tablet or smartphone and it lets your employees easily research, finance and locate their next new or used vehicle locally. They can even value and post an advertisement to sell their current vehicle while they search for another one to replace it. Plus, they will have access to motorcycles, power sport vehicles, RVs and trailers, power boats, personal watercraft and commercial trucks.

Tip #9: Provide Employees with Retirement and Investment Options

In addition to all of the services listed previously, many credit unions offer securities and investment advisory services to help employees achieve their financial goals through companies like Voya Financial Advisors, Inc.

These investment companies offer no cost, no obligation initial meetings. They realize that every employee is unique and has different scenarios for retiring, different risk tolerance for investing, and different short- and longterm needs for their retirement plan; whether they choose to buy stocks, bonds, property, annuities, or other investment options. Tip #10: Offer Your Employees Insurance Options

Just about every employee could use insurance benefits as well. That’s why most credit unions offer a range of insurance plans. These typically include auto insurance for your vehicles, homeowners or rental insurance for where your employees live, affordable life insurance coverage options to protect their family, and accidental death and dismemberment insurance in the case of a tragic, unexpected accident. ru Gil Zeimer is a freelance copywriter with over 25 years of experience. He specializes in direct response copy writing projects, and created this article for Arizona Central Credit Union.

A monthly publication of the MCMS • May 2015 • Round-up • 33

insurance

The Business of Protection By James F. Carland, III, MD

undamentally, insurance is “a system that permits individuals to exchange the risk of a large loss for the certainty of a small loss.” In exchange for a premium, an insurer will protect the insured from a loss in accordance with the terms of the insuring agreement or policy.

James Carland, III, MD Chairman and CEO, Mutual Insurance Company of Arizona (MICA)

Dr. Carland is the Chairman, Chief Executive Officer and President of MICA and the past Chairman of the Physician Insurers Association of America (PIAA), an international trade association of medical professional liability insurance companies. He is the recipient of ArMA’s Distinguished Service Award and the AOMA’s Distinguished Service Award. In 2013 he was awarded the PIAA’s Peter Sweetland Award of Excellence. Contact him by calling 602-956-5276 or email ceo@mica-insurance.com.

However, there are a number of unwritten caveats in that simple statement. Does the insurer have the resources and the ability to fulfill the promise of protection? Are the premium charged and the size of the pool of insureds sufficient to withstand all the losses that may be generated from the pool? And will the insurer be around when it comes time to pay them? Fortunately, purchasers of insurance have access to a few resources to help them better understand the financial ability of an insurer to fulfill the promise of the insurance policy. Insurance rating agencies such as A.M. Best, Fitch and Demotech provide information on the financial strength of an insurer. State departments of insurance provide a degree of assurance that insurers selling policies have the resources to fulfill the promise of protection. And they do receive and investigate complaints regarding insurers’ business practices.

The protection provided by an insurance policy is heavily influenced by claims handling practices. Insurers have been successfully sued for unfair claims handling practices wherein claims staff are rewarded for denying or under valuing claims. Complaints to departments of insurance often are based on slow or non-responsive claims handlers and delayed payments. A call to the department of insurance and a quick internet search can be quite revealing.

Physicians are no strangers to insurance. Virtually all accept insurance payments for the services they provide, and virtually all have homeowner’s, automobile, health, disability, and life insurance policies.

34 • Round-up •May 2015 • A monthly publication of the MCMS

insurance Physicians who are actively involved in the business side of practice are familiar with property and general liability, workers compensation and disability insurance policies, and more recently, cyber liability insurance policies.

However, regardless of whether or not a physician is involved in the business aspects of practice, he or she knows or is at least aware of medical malpractice insurance, or, more appropriately, medical professional liability (MPL) insurance. Unfortunately, many physicians do not realize that there are substantial and quite consequential differences among MPL insurance policies beyond the premium cost. And, not surprisingly, the lowest cost policies may provide the least amount of protection. Medical professional liability insurance has two primary functions: to provide a defense for the insured when an allegation of medical malpractice2 has been made and to compensate a claimant when appropriate.

Commencing with the adoption of statutes in 2004 and

2005, defining the qualifications for expert witnesses and the requirement for an Affidavit of Merit, the number of suit filings in Arizona alleging medical malpractice has fallen substantially. Claims asserting injury caused by medical malpractice, however, remain an ongoing concern. Put another way, patients continue to allege malpractice, but plaintiff attorneys have become more selective in the cases they will take and pursue in the courts.

Over the last fifteen years approximately 75% of MICA’s claims have closed with no indemnity payment. But the cost to get a claim dropped or a suit dismissed is not at all inconsequential. Each claim defended on behalf of a MICA insured and closed with no indemnity payment cost an average of $40,600 in 2014, up from $35,600 in 2010. Corresponding average defense costs for claims closed with an indemnity payment were $107,300 in 2014 and $68,200 in 2010.

Those numbers are important because of a critical difference between MPL insurance policies. MICA pays de-

A monthly publication of the MCMS • May 2015 • Round-up • 35

insurance

“MPL insurance can be more than a shield to defend a physician from allegations of malpractice or to compensate a patient injured by malpractice. Policies like MICA’s provide a benefit that allows, even encourages, a physician to work with a dissatisfied patient to ‘make things right’.” — James Carland, III, MD

fense costs “outside” the limits of insurance. Dollars spent on defense do not reduce the limit of insurance. In some other policies the cost of defense reduces the limits of insurance. For example, with a policy limit of $1,000,000, a claim with $100,000 in defense costs will have available only $900,000 to pay a judgment or settlement. Such a policy is referred to as a “wasting policy.” Recently, a physician with a one million dollar policy limit went to trial with only $200,000 of the limit still available to pay any potential plaintiff verdict, leaving him potentially responsible for any excess.

Increasingly, physicians are concerned with the impact of a malpractice judgment or settlement on their hospital privileges, health plan participation, reports to medical boards and personal reputation. Having an insurance carrier settle for the carrier’s convenience or to save costs can be costly for the physician in a number of ways.

And then there is a carrier that explicitly reserves the decision to settle to itself, but contractually refuses to accept liability if the case goes to trial and results in an excess verdict. Recently, a verdict was handed down for an amount many multiples of the insurance limits available.

MPL insurance can be more than a shield to defend a physician from allegations of malpractice or to compensate a patient injured by malpractice. Policies like MICA’s provide a benefit that allows, even encourages, a physician to work with a dissatisfied patient to “make things right.” Because of National Practitioner Data Bank regulations, it cannot be used if a written demand for payment has been received, but it can help maintain a trusting physician patient-relationship when a problem occurs: Discretionary Medical Payments, or DMP.

DMP will pay, with the named insured’s consent, medical payments that do not include charges for goods or services provided by the named insured up to a specified amount, regardless of fault.4 Such medical payments may be for a second opinion, revision of a surgical scar, or other reparative services that help to maintain good relations between the physician and the patient. Part of defending a physician from allegations of medical malpractice is providing high quality and relevant education that reduces the risk of a claim or lawsuit from ever occurring, while enhancing communication, the delivery of medical care and, ultimately, the patient experience. Risk management programs are a key component of quality medical professional liability carriers.

The differences between policies and carriers are easily discovered by reading the insurance policies and asking questions. The differences go much deeper than the cost MICA has a consent clause that clearly states MICA of an annual premium. And, ultimately, these differences will not settle any medical negligence claim without the have the potential to have real dollar consequences to both ru named insured’s written consent.3 The only exceptions are the physician and the physician’s family. after a judgment, verdict or arbitration award, or the bankReferences ruptcy, death or incompetency of the named insured. 1. International Encyclopedia of Social Policy, Tony Fitzpatrick, Huck-ju Many other policies have no restrictions on their ability Kwon, Nick Manning, James Midgley, Gillian Pascall In Arizona A.R.S. §12-563 delineates the elements required to establish to settle a claim. One policy has another take: it will not 2. medical malpractice as: “The healthcare provider failed to exercise that degree allow the physician to settle unless the physician con- of care, skill and learning expected of a reasonable, prudent healthcare provider tributes 50% of the settlement dollars first. Yet another has in the profession or class to which he belongs within the state acting in the or similar circumstances . . . and . . . such failure was a proximate cause a consent clause that gives the physician “input” into the same of the injury. decision to settle, but settlement is ultimately up to the 3. MICA Policy 12/2010 edition, Section VI. 4. MICA Policy 12/2010 edition, Section VIII. carrier. 36 • Round-up •May 2015 • A monthly publication of the MCMS

Don’t miss your chance

Re sp ser ac ve e to you da r y! IN EVERY ISSUE: From the Exec. Director

Page 4

In Memoriam

Page 8

60 Years

-2015 1955

round-up Marketplace

to advertise in Round-up Magazine!

Celebrating

MCMS Board Meeting Minutes Page 33

To learn more visit www.mcmsonline.com

Volume 61

•

Number 4

•

Page 34

April 2015

Providing news and information for the medical community since 1955.

MEMBER PROFILE: Dr. Christine Harter’s dedication to patient empowerment and community outreach. Page 26

June: Employment July: Education August: Legal

PRESIDENT’S PAGE: Empowering patients through open dialogue, providing patient-specific information and helping them assimilate the information to make an informed decision is a fascinating experience and just as uplifting to a physician as much as it might be to the patient. Page 12 PUBLIC HEALTH: See Me Smoke-Free — The first multi-behavioral smart phone app designed to empower women to quit smoking. Page 16

May 7, 2015, 6-8:30 pm at the Maricopa County Medical Society.

Event sponsored by Arizona Central Credit Union.

Details on Page 13

IN EVERY ISSUE:

To learn more visit www.mcmsonline.com

From the Exec. Director

Page 4

New Members

Page 9

In Memoriam

Page 10

Celebrating 60 Years

-2015 1955

round-up Marketplace

Volume 61

Special Issue: September 2015 Insurance

You’re invited! “Philanthropy in Medicine”

•

Number 3

Page 42

March 2015

•

Providing g news and information for the medical community since 1955.

MEMBER PROFILE: Meet Diana Petitti, MD, MPH and learn about the path she has walked as an epidemiology researcher and public health advocate. Page 30

October: Community November: Membership December: Ranking

FEATURE ARTICLE: Senator Bill Frist, MD reflects on a trip to Cuba and compares its public health system to the United States. Page 20

PRESIDENT’S PAGE: Dr. Stratford believes that all physicians can find a way to participate in public health through committees, by guiding businesses to affiliate with public health issues, and through example by living healthy lives. Page 12 PUBLIC HEALTH: The resurgence of measles transmission in the US after being almost eradicated several years ago provides a teachable moment to re-examine public health strategies and personal and community responsibilities. Page 16

A PARENT’S PERSPECTIVE: Dr. Tim Jacks takes off his Pediatrician hat and puts on his “Papa Bear” hat with an open letter to a parent of an unvaccinated child. Page 24 A MEDICAL STUDENT’S PERSPECTIVE: An A.T. Still University and a University of Arizona College of Medicine – Phoenix student share their thoughts on Public Health. Pages 26 & 28

MCMS OPEN HOUSE: On March 12, 2015 MCMS hosted an open house celebrating the Society’s building facelift. As you will see by the photos a great time was had by all! Page 36 VIEWPOINT: Happy Anniversary to the SS, M&M, ADA & ACA! Page 41

Save the date for “Philanthropy in Medicine” Details on page 13

IN EVERY ISSUE: From the Exec. Director Announcements Marketplace Board of Directors Meeting Minutes To learn more visit www.mcmsonline.com

For more information and rates, contact Candice Scheibel, Advertising Director cscheibel@mcmsonline.com 602-251-2363

Volume 61

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Number 2

Page 4 Page 10 Page 34 Page 36

MCMS Members: Join us for cocktails and hors d’oeuvres as we celebrate the Society’s building facelift with an Open House on March 12. Details on page 3.

•

February 2015

Providing news and information for the medical community since 1955.

Dr. Paul Berggreen is keeping pace with technology. Page 16

Round-up is produced by the Maricopa County Medical Society.

PRESIDENT’S PAGE: Technology has transformed a physician‘s ability to discover, diagnose and treat their patients. However, with great advancements come great responsibility. Page 8

PUBLIC HEALTH: The causes of childhood obesity are many, and as such, more than one approach to treating it is important. Page 12

A CLOSER LOOK: We bring you a summary of a recent initiative led by the AMA to help improve the cumbersome EHR certification process for physicians. Page 25

FEATURE ARTICLE: Senator Bill Frist, MD shares his thoughts with Round-up readers on how our nation’s health IT framework needs to adapt. Page 26

TECHNOLOGY: The legal pitfalls of documentation shortcuts when using EHRs and steps to take to ensure that your practice is properly securing electronic records. Pages 28 & 32

legal

Surviving a Claims Audit: Things to Consider When (Not If) Your Practice is Audited By Robert J. Milligan

Robert J. Milligan Bob Milligan is a shareholder in Milligan Lawless and specializes in healthcare law. He limits his practice to the representation of individuals and companies in the healthcare and life sciences industry. In addition to his law practice, he has received an LLM degree in Biotechnology and Genomics. In that capacity, he completed coursework and independent study in: FDA regulation; pharmacogenomics; biotechnology science; law and policy; clinical research ethics; reimbursement; technology transfer; and technology licensing. He received his J.D. from DePaul University, where he was a Dean’s Scholar, and his B.S. from Northern Illinois University. Contact him at 602-792-3501 or Bob@MilliganLawless.com

s healthcare financing moves into the Big Data era, audits of the claims physician practices submit to federal, state and commercial payors are becoming more common and more sophisticated. Given the hellishly complex healthcare reimbursement rules, even innocent errors can lead to recoupment proceedings and, sometimes, penalties. Practices that have lax documentation and coding requirements are at a higher risk of penalties and possible criminal proceedings. While there is no way to eliminate completely the risk of a significant repayment obligation, a good understanding of the key players, the key issues, and some potential defenses can you defend against a repayment claim. The Key Players

While the Department of Justice and the DHHS Office of Inspector General subpoena medical records and other documents in connection with their investigations, most claims audits are conducted by a relatively small handful of companies or government contractors. Historically, commercial payors did not actively audit their providers, but that has changed in recent years.1 Most if not all large commercial insurers have in-house audit and investigations units, some of which are supported by contract audit and investigation companies. In some circumstances, the insurers seek to educate providers, resolve questions about billing and documentation practices, and preserve the payor-provider relationship. In other cases, insurers are seeking to recover payments and even, it appears, referring their findings to government agencies for consideration of criminal prosecution.

38 • Round-up •May 2015 • A monthly publication of the MCMS

legal On the government payor front, Recovery Audit Contractors (RAC) conduct audits to identify and collect overpayments. The RAC contractor for Region D, which includes Arizona and sixteen other states, is HealthDataInsights, Inc. (HDI). HDI and the other contractors receive data files from CMS and evaluate that data to identify overpayments relating to issues approved by CMS. The list of issues approved by CMS for RAC investigations appear on the RAC contractors’ websites.2 The RACs are paid a percentage of the overpayments they recover. This incentive arrangement, which is familiar to physicians who have been sued by personal injury attorneys, may result in overzealous recovery efforts; when providers appeal RAC overpayment determinations, nearly half of those determinations are overturned.3 Zone Integrity Program Contractors, or ZPICs, also conduct audits. The ZPIC for Arizona, which is in Zone 2, is AdvanceMed. According to the form letter sent by AdvanceMed to practices that are under audit, “the primary goal of ZPICs is to investigate instances of suspected fraud, waste, and abuse.” When the ZPIC identifies evidence of overpayment, that evidence may be provided to

the CMS Medicare Administrative Contractor (Noridian, for Arizona) for recoupment, or to the DHHS Office of Inspector General for investigation of potential fraud.

AdvanceMed and other ZPICs use a variety of methods, including claims data analysis, to identify providers who are candidates for audits, e.g., based on their utilization of particular codes and their comparison with their peers. Once the target is identified, the ZPIC may conduct site visits, patient interviews, and medical records reviews. A letter to your practice from AdvanceMed requesting patient records is an early warning sign that you are under scrutiny. The Key Issues

Current and recent audits have focused on a broad range of issues. These include medical necessity, unbundling, shared/split service billing, incident to billing, upcoding (or under-documentation) of Evaluation & Management (E & M) services, and inappropriate use of modifiers, particularly -59 (for a distinct procedure performed on the same day as another procedure)4 and -25 (separate E&M service on the same day as a procedure).5 While

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A monthly publication of the MCMS • May 2015 • Round-up • 39

legal each of these issues deserves attention, billing for E&M services is a high risk area, for several reasons.

First, E&M billing is an area of significant interest for payors, particularly Medicare. According to a 2012 DHHS OIG report, Medicare payments for E&M services increased 48% from 2001 to 2010; when Medicare spending on E&M services reached $33.5 billion.6 As an indicator of the type of detail currently being gathered, OIG reported that in 2010 approximately 442,000 physicians billed 370 million E&M services; 3,008 of those physicians had an average E&M code level in the top one percent of their specialties, and 1,669 physicians billed the two highest E&M codes within a code family at least 95% of the time. Presumably, the ZPICs can access the names of those physicians, and their data files, to identify targets for audits.

Possible Defenses

Obviously, the best defense to a claim for repayment based on an E&M audit is to avoid that claim, by documenting and coding perfectly. As the studies performed by OIG and others demonstrate, however, perfection is difficult to attain. Another good line of defense, if the recovery being sought is a modest amount limited to a few claims, is to simply make the repayment and to put compliance measures in place to reduce the likelihood of similar problems in the future. In other cases, however, the amount of recovery being sought justifies a vigorous defense, particularly if the auditing agency is seeking to extrapolate results from a small sample size to a much larger universe of claims. In these cases, the following defenses may help mitigate your losses:

Another reason why E&M coding is deserving of particular attention is that several studies have demonstrated very high error rates in E&M coding. For example, in May of 2014, the Department of Health and Human Services, Office of Inspector General (OIG), issued a report of a study the OIG had conducted regarding the accuracy of documentation and coding for E&M services that had been provided. The report reflects the following conclusion, “According to medical record review, 55 percent of claims for E/M services in 2010 were incorrectly coded and/or lacking documentation... ”7

40 • Round-up •May 2015 • A monthly publication of the MCMS

legal 1. Challenge the argument that, “if it wasn’t documented, it wasn’t done.” Commercial payors, Medicare, and the enforcement agencies like to say that, “if it wasn’t documented, it wasn’t done.”8 In reality, here is literature that demonstrates that much of the work physicians do is not documented.9 Consequently, in the appropriate case it is worth the time and effort it might take to demonstrate that while the documentation is lacking, the work necessary to support the code that was selected was in fact done.

2. Challenge the auditors. There is a significant body of research showing that auditors frequently disagree with each other. One article reported on the results of a study in which 300 coders (each with a minimum of eight years of experience in physician coding) were given six hypothetical progress notes to review, and they were asked to select the appropriate codes.10 The level of disagreement regarding the correct code ranged between 50 percent and 71 percent. Consequently, the results obtained by the payors’ auditors should be reviewed closely.

3. Challenge the audit process. In many cases, audit results are based on limited portions of the medical record, such as a single progress note. If that one note fails to support the code selected, a review of other portions of the record, e.g., orders, test results, nurses’ notes, etc. can fill in the gaps, and demonstrate that the work necessary to support the code was done.

4. Challenge the medical reviewer. In most cases involving medical necessity issues, the clinical review is done by mid level providers. Often, these providers underestimate the severity of the patients’ illness or their risk level. Challenging these determinations can reduce your overpayment exposure. 5. Challenge the statistical sampling and extrapolation process. In some cases, the payor may seek to extrapolate an overpayment amount from a small sample size to a large universe of claims. In this circumstance, small reductions in the

error rate for the audited size can yield large reductions in the extrapolated overpayment claim, so the defenses listed above can be even more valuable. In addition, extrapolation claims can be defended through the use of a statistician to review and challenge the sample and extrapolation methodology. Concepts like frames, sample size, randomization, stratification and confidence intervals can be used to challenge statistical validity and contest the overpayment claim. Conclusion

Good documentation and coding practices, along with an effective compliance program, can help reduce the likelihood of a claim for repayment based on medical records audits. If a claim for repayment occurs, however, a prompt and aggressive response can help mitigate your risk. ru

References

1. Hartman-Stein, P., “Commercial Insurers are Actively Reviewing Patient Records for Healthcare ‘Waste,’” The National Psychologist, July, 2014. 2. See, https://racinfo.healthdatainsights.comPublic1/NewIssues.aspx.

3. “Medicare Recovery Audit Contractors and CMS’s Actions to Address Improper Payments, Referrals of Potential Fraud, and Performance,” DHHS Office of Inspector General, August, 2013, OEI-04-11-00680.

4. DHHS OIG claims that forty percent of code pairs billed with the -59 modifier did not meet program requirements in 2003, resulting in $59 million in overpayments. “Use of Modifier 59 to Bypass Medicare’s National Correct Coding Initiative Edits,” November, 2005, OEI-03-02-00771.

5. OIG claims that thirty-five percent of claims billed using modifier 25 did not meet program requirements in 2002, resulting in $538 million in overpayments.

6. DHHS Office of Inspector General, “Coding Trends of Medicare Evaluation and Management Services,” May, 2012, OEI-04-10-00180.

7. DHHS OIG “Improper Payments for Evaluation and Management Services Cost Medicare Billions in 2010,” May, 2014, OEI-04-10-00181.

8. See, e.g., Medicare Learning Network, “Avoiding Medicare Fraud & Abuse: A Roadmap for Physicians,” July, 2014, http://www.cms.gov/outreach-andeducation/medicare-learning-network-mln/mlnproducts/downloads/avoiding_medicare_fanda_physicians_factsheet_905645.pdf.

9. T.R. Dresselhaus, et al., “The Ethical Problem of False Positives: A Prospective Evaluation of Physician Reporting in the Medical Record,” 28 J. Med. Ethics, 291 (2002). 10. King, M., et al, “Expert Agreement in CPT Evaluation and Management Coding,” Arch Int Med. 2002; 162:316-320.

A monthly publication of the MCMS • May 2015 • Round-up • 41

real estate

Innovation Abounds in Healthcare Industry, Medical Real Estate By Perry Gabuzzi & Bill Cook

Perry Gabuzzi

he future may belong to the young. However, the young at heart but over 65 set will determine the future of the healthcare marketplace.

One reason for that is by 2050, there will be 86.7 million people, or 21% of the population, who will be 65 and older in the United States. Those in that category on average visit their physician 2.5 times more often than the rest of the population. In just the next ten years, the number of Americans 65-and-older will grow by 17 million.

Bill Cook Perry Gabuzzi is Senior Vice President-Brokerage Services and Bill Cook is Vice President – Brokerage Services at Plaza Companies. Plaza Companies, based in Peoria, Arizona, specializes in the development and management of medical office properties, technology and bioscience facilities, and senior housing communities. Founded in 1982, Plaza Companies is a full-service firm with a portfolio of more than 5.5 million square feet valued at more than $1 billion. For more information visit www.theplazaco.com.

Because of this, investors will continue to flock to the healthcare marketplace. Investment in sectors such as Healthcare, Information Technologies, Telehealth, Biopharmaceuticals and Bioscience will drive market expansion. Changing models of market access to healthcare will result in a revised delivery system — “a hub and spokes network.” And due to this massive growth, the medical office real estate industry is undergoing rapid and widespread change.

The Plaza Companies team took part in a recent presentation at the Arizona State University W.P. Carey School of Business Masters of Real Estate Program. During the “Innovation in the Health Care Industry” discussion, we discussed how the medical office real estate sector is changing because of the larger trends in healthcare.

And because of this experience, Plaza is seeing the front edge of the shifting and rapidly changing healthcare landscape.

42 • Round-up •May 2015 • A monthly publication of the MCMS

real estate The addition of 30-32 million new people who receive coverage and subsidies will have a huge effect on the system. One effect is that there will be a need for 64 million additional square feet of medical office space. At the same time, healthcare providers aren’t anxious to be the ones in charge of figuring out the best solutions to their real estate needs — they prefer to focus on their mission of providing healthcare.

Other effects are yet to be seen. There are sometimes more questions than answers. Rapid innovation in healthcare—from smart phone apps to retail clinics—has experts asking: • Will hospitals compete with or be replaced by the likes of CVS, Walgreens, Walmart, Target and others as they branch out into providing medical care? • Or will firms like Google, Microsoft, Nike and others invest in healthcare technology?

• How will we care for the expanded population of insured Americans? • How will we care for the aging population of Baby Boomers?

Some shifts and opportunities can be reflected in the role of physicians. More and more, hospitals are buying practices, which means fewer physicians are in ownership roles. Also, today’s young doctors just want to come out of training and practice medicine, not run a business.

So it follows that the younger physicians lean toward hospital employment. Trends show that practices are building around larger hospitals for the best medical office space.

For example, Plaza Companies is partnering with national real estate developer Duke Realty to build a new medical office building on Banner Estrella Medical Campus in Phoenix. The facility, located on the southeast cor-

A monthly publication of the MCMS • May 2015 • Round-up • 43

real estate ner of Loop 101 and Thomas Road, will be called Banner Estrella Medical Plaza II and will be designed to complement an existing building, which opened on the Banner Estrella Medical Campus in 2005.

In the healthcare industry—especially in the medical office and medical real estate—partnerships are playing an increasing and critical role. As an example here in the Valley, the City of Peoria, BioAccel and Plaza Companies have created BioInspire,™ an incubator dedicated to medical device development that provides working capital and space to qualifying companies. More than just a facility, this collaboration was created to connect the medical device community.

Another example comes by way of Theranos, a Palo Alto-based company that’s revolutionizing the way blood tests are done. It recently opened a new 20,000 square foot facility in Scottsdale, and is partnering with retail pharmacies for new health centers.

As a result, there’s more inter-connectivity than ever before between physicians, clinics and the companies that provide products and services to support their critical work. The healthcare industry is becoming more interconnected, and there is more of a need than ever before to locate disparate organizations that all support healthcare efforts in centralized locations.

The end result is an industry in flux—and those who work within the industry must be prepared to be flexible as a result.

Whether you are a hospital executive, a physician in medical practice, or a real estate firm serving the healthcare industry, now is a time to prepare for change and identify future trends. The most successful organizations in the healthcare industry are the ones that are not afraid to innovate or change in a dynamic environment. ru

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46 • Round-up •May 2015 • A monthly publication of the MCMS

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48 • Round-up •May 2015 • A monthly publication of the MCMS

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