Arizona Physician Fall 2020 - FREE

A publication of the Maricopa County Medical Society

Changing Medicine with a Smile pg. 16

Medicine in the Time of COVID pg. 20

Fall 2020

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TOP 9 PODCASTS

MEDICAL

all Arizona physicians should be listening to

1. Body of Wonder Insightful conversations with thoughtprovoking doctors, specialists, authors, and researchers at the forefront of integrative health and wellness. Great podcast sharing ideas and new research that is changing medicine. Hosted by Dr. Andrew Weil & Dr. Victoria Maizes and produced by the Andrew Weil Center for Integrative Medicine at the University of Arizona.

2. Arizona EMCast AZEMCast is a peer-reviewed, evidencebased emergency medicine podcast heavily seasoned with expert opinion. A podcast of emergency medicine core content and practical emergency medicine tips geared toward EM residents and medical students.

AFP: American Family 3.

Physician Podcast This twice a month podcast has faculty and residents of the University of Arizona College of Medicine-Phoenix Family Medicine Residency discussing key clinical points from each issue of American Family Physician (AFP). Each episode includes brief summaries of articles, summaries, editorials, and interviews with family physicians.

Hosted by Steven R. Brown, MD.

4. Modern Medicine Matters David Boyd, MD, a board-certified family medicine physician in Goodyear Arizona, takes a real and raw approach to life. Dr. Boyd ultimately helps listeners achieve comprehensive health in body, mind, relationships and finance.

5. Reimagine Medicine This monthly podcast explores topics that are shaping health care with specialists who are leading the way towards innovative change and challenging listeners to reimagine Medicine. Hosted by Johnathan Lifshitz, Ph.D, and Katie Brite, MD, and narrated by C. Luke Peterson, DO. 2

ARIZONA PHYSICIAN | Fall 2020

6. Zombiefied: A production of ASU and Zombie Apocalypse Medicine Is something taking over your brain?

Zombified is a new podcast about how we are vulnerable to being hijacked by things that are not us. From microbes hijacking behavior, to humans influencing each other, to our brains being taken over by social media, we talk about why zombification happens, why we are susceptible to it, and what we can do about it. Hosted by Dr. Athena Aktipis, a Psychology Professor at Arizona State University and the founder of the Zombie Apocalypse Medicine Alliance.

7. Healthy Medicine Radio Each week Healthy Medicine brings you an hour of intelligent, incisive professionalto-professional discussion on the many aspects of health and health care today, exploring new ways of looking at health, diagnosis and treatment as well as health-care economics and wellness. Host Robert Zieve, MD, practices integrative medicine -- combining standard medical techniques with alternative disciplines new and old -- at Pine Tree Clinic in Prescott, Arizona.

8. Neurosurgery Podcast Welcome to the Neurosurgery Podcast - the world’s first look behind the scenes of medicine’s most intriguing and exciting specialty. Hosted by Michael Y. Wang, MD, FAANS and John Paul Kolcun, MD.

9. Arizona Physician This twice a month healthcare & medicine podcast brings physicians and medical business professionals together to help impact healthcare and medicine across Arizona.

VOLUME 2, ISSUE 4 EDITOR-IN-CHIEF JOHN MCELLIGOTT, MPH, CPH

Contents

MANAGING EDITOR EDWARD ARAUJO COVER & PHYSICIAN PROFILE PHOTOGRAPHY BEN SCOLARO, scolarodesign.com

LAYOUT & PRINTING PRISMA

Medicine in the Time of COVID

ADVERTISING

20

ads@arizonaphysician.com

MARICOPA COUNTY MEDICAL SOCIETY BOARD MEMBERS: LEE ANN KELLEY, MD President MAY MOHTY, MD, FAAP Past President RICARDO CORREA, MD, ESD, FACP Treasurer SHANE DALEY, MD Secretary JOHN PRATER, DO President-Elect GERALD GOLNER, MD, FAAP KARYNE LIMA VINALES, MD BRENDA LATOWSKY, MD RESIDENT AND FELLOW DIRECTOR ANCHIT MEHROTRA, MD MEDICAL STUDENT DIRECTOR MORGAN REEVE, OMS-IV

Features State and County Flu 8 Guidance

hysician Medical 10 PProfessional edicine During the 23 MPandemic Liability and Recession COVID-19: Then and Now

Employee Recruitment, 12

Retention, and

arizonaphysician.com Twitter: AZPhysician Facebook: ArizonaPhysician Instagram: AZ_Physician

hanging Medicine with a 16 CSmile

Technology in the World

of COVID-19

14 Safely Reopening Schools

What Lessons Have 26

Been Learned to Improve

Medical School?

How to Appropriately 28 Refer Patients Who May

Be Suicidal

In This Issue 2 Top 9 Podcasts Arizona Physicians Should Be Listening To 4 MCMS in 2020: Executive Director’s Update 6 How COVID is Changing Medicine: Letter from the President Rajeev Agarwal, MD

Fall 2020 | arizonaphysician.com

3

MCMS in 2020 E X E C U T I V E D I R E C T O R ’ S U P D AT E

John McElligott, MPH, CPH

“When you come to a fork in the road, take it.”

- Lorenzo Pietro “Yogi” Berra Expecting Change

A

fter serving as a Navy gunner’s mate during the Normandy landings, Yogi Berra went on to play for the Yankees for an astonishing 18 years. As a trusted catcher, Yogi and the Bronx Bombers fielded competitive teams, winning five consecutive championships under manager Casey Stengel. That success has persisted over time.

The Yankees franchise succeeds, in part, by expecting change and evolving to fit the prevailing style of baseball.

They take the fork in the road.

How MCMS Adapted So, too, did MCMS take a fork in the road in 2020. We pivoted from in-person networking events to hosting online CME talks and providing a virtual venue for physicians to share their frustrations about practicing medicine during a pandemic and the first global recession triggered by such an outbreak. We dedicated the Summer and Fall 2020 issues of Arizona Physician to examining impacts of COVID-19 and how it has changed medicine.

The impact has been substantial and in a positive way. The Maricopa County Department of Public Health leverages the MCMS network of physicians and our building in midtown Phoenix as a distribution hub for personal protective equipment. Hundreds of doctors throughout the valley picked up tens of thousands of N95 masks, KN95 masks, surgical masks, face shields, nitrile gloves, and gowns. Private practices received the equivalent of hundreds of thousands of dollars in high-quality PPE. Request free PPE at www.surveymonkey.com/r/ RequestCountyPPE. MCMS staff will follow-up with details.

Purchase PPE at https://actionppe.org/3/mcms/.

ActionPPE is the network trusted by doctors throughout the nation.

4

ARIZONA PHYSICIAN | Fall 2020

MCMS has also grown its status as a trusted community partner. We assisted the county and state health departments with soliciting volunteers for back-to-school vaccination clinics, influenza vaccine clinics, and a potential COVID vaccine. We participate in the Roll Up Your Sleeve campaign from the Arizona Department of Health Services to increase use of flu vaccines.

Keep Improving Our organization doesn’t settle. MCMS is always pursuing ways to promote excellence in the quality of care and the health of the community, and to represent and serve its members by acting as a strong, collective physician voice.

One step forward was creating our Diversity Subcommittee. We aim to discuss ways to assess the current racial and ethnic diversity of physicians in Maricopa County and develop a plan for recruiting and retaining a more diverse physician workforce. For example, we learned the Arizona Medical Board and Arizona Board of Osteopathic Examiners do not collect data on the racial and ethnic identity of physicians. Before the medical community sets goals for a more diverse workforce, we need a baseline.

Interested in helping to create a more inclusive medical community? Volunteer online at www.surveymonkey. com/r/MCMSdiversity.

On Deck Practicing physicians are on the field. You’re taking swings for your patients and working hard to ensure they get the care they need. While MCMS supports your interests today, we also have an eye on who is on deck and in the batter’s box. We want to connect medical students with doctors to learn the ropes and prepare for their careers.

We are launching the MCMS Shadowing Program through which practicing physicians would volunteer as

hosts for local medical students to shadow your physicianpatient interactions. This would involve an occasional half or full day of shadowing, as your availability and schedule permit. We expect most of these shadowing experiences to be a one-time experience for the students, and therefore will not require an ongoing commitment on your part.

There will be no expectation to evaluate the medical students. If you are willing to serve as a shadowing host, then please sign up online at www.surveymonkey.com/r/ MCMS_Shadowing_Hosts.

Utility Player Whether your medical team is large or small, consider Maricopa County Medical Society your utility player. We can

play several different positions for you. Need a referral to a lawyer or accountant? Call us. Need a company to collect delinquent accounts? Our Bureau of Medical Economics company remains one of the largest medical collection agencies in the state since 1951. Need source and credential verification services? We got you covered, owning the largest credentialing program in Arizona. Would you like patient referrals? MCMS has a patient referral hotline and online search tool.

Regardless of your work setting, draft MCMS for your team. We will help you to expect changes and evolve as medicine shifts over time. For more information about membership, visit www.mcmsonline.com/join.

Fall 2020 | arizonaphysician.com

5

How COVID is Changing Medicine Lee Ann Kelley, MD

LETTER FROM THE PRESIDENT

I

n 2020 - this most unusual of years - many things are uncertain, but we know without question that COVID-19 is changing medicine. In this Fall 2020 issue of Arizona Physician, we focus on some of those changes and their impact on physicians, patients, and the health of the public.

As we go to press, there are over 7.5 million COVID-19 cases in our country, and 235,000 cases in our state of Arizona, with 223,000 deaths nationwide and almost 6,000 deaths in Arizona due to COVID-19. Before 2020, most physicians would never have believed that we would become so interested (and self-educated) in infectious disease and public health, yet necessity is the mother of invention, as we have become the “go-to” source of COVID-19 information for our patients, families, friends and neighbors. We have attended fewer CME courses this year, but have spent far more time reading and learning -- about COVID-19 and all of its ramifications across a broad spectrum of medical specialty areas as well as about government and public health agencies – and also about new technology to assist us in our practices.

Telemedicine Probably the most obvious technological change for most of us is the rapid pivot to telemedicine for some (or all) of our clinical work. It appears that telemedicine is here to stay, for better and for worse. It clearly reduces the risk of infection exposure to patients, staff, and physicians, and has been generally well-received by all parties. Although we may have found some challenges and limitations in our diagnostic abilities without the usual methods of physical examination accompanied by visual/facial cues and body language, we have gained a more 3-dimensional biopsychosocial approach to treating patients, peering into their homes and personal lives, meeting their family members and pets, gaining a better understanding of their challenges and support systems. We’ve gained family members who can listen and watch the phone and video encounters, the “second parent” who can’t be in the room, extended family members helping with translation, a parent helping a 19-year old child navigating the medical system on their own for the first time. Technology allows family 6

ARIZONA PHYSICIAN | Fall 2020

members to say good-bye to loved ones via FaceTime. As one local physician said, “I’m so glad we have the technology, but so sad we need it so much.” Corporate medicine is delighted to provide personalized portals and apps to connect patients more closely to their physicians, but physicians are finding that 24/7 connection to be a mixed bag, blurring the boundaries between work and homelife. New technologies for remote monitoring and wearables will inevitably replace in-person care to some extent, and this increased data may improve the quality of medicine that we provide.

PPE & Physician Stress Many of our patients have avoided acute and routine care this year due to fear of infection and our practice limitations. This fall we are facing a “catch-up” period as we go into flu season and the ongoing COVID pandemic. We are still frustrated by our inability to obtain proper PPE at reasonable prices for in-person patient care. We have had to become creative to preserve our precious PPE, instituting blocks of clinic time and “curbside” care to minimize PPE usage. This shortage, along with awareness of possible transmission from asymptomatic people and unreliable testing, causes new anxiety with patient encounters, as every encounter potentially endangers the physician and his/her family. This often results in the physician standing as far away as the room allows and spending less direct contact time in the room with patients.

As our stresses mount due to the financial impact of COVID on our practices, we are also stressed by the burden of having to learn new technology in a short period of time. Our support staff has scaled down, and we have had to take on the burden of administrative tasks in addition to our clinical work. Employed physicians continue to face lack of administrative support from their corporations and institutions just when they most need to preserve bandwidth to handle the new diagnostic and technological challenges.

Where Does It End? At a time when our nation needs stability and leadership, our trust in government agencies such as the FDA and CDC has been eroded by inconsistencies and lack

The uncertainty created by a new illness has fortuitously resulted in increased support and communication among physicians, who are banding together out of necessity, gathering online, having honest conversations, consulting colleagues across the country, sharing articles, updates, and the latest information on treatment methods, PPE, and COVID-19 testing availability. of transparency. Public health decision-making seems to be based more on politics than on science. Consequently, our patients’ trust in our medical advice and science has been damaged, which carries over to upcoming COVID-19 vaccines. Physicians already face the challenge of educating patients that established vaccines are safe and effective. The idea of “Operation Warp-Speed” approval of a COVID-19 vaccine has frightened many patients, with recent polls showing it will have a low acceptance rate. To achieve herd immunity, we need a vaccine that is at least moderately effective and is widely administered. To be able to advocate for such a vaccine, we ourselves need to be able to trust that the vaccine is not only effective but safe. This will require transparency from our public health agencies to assure the medical and scientific community that all safeguards are in place to move forward, with no political considerations.

The uncertainty created by a new illness has fortuitously

resulted in increased support and communication among physicians, who are banding together out of necessity, gathering online, having honest conversations, consulting colleagues across the country, sharing articles, updates, and the latest information on treatment methods, PPE, and COVID-19 testing availability. Physicians are speaking up to administrations, contributing to PACs, running for office, fighting for our patients and for each other. We realize that we are empowered by this fellowship with other physicians, and that we are stronger by working together. For these reasons and so many more, I encourage you to take advantage of all that our Maricopa County Medical Society can offer you, as a current or future member.

Stay safe!

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www.MilliganLawless.co m A highly responsive and proactive Arizona law firm providing comprehensive legal services to health care providers.

Fall 2020 | arizonaphysician.com

7

STATE AND COUNTY FLU GUIDANCE F

lu season is underway in Arizona. As health care professionals prepare for a potential new wave of influenza that will coincide with the COVID-19 pandemic, the engagement of all Arizona physicians with the community will be critical in order to robustly respond to these current and emerging health threats. Organizations such as the Arizona Department of Health Services (ADHS) and the Maricopa County Department of Public Health (MCDPH) are both taking steps to ensure adequate resources are available for physicians to fight the flu, and both departments are making recommendations to help guide health care professionals over the coming months.

As ADHS Director Dr. Cara Christ mentioned in a press conference in September, “Every flu season, our hospitalizations increase due to influenza. Getting your flu shot will help prevent hospitalizations from influenza, keeping more hospital beds open.�

As we enter the fall and winter months, ADHS has requested that Arizona physicians continue to actively promote flu vaccination to their patients, families, and friends. MCDPH has ordered 10 times the vaccine it normally orders for a typical flu season so that every resident can get vaccinated, regardless of insurance status or ability to pay.

MCDPH has partnered with non-profits, pharmacies, hospital systems, homeowners associations, fire departments, and faith-based communities to make sure the vaccine is as 8

ARIZONA PHYSICIAN | Fall 2020

widely available as possible. Access to vaccination services is critical, because while roughly 95% of Arizonans vaccinate their children, the number of vaccine exemptions has been rising in recent years.

Understanding which populations are most vulnerable will be important to be aware of as the flu season progresses through the end of the year and into 2021.

Vaccination of high-risk persons is especially important to decrease their risk of severe flu illness, and people at high risk of serious flu complications include young children, pregnant women, people with certain chronic health conditions and people 65 years and older. The Centers for Disease Control and Prevention (CDC) notes that many people at higher risk from flu also seem to be at higher risk from COVID-19, and although flu vaccines will not prevent COVID-19, vaccination will reduce the burden of flu illness, hospitalizations and deaths on the health care system and conserve scarce medical resources for the care of people with COVID-19.

MCDPH is also exploring options to use flu vaccination efforts as an opportunity to exercise mass vaccination for COVID-19. While it is anticipated that the demand will likely exceed the supply, MCDPH is working with university partners to develop a mathematical model for the rapid and equitable distribution to those who are at highest risk and most vulnerable. There are also partnerships between

As the pandemic continues and our daily routines are disrupted, Arizona physicians must remain vigilant in supporting their patients and advocating for healthy communities.

MCDPH and various Maricopa County healthcare systems to make sure that prioritized groups across the county have access to the vaccine. As soon as more information is available about a COVID-19 vaccine it will be communicated to Arizona physicians so that safe, evidencebased recommendations can be made to patients, families, and friends.

Arizona providers who offer seasonal influenza vaccine are encouraged to register for VaccineFinder at https:// locating.health/register as this site will be the primary source that public health departments will utilize to alert the public of where to get flu vaccinations. Additionally, in an effort to provide a uniform flu vaccination message statewide, the ROLL UP YOUR SLEEVE social media campaign found through www.azdhs.gov can be shared with public and private partners. Arizona physicians looking to stay up to date on the state’s flu and COVID-19 case counts can also access this information through dashboards on the ADHS website.

As the pandemic continues and our daily routines are disrupted, Arizona physicians must remain vigilant in supporting their patients and advocating for healthy communities. Until a COVID-19 vaccine is widely available to those who want it, we all need to continue to encourage our patients and families to stay 6 feet away

from others, wear masks, wash and sanitize hands, avoid touching their face and to stay home when they are sick. Routine counseling and encouragement to adhere to health practices by Arizona physicians will help keep transmission down, and while these interventions have been messaged widely for the control of both influenza and COVID-19, they will also help control the spread of many other common illnesses.

This pandemic has stressed our healthcare workers and our entire healthcare system far beyond what we thought we could handle, and we must all continue to collaborate and work together as we enter the flu season. Know that you all play a vital role in the public health system and we appreciate everything you have sacrificed for the health or our Arizona communities. Stay safe!

By William Floor, MPH Candidate, Class of 2020, A.T. Still University, sa201263@atsu.edu

A legacy of caring Hospice, palliative and dementia care • Support for the caregiver Music, massage and pet therapy • Grief support Call 24/7 to speak with a nurse As a not-for-profit, we turn no one away

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Fall 2020 | arizonaphysician.com

9

Physician Medical Professional Liability and COVID-19:

C

OVID-19 has had a profound impact on our social, economic and healthcare systems. Even before it was designated a pandemic, doctors, nurses and advanced healthcare professionals began actively treating highly infectious patients while trying to manage their own personal risk. Personal protective equipment (PPE) was suddenly needed...and unavailable. Many physicians whose specialty skills did not match the requirements needed to treat COVID-19 experienced a collapse in patient visits leading to layoffs and closed offices. Public service announcements emphasized social distancing, and medical practices encouraged patients to call but to stay home. Taking the cue, individuals avoided Emergency Departments, preventative medical screening and vaccinations. Telemedicine exploded as in-person healthcare faded.

Overnight, medical care transitioned from the historical “laying on of hands” to the inevitable extension of social distancing, “history-based” diagnosis and treatment. Complicating the picture was the novelty of the SARS-CoV-2 virus and the conflicting, often contradictory information and recommendations provided by the CDC and the WHO regarding the basic pathophysiology of COVID-19, its prevention and its treatment. Guidelines were issued, withdrawn and countermanded in the space of a few days or weeks.

It wasn’t just physician offices that shut down. So did the law courts. Courtrooms and jury rooms are quite small.

Social distancing is extremely difficult. Trials stopped and few expect civil trials to resume before 2021. But many of the functions of the court remained open, including the ability to file a suit.

The impact on physicians and advanced healthcare practitioners continues to evolve. Many suggest that physicians and other front-line practitioners will be protected from malpractice liability by the “halo” afforded to “heroes.” Others see that as transient at best.

The immediate impact of the pandemic is fewer claims of malpractice; thirty percent fewer than one year ago.

This is consistent with the decrease in patient encounters, fewer screenings and essentially no elective procedures. Suit filings declined, but not to the same extent, likely reflecting the time between an alleged incident, plaintiff counsel’s evaluation and preparation of a suit filing.

Some believe that Governor Ducey’s March 11 declaration of a “public health state of emergency” and his subsequent “Good Samaritan” Executive Order1 provide partial immunity by declaring that physicians and other healthcare practitioners are “presumed to have acted in good faith and [are] immune from civil liability” unless their conduct is considered “gross negligence or reckless or willful misconduct”. It is unclear if this applies solely to COVID-19 related care or to medical or surgical care provided (or not provided) for other illnesses during the COVID-19 pandemic emergency. Many predict the constitutionality of the declaration will be challenged.

In late June, the Arizona Department of Health Services activated the “Arizona Crisis Standards of Care Plan,”2 a plan that provides guidance for triage, expanded scope of practice,

THEN and NOW

and medical resource allocation priorities. These defined care standards, however, may conflict with the statutorily defined standard of care that requires a physician to exercise “that degree of care, skill and learning expected of a reasonable, prudent health care provider in the profession or class to which he belongs within the state acting in the same or similar circumstances” (A.R.S. §12-563:1).

Implicit in the requirement that a physician meet the standard of care is an awareness of the guidance and the recommendations provided by the literature, specialty societies, and local, national and international entities such as the Arizona Department of Health Services, the CDC and WHO. Information and recommendations by these entities have often conflicted and certainly have changed with each passing month as more is learned about COVID-19. If it comes to a claim or suit, it will be necessary to know what “expert guidance” was considered valid at the time care was rendered.

The immediate impact of the pandemic is fewer claims of malpractice; thirty percent fewer than one year ago. This is consistent with the decrease in patient encounters, fewer screenings and essentially no elective procedures. Suit filings declined, but not to the same extent, likely reflecting the time between an alleged incident, plaintiff counsel’s evaluation and preparation of a suit filing.

Published studies clearly demonstrate the dramatic decline in immunizations, cancer screening, and cancer treatment during the pandemic. A recent study published in JAMA Network Open reported 46% weekly drop in diagnoses for six common cancers, and a 52% drop in breast cancer diagnosis alone.3 Modeling predicts a 16% increase in colorectal cancer deaths and 5% increase in lung cancer deaths. Based on these and similar reports, many anticipate a surge in claims alleging delayed diagnosis and delayed treatment.

Not to be forgotten is the dramatic growth in telemedicine. It has enabled medical visits but has severely limited physical assessment and reduced personal interaction. It has allowed physicians to unknowingly practice in states where they are not licensed. But in-state or out-of-state, many have expressed concern that the rapid adoption and widespread use of telemedicine will result in allegations of missed or delayed diagnosis and delayed

treatment. Moreover, telemedicine has been widely utilized but often without the careful attention to documentation requirements and the data integrity, privacy and confidentiality required by the Department of Health and Human Services (DHHS).4 For the moment, the OCR (Office of Civil Rights) of DHHS has “exercised its discretion” in not enforcing DHHS’ requirements. Not to be forgotten are the risks of rapidly adopted and widespread use of digital communications: data theft and HIPPA violations.

Physicians, surgeons and advanced healthcare practitioners are likely to see a gradual return to the increasing trend in claim and suit frequency over the next few years. The question is, will there be a “bump up” in claims and suits as deferred claims are brought forward, ancillary claims are made for care provided or not provided during but not directly related to COVID-19, claims asserted for care provided or not provided to patients with COVID-19 or for failure to recognize complications related to as yet unrecognized long-term complications of COVID-19.

Executive Orders: 2020-07 dated March 11, 2020, 2020-27 dated April 9, 2020 and 2020-42 dated June 25, 2020 Activation: http://azpha.wildapricot.org/resources/sdmac-crisis-standards-activation.pdf Plan: https://www.azdhs.gov/documents/preparedness/emergency-preparedness/response-plans/azcsc-plan.pdf 3 https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2768946 4 https://www.hhs.gov/hipaa/for-professionals/faq/3020/when-does-the-notification-of-enforcement-discretion-regarding-covid-19-and- remote-telehealth-communications-expire/index.html 1 2

By James F. Carland III, MD, Chairman and CEO, Mutual Insurance Company of Arizona (MICA), JCarland@mica-insurance.com

PRIMARY CARE PRACTICES WANTED FOR ACQUISITION Matrix Associates, LLC Represents a Large, Local Physician-led and Physician-run, Multi-specialty Practice Seeking to acquire Primary Care Practices In the Metropolitan Phoenix Area For Further Information, Please Contact:

Jeff Heinemann Matrix Associates, LLC (602) 370-7764 jeff@matrixphoenix.com (All requests are confidential and All Fees are paid by our Client) Fall 2020 | arizonaphysician.com

11

Employee Recruitment, Retention, and Technology in the World of COVID-19

C

OVID-19 has affected all aspects of personal and professional lives. The AMA is reporting that "Physician practices managing patients during the COVID-19 pandemic are confronting new and unique operational and business challenges". Notably, the pandemic is furthering the already existing challenges of staffing, retention and technology in small medical practices. The shortage of healthcare workers was a concern before the pandemic. Now, that concern has intensified. How can a practice quickly hire the staff they desperately need to be successful and continue to give quality patient care? While in a large metropolitan city like Phoenix, the candidate pool is larger; smaller physician practices and those in more rural towns like Wickenburg may be challenged from already dealing with a shortage of healthcare workers. According to a 2019 U.S. Department of Health and Human Services study, more than 59 percent of federally designated Health Professional Shortage Areas are in rural areas.

Recruiting practices in the age of COVID-19 may have pivoted into virtual interviews replacing in-person interviews, building stronger partnerships with staffing agencies who can accelerate the hiring process and participating in virtual job fairs. Leaving no stone unturned, physician practices are exploring candidate pools of laid off workers, such as school nurses, hospitality and restaurant workers. According to the US Bureau of Labor Statistics reported in September of 2020, employment in healthcare operations is projected to grow 15% over the next ten years, adding about 2.4 million new jobs. Resulting in healthcare 12

ARIZONA PHYSICIAN | Fall 2020

adding more jobs than any other occupational groups! As the candidate pool continues to remain competitive, physician practices can consider implementing initiatives such as job shadowing, internships and tuition reimbursement to attract potential candidates. The use of job shadowing and internship opportunities for high school students can generate interest in the healthcare industry before they ever enter the workforce.

Consider implementing a tuition reimbursement program where workers can earn important on-the-job experience while furthering their education. Continuing education and/or certificate programs (such as the medical assistant certification) can drive worker retention and is dually invested in not only their satisfaction but of physicians being able to utilize that credential and new-found knowledge within their practices to their advantage. While a tuition reimbursement program comes with a financial investment, the return on investment can be high.

With or without some of these programs, it's not an easy task to find candidates with the skills and experience to meet current needs, along with navigating interview questions to assess culture fit. But, before the recruiting process is launched, how do you determine what skills and experience are needed to meet current needs? Has the pandemic created a need for a different set of skills and experiences? Is there a need for candidates who offer interchangeable skills? Candidates who can demonstrate a sense of nimbleness and initiative? These are some important questions to ponder before the recruiting process begins. Typical staffing analyses like full-time

equivalent (FTE), may help to determine staffing numbers necessary to deliver exceptional patient care while balancing financial considerations.

Thinking of small practices in particular, the need for interchangeable skill sets may be critical to avoid over- or under-staffing and provide seamless cover for time off without compromising patient care. An additional benefit of this approach may result in a “win-win” situation, with workers feeling more challenged and engaged, by using their wide array of skills. When workers feel engaged, they are more likely to remain. Supplementing your recruiting processes with digital tools like an applicant tracking system can ease this burden.

When workers feel engaged, they are more likely to remain.

Supplementing your recruiting processes with digital tools like an applicant tracking system can ease this burden.

While a variety of tasks can lead to greater worker retention, it’s not the only method available to reduce a turnover rate. A high turnover rate will most definitely impact the practice’s bottom line. The average cost of replacing a worker is estimated to be upwards of 150% of the annual salary. This cost is calculated using the costs associated with recruitment, such as job posting fees; lost productivity and cost to train the new worker. Turnover can also impact the remaining workforce resulting in lower morale and a heightened risk of error covering the extra work. Implementing methods to promote ongoing

communication, cross-training and performance feedback can build a high performing and engaged workforce.

Worker retention, whether during the pandemic or not, is a strategic initiative best demonstrated on a day-to-day basis. During these trying times, Kristin Struble, MD, FAAP, pediatrician and partner at Camelback Pediatrics, has instituted pizza days, distributed gift cards, hosted Zoom happy hours with food delivery to employees’ homes and continued to pay workers when the office was closed. Dr. Struble states, “I am grateful for my staff’s dedication to patients and the practice throughout the pandemic. To retain employees, you have to go the extra mile to show them that you care about them and are grateful for all that they do."

Whether recruiting, retaining or other Human Resources initiatives, iSolved HCM can be a valuable partner in building processes and systems to support small and large medical practices alike. People Services brings a wealth of HR consulting expertise coupled with automated HR tools in an easy-to -use bundled payroll software application taking the burden of managing employee data off the practice to focus on medicine and the patient experience.

By Joyce Heiss, Human Resources Business Partner, iSolved, jheiss@isolvedhcm.com

By Allison Hitzeman, MBA, SHRM-CP, OTR/L, CHT, Human Resources Consultant, iSolved, ahitzeman@isolvedhcm.com

Prisma would like to thank all of our healthcare workers and first responders for keeping us safe.

602 243 5777 prismagraphic.com

Fall 2020 | arizonaphysician.com

13

SAFELY REOPENING

OPINION

SCHOOLS

O

ur Arizona schools closed for in-person instruction on March 13 when there were 12 known COVID-19 cases and no known deaths. As of October 7, there were 222,538 cases and 5,733 known COVID-19 deaths. In reopening in-person education, there was natural anxiety for students, parents, educators, and school leaders.

After calls for written statewide evidence-based benchmarks, Governor Ducey then tasked the Arizona Department of Health Services (ADHS) to come up with such metrics by August 8, with many schools set to open on August 11. On July 23, physicians and educators again called for evidence-based benchmarks as a prerequisite to opening. On July 26, a copy of evidence-based metrics compiled by local physicians was delivered to ADHS Director Cara Christ, MD, MS, and Arizona Superintendent of Public Instruction Kathy Hoffman, MS. Several days later, Dr. Christ and Superintendent Hoffman presented three very weak guidelines: a two-week decline in the number of COVID-19 cases or two weeks with new case rates below 100 per 100,000, two weeks with less than 7% positivity of COVID-19 diagnostic tests, and two weeks with hospital visits due to COVID-like illness below 10%. A three-tiered threshold system was outlined: 14

ARIZONA PHYSICIAN | Fall 2020

red for substantial community spread, yellow for moderate community spread, and green for minimal community spread. ADHS recommended “county-specific public health benchmarks fall within the moderate or minimal spread category in all three benchmarks for two weeks in order to provide hybrid learning.” None of the metrics were firm thresholds that must be met but rather voluntary suggestions.

Though little had been done to ensure a safe transition back to school, the school districts’ insurer added another complicating factor. The AZ School Risk Retention Trust (“the Trust”) struck the phrase “foreign or exotic disease or illness” from coverage. Districts would be uncovered for pandemic liabilities. The Trust then released strongly worded waivers or “acknowledgments of risks” for parents to sign to reinstate minimal coverage. Additionally, many districts required employees to sign waivers of risk. Some districts even mandated non-disclosures to prevent staff from sharing their COVID-19 positive status. These legal maneuverings have further increased distrust from parents and students alike.

Today, many districts have opened for in-person education despite being in the yellow zones or red zones because parents are desperate to get their children back

to school. As students returned, many districts found themselves short staffed as teachers were understandably reluctant to return. Almost one thousand teachers resigned as of August 31. This loss of teachers means that 28% of Arizona classrooms do not have a certified teacher.

Higher education has also been affected. Arizona State University reported only active cases of COVID-19 students and staff. Once the isolation period for these students was over, ASU removed them from the case count. ASU has reluctantly agreed to start reporting the standard cumulative numbers again. ASU also shortened the semester and will be virtual only after Thanksgiving. Maricopa Community Colleges are mainly virtual. And the University of Arizona instituted a shelter in place mandate due to a surge of positive cases on campus.

Despite the available CARES Act funding, most districts in Maricopa County are having to finance their own options for testing and tracing. In other cases, some school communities like Tucson have health department support for no-cost testing and tracing. It is hoped that continued advocacy can get the local health departments to require more robust testing and tracing.

The most important metric, percent positivity rate, has also come under fire because of inconsistencies. ADHS elected to count only the electronically reported numbers, leaving 25-30% of tests uncounted. Some higher risk populations were part of the unreported cases, such as indigenous communities and predominantly Hispanic or

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Black communities. Additionally, the ASU Biodesign Institute started to report percent positivity as the number of positive cases divided by the number of the entire ASU population as opposed to the standard positive cases divided by number of people tested. These inconsistencies leave citizens with little certainty as to the real level of risk.

As physicians, we should support our school leaders as they make the difficult but courageous decisions to open only when truly safer. Educators are not public health experts, just as we should not be put in charge of educating thousands of students. It is impossible to make it 100% safe for all. The goal needs to focus on making it safer while knowing that at least 40% of educators are high risk. Returning to the basics of epidemiology would include control of community spread, enforcement of robust mitigation systems with free accessible testing, contact tracing, isolation, and quarantine. We can, with personal responsibility, as well as holding our school leaders and elected officials accountable, have a thoughtful plan for safely reopening the school that is evidence-based with intentionality for equity.

By Susan Hughes, MD, Retired Physician, Bounce Highest LLC, DrSusan@bouncehighest.com

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Fall 2020 | arizonaphysician.com

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CHANGING MEDICINE with a

Rajeev Agarwal, MD, Agave Pediatrics

R

ajeev Agarwal, MD, is a bundle of energetic joy who moves you after just a few minutes of talking. That positive attitude has helped shape his career as a pediatrician, harnessing the energy to forge long lasting relationships with parents of his patients.

The Beginning Growing up New Delhi, Dr. Agarwal was going to follow his relatives and become an engineer. But then his sister bucked the trend and entered medicine. She would encourage him by saying, “I think you would make a great doctor because you really care about people.”

After earning a medical degree from the All India Institute of Medical Sciences, Dr. Agarwal trained in pediatrics at the University of Texas Medical Branch at Galveston Affiliated Hospitals and completed a fellowship in pediatric nephrology from the University of Florida College of Medicine and Children’s Hospital in Columbus, Ohio.

Dr. Agarwal launched a private practice in rural Virginia but soon found city life was calling. Deciding to head west in 2005, Dr. Agarwal interviewed with several pediatric practices in the Phoenix area but found them to be underwhelming in the doctor-patient relationship.

Dr. Agarwal’s vision was to build deeper relationships with more frank discussions amongst patients and doctors.

He would merge alternative and traditional medicine to fit the needs of the patients. His model would be based on providing a mix of community healing, prevention, nutrition, meditation, and healthy lifestyle, rather than what he saw as “in and out diagnosis.”

“I think we should become caretakers of health instead of caretakers of disease.”

“Having a bigger impact on how people live, what people read, how people see things in life,” Dr. Agarwal states. He believes in learning from patients, so that you can put in place best practices. That approach would lead him to continued success.

At Agave Pediatrics, Dr. Agarwal feels blessed to have built such great chemistry with his fellow providers. They approach medicine with his same fervor. That lead patients in Scottsdale, Goodyear, Chandler, and Glendale to ask why Agave was not in their neighborhoods. After learning some patients were travelling 40 miles to visit the Phoenix office, Dr. Agarwal chose to expand. He says, “We need to go to them. A pediatric office should be easily accessible to parents of children in need.”

Practicing during COVID-19 As the current pandemic has swept across the nation, medical practices have adjusted to the constraints and mitigation measures to prevent the spread of the SARS-CoV-2 virus.

Agave Pediatrics adjusted early on. They increased use of tele-visits, became more aggressive in cleaning office suites, and followed shifting guidance from the state and county. The family-oriented culture focused on clear communication between all stakeholders, including leadership and staff, and allowed Agave Pediatrics to thrive during the chaotic period.

Agave Pediatrics experienced two types of hardships while staying open during the pandemic, one through the lens of their patients and a second from staff.

Dr. Agarwal explains, “Our practice numbers were down 20-30% in revenue of what we would normally see.”

Reimbursements from insurance companies weren’t initially consistent and Agave ate the unreimbursed costs.

For staffing, Dr. Agarwal was able to keep all 75 employees on the payroll, although the drop in revenue forced Agave to reduce hours in all locations. He is convinced the positive culture helped to cultivate staff who

stayed upbeat and supportive of the changes. Leadership checked on employees to track how the pandemic economy was impacting their families. When a few staff members tested positive for COVID-19, others on the team volunteered to shift locations and cover for their ailing colleagues. Such support and efficiency led to the hiring of five more staff.

A requirement to practice during the pandemic was more personal protective equipment, both for staff and patients. “PPE wasn’t easy to come by in the early stages of the pandemic,” says Dr. Agarwal. He feels blessed Maricopa County Medical Society stepped up to help his practice. He also thanks patients’ mothers who made hundreds of cloth masks to ensure the practices would remain open.

Dr. Agarwal found telehealth to be a mixed bag.

Although reimbursement wasn’t a challenge, he found it has been difficult for many patients whose slower Wi-Fi at home hampered the communication. This caused several dropped calls and choppy connections with parents and their children.

Impact of a COVID Vaccine With several vaccine candidates still in clinical trials, it is difficult to predict when and how well any effective vaccine will impact medicine in 2021. Yet, Dr. Agarwal says, “I always plan on a couple of levels. I plan for tomorrow, I plan for a month, I plan for a year, and I plan for five years.”

The most important milestone that will change his planning is release of a vaccine.

Dr. Agarwal understands some people are nervous any vaccine candidate may be rushed to production. That’s why he looks forward to seeing the FDA approve a safe and effective vaccine for use. Whenever that happens, Agave Pediatrics wants to be first in line to distribute a vaccine to its patients and staff.

Thinking of Going on Your Own? Running his own practice has been difficult, especially during the global pandemic and its recession. But Dr. Agarwal does not mince words. If a physician believes going into private practice will be easy sailing, then they should think twice.

Be ready, he says, for a lot of initial disappointment and be prepared to work very hard. Dr. Agarwal finds being in charge is a challenging lifestyle. If you are not absolutely wedded to the practice, then you are going to find it difficult to run. In the early days of Agave Pediatrics, Dr. Agarwal felt the pull to focus on medicine. He learned it was equally important to take care of the business.

Dr. Agarwal believes physicians need to learn about human resources and managing people. In private practice,

“If you’re not ready to work really, really, really hard, you’re going to be unhappy!”

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ARIZONA PHYSICIAN | Fall 2020

this entails hiring the right practitioners and office staff, recruiting and retaining patients, and building core personnel you can trust. It is essential for success. “As a physician, you can’t do it all,” he says. “You need to be able to trust your team to handle their jobs.” Dr. Agarwal also finds that treating medical and office staff fairly goes a long way towards practices flourishing over time.

The Future of Healthcare in Arizona What a year 2020 has been. Like a rock thrown in a pond, the pandemic’s ripples will last for years to come.

Patients are rethinking how they interact with medical offices and seeking options for telehealth services they can access online or through a smartphone. Telehealth, a fledgling market making inroads in some specialties, expanded rapidly and is here to stay.

Dr. Agarwal’s take on telehealth is that insurance companies were initially blind to it, parents were blind to it, and doctors looked at telehealth as subpar care. When physicians were pushed, they found more and better ways to apply the technologies. Dr. Agarwal is convinced telehealth will not replace the human element of a thorough examination, but it can help in other ways.

The decisions of whether the State of Arizona and the Federal government maintain payment parity will greatly impact whether telehealth services remain a strong adjunct to face-to-face visits.

As a pediatrician, Dr. Agarwal hopes the pandemic will encourage more adults and children to receive the flu shot, an essential step to protect individuals and the larger community. Maricopa County Department of Public Health and the Arizona Department of Health Services are moving swiftly to inoculate as many residents as possible this flu season.

Another way Dr. Agarwal sees healthcare interactions shifting is in the patient’s view of cleanliness. Parents of his patients are very conscious of coming into the office. He is convinced private practices, clinics, urgent care facilities, and hospitals will maintain a high level of cleanliness moving forward.

When it comes to the future of pediatric care, Dr. Agarwal predicts more investment in building lasting

relationships with parents. Doctors, he believes, will provide touchpoints at the right times and in ways parents can access, helping to keep patients in their care.

Agave Pediatrics has made getting vaccinations easy.

The process is very quick and doesn’t require seeing a practitioner. Dr. Agarwal foresees more practices following suit, leading to an increase in vaccination uptake.

Dr. Agarwal also predicts greater separation of patients between sick and wellness visits. Agave Pediatrics believes this method has helped to reduce transmission of disease and allows staff to focus on procedures according to whether they work on sick or wellness visit days.

Regardless of what is around the corner, Rajeev Agarwal, MD, will be ready. From a would-be engineer in New Delhi to owning several pediatric locations in Arizona, Dr. Agarwal has evolved and remains laser-focused on providing high quality care for his patients. We encourage you to meet Dr. Agarwal and feel the joy he exudes for medicine.

By Edward Araujo, Communications Coordinator at Maricopa County Medical Society (MCMS), earaujo@mcmsonline.com

ON THE PERSONAL SIDE WITH DR. AGARWAL 1. If you could describe yourself in one word, what

would that be? Human 2. Do you have family? Pets? Yes, my wife is a radiologist. My son is 25 years old and in his first year of medical school. My daughter is a senior in

high school. After my daughter leaves for college,

my wife and I plan on getting a dog.

3. Do you have a hidden talent most people wouldn’t know about you? I like to write and direct plays.

Before COVID, ten other physicians and I started

practicing for a play. We hope to bring it to theaters soon.

4. What career would you be doing if you weren’t a physician? An interior decorator.

5. What book are you reading now? The Power of Now:

A Guide to Spiritual Enlightenment, by Eckhart Tolle.

6. What is your favorite movie? Forrest Gump 7. What is your favorite food? Indian food, as I’m a vegetarian.

8. What is your favorite local restaurant? True Food Kitchen

9. What is your favorite activity outside of medicine?

Gardening. I’m growing plants and vegetables right

now; four types of squash, tomatoes, and okra.

Fall 2020 | arizonaphysician.com

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Introduction

J

MEDICINE IN THE TIME OF COVID

ust as the 1793 Yellow Fever outbreak in Philadelphia and the Spanish Flu Pandemic changed medicine, public health, and society, the COVID-19 pandemic is

changing the practice of medicine. Some of these changes are likely to persist over the long term. This article provides a brief summary of some of the key changes in the laws and behaviors impacting current practice, and some guesses as to which of those changes are likely to persist.

Executive Orders and the Practice of Medicine Current Impact. Since March 19, 20201, Governor Ducey has issued nearly fifty Executive Orders relating to COVID-19. Several of these orders affected the practice of medicine. For example, one of the Orders2 required physicians to delay “non-essential or elective surgery”; a subsequent Order3 directed the Arizona Department of Health Services to establish rules regarding whether and under what circumstances those surgeries could be provided.

Long-Term Impact? Although these Executive Orders and similar orders issued by other executives are likely to be the subject of many policy papers and Law Review articles, addressing whether the orders exceeded the executives’ legal authority, there have been few if any challenges to the orders. This may be a consequence of the dire circumstances in which the orders were issued. In any event, it seems likely that the issuance of these orders will have little if any impact on the practice of medicine over the long term.

Regulatory Relief Current Impact. Several federal agencies have relaxed the restrictions their regulations impose on physicians.4 For example, CMS initiated its Patients over Paperwork program, which directed federal agencies to “‘cut the red tape’ to reduce burdensome regulations.”5 Among other things, this program temporarily relaxed: restrictions imposed under the “Stark law”; coverage restrictions imposed under NCDs and LCDs6 relating to items or services used to treat COVID-19 patients; signature and proof of delivery requirements for Part B drugs and durable medical equipment; and, a host of requirements and restrictions relating to telemedicine.

The DHHS Office for Civil Rights, which enforces HIPAA, also relaxed rules relating to enforcement (see, e.g., the discussion below regarding telehealth).

Long-Term Impact? A permanent relaxation or elimination of these restrictions probably would require cooperation between the two political parties and their appointees. A belief that the necessary cooperation will occur probably requires a triumph of hope over experience. Therefore, with the possible exception of telehealth, described below, long-term changes regarding regulatory relief do not seem likely.

Liability Relief Current Impact. There have been several state and federal initiatives that purport to provide liability protections Fall 2020 | arizonaphysician.com

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for physicians and others involved in the delivery of health care. For example, one of Governor Ducey’s Executive Orders7 states that health care professionals acting “in the course of providing public health services in support of the State’s public health emergency for COVID-19 [are] presumed to have acted in good faith and [are] immune from civil liability.”

At the federal level, the DHHS Secretary signed a Declaration expanding the liability protections established in the Public Readiness and Preparedness Act (passed in 2005 to protect vaccine manufacturers). The Declaration gives licensed health care providers qualified immunity, under state and federal law, for vaccine-related activities undertaken in connection with COVID-19.

Long-Term Impact? Even if these efforts withstand challenges by personal injury attorneys, and the resulting judicial review, physicians have rarely succeeded in limiting their liability for patient care activities. Consequently, it seems unlikely that these changes will have a lasting impact.

Telehealth Current Impact. Of all the relief efforts undertaken by governmental agencies in response to COVID-19, those taken by agencies regulating telehealth have been the most extensive. For its part, CMS drastically (if only temporarily) revised its telemedicine rules on many fronts.8 Under the revised rules, physicians can: provide telehealth services to new and established patients, regardless of patient location; waive copays; use audio-only technology; provide an expanded menu of services; receive the same reimbursement applicable to in-person visits; provide telemedicine services without regard to frequency limitations; and supervise ancillary staff via telemedicine.

The Office for Civil Rights has determined that it will “exercise its discretion not to impose penalties … in connection with the good faith provision of telehealth” during the pandemic.9 At the state level, Governor Ducey has issued Executive Orders facilitating the use of telemedicine, and requiring parity for telemedicine reimbursement. These Orders apply to physicians and others involved in a range of health services,10 including workers’ compensation11 and even veterinary medicine.12 These changes and other factors have resulted in a tremendous increase in both the volume and scope of telemedicine services being delivered. According to

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ARIZONA PHYSICIAN | Fall 2020

one report, “[b]efore the public health emergency, approximately 13,000 beneficiaries in fee-for-service (FFS) Medicare received telemedicine in a week. In the last week of April, nearly 1.7 million beneficiaries received telehealth services.”13 Long-Term Impact? Even before the pandemic, patients generally seemed to accept and even embrace the concept of telemedicine. For example, a 2019 JD Power report on telehealth services, found customer satisfaction for telehealth services had an overall ranking of 852 (out of 1000).14 This was among the highest satisfaction levels in all J.D. Power studies of the healthcare, insurance and financial services industries.

The same report notes that one of the barriers to adoption of telemedicine is that “[p]roviders struggle with awareness and adoption.”

Given patients’ favorable attitudes towards telemedicine, and the meteoric rise in its use during the pandemic, it seems quite likely that an increase in the use of telemedicine will be an enduring outcome of the pandemic. Providers whose practices are not currently set up to meet patient demands for telemedicine should move quickly to remedy that gap in their offerings. https://azgovernor.gov/executive-orders.

Executive Order 2020-10; Delaying Elective Surgeries to Conserve Personal Protective Equipment Necessary to Test and Treat Patients with COVID-19.

Executive Order 2020-32; Requesting Exemption From Executive Order 2020-10 — Elective Surgeries.

4 In addition, CMS implemented a Provider Relief Fund, which allocated $100 billion to reimburse providers for decreased revenue and increased expenses associated with the pandemic.

5 https://www.cms.gov/Outreach-and-Education/Outreach/Partnerships/PatientsOverPaperwork.

6 An NCD, or National Coverage Determination, is a determination by DHHS with respect to whether or not a particular item or service is covered by Medicare. An LCD, or Local Coverage Determination, is a determination by a MAC with respect to whether or not a particular item or service is covered in the particular MAC’s geographic area.

7 The Good Samaritan Order — Protecting Frontline Healthcare Workers Responding To The COVID-19 Outbreak.

8 Physicians and Other Clinicians: CMS Flexibilities to Fight COVID-19. https://www.cms.gov/files/document/covid-19-physicians-and- practitioners.pdf.

9 https://www.hhs.gov/hipaa/for-professionals/special-topics/emergency-preparedness/notification-enforcement-discretion-telehealth/ index.html.

10 Executive Order 2020-15, Expansion of Telemedicine.

11 Executive Order 2020-29, Increased Telemedicine Access for Workers’ Compensation.

12 Executive Order 2020-19, Telemedicine for Pets and Animals.

13 Verma, S, Early Impact Of CMS Expansion Of Medicare Telehealth During COVID-19, https://www.healthaffairs.org/do/10.1377/ hblog20200715.454789/full/.

14 Telehealth: Best Consumer Healthcare Experience You’ve Never Tried, Says J.D. Power Study, BusinessWire, October 28, 2019.

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By Miranda A. Preston, JD, Associate Attorney, Milligan Lawless, P.C., miranda@milliganlawless.com

By Robert J. Milligan, JD, Shareholder, Milligan Lawless, P.C., bob@milliganlawless.com

Medicine During the Pandemic Recession

I

n June of 2020, the National Bureau of Economic Research declared the nation was in a recession. They wrote, “a peak in monthly economic activity occurred in the U.S. economy in February 2020.”1 Often mentioned by economists and politicians, when America sneezes, the rest of the world gets a cold. Although the saying dates to Austrian politician Klemens von Metternich in the 1800s, its modern use reflects the U.S. superpower status.

Part of that economic juggernaut is our exemplary healthcare system, one that is very costly per capita but produces high-quality services for the Americans who can access them. Some have argued the healthcare sector is recession-proof. A more accurate description would be recession-resistant but, as we have seen throughout most of 2020, even the healthcare industry is deeply affected by the global pandemic of COVID-19, as “eventually that [resistance] wears off. The impacts of a recession don't skip the healthcare sector, but they do hit it later than most areas, and the industry also takes longer to bounce back,” experts have warned.2

Impacts on US Healthcare “The drop in health care spending earlier this year was unprecedented in U.S. history,” says Jonathan Ketcham, Ph.D., Earl G., and Gladys C. Davis Distinguished Research Professor in Business, W.P. Carey School of Business. When looking at recession effects on healthcare, up until COVID19, it would be safe to assume that the industry is truly immune to the effects of a recession, as seen in the graph. It is a curious phenomenon to see so many healthcare jobs lost in a global health crisis. This gives us a glimpse into how the healthcare industry makes its money: “treating patients for a deadly illness is far less profitable than offering them elective surgeries”,3 quoted from Isaac Arnsdorf.4 Healthcare does seem to be faring better than other industries. The rate of job loss in healthcare is less than the rest of the economy. However, it is important to note that during the Great Recession, as nearly all other jobs were declining rapidly, jobs in healthcare continued to rise at a good rate. Some economists have suggested that this

Fall 2020 | arizonaphysician.com

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increase is what helped recover the Nation’s economy.3 Perhaps it is time to take a look at healthcare in the lens of “pandemic-proof” rather than “recession-proof”.

Why is there a difference in the way the healthcare economy fared in past recessions, yet in this one, it has sunken like the others? The answer may very well be insurance.

Many Americans receive their health insurance through an employer and when that employment is lost, the insurance goes with it. 5 “In past recessions, patients were insulated from the costs, which made the demand for care what economists call ‘price inelastic’.” In the current pandemic climate, many people are losing their jobs and having to turn to state-funded health insurance which has lower payment margins. Hospitals are designed to thrive in private insurance markets and elective procedures.6 Let’s look at some numbers. In 2000, the American Hospital Association (AHA) estimated that private payers were billed at 116% of the cost to the hospital, and 128% by 2008. Based on data from private employers in 25 states, commercial payers were billed at an average of 208%.

Based on those numbers, shifting just 10% of privately insured patients to Medicaid would result in a loss of 3.2% of revenue, where before the Great Recession that same change would have caused a 0.8% loss. Since the start of the pandemic, 40.8 million Americans have lost their jobs.6 It was estimated that 160 million Americans under 65 years of age had health insurance through their employer before COVID-19. Thirty million workers filed for unemployment between March 15 and April 25.7 According to data on employer-based coverage, that is representative of a loss of up to 20% of the commercial insurance market. Overall, this adds up to a $95 billion loss because of the shift from private to public insurance, and a $33 billion loss due to cost-avoiding behaviors.6

Impacts on Arizona Healthcare "Arizona has one of the strongest economies of all states, and conditions through January, February, and most of March were building on that strong foundation," stated Lee McPheters, director of the Economic Outlook Center

Graph 1. Recessions through U.S. history and the effect on jobs.​3

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ARIZONA PHYSICIAN | Fall 2020

in the W.P. Carey School of Business at ASU, “On the plus side, Arizona could be entering the next recession in relatively good shape.”8 Arizona appeared to be one of the most dynamic economies in the nation when entering the start of 2020.

The Phoenix area was not able to recover from the Great Recession (2007 - 2009) as quickly as the rest of the nation. This was perhaps a great lesson when entering the inevitable recession brought on by COVID -19 a decade later. One huge contributing factor to Arizona’s recession readiness is the transition from a focus on a construction-heavy economy to one that focuses far more on healthcare and bioscience. Christine Mackay, community and economic development director for the city of Phoenix states, “It puts us in a much better position for economic

The last recession lasted about 19 months and the effects lingered in Arizona for years.

The recent advancements in medical learning and health care facilities have unintentionally provided Arizona with a bit of a recession-vaccine: The area and the state have not avoided the recession completely, but as a whole, the state seems to be protected better than others.

recovery. Healthcare and biosciences are as recession-proof as they can be. People always need healthcare.”9 The last recession lasted about 19 months and the effects lingered in Arizona for years. The recent advancements in medical learning and health care facilities have unintentionally provided Arizona with a bit of a recession-vaccine: The area and the state have not avoided the recession completely, but as a whole, the state seems to be protected better than others.

Pre-pandemic employment in biosciences for the Phoenix-Mesa-Chandler metropolitan area was sitting at about 44,700 jobs. In April, while most job forces were starting to feel the pain of state-wide shelter in place orders, the jobs in biosciences in this area grew to 46,200.

Meanwhile, healthcare sectors were being hit by a decline in patients seeking elective procedures and non-essential healthcare services. This may have factored into the decline from 335,300 jobs in February to 318,200 by July.8

How to Respond The U.S. economy will recover but it will continue to evolve, as it always has. More physicians are shifting toward digital forms of patient care. However, this still leaves some questions about patients who are losing their insurance coverage and procedures that must be done in person.

Doctor’s offices saw a nearly 60% drop in visits early in the pandemic, with ophthalmology and dermatology seeing a drop in visits greater than 70%. Now, nearly 30% of these visits are provided via telemedicine, but this technological shift has only partially compensated for the drastic decrease in in-person care.10 Employee care is more important now than ever.

Employers should promote mental health care for their employees to keep morale up in difficult times. Fears about job security, financial security, and health security are at an all-time high. Mental health care is paramount and needs to be discussed and addressed.11 A COVID-19 vaccine is inevitably on the horizon and

plans for distribution should be developed now. Guidelines need to be put into place so that the most vulnerable have access to the vaccines as they come out, and that those who can wait do so. Access to vaccines needs to be planned so that there is not a rush and a subsequent shortage. It is important that there is a way for those who are uninsured to have access to vaccination at an affordable price.12 Most importantly, the public needs to be educated, informed, and engaged. The public needs access to clear and understandable facts from trusted, reliable sources.

Overcoming the pandemic will rely on improving communication and educating the public.12 Broad actions moving forward are reliant upon expanding health insurance and strengthening the nation’s public health infrastructure.12 In addition to accessible health coverage, public health at all levels should be better funded.

Because of the impact of the epidemic, federal funding will likely be necessary to get the public health system where it needs to be to protect our country from something like the COVID-19 pandemic happening again in the future.12 Determination of the February 2020 Peak in US Economic Activity. June 8, 2020. The National Bureau of Economic Research. Cambridge, MA.

Accessed online at https://www.nber.org/cycles/june2020.html.

Myth diagnosis: Is healthcare recession proof? November 22, 2019. Healthcare Dive. Accessed at https://www.healthcaredive.com/news/ myth-diagnosis-is-healthcare-recession-proof/567470/.

3 Why 1.4 million health jobs have been lost during a huge health crisis. May 8, 2020. The New York Times. Accessed online at https://www.nytimes. com/2020/05/08/upshot/health-jobs-plummeting-virus.html.

4 ‘An arm and a leg’: Health care takes a financial hit in the midst of a pandemic. May 11, 2020. KHN Podcast. Accessed at https://khn.org/news/

podcast-an-arm-and-a-leg-health-care-takes-a-financial-hit-in-the-midst-of-pandemic/.

5 Health care workforce is recession proof. Is it ‘pandemic proof’? April 20, 2020. Politico. Accessed online at https://www.politico.com/ news/2020/04/20/health-care-workforce-crisis-197468.

6 Are U.S. hospitals still “recession-proof”? September 24, 2020. New England Journal of Medicine. Accessed online at https://www.nejm.org/doi/

full/10.1056/NEJMp2018846.

7 How the Covid-19 recession could affect health insurance coverage. May 4, 2020. Robert Wood Johnson Foundation: Quick Strike Series. Accessed online at https://www.rwjf.org/en/library/research/2020/05/how-the-covid-19-recession-could-affect-health-insurance-coverage.html.

8 Arizona braces for a Coronavirus recession. March 18, 2020. AZ Central: Arizona Republic. Accessed online at https://www.azcentral.com/story/

money/business/economy/2020/03/18/arizona-likely-heading-recession-along-u-s/5071487002/.

9 Phoenix invests big in healthcare and biosciences, hoping to boost economy and add jobs. September 17, 2020.

AZ Central: Arizona Republic. Accessed online at https://www.azcentral.com/in-depth/news/local/arizona-science/2020/09/13 bioscience-and-health-care-industries-expand-and-add-jobs-phoenix/3392691001/.

10 Health care spending has actually plunged in the middle of the pandemic. Here’s why. May 7, 2020. CNN Business. Accessed at https://www.cnn. com/2020/05/07/economy/health-care-downturn-coronavirus-pandemic/index.html.

11 Moving forward differently. July 16, 2020. Atlantic Health System. Accessed at https://www.atlantichealth.org/about-us/stay-connected/news/content- central/2020/covid-19-coronavirus/community-conversations/moving-forward-differently.html.

12 A roadmap to reset the nation’s approach to the pandemic. 2020. Association of American Medical Colleges. Accessed at https://www.aamc.org/ covidroadmap/roadmap#inequities.

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By Hailey Lowery, MPH Candidate, Class of 2020, A.T. Still University, sa180293@atsu.edu

Fall 2020 | arizonaphysician.com

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WHAT LESSONS HAVE BEEN LEARNED TO IMPROVE MEDICAL SCHOOL? 2020 MCMS Medical Student Essay Contest Winner

“We are all waves in the same sea, leaves of the same tree, flowers of the same garden.”

S

tanding in the hot Arizona summer sun, together with dozens of volunteers giving up their Saturday to help sort a parking lot’s worth of donations to be shipped to the Navajo Nation, I was reminded of this quote, often attributed to Seneca, that was inscribed on the shipments of masks donated by a Chinese company during the peak of Italy’s COVID-19 crisis. Young and old alike, we all stood with sweat dripping around the contours of our masks,

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placing bags of rice, beans, canned food, toiletries, and more into boxes for shipment to our Navajo neighbors. The collective community effort to amass the tons of donations itself was impressive – an hour into the shift, there was barely space to walk with all the boxes of donations that had been unloaded to be sorted. Despite the fact that grocery stores and supply chains had been disrupted for all of us, people were still giving what they could with such open arms. As I watched a five year old boy who struggled to spell “donation” on the sorted boxes instead master the tape gun and use his talents to help create an endless supply of pre-assembled boxes to hand off to the other volunteers who dug through the donations to assemble care packages, I smiled. This was just one of the many times during the

pandemic where I was awestruck and uplifted by the love and ingenuity that pours out despite collective suffering.

Despite all the goodness I saw through COVID-19, internally, as a medical student, there was a deep, disturbing dissonance that I couldn’t shake. On one hand, I felt the pressures that come with being a student – we are told to study hard now and do well on STEP 1 so that we can secure a future and be a good doctor like the thousands of doctors who work at the frontlines, putting their needs aside to save the lives of others. On the other hand, I felt the desire to find ways to help the community during a time of uncertainty and struggle – after all, as someone going into medicine amidst one of the largest healthcare battles of our generation, how could I stand around and be idle? Inherently, education can feel like a selfish pursuit – a system that is designed around the pursuit of individual knowledge is not a system that rewards selfless acts for the common good. Every hour that I spend studying is another hour I could have spent delivering groceries to elderly neighbors, designing informational flyers to support COVID-19 information dissemination, or finding creative ways to help healthcare workers stay safe amongst PPE shortages.

The irony of it all is that most of us join medicine because of a desire to help in one shape or form, yet in the pursuit of this noble goal, our desires can often become muddled by the competing demands of a rigorous education system and the rewards of delayed gratification. How might we help students face this dissonance and tear down the semblance of a false dichotomy? How might we build medical education systems where we can have confidence that our value in healthcare can start before we have the two letters behind our name – that our ability to succeed as a physician won’t be measured by our STEP scores but will instead be measured by a selflessness that doesn’t wait until we are full-fledged physicians?

The lessons that I have learned from COVID-19 are the lessons that will make me a good physician, a good citizen, a good friend, and a good neighbor. They are the lessons that books can’t teach and scores won’t show. From

the cable companies providing free Wi-Fi to children and families so they could transition to online schooling, to the Michelin star restaurants converting to soup kitchens to feed the needy, to the breweries converting beer recipes to hand sanitizer machines, to my medical school peers rallying others to give blood and collect PPE, to the grocery stores giving extra hours and extra support to the elderly and immunocompromised, I saw a world where empathy and kindness trumped profit and selfishness. I saw a world where healthcare workers and frontline staff stepped in to work longer hours and sacrificed their personal lives, often sleeping in hotels or in their offices to prevent spreading the disease to their loved ones at home. I saw unsung heroes like taxi drivers drive symptomatic patients to the ED to be tested, free of charge. I saw a world I wanted to be a part of – a world where I didn’t stand on the sidelines in pursuit of the next exam or the next educational milestone. I saw a world I’d be proud to tell my future children about – a world that saw beyond difference and personal struggles and rallied around our common humanity.

Through struggle, we see human resilience and generosity rise, as we stand in solidarity knowing we are all waves in the same sea. The fear of an unknown virus - the wrath of an indiscriminate disease - affects all of us, no matter race, country, educational status or identity. Though the pain of coronavirus has been deep, the rallying spirit of my loving classmates, family, friends, and strangers has taught me lessons no curriculum could ever prepare us for, and for that, I am forever grateful. To those who have sacrificed, loved, and given during COVID-19, you are my teachers, my heroes, and you are the ones who have reminded me that the journey to becoming a great doctor starts now in the choices I make and the things I prioritize.

By Patricia Bai, MS-II, Mayo Clinic, Alix School of Medicine, bai.patricia@mayo.edu

Fall 2020 | arizonaphysician.com

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How to Refer Patients who are Suicidal K

nowing how to appropriately refer a patient who self-identifies as suicidal, or whom you determine to be depressed, can be perplexing—made even more difficult during the COVID-19 pandemic. While standard procedure has always been to refer suicidal individuals to immediately seek care in an emergency department, those who have not contracted COVID-19, including those with suicidal thoughts, may be hesitant to seek care in emergency rooms. You have the opportunity now to put tools and resources in place to address behavioral health concerns before they become crises.

So, what to do with the patient who you are concerned may be suicidal? AHCCCS recommends the following: Begin with a best practice screening tool. There are several available; two you may want to consider: • w The Columbia Suicide Severity Rating Scale (C-SSRS) or the Suicide Assessment Five-Step Evaluation and Triage (SAFE-T).

If you determine the patient is acutely suicidal: w Do not leave patient alone. Utilize EMS and/or contact the crisis line in your region to assist.

If you determine the patient is not acutely suicidal: w Identify a friend or family member who will be physically present with them until they can get into care. w Encourage the patient, and any family or friends

who may be present, to immediately remove

firearms and unnecessary medications from the home.

Follow up with your patient. Significant research shows that individuals treated for suicidal ideation who receive a phone call, text message, or letter within two weeks of being seen are less likely to die by suicide than patients who don’t receive such messages.

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ARIZONA PHYSICIAN | Fall 2020

Additional Resources: • Arizona 2-1-1 https://211arizona.org/ • ResilientArizona.org connects any individual in crisis during COVID-19 to help regardless of insurance or citizenship • Teen Life Line phone or text: 602-248-TEEN (8336) • Veterans Crisis Line: 1-800-273-8255 (press 1) • Be Connected: 1-866-4AZ-VETS (429-8387)

CRISIS HOTLINES: Maricopa County served by Mercy Care:

1-800-631-1314 or 602-222-9444 Cochise, Graham, Greenlee, La Paz, Pima, Pinal, Santa Cruz and Yuma Counties served by Arizona Complete Health - Complete Care Plan:

1-866-495-6735 Apache, Coconino, Gila, Mohave, Navajo and Yavapai Counties served by Health Choice Arizona:

1-877-756-4090 Gila River and Ak-Chin Indian Communities:

1-800-259-3449 Salt River Pima Maricopa Indian Community:

1-855-331-6432

By Kelli D. Williams, MPH, State Suicide Prevention Specialist, Arizona Health Care Cost Containment System (AHCCCS), kelli.williams@azahcccs.gov

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