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A combined publication of the Arizona Medical Association, Maricopa County Medical Society, and Pima County Medical Society

February 2017

Government involvement in healthcare: your feedback pg. 19

Compromised access: healthcare views with

Richard Manch, MD pg. 23

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February 2017 |


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Physician Profile

What is the purpose of government? Thoughts on appropriateinterventionand expanding access with Richard Manch, MD.







Features 15 19 /AZPhysician facebook: /ArizonaPhysician /azphysician

Post-election: top policy changes to watch in 2017 How do physicians feel about government’s role in healthcare?

32 40

Physicians react to Tom Price Combating government incursion upon the patient-physician relationship

In This Issue 4

What’s Inside


Public Health: Funding


President’s Page


Government in Healthcare


Congressional Corner with Senator Jeff Flake


Legal: Government’s Role


Policy Corner


Community: Ryan House


Public Health: Flu in Arizona


Insights into Pre-certification

February 2017 |


What’s Inside

Jay Conyers, PhD

For the wealthiest country in the world…to not have figured out access to basic healthcare as a fundamental right for individuals, I think is a little bit of a national embarrassment. John Jay Shannon, MD, CEO of Cook County Health & Hospitals System (Chicago)


ast month we put out the inaugural issue of Arizona Physician and hope you all enjoyed reading it. Our teams put a lot of sweat equity into designing the first issue and couldn’t be more proud of how it turned out. But as the saying goes, there’s no rest for the weary. While the first issue was in press, we quickly turned our attention to the issue you’re holding in your hands right now. This month, we’re looking at government’s role in healthcare. When the Affordable Care Act (ACA) was enacted in 2010, the role of the federal government in our healthcare system grew to the largest in our nation’s history. Love it or hate it, it’s had a dramatic impact on how people access care, and how physicians deliver it. And with Congress fiercely determined to repeal and replace the ACA, there is much angst as to how that role might evolve. It’s likely going to be a wild ride, so hop on board!

So what’s inside? This month, we profile Dr. Richard Manch, head of Dignity St. Joseph’s liver program and a mainstay in the Phoenix medical community for more than four decades. He’s seen government’s role in healthcare ebb and flow over the years, and he shares with us his thoughts on how it’s impacted your profession. We hope you enjoy his story and his perspective on the interplay between government and medicine. In this issue we have a number of great articles on how government is impacting healthcare, including one that looks ahead to post-election policy changes that may come down the pipeline soon. We also have a compelling article 4


that asks physicians how they feel about Dr. Tom Price, President Trump’s pick for Health and Human Services Secretary. Dr. John Middaugh, member of the MCMS board, penned an assessment of how public health systems are impacted by the ACA, and how funding disparities have left Arizona near the bottom when it comes to investment in public health programs. Our congressional corner this month is from Senator Jeff Flake, and our policy summary, authored by the Arizona Medical Association’s Pele Fischer, lays out some key legislative items that all physicians should be aware of. For public health, Arizona Department of Health Services assesses flu in Arizona and our legal corner examines the carrots and sticks used by the government to help drive healthcare. We also have an interesting article from Blue Cross Blue Shield Arizona discussing the benefits of pre-certification. We profile Ryan House as our community health partner this month, and have the first installment of the MICA Medical Foundation student essay contest. This month’s winning essay was submitted by University of Arizona Tucson medical student Alex Alvarez, who shared with us his thoughts on the government’s impact on the doctor-patient relationship. And lastly, our survey this month looks at what role physicians feel government, both state and federal, should play in the way care is delivered. It’s another packed issue of Arizona Physician, and we hope you enjoy reading it. Next month we focus on women in medicine, and follow that up with our April issue examining the opioid crisis. Check out our website,, to read more and see what else we’re up to (a lot!).



et me welcome all of you in my first article of 2017. Our new collaboration with multiple medical societies and the Arizona Medical Association (ArMA) is an effort to create shared services and efficiency, and hopefully all us physicians recognize the importance of coming together for our greater good. For some time, I have been thinking about the topic, “the Government’s role in medicine.” Last summer I was at a hospital retreat where the speaker, who was General Counsel for the hospital system, opened with this statement: “If you’re not at the table, you’re on the menu.” It was a sobering reminder that in this day of Accountable Care Organizations (ACO) and Center for Medicare & Medicaid Services (CMS) payments, we were being reminded as doctors that we did not have our individual places at the table, but only through our larger brother – the hospital ACO.

To impact and influence I researched articles on the subject to avoid ‘reinventing the wheel’ and it is clear that recommendations for the Government’s role in medicine vary based on political and philosophical backgrounds and leanings. What is becoming clearer to me, is that perhaps our role as physicians and leaders is to impact and influence the government’s role in medicine. To many of you this may sound like too little, too late. In this landscape of Big Pharma, hospital corporations, ACOs, and expensive technologies, how can we have any influence on how things unfold? We have been led to believe that any unified physician voice is considered Antitrust, and we bicker amongst ourselves at the earliest mention of coming together. However, Antitrust attaches to collective bargaining for fees for services, not working towards influencing local, state, and federal government decision-making in healthcare. As individual citizens, each of us votes and supports our candidate. Yes, you say, we pay money to ArMA to do this for us. But there is more we can and should do. As our younger colleagues can attest, the paradigm to participate in politics has changed. Smart phone polls and emails are now counted as much as our lobbyist’s activities, possibly more so in the

John L Couvaras, MD

local and state environment. Last year, we were outnumbered and out-represented by other interests and their electronic representation to our state representatives. This is one simple fix that we are seeking to implement at the Maricopa County Medical Society. There are others, but it requires we come together, not just in membership fees, but as a living, breathing, thinking, and proactive entity. This requires each of us realize how we are making our decisions. There are two key elements in decision theory: that which seeks to maintain a gain and limit losses, and how we frame things in our minds. The Nobel laureate, Danny Kahneman said, “No one ever made a decision because of a number. They need a story.” Here are some of my stories.

Accepting the usual and customary We are not allowed to discuss our contracted professional fees amongst ourselves, and more so, not even the details in our contracts. To suggest that some doctors are getting 40% of Medicare whilst others are pegged at 200% is a violation of our managed care contracts. This is much the same as the experiment with the monkeys, cucumbers, and bananas. As long as they think they are all getting cucumbers, the monkeys perform well. But, give one monkey a banana, and the other monkey is unhappy and throws his cucumber at the Trainer. We were told over the years to accept ratcheted-down prices for services based on usual and customary prices and we were directed to a website owned by a company called Ingenix. Later a court determined this company was owned by United Healthcare, and forced the company to be sold/ removed from United Healthare (UHC), and now is called Still, too late, since the decade of damage of getting frustrated doctors to give in and accept a continuously reducing fee for service had now created a “usual and customary rate” (UCR) that would represent a new benchmark in professional fees. This ended up in another similar settlement against Aetna in 2009, who benefitted from Ingenix’s artificial use of false UCRs. Who at the table benefitted from this activity? February 2017 |


Who is really benefiting? We moved to electronic billing through clearing houses. One of these clearing houses is Optum, owned by United Healthcare. Does it seem correct that we are voluntarily sending competitor reimbursement schedules to a company that has a connection with another third party administrator (TPA)? This seems like playing poker with a TPA, and having to show all your cards with each hand. You can never win in this arena and neither can the other TPAs. What happens to competition? As doctors, we are perceived by many in the public to be a guild, artificially maintaining high prices on services. Maybe this used to happen, but not in decades. Since the 1970s, I would estimate that medicine and healthcare has become more complicated by two orders of magnitude. In 2007, the cost for healthcare in the U.S. was estimated to be $2 trillion, and $600 billion of that was administrative costs. That is 33%. Even now after Obamacare, that 33% was legislated down to 18% by 2012, and any overage by a TPA would need to be refunded after a 4-year audit. Did you consider why in 2016 so many of the TPAs in the state may be complaining they did not make any money on the exchanges? Are you aware that as of 2016, these TPAs had to repay almost $200 million in excess collections from 2012, and had had this ‘loan’ for the last 4 years? Facebook has been running the salaries of the CEOs of the TPAs with annual options and benefits, showing them to be a combination totaling $7-50 million per CEO per year. I have been particularly flummoxed by the $1.5 billion retirement of the CEO of UHC around 2005. That translates into $2000 extracted from every doctor that year. Even if all 765,000 doctors were paid an average of $500,000 a year, this would translate into $380 billion. Remove the incentive to do defensive medicine, extra and presumably unnecessary testing and procedures, and the exorbitant $600 billion in administration, and I think we would be moving in the right direction. But let’s not fool ourselves about getting an average of this money. The last four years the employed doctor in large hospital systems throughout the Sunbelt has been getting a starting salary of around $250,000 for the first year, but will often get reduced by the end of the year. Most doctors will stay on, hoping to work harder to get back to par, and in decision theory this is minimizing their loss in their hopes to preserve a gain. In the private sector, this starting pay inflation has confused the rest of us, especially when we wonder how to compete to recruit. It turns out the ACO hospital got a Federal bone from CMS to be able to bill 140% of Medicare, for 4 years, ending in 2016. We only get 100% or less. Which party at the table do you think has been benefiting? I cannot understand how Copaxone, a drug for MS that used to cost $750/month became, overnight, $10,000/month. How did Big Pharma, after Obamacare, take such advantage and raise profits on meds by over double? In the Pharmaworld, this increase translates into over $200 billion in a year. Where did this money come from to pay for all this? Well, your TPA, and sometimes your insurance company, 6


We can no longer imagine that we will be okay by allowing the others at the table to make all the decisions that effect us and our patients. We need your voices to create change, not just your donation. We need to be heard by our state government, and have them want to come to us for opinions and advice.

simply off-put these costs onto the consumer by raising the premiums and the deductibles. Sounds like somebody at the table is getting a lot of bananas while the rest of the monkeys are not even getting their cucumbers.

Owning our care decisions As a group, we have been the drivers and brains of how actual medical practice and healing occurs. “As physicians, we are meant to be the perfect agent for the patient as well as the protector of society. Physicians deal with patients one at a time, whereas health policy makers deal with aggregates. But in physicians, there was determined a conflict between the two roles,” said Dr. Redelmeier, who wrote about a medical analogy of Samuelson’s bet: people will refuse to accept a mathematically favorable bet, but agree to a large enough repetition of the same bet. He showed, “in treating individual patients, the doctors behaved differently than they did when they designed ideal treatments for groups of patients with the same symptoms.” The point is not that the doctor was incorrectly and inadequately treating individual patients. The point is that he/she could not treat the patient one way, and groups of patients’ suffering from precisely the same problem in another ways, and be doing the best in both cases. That is unless they had guidance and feedback from things like evidence based-medicine. But this big-data approach to the problem was deemed too burdensome for doctors, and we were not trusted to be able to see or react to our flawed decision making, and needed our managed care overseers with their algorithms and decision trees. All of these efforts to manage and contain costs in medicine have been directed upon physicians, when I (and others) have stated we are but a small fraction of the overall budget. Instead of squeezing doctors’ reimbursement to contain costs, Pharma costs and Hospital costs need to be addressed and a portion of the realloca-

tions redistributed to the doctors. In frustration, the Government is trying to contain the budget and parse it out to states to allow the localities to determine what will be the best medical delivery system. ACOs from CMS have spawned pioneer ACOs into private insurance and hospital systems. The pie is being divided once again, and he who cuts tends to get the biggest slice, and makes all the decisions besides. To solve this problem with my kids the rule was, “he who cuts, the other chooses.” During the 1990s, authoritative medicine had given way to “evidenced-based medicine” but even this approach was hijacked by everyone, including physicians. TPAs liked it because it allowed them to not pay for what they could now call “unsanctioned” or “un-vetted” procedures. It slowed down acceptance of a procedure, until “adequate” evidence was published. Evidenced-based medicine was supposed to be a method of analyzing data to confirm if one approach to medical care was equal, less, or superior to another. It was not meant to be used to ration care, or slow down or refuse payment, but it has been. It was not supposed to be used by competitors to prevent innovation, but it has been. This approach begat “meaningful use,” and we know where this has gotten us.

Algorithms and decision trees Managed care has come to believe it can practice better medical care delivery through decision tree analysis of specific illnesses. This seems initially appealing as it allowed us to integrate a midlevel practitioner, such as a Nurse Practitioner (NP) or Physician’s Assistant (PA) into the medical delivery system and pay them less than physicians to deliver care. In theory this sounded good, but let’s see how this is playing out. Initially patients complained they did not want to see the NP/PA if there was a choice between them and the doctor. As things progressed and choice wasn’t an option, the distinction in titles of “Dr” X and “Midlevel” Y became presented to patients as simply X or Y, and we began to all be considered “Healthcare Providers.” The difference in billed services for X or Y has slowly diminished, because why pay more for Dr X’s same services that can be had by provider Y? There is logic to this evolution. It relies on a core assumption that medical decision-making can and will be neatly quantified into some computer algorithm or decision tree analysis which, for now, does not exist. For now, the 100-fold increase in the complexity of medical practice requires a hierarchical deployment of intellectual resources. Physicians have historically culled the brightest and most competitive students into their ranks for a reason. Medicine is hard and complicated, and getting more so every day. Even with decision trees available, who will decide what diagnosis to apply, to then apply the appropriate decision tree? The Watson computer program is fed massive quantities of studies and new information to predict a cancer diagnoses. 70% of the time it is in line with the established experts, but 30% of the time it identifies a new option not considered by the human experts. This is a start.

As in most things, there is a planned obsolescence in the practice of medicine, not only for doctors, but for midlevels and most other roles. I’m not suggesting this will occur in our lifetimes, but if other work environments are any indication, we may all be expected to go the way of switchboard operators and elevator attendants. But, until then, we are the providers. No, we are the deciders, and we are supposed to be making the decisions in the land of medicine.

We need to be heard So, after framing some of the situations in medicine, I would argue that few, if any of us should continue to see our situation as a good status quo. And remember, tomorrow’s salary will most certainly be less. We no longer eat in the Doctor’s lounge, but the Health Provider’s lounge, and most hospitals/ACOs are moving towards an employed physician model where the practice of medicine is dictated by decision trees that interfere or remove our fiduciary obligation to the individual patient. We have to see things as they are – that our reference point is a state of mind. We have been and continue to be facing risky choices but are failing to put them into context – and this context is that we all are facing a losing proposition. Given this, we should choose the gamble to come together to learn from our collective knowledge, and become proactive in the healthcare delivery process. We can no longer imagine that we will be ok by allowing the others at the table to make all the decisions that affect us and our patients. We need your voices to create change, not just your donation. We need to be heard by our state government, and have them want to come to us for opinions and advice. Ultimately, it will be our influence locally and in the state that will direct our Government’s role in medicine. We will be reaching 17,000 physicians with our publication, and these numbers will not be ignored. Let’s make the practice of medicine great again! John Couvaras, MD, FACOG is the president of the Maricopa County Medical Society and is board certified in OB/GYN and reproductive endocrinology. He is the founder of IVF Phoenix and has been providing fertility treatment services in the valley for more than 25 years. Dr. Couvaras previously served as the director of reproductive endocrinology and assisted reproductive medicine and chairman of the department of obstetrics/gynecology at Paradise Valley Hospital. References 1. Lewis, Michael. The Undoing Project: A Friendship That Changed Our Minds. 2016 2. Samuelson, Paul A. Risk and Uncertainty: A Fallacy of Large Numbers. Scientia: April-May, 1963.

February 2017 |


Congressional Corner S E N ATO R J E F F F L A K E , A R I Z O N A


arlier this month, individuals across the country were once again faced with fewer choices and increased costs when purchasing health insurance coverage. Unfortunately, this has been a common occurrence since the Affordable Care Act’s (ACA) inception, and no state is feeling the pinch more than Arizona. As our home-state physicians, you know better than anyone the toll this marketplace uncertainty is having on individuals and their families. You strive to provide world-class care to your fellow Arizonans, yet the unworkable federal health care apparatus has made it nearly impossible for thousands of patients to access your potentially lifesaving services. While no one would argue that the system was perfect prior to the ACA, the metrics in the years following implementation are staggering. Prior to the flawed roll-out of the exchanges in 2013, Arizona had 24 health insurance companies offering plans in the individual market. But just last year, residents in Maricopa County had only eight private insurers to choose from on As if that wasn’t bad enough, a few months ago, individuals all across Arizona received notifications that their insurance plans were no longer being offered, despite the Obama administration’s assurances that they could keep their plans. For many, this will mean finding a new doctor, severing longtime relationships during which patients grow comfortable with their preferred physician. Newly-stripped of their health insurance, residents in 14 of Arizona’s 15 counties logged onto the exchanges to shop for new plans, only to discover that instead of a vibrant marketplace of quality policies, they were left with only one insurer to choose from. Of the few plans that were ultimately made available on the exchange, the average policy came with a premium hike of nearly 50 percent. With only one game in town, there was no option to shop around for a better deal. To help put this all in perspective, I recently compared the average cost of health insurance in Arizona to one of the most important purchases a family will ever make: 8


owning a home. Sadly, throughout most counties in Arizona, it’s now cheaper to put a roof over your family’s head than it is to pay your monthly health insurance premium under Obamacare. Arizona is ground zero for the structural failures that are plaguing insurance markets around the country. Insurance exchanges are on the verge of collapsing, premiums, deductibles, and out of pocket costs are skyrocketing, and our health care system is in desperate need of reform. That is why the first vote I cast in the 115th Congress was to begin the process of replacing the existing law with something that works. This is challenging to say the least, and it is my mission to ensure my constituents, both providers and patients, are not abandoned in the process. Part of any solution for reforming our health care system must start by putting consumers back in charge of their own health care, and I’ve introduced a bill that will do just that. The Health Savings Account Expansion Act provides individuals and families with the freedom to choose the health care that best meets their needs, and allows them to use their Health Savings Accounts on the medical products and services they value the most. HSAs give consumers greater personal responsibility and control over their health care dollars by providing them with a tax-advantaged savings option for their medical expenses. The HSA Expansion Act strengthens this important tool by nearly tripling the arbitrarily low contribution limits, thus allowing for greater tax equity and more universal participation in HSAs. We know HSAs work, and I want to maximize their impact. The bill would then allow individuals to use these expanded HSAs to help cover the costs of their monthly health insurance premiums. This is a critically important

If we hope to lift that burden off the backs of your patients, and the cascading impact it has on you as physicians, we must recognize that the key to reforming our health care system is not more government intervention. feature, particularly for middle-class families whose income falls slightly above the qualified threshold for subsidies, but whose health insurance has become unaffordable. The timing of these legislative fixes could not be more imperative. Arizonans are struggling under the weight of a bureaucracy that is complicating their health care decisions, which are some of the most personal and important decisions anyone can make for themselves and their families. If we hope to lift that burden off the backs of your patients, and the cascading impact it has on you as physicians, we must recognize that the key to reforming our health care system is not more government intervention. Rather, it’s about allowing individuals the freedom to take

back control of their own health care and incentivizing prudent decision making. This past election, voters across the country flatly rejected the failed promises of the Affordable Care Act and handed Republicans the chance to make good on their six year promise to replace the law with something better. We now have the opportunity to fundamentally reform our health care systems so that all consumers have access to affordable, high quality care. I believe this is a good place to start. Going forward, I will work with the Arizona physician community to help guide my thinking on what is best for patient care.

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February 2017 |


Policy Corner

Pele Fischer, JD



n the last edition of Arizona Physician, I provided an overview of the sunrise applications requesting regulation and expansion of scope of practice. For health professions this is determined at the state level through an established mechanism called the sunrise process. These sunrise applications were reviewed at a December 16, 2016 hearing, and the outcomes set the stage for some of the health policy issues we will see this legislative session in Arizona. The Arizona Medical Association (ArMA) represented physician concerns at the legislative committee hearing where lawmakers reviewed the applications. ArMA worked in collaboration with our physician community partners including Arizona Osteopathic Medical Association (AOMA), Academy of Pediatrics (AzAAP), and Academy of Family Physicians (AzAFP). The hearing lasted more than eight hours and all of the decisions met or exceeded expectations of organized medicine. Physicians who participated dedicated their entire day to be at the hearing to ensure that sound medical science and patient safety concerns were well represented and effectively conveyed. There were nine sunrise applications submitted by the September 1 deadline. Two of the sunrise applications, regulation of phlebotomists and scope expansion for naturopaths to administer IV antibiotics, were withdrawn prior to the hearing. Of the remaining seven, only two were not approved.

Requests for expansion of scope of practice: CRNAs; Naturopaths; Pharmacists; Podiatrists

• Arizona Association of Nurse Anesthetists – APPROVED;

Negotiations between CRNAs and ArMA are ongoing regarding updates to current statutory language which require the administration of anesthetics by a CRNA be done under the direction of and in the presence of a physician or surgeon, adequately reflecting current health care delivery in Arizona. Patient safety and physician-led care are of paramount importance to physicians in this negotiation. Arizona Naturopathic Medical Association – NOT



APPROVED; This application requested authority for naturopaths to sign medical exemptions for required immunizations. The physician groups strongly opposed this application, citing concerns that Arizona has some of the most lenient exemption policies and as a result, herd immunity has been compromised. Allowing another pathway for exemptions will only worsen a serious public health concern. Arizona Pharmacy Association – APPROVED; After a lengthy series of stakeholder meetings and back and forth negotiations, the Arizona Pharmacy Association finally scaled back its sunrise application enough to receive approval by the committee. The approved proposal would allow pharmacists the ability to prescribe over the counter and prescription nicotine replacement products (inhalers and sprays); this does not include Chantix or Zyban. It would also allow pharmacists the ability to extend a routine, non-controlled, chronic medication for an amount equal to or less than 14 days (to be further negotiated) under certain circumstances. The CORE Institute (regarding Podiatrists) – APPROVED; The physician groups all supported this sunrise application that would allow podiatrists the ability to perform toe and partial foot amputations.

Requests for regulation: CHW; Art Therapists; Dental Therapists

• Arizona Community Health Workers Association • •

(Requesting voluntary certification for Community Health Workers) – APPROVED; Arizona Art Therapy Association (Requesting regulation of Art Therapists) – APPROVED; Dental Care for AZ (Requesting licensure of Dental Therapists) – NOT APPROVED

53rd Arizona Legislature & State of the State Arizona’s 53rd legislature was called to order on Monday, January 9, and Governor Doug Ducey gave his State of the State address. This is the Governor’s annual opportunity to publicly set forth his expectations and

priorities for the coming months and years to the assembled Legislature and other state elected and appointed officials. Governor Ducey’s speech focused on the theme of “boundless opportunity” that Arizona has to offer, and devoted the bulk of his remarks to public education, proposing a number of significant reforms. The Governor called for continued and expanded effort for efficient licensure of various professions and decreased regulations. He spoke of a new state website, www.redtape., where citizens can report tedious regulations within state government, with the goal of repealing 500 onerous regulations by the year’s end. The Governor proposed providing up to an additional 12 months of TANF (welfare) assistance to Arizonans’ actively job-searching; additional efforts to reduce recidivism such as Employment Centers to assist inmates in finding jobs; improved public safety by continuing the efforts of the Border Strike Force; enacting drug addiction prevention efforts; and funding cyber security. While Governor Ducey’s remarks were limited in the area of health care, he did state that he wants to add SCID, Severe Combined Immunodeficiency, to the newborn screening requirements in Arizona. Regarding the opioid epidemic, the Governor stated that he wants to see a physician continuing

medical education (CME) requirement, one hour of the forty biennially required CME hours, on the subject of drug addiction. He also stated that he has issued a new executive order allowing inmates facing addiction when leaving prison the opportunity to enter into a pilot program to be treated with Vivitrol to help with their transition. Governor Ducy’s executive budget was released on January 13. We will review it carefully for implications for healthcare and will provide updates and insights in the next issue. Governor Ducey’s state of the state address and executive budget sets the stage for the legislative session. Now the legislature begins its hard work. Beyond the policy areas already mentioned, there are numerous other health-related issues that ArMA is currently engaged in and will likely be addressed in some capacity during the 2017 legislative session. These include: balance/ surprise billings, health-related board reforms, addressing the opioid epidemic, the future of healthcare reform, specifically, “repeal and replace” of the Affordable Care Act (ACA), and the future of Medicaid/AHCCCS expansion. Pele Fischer, JD, is the Vice President of Policy & Political Affairs for the Arizona Medical Association.


Big Thanks.

Blue Cross Blue Shield of Arizona values the contributions and efforts of Arizona physicians in caring for our members.

February 2017 |


Unpredictable, not unbeatable:


Medical Director of Epidemiology and Disease Control Arizona Department of Health Services

Number of Lab-Confirmed Influenza Cases Reported, by Week of Report: 2014-2017

Flu is unpredictable.

Flu in Arizona is unpredictable. Arizona flu season follows the national trend except when it starts later and runs longer (2010-2011). Arizona flu rates reflect the national picture except when Arizona is the highest in the nation (2015-2016). Arizona mirrors national flu vaccination rates, except when it’s 49th lowest (2012-2013).





3000 Number of Cases

Flu peaks every February, except when it peaks in March (2015-2016). Flu hits the very young and very old, except when it hits the younger and middle-aged (2013-2014). Flu can be prevented by vaccination, except when it drifts from the vaccine (2014-2015).

2500 2000 1500 1000 500 0

Week of Report

Clinicians can still fight against this unpredictable foe. Know what flu looks like in Arizona, specifically. For example, last year’s flu season ran late and severe, with Arizona having the highest rate of illness in the country. Make the weekly state flu report a favorite link: preparedness/epidemiology-disease-control/flu/index.php#surveillance-home. 2) Do not be complacent about giving flu shots. Arizona is among the lowest flu coverage states in the nation, and ICUs have anecdotally reported that their severe flu patients are unvaccinated. Administer vaccinations in clinic or recommend another local site: 3) Do not depend on rapid flu tests. Because false-negative results are more likely during flu season, significant clinical decisions cannot be made based on a negative RIDT alone. See this and other new studies on the Arizona Infectious Disease Mobile app (IDAZ), created for Arizona clinicians: in the App Store and Google Play. 4) Call Arizona public health if something is off during flu season. Public health is a resource for consultation and testing. If there appears to be higher rates of secondary pneumonia, resistance to antivirals, preferential attacks on patients with certain morbidities, or more, contact the local health department: 1)

The only predictable thing about flu is its harm to Arizonans (last season: over 23,000 lab-confirmed cases and 880 related deaths). Clinicians, keep up the fight! 12


Public Health in Arizona

New Opportunities BY JOHN MIDDAUGH, MD


or the past eight years the United States has focused on its health care system in the aftermath of the passage of the Affordable Care Act (ACA). Its complexity and cost has guaranteed controversy. With a new Republican President and Congress committed to repealing the ACA, no clear remedy has emerged, and funding to public health agencies still at risk. In 2015 U.S. health expenditures were estimated to be about $3 trillion a year, accounting for 18% of the U.S. economy1. In spite of the success of the ACA in extending health coverage to more than 20 million previously uninsured people, millions remain uninsured without access to health care. And, in spite of the huge expenditures, the performance of the health care system is mediocre. A serious unintended consequence of the ACA has been the neglect of the public health system in the U.S. During the past eight years, understanding and support of public health agencies has drastically declined, especially at the state and local levels. Since 2008 more than 40,000 public health jobs have been lost, essential program services eliminated, and capacity reduced.2 Many public health agencies were forced to divert staff and limited resources to public health preparedness, further compromising core public health programs. Proponents of the ACA incorrectly believed that many public health programs and services would not be needed because the health care system would provide care to those who were newly covered by the ACA. This idea was perpetuated by applying new terms to market and advocate for passage of the ACA. Population health and individual clinical care for preventive health services became synonymous with the public health system. This confusion resulted in diverting millions of dollars from state and local public health agencies. Public health protects the community. Public health authority is derived from the U.S. Constitution under powers reserved to the States. Because public health services are essential to protect the community, public health agencies rely on local and state funding for support. While public health agencies provide some clinical health care services to

individuals, public health agencies exist primarly to protect communities by providing complex and sophisticated services that individuals, acting alone, cannot achieve for themselves. Public health agencies are service agencies. While they may provide some clinical care, conduct limited research, and provide some training, they are the source of community protection. Public health is not the same as healthcare services, and the ACA does not provide public health services. For example, individual health care providers respond to infectious disease threats and may require considerable expertise to treat the patient. If a case of meningococcal meningitis or botulism is diagnosed, the health care provider is focused on care of the patient. The public health agency is responsible for investigating the source of the infection, who was exposed, and providing prophylactic medications or confiscating the implicated food. In these circumstances, the public health agency has no one to bill, and there is no one else to conduct the investigation. One of the most basic, fundamental activities of public health agencies is to conduct public health surveillance. Public health agencies are founded on authority based in the U.S. Constitution and local and state public health laws to enforce public health measures enacted as local and state statutes, regulations, and administrative procedures. Some of these essential protections are collecting population data; monitoring births, deaths, marriages, and divorces; disease reporting; isolation and quarantine; regulating safety of drinking water, waste disposal, clean air, food and drug safety; and control of zoonotic diseases and vector control. Public health also monitors the health of the population and identifies threats and risk factors. It designs programs to reduce or eliminate these threats or risk factors and monitors the effectiveness of control measures. Maintaining public health systems requires highly skilled professionals drawing from many academic disciplines and specialties. Excellence and capacity cannot be obtained overnight. Sustained funding and political and community February 2017 |


support are essential to achieve success. Public health outcomes can be measured. When public health programs are effective, diseases and injuries and deaths and disabilities are prevented. When disease outbreaks are prevented, there is no media coverage. So, public health programs can become invisible and often are taken for granted. Unfortunately, it often takes a break down in the system or a new disease outbreak to provide examples of the essential value of the public health system. For example, the recent exposure of residents of Flint, Michigan to lead in the city’s drinking water was the result of severe budget cuts of the public health agencies. Threats to public health are constantly present and new threats emerging. For example, the nation is grappling with a massive epidemic of prescription drug overdose deaths; life expectancy of the new generation is predicted to fall for the first time due to the epidemic of obesity and diabetes; and the recent outbreak of Ebola virus in West Africa and Zika Virus in Brazil and its rapid spread. Only a viable and valued public health system can protect communities. Comparing local and state public health agencies in the U.S. is very difficult. There are many different models and structures in the country. The United Health Foundation and Trust for America’s Health have collected information on public health funding and public health measures annually for decades, as has the National Association of State and Territorial Health Officers (ASTHO) and National Association of County and City Health Officers (NACCHO). Health in Arizona is seriously neglected, under-funded, and under-staffed. The median funding for public health from state and federal sources in the U.S. is $85.52 per person. In comparison, Arizona funding if $38.50 per person, ranking 49 of 51. Arizona provides $8.40 per person in state funding for public health compared to the U.S. median of $31.06 per person. Among states in the Southwest, only Nevada provides less funding than Arizona. Comparing public health population, number of visitors, and funding between the Southern Nevada Health District, Nevada, Seattle-King County, Washington, and Maricopa County Health Department, Arizona, the Maricopa County Health Department has more than double the population and the fewest full time employees (FTEs). Maricopa County funded its public health agency in FY 2016 at $11,467,877 in general revenue, or only $2.75 per person, among the lowest in the U.S. Population projections estimate that Arizona will grow by 588,536 people by 2020. Without an increase in public health funding and staff, the Arizona Department of Public Health and the Maricopa County Department of Public Health will fall further behind. The future also will bring new public health challenges and threats. Some of the most certain will be related to bioterrorism, climate change, emerging infections, zoonotic diseases, antibiotic resistance, global travel and immigration, global food supply, and population growth. Arizona trails most of the states in many public health outcome measures. This is of great concern, because these summary measures hide wide disparities among different racial and ethnic groups, among those earning less income, and among those who have less education. Arizona and 14


Maricopa County lag behind many other states and counties in childhood immunization rates (19-35 months old). Of greater concern is that many charter schools do not enforce childhood vaccination requirements, and many have less than 40-50 % of their children fully vaccinated. “Never events” are well described in hospital medical care. For example, the amputation of the wrong limb is a “Never event.” Removal of the wrong kidney is a “Never event.” In public health, “Never events” should include congenital syphilis. Yet, there have been between 12 – 24 cases of congenital syphilis in Arizona each year for the past ten years. There has been a resurgence of syphilis and HIV infections, and the rates of gonorrhea and chlamydia have been climbing. Arizona has been heavily impacted by the prescription drug epidemic of overdose fatalities. Summary data on public health outcomes document that the public health status in Maricopa County and Arizona is worse than a majority of other states. These summary statistics do not reflect the wide disparities and far worse health status among certain racial and ethnic groups, those who are less well off economically, and those who are less educated. With the population expected to grow by almost 600,000 people by 2020, the public health system will not be able to maintain even existing levels of public health. No matter what solutions to the ACA are implemented, health care services will not include public health support nor will these public health disparities lessen. Public health agencies rely on local and state tax revenues to support the public health programs that protect all people in the community. In 2016 the Arizona Medical Association and Maricopa County Medical Society passed resolutions calling for increased support for public health in Arizona. Now is the time to strengthen public health in Arizona and protect our future. References: 1. McGinnis JM, Diaz A, and Halfon N. Systems strategies for health throughout the life course. JAMA. 2016; 316: 1639-1640. 2. National Association of County and City Health Officials. Local Health Department Job Losses and Program Cuts: Findings from the 2013 Profile Study. July 2013. Sources of Fiscal and Health Measures Population Data. Arizona Department of Administration. Office of Employment and Population Statistics, 12/11/2015. Arizona Population Projections: 2015 to 2050, Medium Series. Maricopa County FY 2016 Adopted Budget. Appropriated Expenditures and Other Uses by Department, Fund, and Function Class. Page 17 of 21. Hoffman L, England B, Barraza L, and Kang P. Analysis of the Proposed Implementation of a Public Health District in Maricopa County. University of Arizona College of Medicine—Phoenix, Maricopa County Department of Public Health, and Mel and Enid Zuckerman College of Public Health. 2015. United Health Foundation. America’s Health Rankings 2015. Trust For America’s Health (TFAH). Investing in America’s Health: A State-by-State Look at Public Health Funding and Key Health Facts. April 2015. Maricopa County Department of Public Health, Office of Epidemiology, Maricopa County Health Status Report 2013, Reference Tables. Phoenix (AZ): 2015.

Post-election top policy changes to watch in 2017 BY KAREN APPOLD February 2017 |



hile every new year brings change, with Donald Trump elected to become the next President and the U.S. House and Senate both having Republican majorities, managed healthcare executives will see more changes than usual in 2017 – beginning with repealing and replacing most of the provisions in the Affordable Care Act (ACA). Experts in the industry state their cases for what they expect will occur over the coming months regarding the ACA, the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA), CMS, Medicare, Medicaid, and more.

ACA changes President Trump made repealing and replacing the ACA a core position of his presidential campaign. “Although Trump will help to drive the approach and agenda for such an effort, congressional Republicans will bear most of the burden for fulfilling this promise,” says S. Lawrence Kocot, MPA, JD, LLM, national leader, Center for Healthcare Regulatory Insight, KPMG, LLP. “Attempting to repeal the law as a whole through regular order is highly unlikely given the probability of a likely Democratic filibuster. The more likely path would be to repeal portions of the law through a reconciliation bill (similar to H.R. 3762, an approach that passed the House and Senate before being vetoed by President Obama in 2015). This reconciliation would likely target some major provisions such as the individual and employer mandate, insurance subsidies, and Medicaid expansion funding, while preserving some that enjoy bipartisan consensus, such as guaranteed issue and insuring children up to age 26 on their parents’ policies – which Trump said he may support after he was elected.” Congress would then likely craft a replacement bill that could contain new approaches to cover millions of Americans that might lose coverage through a repeal effort. But the timing of repeal and replacement is uncertain; the repeal process could occur as early as Trump’s inauguration day of January 20, but the crafting of a replacement could take significantly longer as a growing number of congressional Republicans seem to agree that bipartisan support may be necessary for this to be sustainable, Kocot continues. Finally, the new administration could starve health insurance exchange funding and alter other regulatory provisions of the ACA through regulatory and sub-regulatory processes, or through non-enforcement, Kocot notes. Joel White, president of the Council for Affordable Health Coverage, also expects Trump to make repealing and replacing the ACA a top priority. “The market faces significant challenges, including rising costs and premiums, less competition, and weak enrollment,” he says. “Both Republicans and Democrats want to improve the market, but differ significantly on how to do so. “What cannot be repealed or blocked through regulations, Congress will repeal and replace,” White says, adding that he believes the replacement will focus on affordability, then access, and then coverage and will include some of the provisions already in law. Sally C. Pipes, president and CEO, Pacific Research Institute, points out that Speaker of the U.S. House of



Representatives Paul Ryan – along with House Republications – has already put forward a replacement plan, “A Better Way,” which would repeal many of Obamacare’s mandates and regulations. However, it is not in legislative form yet nor are the costs worked out. The GOP plan also provides $25 billion in funding over 10 years to state-level “high-risk” pools. “These pools would provide subsidized coverage for individuals with extremely expensive chronic conditions to manage,” Pipes says. “That leaves the standard insurance pool with patients who have common, actuarially predictable health risks. Insurers would be able to predict with much greater accuracy how much it would cost to pay for these individuals’ care – and could therefore offer lower, more stable premiums.” White predicts that Congress will use the budget reconciliation process to both reform healthcare and control healthcare costs, which he projects to be the single largest category of federal program spending over the next 10 years. “This package will include many changes to physician and hospital payments designed to further efficiency, quality, and safety,” he says. “While MACRA – the law that replaced the failed Medicare Sustainable Growth Rate (SGR) law (which required double digit payment cuts unless Congress overrode them) will continue to move payments from volume based to value based, I do expect some tweaks to be made by the incoming administration regarding how the program is implemented. For example, Trump’s administration could change how Advanced [Alternative Payment Models] APMs are approved, including greater flexibility on how models are vetted and adopted and ultimately paid for.”

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Some APMs have been developed such as medical homes and accountable care organizations (ACOs), while some have not yet been fleshed out. MACRA relies on the Center for Medicare & Medicaid Innovation (CMMI) to validate the models in ACOs. “If Congress repeals Obamacare and CMMI along with it, MACRA will likely need to be amended to ensure promising new care delivery and payment systems that introduce good incentives into Medicare to drive costs lower while paying for better outcomes,” White says. On the topic of CMMI, Pipes says, “Republican members of Congress have previously criticized CMMI’s role in payment reforms and may push for congressional approval on new payment models going forward.” While not popular with doctors, she does not expect MACRA to change much because of its bipartisan support. Weighing in, Kocot says, “Although the new administration may seek to alter the development and financing of new APMs through MACRA or adjust timelines for clinicians to prepare, the new administration is unlikely to try and repeal MACRA or slow the move away from fee-for-service given MACRA’s bipartisan support. Physicians and other providers reimbursed through Medicare Part B should anticipate continued focus on payments based on the quality and efficiency of care that they provide.” François de Brantes, executive director, Health Care Incentives Improvement Institute, expects that over time, more providers will participate in advanced APMs than the number of providers who will participate in the Merit-Based Incentive Program (an alternative option physicians can choose to participate in under MACRA). “The Merit-based Incentive Payment System (MIPS) is painful for most physicians because the majority will see stagnating fee schedules way into the future. A few will see increases and some will see decreases, but they will have to wait until months after the end of a performance year to discover their fate. Many will opt for APMs as a result,” he says. “However, the MACRA rule doesn’t give a lot of options, and I think we will see a lot more APM proposals coming from physician groups in 2017. It has yet to be seen whether the new administration is willing to experiment and accept a lot of APM options.” With growing discontent about the continued growth of the quality-industrial complex as evidenced by the 2,398 page MACRA final rule, Susan Nedza, MD, MBA, senior vice president of clinical outcomes, MPA Healthcare Solutions, says some providers have done the math and are considering simply accepting the negative payment adjustment as the cost of compliance increases and the likelihood of success decreases. “Thus, MIPS provisions regarding the reporting of quality data that are linked to Medicare Part B physician fees may continue to be delayed or watered down,” she says. “But it is unlikely that the MACRA provisions that support participation in APMs will be impacted as they enable shifting of financial risk onto providers.” Ethan Rii, a shareholder at Chicago, Illinois-based Vedder Price, who focuses his practice on healthcare transactions and regulatory matters, points out that MACRA’s full effects won’t hit until 2019. “But understanding how best to position physician practices and their reimbursement strategies can make a significant impact on future growth,” he says. “For

example, we may see greater consolidation among medical practices in 2017 given the need to have the proper infrastructure to best demonstrate quality care and recoup the payment benefits of MACRA.”

CMS payment changes Given the uniform desire to create transparency in reimbursement and continue the focus on quality and outcomes, CMS is likely to continue its focus on these two fronts, Rii maintains. “Reimbursement pressures will not go away – we could see more demonstration projects, expansion of bundled payment initiatives, and value-based reimbursement structures,” he says. Rii also believes that Medicare may experience great change. “Medicare is the closest thing the United States has to a single-payer system, and a vast number of healthcare providers are dependent on Medicare reimbursement,” he says. “In that regard, there may be a greater push toward narrow networks and managed care initiatives. We may also see greater reform overall for the payment of skilled nursing and post-acute care services. Home health is a booming area; that industry is ripe for reimbursement policy changes.” Furthermore, Rii expects changes in how reimbursement structures are passed down to individual physicians and providers in how they get paid. “Today, most physician employment contracts are either fixed salary or productivity based, applying the concepts of work relative value units (wRVUs) and other traditional productivity calculation methodologies,” he says. “Quality remains a limited part of the overall compensation package, but with greater change to overall reimbursement, I think physician contacts will follow that trend, moving away from traditional arrangements and becoming more dependent on quality and other incentive metrics.” On a related front, de Brantes believes that Medicare Part B changes and other potential changes to physician and hospital payments are likely to be more constrained and will no longer be mandated. “It’s very likely that the new administration, buoyed by Congress, will favor Medicare Advantage plans,” he says. “Much of the push for changes in physician and hospital payments will depend on the extent to which Medicare Advantage plans can move more aggressively to APMs.” Nedza believes that any new congressional legislation will include provisions to lessen the impact of hospital value-based programs such as the hospital readmission program by lessening penalties for readmissions, decoupling Medicare’s Hospital Compare ratings from payment, granting exemptions to safety net hospitals, or delaying changes to disproportionate share hospital (DSH) payments.

Other possible changes White believes dramatically expanded account-based plans such as health savings accounts and health reimbursement accounts, and the use of data and tools to promote healthcare transparency, will take off this year. “Inspired by a desire to empower consumers and consumer-based healthcare, Congress will enact changes and incentives that will put February 2017 |


consumers and payers, including employers, in the driver’s seat,” he says. On another front, Nedza expects hospitals, physicians, and managed care organizations to continue to face strong forces that are focused on controlling costs. “The ability to risk-adjust across populations and to modify care delivery to manage this risk will determine success,” she says. “This means that the focus will move to managing overuse of services, technology, hospitalizations, and specialty drugs while leveraging models that link quality outcomes to cost at a patient, hospital, and carrier level.” Ultimately, Peter Hilsenrath, PhD, Joseph M. Long Chair in Healthcare Management and professor of economics, University of the Pacific, says a robust infrastructure spending program coupled with tax cuts touted by Trump could provide the fiscal stimulus to alter the macroeconomic environment marked by low interest rates, expansive monetary policy, and anemic growth. “Higher growth rates, if realized, will provide more latitude for growth in healthcare,” he says. “On the other hand, protectionism, or interest rates that rise too far too fast, could derail growth and possibly usher in a recession with negative implications for healthcare.” Karen Appold is a medical writer in Lehigh Valley, PA. Copyrighted 2017. Advanstar. 124847:0117DS



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The Government’s Role in Healthcare: What Physicians Think



s we prepared to look at aspects of the government’s role in healthcare in this month’s edition, we issued a survey seeking physician perspective. We had an unprecedented participation rate. Thank you to everyone who took the time to share perspectives and insights!

The role of state government When asked about whether the Arizona government should consolidate the majority of health regulatory boards into a single licensing entity (as was proposed in 2016 legislature), the majority of respondents felt that the current

board structure, and process for handing out disciplinary rulings, should remain unchanged. Ultimately, physicians feel that other physicians are best qualified to review conduct and potential disciplinary action: “Due to the complexity of medical practice, physicians should maintain control of licensing and investigation into the practice of medicine and complications of such.” When asked if alternative patient payment models such as those of concierge care should be subject to the same regulation as insurance companies, 68.3% of respondents felt that physician groups who offer this type of direct pay

February 2017 |


Should the government determine the price of pharmaceuticals for Medicare patients?



Should be allowed for high-cost specialty drugs

Should be allowed



Not sure

Should not be allowed

Who should handle disciplinary action?

60.8% Current structure and process remain unchanged


16.0% Not sure


Combination Medical Boards/ ADHS/another state agency

ADHS or another state agency

Should the government set quality and safety standards for patients?


should put in place guidelines as recommendations

16.1% should put in place guidelines

26.6% Should play no role

2.6% Not sure



model should be free to work directly with their patient populations, and should not be subject to regulation by that state’s Department of Insurance. “This is not an insurance model; why should it be regulated as something that it isn’t?” However, 19% of respondents did indicate support for a lesser degree of regulation on this direct pay model. By way of explanation, one respondent offered “I don’t object to this model, but I do think the group offering the care should be required to publish the extent of what they will and will not cover. That would protect the patient and the group practice against devastating illness and/or malpractice litigation.” Most respondents favored the role of state government in ensuring that all citizens have access to coverage, although, again, the shape of that role varied in the comments. One physician offered, “The state government should be the venue through which we can modify the shape and form health care takes in individual states… Physician leaders in these states and the legislature should work together to create a system that works with the ultimate goal being affordable access for every citizen.”

The role of federal government An overwhelming majority of respondents agreed that HHS should be allowed to negotiate all drug prices. A number of respondents cited the prohibitive cost aspects of prescriptions and subsequent substantial impact on their patients’ lives; this in turn causes worry for physicians. One physician pointed out that the current inability of HHS to negotiate prices was a result of Congressional decision; another physician stated that “HHS should control its own costs by evaluating the parts of its business that are ineffective and intrusive without value added and eliminate those expenses.” And another physician felt that “Drug prices need much more exposure to market forces, including competition from imports.” Twenty-six percent of respondents thought government should play NO ROLE in setting quality and safety standards for patients, and leave hospitals, clinics, facilities, and physician practices to determine their own quality and safety metrics. A majority of respondents, 54.6 %, thought government should put in place guidelines as recommendations for hospitals, clinics, facilities, and physician practices. Comments ranged from “There is clearly a role of guidelines as long as they are evidence based,” to the more frustrated, “Keep the government out of medicine. [Government] screws up everything it meddles in.” A number of comments concurred with the position that “guidelines should emanate from professional societies and boards.” A little more than half of the respondents felt the federal government has a duty to ensure all citizens have access to coverage, but fell short of supporting a mandate or requirement for health coverage. A number of respondents identified a single-payer system as consolidation of the existing structure, making the points that “the government is already paying for most

health care, but in a very fragmented system that has at least 30% overhead for insurance company marketing and profit.” Most comments offered nuanced discussion of solutions, desiring to see patients not lose their insurance, but achieve universal health coverage through a la carte access to health insurance, “The federal government has a duty to the permit insurance companies to offer a variety of types of coverage, unrestricted by state boundaries, and allows plans like the Health Savings Account, and help states fund for the indigent and non-insurable.” While 70.2% of respondents supported universal coverage as an appropriate and achievable goal, 47.3% felt it was not achievable based on current structure of healthcare system. Among comments to this question was some consideration of what “universal coverage” really implies. One respondent pointed out that this is often considered to have the same meaning as “single payer.” And there were equal number of comments indicating their opposition to a single payer and looking to market solutions as there were in support of a single payer. One physician felt “But we are headed to a 3 tier system; Government funded healthcare, Health Insurance as part of Employment benefits, and, Cash or Private Pay.” Another stated, “We should have the free market decide coverage for all who are not insured: Insurance companies should have access across all state lines, Tort reform, and block grant Medicaid to the states and have them manage the care.” Given the rancor toward the ACA often encountered in media coverage of the medical community, there were a surprising number of comments offering that the ACA should have been fixed or improved rather than outright repealed. In the words of one physician, “The ACA has some excellent components. Expanding coverage within Medicare, extending parental coverage of kids to 26, no pre-existing conditions, etc. It is too much of a compromise, and too bureaucratic and too expensive to manage. We would have been better off to include the favorable points and expand Medicare and Medicaid.”

Should physician groups offering a monthly fee payment alternative follow state insurance regulations?





YES, but to a lesser extent



Not sure

What role should the federal government have in the health of our citizens?


Should ensure that all citizens have access to coverage

21.6% 17.8%

Should play no role


Should mandate coverage, or else face a penalty or fine

Not sure

What role should the state government have in the health of our citizens?


Should ensure that all citizens have access to coverage


Should mandate coverage, or else face a penalty or fine


Should play no role

9.2% Not sure

Should we continue to work toward universal healthcare coverage in the US? SHARLA HOOPER Sharla is the Managing Editor for Arizona Physician and serves as Associate Vice President of Communications and Accreditation for the Arizona Medical Association.

27.1% NO


YES, but under a different healthcare system structure

22.9% YES


Not sure

February 2017 |


Appropriate intervention and expanding access: A CON V ER S AT ION ON GOV ERNMEN T A ND HE A LT HC A RE WI T H

Richard Manch, MD

BY DOMINIQUE PERKINS Article Photos by Denny Collins Photography

February 2017 |


The magic of medicine Life can take a winding path at times, and it is interesting to look back and wonder how things would be different if you had turned left instead of right at a crossroads. We often ask our profile physicians what they think they might have done if they had not pursued a career in medicine, and they usually make a good guess, or select something based on a hobby they have come to enjoy. But in the case of Dr. Richard Manch, the moment of decision was clear. While he was interested enough in medicine to enter college as pre-med, he focused on drama, music, and anthropology. He played regularly in a folk music group, both on guitar and the banjo. One of his bandmates tried to convince Manch to choose a career in music over one in medicine. “He went on to be a successful music producer,” Manch said of his friend, working with artists such as Linda Ronstadt, Boston, and The Eagles. Manch chose a different path. “Being a physician seemed like a magical thing, a special ability that one could work hard to achieve,” he said. “I love being a physician, and feel very privileged every day to do what I do.”

A three-phase career After completing an internship at Buffalo General Hospital in New York, Manch became enamored with the desert southwest. He completed his residency at Maricopa Medical Center in Phoenix, and then a gastroenterology fellowship at the University of New Mexico. He returned to Phoenix to practice, joining a group based at Good Samaritan in 1976. This began what Manch would call phase one of his medical career, and he would continue to practice gastroenterology for 12 years. He then went back to school, obtaining a master’s degree in health administration. He worked in management for about three years at Samaritan Health Services (which has since become Banner Health). After leaving his managing role, he began working full time with Good Samaritan. His role was initially an academic one, but when Good Samaritan restarted liver transplants in 2000, Manch’s role quickly morphed into full hepatology, launching phase three of his medical career. Manch has remained a full-time hepatologist for the past 16 years, and is board-certified in transplant hepatology. He moved to Dignity St. Joseph’s over four years ago to start a new liver program there.

Government involvement in care Given the dynamic nature of his career, Manch is no stranger to changing roles, and he’s had the opportunity to view the involvement of Government agencies on the healthcare arena from several different positions. Since the development and introduction of Medicare, government has played a major role in healthcare in America, Manch said. However, since then, he doesn’t feel that role has changed a great deal. 24


This is despite several attempts, beginning with President Clinton’s plan, which Manch said failed mainly because it was too complex and too expensive, and through to the Obama administration and its renewed attempts to accomplish expanded access to care. “The Affordable Care Act (ACA) is also flawed, in part because of compromises dictated by political circumstances,” he said. While it nudges us in the right direction, removing pre-existing condition restrictions, it is still greatly impaired, Manch believes. Because it depends on private insurers, unsustainable premium increases have probably doomed it, he said, and the recent election outcome will likely doom it further. “I think that’s unfortunate: in my view, it needs to be fixed, not eliminated,” he said. When asked specifically about the state of Arizona, Manch points out that while many consider the Arizona Healthcare Cost Containment System (AHCCCS) to be one of the better healthcare entitlement programs in the nation, initially it failed miserably because the health plans developed to provide the coverage were not operated with the appropriate expertise. “Simple insurance concepts such as tracking the ‘incurred but unreported liabilities’ were not managed properly, or at all,” he said, by way of example. “But eventually, the various difficulties were resolved, and Arizona Medicaid (AHCCCS) became the model for many other states over the years.”

Speaking of Obamacare The topic of Obamacare has been highly politicized, and has become a divisive conversation in the national arena. Manch believes it is a step in the right direction, though hardly perfect as currently implemented. “It needs to be simplified, and a way must be found to either cover the financial risk borne by the insurers, or perhaps take the insurers out of the process and have the government bear all the risk,” he said. While the effort to expand care and coverage is worthwhile, the ACA has currently led to fewer coverage options and higher premiums, Manch said. This provides a clear obstacle to patients. “I also believe it further weakens the leverage and control that we as physicians and other providers still wield in the healthcare system, and tends to give too much power to the major, well-financed entities, such as the large insurance companies and health systems,” he said. As evidence of this, Manch points to Accountable Care Organizations, stating that while the best of them are thoughtfully constructed, they require a level of cost and quality management that doesn’t really exist currently, making them unsustainable.

Debating control Much debate has risen in recent years over the Health and Human Services (HHS) and Centers for Medicare &

Medicaid Services (CMS) being bound by a federal law restricting them from negotiating drug prices with the pharmaceutical industry. Considering CMS is the largest purchaser of drugs, many believe they should be able to better control prices. Manch describes the issue as troubling and complex. Branded drugs are expensive, and many insurance plans require a large, upfront deductible, which can often be entirely consumed by a single drug. “Patients on Part D Medicare often fall right into the ‘doughnut hole’ and are stuck for the cost,” he said. In an effort to obtain the drugs they need at a lower price, an elaborate infrastructure has developed, with many patients purchasing drugs through Canadian pharmacies, which get them from developing countries. Manch said that while this “work-around” can get patients access to the drugs they need, “It doesn’t make much sense to me, if we are the country we claim to be.”

However, he has also been involved on the other end of the situation, and described drug research and development as an, “exhaustive, expensive, and lengthy process.” This means that should the government step in to regulate drug pricing, the research and development of new drugs could suffer. “Still, some drug pricing is neither rational nor fair, as the media have pointed out in recent years,” Manch said. “I believe the answer lies in the establishment of some sort of drug pricing protocols, which would obligate drug companies to document in greater detail and with more transparency their pricing strategies.” In addition to questions of cost control, government mandates are also in debate concerning prescription monitoring, specifically of opioids. “I believe the overprescribing of opiates is one of the major crises in medicine in the U.S. today,” Manch said. When he was in medical school, Manch remembers February 2017 |


being taught never to prescribe opiates for chronic disorders. A lot has changed since then, and Manch shared his view that the medical establishment has lost total control of opiate prescribing. “So this is indeed an area in which government intervention is both needed and appropriate,” he said. “Although this smacks of government control of medicine, medicine can’t control it so government must. Isn’t that the role of government?”

Expanding technologies and treatments As medical technology advances, and we turn more and more to high-tech methods of care, such as telemedicine, medical practice across state lines becomes more of a reality. With these advances, governance and monitoring discussions are inevitable. Manch feels that whatever the thoughts on oversight, government in general should support the development and use of telemedicine and other technologies to expand access to providers, especially in those circumstances where specialized care is unavailable. Manch described St. Joseph’s Project ECHO Hepatitis C program, which he said allows local providers to treat hundreds of their own Hepatitis C patients with tele-monitoring supervision from their center in Phoenix. The program has received national recognition, and sparked a movement in Congress to provide payer support for the concept in many disease-states. “I believe the public and private payers can and must do more to support these kinds of approaches through direct

and code-based reimbursement,” he said. “I see this as an example of how technology has made the practice of medicine much better, unlike the electronic medical record, which has in my opinion greatly worsened the practice of medicine, but that is another issue entirely!” Manch said that currently, the Food and Drug Administration (FDA) does fairly well in improving access to advanced medical technologies and treatments, but that some of its policies are cumbersome, and prone to cause needless delays. “Also I have perceived that the FDA is somewhat inconsistent and seems to allow more latitude for some pharmaceutical manufacturers than others,” he said. Manch strongly disapproves of such favoritism, and is also strongly opposed to branded drug direct-to-consumer advertising. However, he said that disease-state advertising can prove an advantage by raising awareness and advocacy for testing and treatment.

DOMINIQUE PERKINS Dominique is the Associate Managing Editor for Arizona Physician and serves as the Communications Coordinator for the Maricopa County Medical Society.

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On the

personal side..

February 2017 |



Legislative Reception Hosted by the Arizona Medical Association, Maricopa County Medical Society and Pima County Medical Society








Each year, our organizations partner to host an informal reception honoring the Arizona State Legislature. The Legislative Reception offers a unique opportunity for Arizona legislators and our physician board members to learn more about each other, policy initiatives, health care issues, and identifying opportunities to work together.

1 Dr. Jason Jameson, Dr. Kenneth Poole, State Representative Heather Carter, and Dr. Aaron Mangold

2 Dr. Azmi Nasser

and ArMA’s Pele Fischer

3  Dr. Julie Kwatra, Dr. Robert

Marotz, and State Senator Katie Hobbs

4 Dr. John Coury, Dr. John Bass and State Rep Kelli Butler

5 ArMA Past President Dr. Nathan

Laufer, ArMA President Gretchen Alexander, and MCMS President Dr. John Couvaras

6 State Representative Pamela

Powers Hannley, and ArMA EVP Chic Older


7 Dr. Bill Thrift, State

Representative Tony Navarette, State Representative Jesus Rubalcava

8 State Senator David Bradley

talks with Dr. J. Michael Powers

9 State Representatives Vince Leach and Jay Lawrence

10 Steve Barclay, State

Representative Maria Syms and Dr. J. Michael Powers enjoy a laugh






Government in Healthcare



overnment-sponsored healthcare legislation funded through the Affordable Care Act (ACA) has had a significant impact on the number of Americans now receiving healthcare and has effected the way care is delivered. Along with the ACA, the other key piece of government legislation that has had a major impact on providers and patients is the Medicare Access and Chip Reauthorization Act of 2015 (MACRA). These two instances of federal legislation, when considered together, are completely revolutionizing not only the way care is given to Medicare beneficiaries, but how that care effects almost every demographic and the varied elements of our society.

The ACA and Quality One of the major provisions of the ACA, which is often lost in the debate over the cost of insurance premiums, is the overarching impact this law has on the quality of care being delivered by providers across the continuum. Of the 10 titles included in the ACA, nearly one third deal exclusively with non-insurance-related topics: Title III – Improving the Quality and Efficiency of Health Care, Title IV – Prevention of Chronic Disease and Improving Public Health, and Title VII – Improving Access to Innovative Medical Therapies.1 These titles contain statutory language which emphasizes improving the delivery of evidence-based care and is expressed by three overarching aims: improve the quality of care, lower cost, and improve the health of populations and communities.2 These three aims form the basis of a National Quality Strategy, and are advanced by focusing on six well-defined priorities: (1) Make care safer by reducing harm in the delivery of care; (2) Ensure that patients and families are engaged as partners in their care; (3) Promote effective communication and coordination of care; (4) Promote effective prevention and treatment for leading causes of mortality, starting with cardiovascular disease; (5) Work with communities to promote wide use of best practices to enable healthy living; and (6) Make quality care more affordable for providers, payers, and government by developing and spreading new health care delivery models.3 The ACA also incorporated another important federal law that immediately preceded it, the American Recovery 30


and Reinvestment Act of 2009.4 This ruling established the requirement for electronic health record adoption by all Medicare providers within five years of enactment and mandated “meaningful use” of their electronic medical records (EMRs) in order to receive full Medicare payments. Part of this process involves setting up patient portals that can be accessed by individuals to enable them to obtain accurate, up-to-date information about their health. This transparency ushered in a new era of provider-patient relationships wherein patients can now engage their provider electronically and securely access their personal health information. Another of the major ACA provisions is the emphasis on the quality of care being given to patients and the reporting of that care using EMRs. Examples of quality reporting include verifying immunizations for influenza and pneumonia, and specialty specific measures for both patient facing and non-patient facing providers. This process helps ensure evidence-based treatments are administered and documented as a means of determining reimbursement and lowering costs. The ACA has improved care delivery by creating a quality reporting system that is patient-centered, reliable, effective, efficient, accessible, and safe for patients receiving federally administered Medicare and Medicaid healthcare.

Healthcare Legislation Tied to Quality MACRA incorporates some of the mandates of the non-insurance-related titles of the ACA by using EMRs as the vehicle for quality measures reporting in the Quality Payment Program’s (QPP’s) Merit-based Incentive Payment System (MIPS). The rationale behind the QPP is to remove the arbitrariness of the previous fee-for-service model, which tied reimbursement to the quantity of services provided rather than the quality of those administered services, and create a cohesive, integrated systems approach to healthcare. MIPS looks at four weighted, evidence-based categories (i.e., quality, cost, practice improvement activities, and advancing care information using EMRs) in determining a composite performance score employed in calculating positive or negative adjustments to Medicare provider reimbursement.5 This approach creates equal opportunity for patients, providers, and payers by establishing risk-adjusted models of care and

“ We look forward to further engagement with physicians and other clinicians toward our shared goal of the highest quality of care and best outcomes for patients.” – Andy Slavitt Former Acting Administrator Centers for Medicare & Medicaid Services

payment that rewards high-quality, low-cost care. Additionally, the QPP incentivizes innovation in care delivery through the adoption of alternative payment models (APMs) including patient centered medical homes, accountable care organizations (ACOs), and public-private partnerships such as the Comprehensive Primary Care Plus (CPC+) initiative.6 As the Quality Innovation Network-Quality Improvement Organization (QIN-QIO) contracted with Medicare for Arizona, California, Ohio, Florida, and the U.S. Virgin Islands, Health Services Advisory Group (HSAG) has almost four decades of experience in assisting providers and Medicare beneficiaries to improve the quality of healthcare by offering assistance in evidence-based interventions and information that leads to better health. Our contracts with Medicare and Medicaid include robust metrics to gauge the effectiveness of interventions that improve both process and outcomes throughout the continuum of healthcare. This work encompasses the reduction of healthcare-associated infections, adverse drug events, and unnecessary hospital admissions and readmissions; physician and provider assistance in EMR use to increase immunizations, alcohol, drug, and tobacco screening and cessation; diabetic patient education and outcomes improvement; antimicrobial stewardship; and other quality innovation projects that ultimately better the health of individuals, populations, and communities and reduce costs. HSAG works with nursing homes to decrease and eliminate falls, pressure ulcers, and C. difficile occurrence as part of an inclusive approach to engage communities and increase communication between providers and patients. All of these activities are government-sponsored, ongoing efforts to enhance care for all U.S. citizens regardless of age, gender, or race. In addition to these programs, federal and state governments are putting special emphasis on assisting those populations that are most vulnerable including the poor, the medically underserved, and those with socioeconomic disparities precluding their ability to access good quality healthcare. HSAG, through our contracts with Medicare and 17 state Medicaid programs, is actively engaged in the work of healthcare quality improvement through programs that assist providers and patients directly, all of which are funded by legislative mandates that are paid for with tax

dollars at no cost to those receiving assistance. Regardless of the changes that will be made to the ACA under the new administration in Washington DC, focusing on quality should continue as a fundamental principle to inform decisions about government involvement in healthcare for the foreseeable future. HSAG remains committed to our partnership with government to ensure that Medicare and Medicaid beneficiaries receive the best healthcare by an informed and connected provider community in every instance every time. Howard Pitluk, MD, MPH, FACS, is Vice President, Medical Affairs & Chief Medical Officer; and Mary Ellen Dalton, PhD, MBA, RN, is Chief Executive Officer. This material was prepared by Health Services Advisory Group, the Medicare Quality Improvement Organization for Arizona, California, Florida, Ohio, and the U.S. Virgin Islands, under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. The contents presented do not necessarily reflect CMS policy. Publication No. AZ-11SOW-XC-01242017-01 1

U.S. Department of Health and Human Services. The Affordable Care Act, Section by Section. Available at: healthcare/about-the-law/read-the-law. Accessed on: Jan 9, 2017.


U.S. Department of Health and Human Services. About the National Quality Strategy. Available at workingforquality/about.htm#aims. Accessed on: Jan 9, 2017.




American Recovery and Reinvestment Act of 2009. Available at: Accessed on Jan 9, 2017.


U.S. Department of Health and Human Services. The Merit-based Incentive Program. Available at: Quality-Initiatives-Patient-Assessment-Instruments/Value-BasedPrograms/MACRA-MIPS-and-APMs/ Merit-based-Incentive-Payment-System-MIPS-Overview-slides.pdf. Accessed on: Jan 9, 2017.


Centers for Medicare & Medicaid Services. Comprehensive Primary Care Plus. Available at: initiatives/comprehensive-primary-care-plus. Accessed on: Jan 9, 2017.

February 2017 |



react to

Tom Price

nomination A

t first glance, Congressman Tom Price, MD, looks like a solid pick to head the U.S. Department of Health and Human Services (HHS). Representing Georgia’s 6th District since 2004, he serves on the House Committee on Ways and Means and was named chair of the House Committee on Budget, but most importantly, he’s a doctor that can bring the physician viewpoint to an agency that is often accused of lacking empathy for those tasked with meeting HHS regulations while treating patients. But when you go beyond the basic bio, some doctors fault – while others applaud – his outspoken opposition to the Affordable Care Act (ACA) and government spending, which includes support for privatizing Medicare. Presidentelect Donald Trump said during the campaign he would leave Medicare alone, so it remains to be seen what official policy will come out of the White House, but some physicians worry the appointment of such an ardent opponent of universal coverage and healthcare entitlement programs could have an adverse effect on patient health. Others say 32



having a doctor in that position will bring some common sense to an agency sorely in need of an overhaul. “I’ll gladly throw my support behind a physician to lead HHS,” says David Allison, a plastic surgeon in Gainsville, Virginia, in an email. “Does anyone really believe that Hillary Clinton (a lawyer) would improve the situation for doctors and their patients?” Elizabeth Seymour, MD, a family practitioner in Denton, Texas, is also in favor of the appointment. “It’s refreshing that we have a third-generation physician appointed to HHS. With his family’s history, he knows the ropes of medicine. His stance on many healthcare issues is aligned with mine as a practicing physician.” Her comments were echoed by Howie Mandel, MD, an OB/GYN in Los Angeles. “Dr. Price is a stellar choice for secretary of HHS – a physician’s physician who has actually practiced medicine, a surgeon who can operate as well as teach, a policy wonk that understands the interwoven bureaucracy of HHS as well as the American health system…”

Physician organizations speak out Professional organizations had varied reactions to the nomination, with the American Medical Association (AMA) stating it “strongly supports the nomination” based on his leadership in the “development of health policies to advance patient choice and market-based solutions as well as reduce excessive regulatory burdens that diminish time devoted to patient care and increase costs.” This stance sparked a letter of protest from Clinician Action Network, a grassroots organization committed to evidence-based policies that puts patients first. The letter received over 5,000 signatures in a week and sparked a #notmyAMA hashtag on Twitter. The Association of American Medical Colleges (AAMC) stated that Price is “a strong choice for HHS Secretary.” But the American Medical Student Association (AMSA) condemned the nomination, stating Price’s track record shows opposition to women’s health care services, “continued discriminatory rhetoric and votes cast against LGBTQ populations and failure to recognize the importance of mental health within our healthcare system.” Much of the opposition to the nomination from physicians is based on concerns about what will happen to those currently receiving insurance from the ACA marketplaces and what will happen to underserved populations with Price at the helm of the HHS, a view stated by Tyler Winkelman, MD, an internist and pediatrician, in Ann Arbor, Michigan. “Not only is Dr. Price willing to cut health insurance for the most marginalized members of society, but he also has

But when you go beyond the basic bio, some doctors fault – while others applaud – his outspoken opposition to the Affordable Care Act (ACA) and government spending, which includes support for privatizing Medicare. shown little appetite for holding physicians accountable for the care they provide,” Winkelman said in an email. “Dr. Price has voted to pay physicians for the number of procedures they perform, rather than the quality of their work.” Some of those concerns are also shared by Scott Helmers, MD, a family physician in Sibley, Iowa. “It is heartening that HHS may be headed by someone who has actually practiced medicine. I am wary, however. I would prefer the physician be someone with experience in primary care who has served citizens stressed by health care bills. Destroying the ACA without a superior plan will be a step backward.” The disparity of opinions received by Medical Economics

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February 2017 |


reflect the results of a Merritt Hawkins poll, which showed that of the 1,094 physicians surveyed, 46% feel generally positive about Price, 42% feel generally negative while 12% are neutral. When it comes to the ability of patients to access quality care, 47% believe Price will detract from that ability and 42% think he will improve it, with the remaining 11% neutral. Price needs a simple majority to be affirmed by the Senate, where Republicans hold a 54-seat majority.

Speaking for those who can’t, docs petition vs. Price The AMA has historically been seen as the de facto mouthpiece for physicians, but when it issued a strong endorsement of Tom Price for secretary of the U.S. Department of Health and Human Services, a trio of doctors stepped forward to oppose it. The movement, dubbed the Clinician Action Network, was founded by Manik Chhabra, MD, Navin Vij, MD, and Jane M. Zhu, MD, MPP, all internists, a few weeks prior to Price’s nomination to harness the growing sentiment that the people making healthcare policies aren’t the ones practicing medicine. So it’s somewhat ironic that the first major action taken was to oppose the potential appointment of a physician to a cabinet post, a move the network founders say was necessitated by Price’s views on healthcare network. “The very strong endorsement of Dr. Price caught us off guard,” Chhabra told Medical Economics. “Especially when his views are not aligned with the goals of the AMA. His policies



are not in the patients’ best interest.” None of the founders is a current member of the AMA, but all have been in the past. The goal of the letter is to show the AMA that not everyone agrees with their endorsement and to point out to non-physicians that the organization does not represent all doctors. The letter, which has more than 5,200 signees, is being sent to both AMA leadership and members of Congress. The founders of the group are concerned that access to care will be curtailed, hurting those who need it the most. While they don’t claim the Affordable Care Act or other programs are perfect, they agree that Price represents a danger to accessible care. Zhu says that Price should be judged on his policies and positions and should not be given a free pass just because he is a physician. “Part of our responsibility is to advocate for patients who can’t advocate for themselves,” says Vij. “It’s important to think about patients that are most vulnerable and the issues they face.” Zhu says that no matter what happens, the group will continue to advocate to support evidence-based policies that put the patient first. “I think a lot of my colleagues have seen improvements in access to care,” says Chhabra. “I’m scared to see what happens if most of it is dismantled.” Todd Shyrock is a contributing writer for Medical Economics. Copyrighted 2017. Advanstar. 124846:0117DS

Government’s role in health care: Some carrots and many sticks BY BOB MILLIGAN


he role of government in the United States health care system is somewhat analogous to the role of carbon in organic chemistry: government involvement very nearly defines healthcare. As a result, it is difficult and maybe impossible to identify any aspect of the health care system that is insulated from the impact of government action. In a very general sense, government agencies (including federal and state government agencies) function in at least two capacities in health care: as customers, and as enforcers. As the single largest health care payor group, government is an essential source of revenue for most physician practices; as the enforcer of an arsenal of laws and regulations that regulate health care, government has the potential to push any physician practice, large or small, into ruin. This article will provide an overview of a few of the more influential aspects of government’s role in health care.

The carrots According to CMS National Health Expenditure (NHE) data, NHE grew 5.8% in 2015, to $3.2 trillion, or about $9,900 per person. This represented 17.8% of gross domestic product. Combined Medicare and Medicaid spending accounted for 37% of the total: Medicare spending for the year was $646.2 billion (up 4.5% over the prior year), representing 20% of the NHE; Medicaid spending totaled $545.1 billion (up 9.7%), representing 17% of total NHE.

Private health insurance spending for the year was $1,072.1 billion (up 7.2%), representing 33% of total NHE1. According to one study, these numbers may understate significantly the weight that government funding has on health care. A report by Barclay’s Equity Research Group estimates that while employers account for 43% of the major carriers’ covered lives (vs 39% for government programs), government spending accounts for 64% of the carriers’ revenue, vs only 6% that comes from employers2. A significant percentage of the NHE, $634.9 billion, is paid for “physician and clinical services.”3 Consequently, while government payors’ rates are not particularly attractive to many physician practices, they represent a revenue source that most physician practices could not survive without. In addition to the dollars they control directly, government programs effect health care reimbursement indirectly, in a number of ways. For example, CMS has introduced a number of initiatives involving risk-based reimbursement models, e.g., the Bundled Payment for Care Improvement Program. As providers learn to manage risk in these sorts of programs, they seek to engage in similar programs with commercial carriers. Coverage decisions by government programs also influence private payors, particularly with respect to tests and treatments based on emerging technologies. According to the Robert Wood Johnson Foundation, “Medicare’s February 2017 |


decisions about coverage of a new technology have the potential to impact patterns of care across the country.”4 Finally, the fee schedules government payors set for physician services have an impact on the amounts commercial insurers will pay for those services, as many commercial insurers set their fee schedules as a percentage of the Medicare fee schedule. According to one study, a dollar increase in Medicare reimbursement for physician services resulted in a 16% greater increase for reimbursement from commercial insurers.5

The sticks In its role as an enforcer, government impacts physician practice in a great many ways. The enforcement activity that likely, and understandably, generates the most fear and loathing is the enforcement of government rules relating to billing for services provided to government health care program beneficiaries, including the federal False Claims Act, the Anti-Kickback Statute, the Stark Law, and the state law analogues of some of these statutes. “Fraud and Abuse” enforcement The federal government in particular spends hundreds of millions of dollars a year enforcing these rules. The two principal federal enforcement agencies, the U.S. Department of Justice, and the DHHS Office of Inspector General issue a joint report each year summarizing the results obtained by their efforts, and the results are eye-opening. Their most recent report, for FY 2015, states that the federal government recovered over $1.9 billion in health care-related judgments and settlements in that year. These recoveries represented a return on investment of $6.10 for each dollar spent.6 FY 2015 enforcement actions included 983 new DOJ criminal health care fraud investigations, 613 health care fraud convictions, and 808 civil health care fraud investigations, with over a thousand health care matters pending at the end of the year. Not to be outdone, OIG reported 800 criminal actions and 667 civil actions, as well as exclusion of 4,112 individuals from participation in government health care programs. Many physicians and other providers take some comfort from the mistaken notion that these enforcement activities are not directed towards “the little guy.” A review of the press releases posted on the Medicare Fraud Strike Force website makes it clear that the Strike Force is pursuing cases against providers large and small.7 HIPAA By now, most physicians know (and all physicians should know) that HIPAA regulates how they use, disclose and secure patient information, and that HIPAA obligates them to implement and adhere to very detailed and specific policies and procedures to ensure the privacy and security of patient information. These rules have forced many physician practices to change how they store, use and communicate patient information. They also obligate physicians to conduct a risk analysis to determine the vulnerability of their patient information; to encrypt patient information so it can’t be 36


accessed by third parties if it’s lost or stolen; to develop written policies and procedures for handling their patient information, and for dealing with prohibited disclosures of the information; and to put “business associate agreements” in place with their vendors and business partners (including lawyers) who access patient information. The HIPAA rules are enforced by the DHHS Office for Civil Rights. According to OCR’s November, 2016 summary of its enforcement activities,8 OCR investigated and resolved 24,617 cases. In some of those cases, OCR simply provided “technical assistance” to the providers; in others, it directed the providers to implement corrective actions, as an alternative to the imposition of fines. In forty-one cases against large and small providers, OCR obtained settlements totaling $48,679,700 from providers. OCR also referred 589 cases to the Department of Justice for criminal investigation. State Medical Boards Allopathic and Osteopathic Medical Boards play an active role in the regulation of the practice of medicine. For example, the Arizona Medical Board investigates complaints against physicians for “unprofessional conduct.” The Arizona statute that authorizes the Board investigations and defines “unprofessional conduct” provides a laundry list of prohibited acts and omissions, ranging from disclosing professional secrets and misleading advertising to malpractice and having sexual relations with patients. Although many of the acts and omissions that constitute unprofessional conduct are obviously and inherently problematic, some of the prohibitions are quite subjective. For example, given the subjectivity of decisions regarding appropriate prescribing of controlled substances, Board investigations into physician prescribing practices can put well-meaning physicians who engage in medication management for chronic pain patients at significant risk. Prescribing practices also are subject to DEA regulation, which is discussed below. The Board statute also makes it an act of unprofessional conduct to charge a “clearly excessive fee.” In an attempt to bring clarity to the question of what constitutes an excessive fee, the Arizona Medical Board in recent years developed a policy to the effect that any fee greater than three times the Medicare Allowable was an “excessive fee.” It is not clear whether the Board intends to enforce that policy, and recent court decisions on antitrust issues have raised issues about the Board’s authority to regulate physician fees.9 Another highly subjective definition of “unprofessional conduct” is the prohibition against the use of “experimental forms of diagnosis and treatment” without IRB approval and other protections typically included in human subject research. Given the subjectivity and uncertainty as to what constitutes an “experimental” treatment, this provision has the potential to impact physicians interested in innovative therapies, e.g., stem cell therapy. Food and Drug Administration (FDA) Physicians interested in bringing innovative therapies to their patients might also beBsubject scrutiny theP FDA. Y S H to AR L A Hby OO ER

As a general proposition, the FDA does not regulate the practice of medicine.10 This general rule enables physicians to use drugs and devices “off label” based on their own medical judgment. However, the FDA can and does intervene when physicians employ tests or therapies that were developed, sold or distributed in violation of FDA statutes and regulations.11 For example, the FDA has investigated obstetrician/ gynecologists who have purchased and implanted IUDs obtained from Canadian distributors.12 More recently, there has been a flurry of discussions, articles and arguments regarding the scope of the FDA’s authority over physicians’ use of stem cell-based therapies.13 Drug Enforcement Administration (DEA) Given the increased attention being paid to problems associated with prescription drug use, particularly opioids, it is not surprising that the DEA is actively investigating physician prescribing practices.14 Often, a DEA investigation will coincide with Medical Board investigations relating to the physician’s practices for prescribing, storing or dispensing controlled substances. These FDA investigations often result in the issuance of a “Show Cause Order,” which includes a recommendation for revocation of the physician’s DEA Registration. For most physicians, particularly those involved in providing pain management services, revocation of registration is fatal to their professional practices. Arizona Department of Health Services (AzDHS) Historically, the facilities licensing arm of AzDHS did not effect physician practices significantly. This is because the statute that requires many health care facilities to obtain a license from AzDHS exempts “private offices and clinics of health care providers licensed under title 32”15 (which includes physicians) from the facilities licensure requirement. In September of 2016, the AzDHS licensing division issued a Substantive Policy Statement setting forth its interpretation of the exception quoted above.16 In that document, AzDHS articulates its position that the exception does not exempt, e.g., physician practices that are owned in whole or in part by individuals who are not licensed under title 32. That would mean that a practice owned by a husband and wife would have to be licensed if either the husband or the wife is not a professional licensed under title 32. Also, the Policy Statement seems to indicate that if a practice that (a) is owned by multiple physicians and (b) operates multiple offices, the practice would need to license its offices unless each owner spends at least eight hours per month on patient care activities at each office.

References: 1 NHE Fact Sheet - Centers for Medicare & Medicaid Services, December 2, 2016, accessed at nationalhealthexpenddata/nhe-fact-sheet.html. 2

Troy, TD, How the Government as a Payer Shapes the Health Care Marketplace, American Health Policy Institute, 2015.


National Health Expenditures 2015 Highlights, accessed at https:// highlights.pdf. .


How the Government as a Payer Shapes the Health Care Marketplace, fn. 2.




The Department of Health and Human Services and The Department of Justice Health Care Fraud and Abuse Control Program Annual Report for Fiscal Year 2015, accessed at https://


DHHS Office of Inspector General/United States Department of Justice, Investigations Press Releases, accessed at https://oig.


DHHS Office for Civil Rights, Enforcement Highlights, November 30, 2016, accessed at index.html.


Fraser, E., Opinion Analysis: No antitrust immunity for professional licensing boards, Scotusblog, February 25, 2015, accessed at opinion-analysis-no-antitrust-immunity-for-professional-licensing-boards/.


Berry, C. The Dividing Line Between the Role of the FDA and the Practice of Medicine: A Historical Review and Current Analysis, LEDA at Harvard Law School, accessed at https://dash.harvard. edu/bitstream/handle/1/8846812/cberry.html?sequence=2.


21 USC 396. “Nothing in this chapter shall be construed to limit or interfere with the authority of a health care practitioner to prescribe or administer any legally marketed device to a patient for any condition or disease within a legitimate health care practitioner-patient relationship. This section shall not limit any existing authority of the Secretary to establish and enforce restrictions on the sale or distribution, or in the labeling, of a device that are part of a determination of substantial equivalence, established as a condition of approval, or promulgated through regulations. Further, this section shall not change any existing prohibition on the promotion of unapproved uses of legally marketed devices.” (Emphasis added.)


E.g., Lowes, R., Physicians Risk Lawsuits, Prison for Using Unapproved IUDs, Medscape, July 29, 2010, accessed at http://


McFarling, U., FDA weighs crackdown that could shut hundreds of stem cell clinics, STAT, September 9, 2016, accessed at https://


See, e.g., U.S. Department of Justice-Drug Enforcement Administration, Diversion Control Division, Cases Against Doctors, which lists criminal cases against doctors, and administrative actions (registration revocation actions), accessed at html.


There are “exceptions to this exception,” under which, e.g., facilities that keep patients overnight, and abortion clinics, are required to obtain licenses.


The notice for the Statement is available at public_services/register/2016/39/23_substantive_policy_statements.pdf.

Conclusion There was a time, within the memory of many physicians practicing today, when a physician’s only interaction with government was the filing of a tax return on the income earned by the practice of medicine. Clearly, those days are gone. Physician organizations now need to be aware of, and comply with, a wide array of government rules and requirements.

February 2017 |


Ryan House

Opening Doors and Opening Hearts 38



yan House is leading the way in caring for children with life-limiting and terminal conditions in Arizona. One of two facilities of its kind in the nation, Ryan House opened on St. Joseph’s campus in 2010 following a grassroots education and fundraising campaign to bring the free-standing pediatric palliative care facility model to the U.S. from England. In Maricopa County alone there are 4,500-5,000 children annually who are living with a life-limiting or terminal condition. Providing high quality care for this high-cost population with acute and chronic medical needs - while meeting the child’s and family’s psychological, social, emotional and spiritual needs - challenges our systems, beliefs and values and demands innovation. Ryan House is the family-centric, innovative, cost-effective answer to a gaping need and serves children statewide. Our programs include:

Pediatric respite care Respite care is a gift of time;

short-term overnight stays that help a family take breaks from the stress of ‘round the clock’ home care. It also creates opportunities for kids to be kids, where they can spend time with other children like them. Respite care becomes a necessity, not a luxury. It is the solution for renewed energies and fresh perspectives, as regular “time off” for caregivers is essential to help prevent family fatigue and breakdown. At Ryan House, children and families can receive up to 28 days of respite care per year. Families can also choose to check-in as a family or drop their child off. This allows Ryan House to meet the needs of all families and all comfort levels.

Pediatric palliative care Pediatric palliative care is both a philosophy and method of care. It aims to holistically identify and alleviate the physical, psychosocial, spiritual, and emotional pain for both the child and the family. Its primary goals are to enhance quality of life, minimize suffering, optimize functions, and provide opportunities for personal growth. Life enhancing therapies Certified child life specialists and trained volunteers provide activities that address the isolation, pain, and fear children and their siblings face with diagnosis. They also improve overall quality-of-life by providing opportunities to experience new sensations, develop skills, and gain confidence. Activities include: legacy building, art, music, pet, sensory, recreational, and hydro-therapeutic activities.

Pediatric end-of-life Families with a child facing end-of-

life receive supportive planning and compassionate care consistent with clinical, cultural, and ethical standards. Ryan House also provides parents or guardians and siblings with a loving system of support and comfort. End-of-life care is provided in partnership with our Care Partner, Hospice of the Valley Ryan House supports children over long periods of time with the goal of helping children and families live their best life possible. We focus on abilities and living, rather than disabilities and dying. We strive to maximize living.

Grief and bereavement support Ryan House offers

ways, including: Sibshops, family counseling through various programs, an annual community event to honor passed children and bereavement boxes to families that are filled with special keepsakes. Additionally, the Care Team provides anticipatory grief support to children, siblings, and their families. Ryan House is a second home to families and enables both the child and family to cope with the most difficult of situations. Ryan House has nationally recognized, expert medical direction in providing world-class care. Kevin Berger, M.D. is a general pediatrician and partner at Phoenix Pediatrics and a member of the Ryan House Board of Directors. Tressia Shaw, M.D. directs the Palliative Care Program at Phoenix Children’s Hospital, which she created in 2009. Wendy Bernatavicius, M.D. directs the Special Needs Clinic and conducts Palliative Care consults inpatient at Phoenix Children’s Hospital. All three physicians are Board Certified in Hospice and Palliative Care Medicine and long-time medical directors with Hospice of the Valley. Ryan House, in your backyard, represents the best in health care and can help the children and families you know and serve them at no cost. We work alongside pediatricians and specialists to provide coordinated, personalized and beautiful care, and help families and providers navigate complex decision-making. There are also several ways to get involved at Ryan House. Some ways to volunteer include:

Care team volunteer The volunteer will assist clinical staff to meet the needs of the children and families staying at Ryan House. While the Care Team is responsible for all the direct care of the children, in-house volunteers also play a vital role in supporting the needs of Ryan House. Roles include assisting with general housework, laundry or cooking for the children, all which help to make Ryan House a home. Volunteers are also involved in activities directly with the children such as reading, arts and crafts, games, playing music and more. Volunteers must be at least 18 years of age and be accepted though an interview process. Community volunteer We gladly welcome individuals or

groups who are looking for short term volunteer opportunities to get involved in Ryan House. These community volunteers perform a wide variety of tasks from assisting at events to performing short-term or one-time, group or individual projects. No training is required. If you or your group is interested in volunteering at one of the many special events that Ryan House hosts, or hosting a volunteer day at your workplace, or doing a project at the House, please contact us with the date you’re interested in and the number of individuals in your group. We will work with you directly to find a meaningful project for your group. For more ways to get involved, we ask you to call and learn more or come for a tour. See the best in local health care and together let’s better serve all of Arizona’s children. For more information please contact Ryan House Executive Director, Alyssa Crockett, 1-602-200-0767 or acrockett@

grief and bereavement support to families in a number of February 2017 |


This essay was selected by the University of Arizona School of Medicine from a group of student essays that were submitted in response to a question concerning government’s role in healthcare, and, specifically, how it impacts the doctor-patient relationship. This essay was prepared and submitted by the student author in his personal capacity. The opinions expressed in his essay are the author’s own and do not reflect the views of the Arizona Medical Association, Maricopa County Medical Society, or Pima County Medical Society.

Combating Government Incursion upon the Patient-Physician Relationship BY A LE X A NDER A LVA R E Z


n order to consider what physicians and medical trainees can do to ensure that government does not further erode the doctor-patient relationship, we must first look at how government has undermined this relationship in the past. For the sake of this essay, I would like to consider Arizona’s 2011 Revised Statute (ARS) 36-2156, which, amongst other regulations, requires fetal ultrasound to be performed at least twenty-four hours prior to any abortion.1 Regardless of one’s stance on the United States Supreme Court’s 1973 decision on Roe v. Wade and subsequent challenges to the legality of abortion care, this Arizona statute reveals how government regulation can undermine physician-patient relationships and provides a window into how those in the medical community can combat it. The issue with ARS 36-2156 and other state and federal laws like it can be found in their encroachment on the primary elements of the physician-patient relationship – patient autonomy and partnership in decision-making. In a 1992 article in the Journal of the American Medical Association, Drs. Ezekiel and Linda Emanuel described that the core aim of the physician-patient relationship is such autonomy and partnership, or in their words: “[helping] the patient determine and choose the best health-related values that can be realized in the clinical situation”.2 By mandating physicians to perform imaging before abortion, our state destroys patients’ autonomy: patients are no longer allowed the self-determination to decline a test that is not medically necessitated for an abortion (as defined by the American College of Obstetricians and Gynecologists3). By so doing, the state also sabotages the decision-making partnership between physician and patient: patients and physicians can no longer follow Emanuel’s precept to reason together in choosing what treatment pathway to follow; rather, physicians are forced to perform fetal ultrasound. In their 2012 “Statement of Principles on the Role of Governments in Regulating the Patient-Physician Relationship,” the American College of Physicians extends this assessment to all such government-mandated treatment stating that “Even laws and regulations that mandate a test...when generally consistent with the standard of care...should be approached cautiously, because they cannot allow for all potential situations in which their application would be unnecessary”4. An obvious and oft-encouraged solution to this problem is for physicians to be involved in state and national medical associations. By so doing, they can lobby against new federal and state laws like ARS 36-2156 from further dismantling patient-physician relationships. Although medical associations are successful in many of their legislative initiatives each year, innovative ideas must be enacted in order to advocate for patients who would be negatively affected by proposed statutes that these organizations currently do not address, or in which our legislators fail to listen. The solution I propose addresses what many legislators are constantly concerned



about – favor with their constituencies. I believe that physician engagement in community-based educational programs on medical legislation will empower patients in influencing their elected officials to vote to protect the physician-patient relationship. While organizations like Planned Parenthood currently enact such measures, because of the perceived partisan nature of the organization, their scope is often limited. As such, I believe that non-partisan medical organizations need to make concerted efforts to reach out to their patients – the citizens of Arizona. In so doing, they must inform those patient-citizens of Arizona’s legislative proposals and public ballot measures that could negatively effect their autonomy and their partnership with their providers. Had patients been made aware of the compromise made to their ability to make their own healthcare decisions with ARS 36-2156, they may have been able to convince the fifty-eight legislators who voted to approve the proposal not to do so. It is, thus, our responsibility as members of the medical field whose primary concern is our patients’ welfare to fight against such incursion of health autonomy and partnership. If government actions are so disparaging these two key elements of the physician-patient relationship, then it is time for us to partner with our patients to ensure that we can politically advocate together for preservation of our relationship. The patient-physician relationship should not be encroached upon by partisan politics like those found in the passing of ARS 36-2156; by educating patients on how laws might unfairly effect them apart from identity-based politics, we may be able to stop this encroachment.

References 1 Arizona State Legislature. Arizona Revised Statutes Title 36-2156. 2 Emanuel, E.J., and L.L. Emanuel. “Four Models of the Physicianpatient Relationship.” JAMA. Apr 1992;267(16):2221-6. https:// 3 The American College of Obstetricians and Gynecologists. “Medical Management of First-Trimester Abortion. ACOG/SFP Practice Bulletin. Mar 2014;143. Practice-Bulletins/Committee-on-Practice-Bulletins – Gynecology/ Public/pb143.pdf?dmc=1. 4 The American College of Physicians. “Statement of Principles on the Role of Governments in Regulating the Patient-Physician Relationship.” Jul 2012. policies/patient_physician_relationship_2012.pdf.


Alex is a second year MD/PhD student at the University of Arizona College of Medicine – Tucson. He completed his undergraduate in Biomedical Engineering at the University of Arizona and is staying in the city for medical school. After he finishes pre-clinical coursework in June, he will begin his PhD studies in Biomedical Engineering, developing novel ultrasound techniques for clinical applications. Alex also plans to continue to engage in community organizing and advocacy efforts, especially related to criminal justice reform.

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Insights into the Pre-Certification Process B Y D A N I E L P. A S P E R Y, M D , M B A


hat if there was a way to enhance care delivery and reduce the risk of medical errors – all while preventing an unnecessary financial strain on patients and the healthcare system at large? There is. Pre-certification helps address these goals and more, and they are just a few of the reasons insurance companies, including Blue Cross Blue Shield of Arizona (BCBSAZ), use the process. As you discuss pre-certification with your patients and staff, I am hopeful these seven insights into our process at BCBSAZ, along with its benefits, will help advance those conversations in a meaningful way.


BCBSAZ Pre-Certifications by the Numbers 32,000 2,600 1,500 400 14 4 per year

per month

It protects patients financially. If you file a claim

per month reviewed by nurses

after services are rendered and it’s denied because of lack of coverage, this could adversely affect your patient financially. Pre-certification helps both you and your patient avoid unexpected expenses. At BCBSAZ, we require pre-certification for various services and procedures such as durable medical equipment, MRIs, transplants, genetic testing and inpatient surgery. (The full list is available online at: When you submit your pre-certification request, we are verifying this patient is insured by BCBSAZ and is covered for this particular procedure according to their plan.


It safeguards against medical errors. During the pre-certification process, we work to confirm that the requested service or procedure correlates with the member’s records. For example, we might see a history of right knee pain with a request for a left knee procedure. A clerical error like this would be caught well before the procedure, upholding patient safety.


It can help improve care delivery and the patient experience. As part of pre-certification, we



per month reviewed by physicians nurses on staff

physician reviewers

consider the care setting. For example, we recently worked with a member who underwent an infusion therapy every other Saturday. For an entire day, this mother of two young children sat in a hospital. We asked: Could the care be provided at her home instead? It could, and in doing so, we could improve her quality of life and decrease costs at the same time – all while the quality of care and outcomes remained uneffected.


It’s a process (and a fast one) driven by clinical experts. Doctors and nurses staff our pre-certification program. Once technicians review the request and

check the patient’s eligibility, network status, and benefits, an RN steps in to evaluate the request according to the medical necessity criteria which includes the BCBSAZ Medical Coverage Guidelines. These evidence-based guidelines are updated annually based on the latest literature and address medical necessity and investigational/experimental treatments. If the criteria for a treatment are met, the request is approved; if not, it goes to our medical directors – all physicians – for further review. Only a medical director can deny a pre-certification. The entire process typically takes 24-48 hours.

Pre-Certification Team Member Spotlight Mary Campbell, RN

Care Coordinator, Pre-Certification Blue Cross Blue Shield of Arizona Team member since 2007


There is a mechanism for further discussion.


The majority of pre-certification requests are approved. We want your patients to get the care they

When providers and their staff have questions about pre-certification process with BCBSAZ, they are lucky to have Mary Campbell there to help. Throughout her 40-year career in nursing, Mary has seen and done it all. She has worked as a staff RN at a high-risk neonatal center and as a visiting nurse with countless hospital systems in both Illinois and Arizona. During this time, she developed front-line experience and insight into how to work with all types of insurance, including indemnity, HMO, Medicaid/ AHCCCS and Medicare. Since joining the pre-certification team at BCBSAZ in 2007 as a care coordinator, she leverages this expertise to help both providers and members navigate the pre-certification process. Mary helps members understand what pre-certification is and works with BCBSAZ’s medical directors respond to the various requests that come to the team. When interacting with providers she manages to flow of requests from physicians’ offices and facilities, ranging from an approval for an office visit, to an out-of-network provider wanting in-network benefits, to someone wanting surgery. In the quiet time between urgent requests, she writes letters and reviews charts. “Provider’s offices can range from a one-person practice to a multi-person team,” says Mary. “No matter the request, my goal is to helping them get answers and satisfy the members’ needs whenever possible.” “When it comes to the patient (our members), they are often are scared, anxious and they’re calling for help,” explains Mary. “I get to problem-solve and interact with people who are having difficulties.” “They want to know, ‘Why are things happening the way they are happening, or why are they not happening at all?’ she says. “We are here to help, so I’m always looking for ways to make it easier for them to understand their insurance and how we work with their provider.” “It’s gratifying to use my 40-plus years of nursing and insurance experience to help people in need. I can’t think of anything else I’d rather be doing,” says Mary.

You have the right to appeal all denials. What’s more, for medically necessary denials, you may speak directly with the medical director who reviewed your request before it reaches an appeal. So, if the denial was based on lack of information, you will have an opportunity to supply it and talk through any other issues.

need, and we ultimately approve most requests we receive.


We provide everything you need to know. By

working together we can help educate patients on their benefits, how to use their network, what’s covered, and even about the types of procedures that require pre-certification. In addition, we strive to make sure you and your staff have the information you need to be able to submit complete records, which helps reduce denials and appeals – saving you time in the long run. We publish our Medical Coverage Guidelines on our website, and you can also use our provider portal to check a member’s eligibility and benefits details.

Arizona Physician (USPS 020-150) is published 12 times per year. It is a combined publication of the Arizona Medical Association, Maricopa County Medical Society, and Pima County Medical Society, 326 E Coronado Rd., Phoenix, AZ 85004. Periodicals postage paid at Phoenix, AZ. Postmaster, send changes to: Arizona Physician, 326 E Coronado Rd., Phoenix, AZ 85004. 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 reserved. Volume 1, Issue 2

February 2017 |


Working together At BCBSAZ, our goal is to partner with you and do what’s right for the patient—both medically, and with care that is consistent with the patient’s health plan benefits. Even if a request for a service or procedure is denied, the final treatment decision rests with you and your patient. We appreciate the time and effort you and your staff take to engage in the pre-certification process and to help inform and support your patients along the way. For our part, we will continue to endeavor to make pre-certification a clear, efficient process. Because when we work together, pre-certification can improve care and efficiencies, lower costs, and decrease risks for everyone.

Daniel P. Aspery, MD, MBA, is Vice President Health Services, Medical Director, Blue Cross® Blue Shield® of Arizona, and provides his expertise to multiple departments within the Health Services Department, including care coordination, medical claims review, medical risk assessment, case management, medical policy, medical appeals and grievances, and disease management. He is a member of the American Academy of Family Physicians, the Arizona Academy of Family Physicians, and the Arizona Medical Association. Contact your network contract specialist (NCS), visit the Provider Portal on or call the Provider Relations Department at (866) 976-2583.

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Arizona Physician Magazine, February 2017  

A combined publication of the Arizona Medical Association, Maricopa County Medical Society, and Pima County Medical Society.

Arizona Physician Magazine, February 2017  

A combined publication of the Arizona Medical Association, Maricopa County Medical Society, and Pima County Medical Society.