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

July 2017

Improving Access & Choice:

a sit-down with Sara Salek, MD pg. 23

Scope of AHCCCS:

What physicians think of Arizona’s Medicaid care model pg. 30




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Physician Profile

Expanding access through streamlined processes and expanded choice: a conversation on the efficiency of AHCCCS with Sara Salek, MD.

Features 14


How Patients Far From Phoenix are Getting Cured of Their Hepatitis C GOP’s “Obamacare” Replacement Would Put State in Control

30 34

What Physicians Think: Scope of AHCCCS Population Health Management: A Model of an Integrated Service Delivery System

In This Issue 4 What’s Inside 6 President’s Page 9 Policy: 2017 Gains in Public Health 11 Congressional Corner with Ruben Gallego 13 Rural Health: Arizona Healthcare

19 Patients over Standards: Serving with IHS 28 Event Photos: ArMA President’s Award’s Banquet 38 Community: Hospice of the Valley 41 Critical Path Institute: Advancing Therapeutics from | arizonaphysician.com Julyfor 2017 3 AZ the World


Jay Conyers, PhD

It’s one of the finest highway networks in the world – and nobody seems to care that the basic idea was copied from the Nazis. T.R. Reid


’m sure it seems strange that I would begin my introduction to this issue with a quote about highways and Nazis, but bear with me. I recently finished an interesting book by T.R. Reid, a well-known reporter, film correspondent, and author who’s scoured the globe examining healthcare systems. In his 2009 bestseller The Healing of America, Reid discusses our nation’s aversion to ‘socialized medicine’ or other nationalized health systems, such as those in Canada, Great Britain, Germany, and Japan. In wondering why so many Americans oppose the idea of adopting a ‘system’ from another country, Reid recalls how President Dwight D. Eisenhower was faced with the possibility of our nation spiraling into a depression less than twenty-five years after the 1929 market crash. In response, he called on his agencies to come up with solutions to the steadily climbing unemployment rate. Fortunately for Eisenhower, the solution had stared him directly in the face some three decades earlier when he helped lead a caravan, as a young lieutenant colonel in the Army, across the Lincoln Highway. The two-month journey moving tanks and trucks from one coast to the other was perilous and showed the need for a more robust system of roads. Decades later, Eisenhower got a glimpse of how a highly-organized system of highways could modernize a nation. In his memoirs, he penned, “After seeing the autobahns of modern Germany, and knowing the assets those highways were to the Germans, I decided, as President, to put an emphasis on this kind of road-building.” And so, he signed the Federal-Aid Highway Act in 1956 to help jumpstart a stagnant economy. The 41,000 miles of national highways helped give most Americans access to the rest of the country.



To many, our healthcare system of today might look like what our highway system looked like prior to Eisenhower’s vision for a ‘connected’ America. Without proper roads, a family in rural Pennsylvania might never have had the opportunity to see the glitz and glamour of New York City. The same can be said about a patient needing specialized care to treat a chronic disease but simply not having the financial means, or adequate health insurance, to cover the costs. When we talk about underserved, we’re talking about those who have limited access to healthcare. Access might be limited by financial constraints, or geographic boundaries, or immigration status. But how much of this do we actually have here in our state? According to the U.S. Census Bureau, only Michigan and Mississippi have higher poverty rates than Arizona, with 21.3% of our state’s residents living below the poverty line. Arizona also has one of the highest illegal immigrant populations – based on percent of total residents – with only Texas, Nevada, California, and New Jersey claiming more than our 4.9%. Our state also has the nation’s second largest Native American Indian population, with more than 300,000 inhabitants across the 17 sovereign nations and roughly a quarter of Arizona’s geographic expanse. To say we have populations of underserved individuals is, quite frankly, an understatement. Fortunately for many, access to care is achievable through the numerous programs that help those in need. Despite being the last state in the U.S. to implement a Medicaid program, AHCCCS is widely regarded as a model program for other states to follow. Indian Health Services (IHS) provides direct medical care and public health

programs to many Native Americans throughout our state (although many would argue that the services are lacking). Arizona is also home to numerous non-profit organizations dedicated to serving those in need. Look no further than Missions of Mercy, El Rio Community Health Center, and Circle the City, to name a few. Many are open to all, but others focus on a niche population. Take for example Phoenix Children’s Crews’n Healthmobile, the mobile unit that brings much-needed medical care to the thousands of youth living on the streets of Phoenix. Or Asian Pacific Community in Action (APCA), which offers programs to help empower Asian Americans, Native Hawaiians, and Pacific Islanders to improve their health. Despite the availability of social programs and non-profit groups doing all they can, need still exists. So what’s inside? This month, we profile none other than Dr. Sara Salek, Chief Medical Officer for AHCCCS and proud Arizona native. She shares with us her story, and what our state is doing to care for those in need. For our Congressional Corner we we hear from Congressman Ruben Gallego, of Arizona’s 7th district, and Will Humble of the Arizona Public Health Association fills us in on gains in public health this legislative session. For our community partner we profile Hospice of the Valley and the work they do to help those in need. We also feature several articles discussing the concerns of rural health, AHCCCS, and care delivery, as well as other topics. Next month, we focus on employment, and examine the decision many physicians face at least once in their careers

When we talk about underserved, we’re talking about those who have limited access to healthcare. Access might be limited by financial constraints, or geographic boundaries, or immigration status.

– to be or not to be employed. Many factors are making it more and more difficult for physicians to hang out the proverbial shingle, but what can be done to help independent physicians stay afloat? Look for our issue next month as we examine growing trends in physician employment. Until then, enjoy the rest of the summer, either here or somewhere else a wee bit cooler… Jay Conyers, PhD, is the Editor-in-Chief for Arizona Physician and serves as Executive Director of the Maricopa County Medical Society.


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President’s Page NURTURING LEADERS WITHIN ORGANIZED MEDICINE The following are comments delivered as the inaugural address by Dr. Hamant at the Arizona Medical Association President’s Awards Banquet on June 2, 2017.


t is my honor and privilege to be this year’s President of the Arizona Medical Association (ArMA). I want to thank all my fellow physicians at ArMA for entrusting me with this responsibility, particularly in this year of transition. I am able to stand before you as the new ArMA president only because I stand on the shoulders of the previous presidents, some taller than others, but none the less all giants. If all the past-presidents could please stand and be recognized for their service... I will be calling you all frequently in the coming year for your good counsel. Dr. Alexander and the other distinguished presidents have left me with a leadership legacy that I hope to be able to emulate. I am here tonight before you because of two mentors, Mr. Steve Nash, formerly the Executive Director of the Pima County Medical Society, and Mr. Chic Older, the Executive Vice President of ArMA. They both encouraged my involvement in organized medicine and have offered me sage advice over many years. It would not be possible for me to be here tonight before you without the unwavering support of my wife, Dr. Lynnell Gardner, a gynecologist. They say behind every successful man is a strong woman. Well in my case that is an understatement. Her support has been immense and greatly appreciated. We have practiced together in Tucson since 1989 in the same office. So, we are partners in more than one sense of the word. I would also like to acknowledge my two children; Richard, an IT consultant, and Laura, a third-year medical student here in Phoenix at the College of Medicine. I am so proud of their accomplishments. I would like to take a few moments to tell you something about my personal history. Everyone in the room I am sure has a unique and interesting story to tell but I would like to take this opportunity to give you a sense of where I come from. I was raised as an Air Force brat. If you have served in the military you have an idea of what that means. I found the experience of living all over the world and many parts of the U.S. to be quite formative. Moving frequently, I had



Michael Hamant, MD

the opportunity to attend three high schools (and I thought of it as an opportunity, not a burden) which forces one to become quite adaptable. I also became a “joiner” in order to fit into my new surroundings quickly. Growing up in a military family had another influence on my personal philosophy. Living with government employees is Washington for five years left me with an appreciation for government and the positive effect good government has on civil society. I appreciate that my idea of a good government protection might be considered someone else’s onerous government regulation. I don’t think I would feel safe flying without the FAA, drinking water without the EPA, or filling prescription medication without the FDA, among many government protections. Although I know my opinion is a minority one, I support HR 676, the “Improved Medicare for All Act” that now has 111 co-sponsors in the House. My father’s experience growing up poor during the Depression, then getting his college degree in architecture on the GI Bill after serving in WWII, was my family’s personal experience of what a great government policy can accomplish. I came to Arizona at age 16, so I am a semi-native, finished high school in Flagstaff, then went to NAU for college, but could not get into medical school upon graduation. So, I completed a master’s degree at NAU, but still could not get into medical school. I then decided to enroll in medical school in Guadalajara, Mexico. Former ArMA President Dr. William Thrift was a classmate of mine there. We were both able to eventually transfer to the UA College of Medicine in Tucson and graduated in 1983. What are the odds of two former Guadalajara students both becoming ArMA President? Probably has something to do with how badly we wanted to be physicians, our perseverance in obtaining our goals, and how much we appreciate the opportunity to practice medicine. After completing my family medicine residency, I returned to Tucson and Lynnell and I opened our solo private practices. We are both dinosaurs, but still going strong despite all the changes and challenges of practicing medicine today. So now you have an understanding of my background. Although I am in solo practice, I have spent my career as a “joiner.” I became involved in my hospital medical staff

eventually becoming a member of the hospital board of directors. I became involved with a large physician run IPA and served a term as the president of its board. Eventually I found organized medicine at the Pima County Medical Society which led to my participation with ArMA - culminating with my role this year as president. Dr. Alexander and I were able to attend the Leadership Academy as guests of the California Medical Association last month. I have been thinking about leadership for some time as my term for president was coming up – much too quickly I might add. What makes a good leader? We can all name good historical leaders from political life, but what makes a good leader in other circumstances, in business, not-for-profits, or professional societies? Are there commonalities? Identifying and nurturing leaders within organized medicine should be encouraged and not left to chance. Nor should we solely depend upon our society executives to find our future leaders. I think we need a more systematic approach. Some leaders may be born, but most are mentored, trained, and learn to lead through experience, as in my case. Most of those in this room are leaders and the collective wisdom is evident. Think of what constitutes a good leader. Who were the mentors and leaders in your experience? Who were effective and admired? Now that you have that leader in mind, consider what he or she is like. I am sure that most of us will come up with characteristics that are quite similar. Leaders are first of all competent in their field, and physicians are highly competent, but many physicians do not have natural leadership qualities. (Studies show humility is a trait common to effective leaders, but many physicians seem to lack the gene for humility). Leaders are almost universally people of character and high morals. Leaders are good listeners as well

as communicators, consensus builders, and provide goals and expectations. Some leaders are bold visionaries, some risk takers, others show flexibility and adaptability. What steps can ArMA take to identify and mentor the future leaders of organized medicine? With your assistance, I hope to spend some time this year addressing this goal. ArMA this year of course is going through a leadership change with the retirement of Chic Older, who has not only been the face, but the heart and soul of ArMA for three decades. He will not be easy to replace but this transition will offer the opportunity to ArMA for re-evaluation and a new leader will build upon Chic’s legacy and I am sure take ArMA to new heights. The work of many in this room on the board of directors, the executive committee, the search committee, the finance, legislative, public health, and medical education committees among others have shown a dedication and engagement with ArMA that is really impressive so I know that the future of ArMA is strong. We need to identify and nurture future leaders. But there is an apathy and frustration with the practice of medicine that has led to an epidemic of burnout. Too many of our colleagues are unhappy, which effects patient care, and can result in leaving clinical practice or early retirement. The average PCP now retires at age 60! The average PCP now spends more time documenting in the EMR and other non-compensated activities than in face-to-face patient care. There is no question that the work environment for physicians has changed dramatically and will continue to change. This combination of factors has led to burn out rates reported to be between 35% and 55% depending on specialty. Physician organizations like ArMA need to develop programs to help physicians combat burnout. The collegiality of ArMA is my personal antidote to burnout and my

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involvement gives me professional satisfaction outside of patient care. In my opinion, too many physicians blame the evil insurance companies, their damn EMR, the horrific government regulations, or the difficult patients for their unhappiness. One of my goals this year will be to develop programs to help the physician healers help heal themselves and treat burnout before it becomes entrenched. Burnout is evidenced by cynicism, hostility, decreased productivity, increased errors, and increased patient complaints. If not turned around burnout can lead to impaired physicians, divorce, early retirement, or tragically, suicide. There are strategies to combat burnout and it is important to identify the signs in ourselves before it becomes critical. Time management, taking vacations, CME on burnout, leadership training, and learning to say “no” can all help in avoiding burnout and returning the joy to practice. The causes of burnout, including the bureaucratic hassles, too many hours, too many patients, uncompensated tasks, working harder to make less, which, added on to family stress, can be overwhelming. Physicians who practice in groups or hospital settings may be identified in their systems as potentially suffering from burnout. But what of physicians like myself in private practice who may not have the same institutional support systems? One of the propositions under consideration at the ArMA House of Delegates is to re-institute the medical student and resident and young physician sections. I commend Dr. Ross Goldberg for spearheading that effort. That idea and the work that Past President Dr. Zuhdi Jasser has done at the AMA with the private practice section, has led me to believe that we need to approach the organization of ArMA in a new light. Not based on geography but instead based on practice setting. I have more in common with a solo or small practice physician in Phoenix or Flagstaff, which are now in the Maricopa and Rural Caucuses respectively, than with a large employed group practice across the street from me in Tucson. So, I would propose to develop within ArMA six different interest groups:

1. 2. 3. 4. 5. 6.

small practice large practice employed physicians academic physicians residents and young physicians medical students. Each of these groups have unique needs and experiences. For instance, small groups have great difficulty with the IT reporting requirements of MU and now MIPS. Employed physicians have contract and compensation issues that are unique to their setting. We are already targeting membership strategies differently for these groups, but once they are in ArMA they are not differentiated. I envision that each group will have separate web blogs and eventually tailored CME activities. I believe that this will create a new synergy and enhance membership growth. Further, leaders will emerge from these sections who will become the backbone of ArMA in the years to come. To summarize, my three goals for ArMA this year are: 1. develop a leadership training program; 2. develop programs to address the epidemic of physician burnout; and 3. to establish the interest group sections within ArMA based on practice setting and not geography. I again thank you for this opportunity to be your president. I welcome the many challenges in the year ahead. We will be selecting our new EVP, continuing the process of selling our building, and reaching out to many new potential members with the interest groups. Of course, ArMA will continue to have our historically strong advocacy agenda at the legislature under the stewardship of Pele Fischer and Steve Barclay. Our number one priority is to continue to grow membership so that the financial resources are available for ArMA to be the best run and effective organization that works for all the physicians and our patients in this great state. Thank you.” Dr. Michael Hamant is a private practice family physician in Tucson and the 126th President of the Arizona Medical Association.

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Will Humble, MPH

he Arizona State Legislature’s 2017 Regular Legislative Session ended with some solid gains for public health. There were some missed opportunities and some losses (especially when it comes to future voter initiative possibilities), but on balance, a good session.

transplant can successfully treat the disorder. It’s especially important to test for SCID in Arizona because the disorder is much more common in certain populations in Arizona: 1/2,000 among Navajos and Apaches and about 1/20,000 among Latinos.

Emergency dental care

Clarifying certified registered nurse anesthetist practice

The biggest public health win came inside the budget, which directs Arizona’s Medicaid program, AHCCCS, to begin covering emergency dental services for all adult Medicaid members. The services are capped at $1,000 per person per year. AHCCCS will be working on a definition of emergency dental services this summer. Kids that have their insurance through AHCCCS have comprehensive dental coverage that includes preventative services. Big win for public health!

Primary care loan repayment The state budget authorized an additional $350,000 per year to go into the state’s loan repayment program, bringing the total funds to $1 million per year...which will potentially qualify Arizona for up to an additional $1 million in federal funds. These new resources are timed perfectly to take advantage of the revamping of the program over the last few years. In a nutshell, this program gives primary care and other front-line health practitioners an opportunity to get significant relief for their student loan debt by practicing in rural and underserved AZ.

Newborn screening The state budget authorizes Arizona Department of Health Services (ADHS) to increase their newborn screening fees by $6 per test so the Arizona State Health Lab can afford to test babies for Severe Combined Immune Deficiency (SCID). Babies born with SCID look normal at birth but they can’t fight infections. They often die before one year of age without medical treatment. If SCID is caught at birth (before the onset of infection) a bone marrow

Nurse anesthetists are a key practitioner across Arizona, especially in rural areas. Some disconnects with respect to the supervision of nurse anesthetists and prescribing and administration authority had been causing access to care problems in rural Arizona. In a nutshell, SB 1336 outlines medication orders and prescribing authority for nurse anesthetists and makes it clear that a physician isn’t liable for anesthetic administration by a nurse anesthetist. It also modifies the definition of “presence” (relating to supervision) of these practitioners and outlines medication orders and prescribing authority. This new law got through with some hard work and compromise by folks who kept their eye on the access to care ball in Arizona.

Outpatient occupational therapy for Medicaid members For many years AHCCCS has covered occupational therapy services in an inpatient hospital setting for all members, for outpatient members under 21, and for adults that are enrolled in Arizona Long-Term Care System (ALTCS). The state budget funds AHCCCS so that it can start providing coverage for occupational therapy as an outpatient health service for all their enrollees (when it’s medically necessary).

Asthma management Schools will be better able to help kids with asthma to manage their symptoms next school year thanks to the passage of HB 2208. It lets trained school staff administer (or help administer) an inhaler for a student in respiratory July 2017 | arizonaphysician.com


distress. The new law also outlines the training required and provides immunity from civil liability (lawsuits). The University of Arizona’s Western Region Public Health Training Center has Stock Albuterol Inhaler Training for School Personnel available on their website already, and the e-learning course provides the training needed for schools to implement this new law.

Sunscreen use at schools & camps Schools, parents and kids will be better able to protect children from damaging UV rays as a result of the passage of HB 2134. The legislation will make it clear that kids can take and use sunscreen at school and camps, and that school, preschool and camp staff can help them put it on. Some school districts and camps had prohibited sunscreen unless a parent provided written consent and an order from a physician. This new law clarifies for schools, camps, and day cares that it’s acceptable for kids to have and use sunscreen. It also gives schools, camps and day care centers protection from lawsuits.

Drug overdose & poisoning prevention HB 2493 sets up a drug overdose review team at the ADHS. It will be a 21-member team consisting of nine heads of various government entities (or their designees) and 12 members appointed by the ADHS Director to: • Develop a data collection system regarding drug overdoses; • Conduct an annual analysis relating to drug overdose fatalities; • Develop standards and protocols; • Provide training and technical assistance to local Teams; • Develop investigation protocols for law enforcement and the medical community; • Study state and local laws, training and services in order to recommend policies to decrease drug overdose fatalities; and • Educate the public regarding drug overdose fatalities.

Missed opportunities There were several missed opportunities to improve public health that were proposed but failed to get through the legislative process: • Comprehensive oral health coverage for pregnant Medicaid members; • Voluntary Certification for Community Health Workers; • Requirements for recess time for physical activity in schools; and • Changing the age at which folks can but tobacco products and e-cigarettes to 21 from 18.

New laws posing public health challenges Many of the bold moves to improve public health policy have come via the Citizen’s Initiative process that’s written into Arizona’s Constitution. A few examples are the Smoke Free Arizona Act; tobacco education and prevention; First



Things First; and Proposition 204 which extended Medicaid eligibility to 100% of federal poverty. Future citizen’s initiatives geared to improve public health will be more difficult to get on the Arizona ballot as a result of the passage of two new laws: HB 2404 and HB 2244. • HB 2404 prevents signature gatherers from getting paid by the signature (for voter initiatives), making it more difficult to provide the work incentive needed for gatherers to be efficient. This will in turn make it more difficult to get the large number of signatures that are needed to get citizens initiatives on the ballot in the future. • House Bill 2244 changes the initiative compliance standard to “strict compliance” from the current “substantial compliance.” This law will make it easier for opponents of public health initiatives to knock our initiatives before voters have a chance to weigh in. On balance, it was a good year for public health in Arizona. I include a big shout out to the staff and members of Arizona Medical Association (ArMA) for your efforts to improve public health in Arizona. Advocacy works! Will Humble, MPH, has worked in the field of public health in Arizona for more than 30 years including 25 years at the Arizona Department of Health Services and six years as the Director (2009-2015). He is currently the Executive Director for the Arizona Public Health Association.



ecently, I received a letter from one of my constituents who was going through a family medical crisis. Her brother-in-law – let’s call him Steven – suffers from a serious autoimmune condition, and before the Affordable Care Act passed he was unable to get medical insurance. He and his family literally had to sell the family farm to pay for his medical care. The Affordable Care Act put patients like Steven back at the center of our healthcare system. It made healthcare coverage possible for over 20 million Americans who otherwise would have had to pay out of pocket for their medical needs. Obamacare isn’t perfect. But instead of taking steps to improve and fix what’s wrong, Republicans are taking a hatchet to the whole thing – and life-saving care for millions of Americans is on the chopping block. Donald Trump’s healthcare plan is a disaster. According to the CBO, it will kick up to 24 million people off their coverage and raise premiums and out of pocket expenses for millions of working and middle class families. It undermines protections for those with pre-existing conditions. Trumpcare also guts Medicaid, cutting its funding by $880 billion over 10 years and forcing states to pick up the tab. By the year 2020, Arizonans will receive on average $3,500 less in subsidies and be offered fewer health options than they were under Obamacare – meaning people will be paying more for less care. Seniors aren’t safe, either. The Trump-Ryan healthcare plan raids the Medicare Trust Fund, robbing seniors of hundreds of millions of dollars’ worth of care. It also rescinds an Obamacare rule that protects older people from higher costs – giving the green light to insurance companies to charge older Americans up to 66% more. Ultimately, lower-income and older people will be hit the hardest. According to the Kaiser Family Foundation, a 60-year-old living in Phoenix and earning $40,000 will have to pay an additional $12,370 per year to buy a policy. Sadly, it will be those who are already suffering from health problems that have the most to lose. Trumpcare eliminates Essential Health Benefits and protections for

The bottom line is that all Arizonans – and all Americans – should have access to quality, affordable healthcare services. That should be the number one focus of any health plan. Any politician who prioritizes anything else will be held accountable.

July 2017 | arizonaphysician.com


pre-existing conditions for millions of Americans – meaning insurance companies will no longer be required to provide coverage without lifetime limits in areas like mental health care, pediatric dental and vision care, maternity care or prescription drugs. Carriers would also no longer be required to cover annual exams and preventative tests. That means that the only people who purchase this coverage will be those most likely to use it – which will rapidly increase the cost of that coverage, if insurance providers even decide to offer it at all. Without coverage in these critical areas, patients could face catastrophic costs and could even be forced to go without life-saving care. Before the Affordable Care Act, 62% of people who purchased their own health insurance didn’t have coverage for maternity services, 34% didn’t have coverage for substance abuse services, and 18% weren’t covered for mental health services. And to what end are Republicans fighting so hard to strip Americans of their healthcare? They plan to put that money directly into the pockets of the richest 1% – providing enormous tax cuts to those who need it least. That bears repeating. Republicans are putting people’s lives at risk in order to give a tax cut to the rich. And Republicans know it’s a raw deal – it’s why they rushed a vote in the House of Representatives without holding any

hearings and before the Congressional Budget Office could issue an analysis of the bill’s implications. However, instead of standing up for their constituents, they dutifully fell in line behind Paul Ryan and Donald Trump. Trumpcare will undo all of the progress we’ve made and force more Americans with life-threatening medical conditions to fend for themselves. That’s not only unjust – it’s also un-American. More than 50 national organizations agree. The AARP, the American Cancer Society, the American Hospital Association, and the American Medical Association are all strongly opposed to the bill. Instead of plundering our current healthcare system and leaving millions without coverage, Republicans should be working to improve upon Obamacare’s shortcomings and leave intact its successes. The bottom line is that all Arizonans – and all Americans – should have access to quality, affordable healthcare services. That should be the number one focus of any health plan. Any politician who prioritizes anything else will be held accountable. Congressman Ruben Gallego represents Arizona’s 7th Congressional District in the U.S. House of Representatives, serving on the House Armed Services Committee and the Natural Resources Committee. Congressman Gallego is a veteran of the U.S. Marine Corps, having served in Iraq with the well-known combat unit Lima 3/25.

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Rural Health:

Arizona Healthcare BY DANIEL DERKSEN, MD


rizona lost a greater share of jobs (300,000) during the Great Recession than all but one state (Nevada). It also took Arizona longer to recover than all but eight states, finally replacing the jobs it lost in 2016, with the largest gains in the health sector (75,000). Correlated with the sturdy health sector job growth, Arizona experienced a dramatic reduction in its uninsured, through Medicaid/AHCCCS restoration and expansion (400,000) and ACA Marketplace subsidized coverage (150,000). Arizona hospitals experienced a sharp reduction in uncompensated and charity care as more were covered. However, the economic and job gains accrued largely to metropolitan areas, while Arizona’s rural counties and communities recovered more slowly and unevenly; many have yet to recover the jobs lost during the economic downturn. Emerging threats to Arizona’s economy in general, and its health sector in specific, loom with the U.S. House of Representative’s American Health Care Act (AHCA) passed May 4, and the Senate’s Better Care Reconciliation Act (BCRA) draft publicly released on June 22. The Congressional Budget Office estimates that the bills would cut $772 billion (BCRA) to $834 billion (AHCA) over the next 10 years, and result in about 23 million more U.S. uninsured. That translates to 500,000 more uninsured in Arizona, and cuts of over $7 billion to Medicaid/AHCCCS from 2018-2026. The magnitude of the proposed federal cuts could mean Arizona’s return to its darkest days of recession and quarterly job losses. Over 60% of federal Medicaid expenditures relate to just two eligibility categories – the elderly and the disabled. Arizona is in the top five states in terms of growth of its low-income, elderly population, and Arizona has the eighth lowest per capita Medicaid expenditures. In the per person cap or block grant federal Medicaid payment methodologies envisioned in the Senate and House bills, cost efficient states with a rapidly growing elderly population would be punished. Both bills repeal a key provision of the Social

Security Act (SSA) that requires the federal government to pay for a minimum of 50% of a state’s Medicaid costs. The Arizona Federal Medical Assistance Percentage (FMAP) is 69%. Either bill would shift Medicaid from SSA federal entitlement funding – to the discretionary side of the federal budget – and risk more cuts in the annual discretionary federal budget appropriations battles. The bills fail to address the nation’s 33,000 opioid involved overdose deaths in 2015. The CDC reported mixed progress in prescription opioids as reflected in the staggering U.S. per capita morphine milligram equivalents (MME) peak in 2010 of 782 MME, down to 640 MME in 2015. The 2015 rate of 640 MME remains 3.5 times higher than the 1999 rate of 180 MME. Key social determinants of health are correlated with higher opioid MME rates in low income, rural, and lower educational attainment populations. In 2016, Arizona had 790 deaths related to opioid overdose, an increase of 74% over the last four years. In response, Governor Ducey signed an emergency declaration on June 5 to address this public health emergency. The CDC report released on July 6 provides data on where to focus education and intervention efforts. The majority of Arizona counties exceed the 2015 national per capita average of 640 MME, and several are close to or exceed twice the national average: Cochise (1,130 MME), Gila (1,812 MME), Graham (1,581 MME), Mojave (1,737 MME), and Yavapai (1,186). Medicaid coverage increases opioid addiction treatment options. It is crucial that our physician experience, voice and leadership remain actively involved in state and national reform deliberations to assure that all of our patients have coverage and access to high quality, affordable health care. Daniel Derksen, MD is a family physician, and Director of the Arizona Center for Rural Health at the University of Arizona. He is the President of the Arizona Academy of Family Physicians. July 2017 | arizonaphysician.com


Serving the W Medically Underserved in Rural Arizona:

How Patients Far from Phoenix are Getting Cured of Their Hepatitis C RICHARD A. MANCH, MD



hile Hepatitis C (HCV) treatment has become much less challenging and much more effective in recent years, most treatment requires a patient to have access to specialty care at some level. Delivering HCV therapy is particularly challenging in rural and other medically underserved communities because of both the lack of specialty care and the long distances patients would have to travel to seek care from specialists located in urban centers. Making the problem even more acute is the fact that there is a high prevalence of HCV positive patients in rural and underserved locations, particularly in the state of Arizona. New CDC screening recommendations are likely to identify more potential candidates for treatment, while the number of providers treating HCV is diminishing. A direct telemedicine approach is often complex to initiate and generally does not reach enough patients. When it opened its doors in 2012, the new Center for Liver Disease and Transplantation at St. Joseph’s Hospital and Medical Center in Phoenix was faced with the daunting challenge of accommodating the many hundreds of patients throughout Arizona seeking treatment for their Hepatitis C with the new, highly effective and well-tolerated therapies that were beginning to become available. The Project ECHO model (ECHO = Extension for Community Healthcare Outcomes), first developed by Dr. Sanjeev Arora of the University of New Mexico, had been shown to be an effective means of supporting local primary care treatment of HCV and held the promise of dramatically increasing the numbers of patients receiving treatment. So the plan was to replicate the Project ECHO model with sites across Arizona, primarily focusing on rural, medically underserved communities. The program was initiated with North Country Healthcare, a federally qualified health care clinic organization with multiple sites in Northern Arizona across the 350 mile span of Interstate 40. The intent was to replicate ECHO with minimal resources and employed staff and seek grant support from government and industry sources. Initially a unique “Synchronous Cohort”

strategy was implemented to give new treaters confidence and enhance the learning experience, particularly since some of the older, more complex therapies were still in use at that time. With this approach, cohorts of patients were accumulated and started on therapy simultaneously across all sites, so that treatment milestones and side effect management could be accomplished in a combined teleconferencing learning environment. The program was awarded $500,000 in CDC grants and $250,000 in industry grants, which covered the costs related to acquisition of sophisticated teleconferencing equipment, licenses, and initial staff support. The program at St. Joseph’s has been featured in numerous medical presentations and journals. HCV therapy continues in nearly all North Country Healthcare sites (Flagstaff, Ash Fork, Seligman, Winslow, Holbrook, St. Johns, Springerville/Eager, Kingman, Lake Havasu City, Showlow, Payson, and Bullhead City). Additional sites include the IHS facilities in Winslow and Sells, and hospital clinics

in Bisbee and Douglas. To date, many hundreds of patients have been cured of the HCV locally by their primary care providers (MD, DO, NP, PA) with weekly or bi-weekly CME case teleconferences. The providers use a HIPPA secure shared database with the Phoenix-based HCV specialists at St. Joseph’s and all communication is face-to-face, provider-to-provider. Labs are submitted and reviewed weekly before and during each teleconference, and most sessions include a didactic presentation from the Center specialists conducting the program. While the St. Joseph’s ECHO program has limited itself to the treatment of Hepatitis C, the Project ECHO concept is now used worldwide for nearly all disease states, utilizing Dr. Arora’s concepts of “force-multiplication” and the notion of “de-monopolizing knowledge.” The St. Joseph’s program remains one of the oldest and most consistent HCV-specific Project ECHO sites, helping local providers in underserved rural communities become experts in the management of the very important disease.

The Arizona Department of Health Services and the University of Arizona College of Medicine Phoenix are partnering in a new study surveying how physician knowledge, attitudes and practices impact healthcare access for Hepatitis C patients in Arizona. The survey takes several minutes to complete. All answers will be recorded anonymously, and will not be used for any purpose other than that stated above. Participation in this study is completely voluntary and is open to any healthcare provider interested in participating. An Institutional Review Board responsible for human subjects research at The University of Arizona has reviewed this project and found it to be in compliance with all state and federal regulations and University policies designed to protect the rights and welfare of participants in research. To participate, visit: https://azdhs.qualtrics.com/jfe/form/SV_07b1adyM8peXkdT

July 2017 | arizonaphysician.com


GOP’s ‘Obamacare’ Replacement Would put State in Control of Medicaid Eligibility BY KEN ALLTUCKER



Editor’s Note: While several attempts to repeal the Affordable Care Act (ACA) failed in the Senate in July, the political situation around repeal – or repair – remains fluid.


ouse Republicans pushed through legislation that seeks to dramatically overhaul the government-funded insurance program that covers nearly two million low-income and disabled Arizonans. If the repeal and replacement of the Affordable Care Act passes the U.S. Senate, it could put difficult and expensive health-policy decisions on the shoulders of Gov. Doug Ducey and the Arizona Legislature. The American Health Care Act aims to remake the rules of the private insurance market, also enabling states to decide whether insurers can charge consumers more based on their health status if the consumer’s coverage lapses. In a decision that could affect the coverage of more than half a million Arizonans, the GOP health plan would halt funding of the Medicaid expansion in three years. In 2020, Medicaid would be converted to a per capita funding formula that some experts warn could put states with more efficient programs like Arizona at a disadvantage. “We’re very concerned,” said Dana Wolfe Naimark, president and CEO of Children’s Action Alliance. “Medicaid funds are being slashed. Every state is going to be under enormous pressure to cut.” No job, no coverage? With more decision-making authority shifted to states, Arizonans could face tougher Medicaid eligibility standards. Arizona already is on the path toward stricter Medicaid eligibility for the state’s poorest residents on government-funded insurance. In 2015, the state enacted Senate Bill 1092, sponsored by Sen. Nancy Barto, which sought to require “able-bodied” adults on Medicaid to have a job or be looking for one in order to keep their coverage. The legislation also sought to cap lifetime eligibility at five years. The law requires the state’s Medicaid program, the Arizona Health Care Cost Containment System (AHCCCS), to file a “waiver application” by the end of March each year seeking permission to make those changes until the federal Centers for Medicare and Medicaid Services (CMS) allows them. The Obama administration rejected most of Arizona’s waiver application last year, deciding that co-payments, a five-year eligibility limit and locking out enrollees for up to six months for failing to pay premiums would “undermine access to care.” Arizona halted the application this year as Congress pushed through the GOP health-care bill. “With the new administration and the prospect of an Obamacare repeal and replacement ... a delay is understandable,” said Barto, (R-Phoenix). AHCCCS representatives cited possible changes in how President Donald J. Trump’s administration handles waiver requests as one reason for the delay. Health and Human Services Secretary Tom Price and Seema Verma, the administrator overseeing CMS, said in a letter to governors that Trump’s administration would favor reforms to Medicaid coverage for able-bodied adults that help them “prepare for private coverage.” Among the items highlighted in the Price-Verma letter are reforms that Arizona sought last year, including making Medicaid recipients pay a small premium, health-savings accounts, co-payments for July 2017 | arizonaphysician.com


hospital emergency rooms and limits on non-emergency transportation. The Price-Verma letter seemingly invites the same reforms the state previously sought. Before Trump appointed her to oversee the agency that regulates Medicaid and Medicare, Verma worked as a consultant and helped states such as Indiana, Iowa and Kentucky to overhaul their Medicaid programs with the types of conservative hallmarks Arizona is seeking. Ducey’s staff is still looking to rework Arizona’s waiver based on what comes out of Congress. “We are currently drafting the waiver after waiting to get a better idea what changes would be implemented from Congress,” said Patrick Ptak, a Ducey spokesman said this week. Some question how much the work requirement and establishing health savings accounts for some Medicaid recipients would cost the state to administer. In Arizona’s initial waiver application, the state said that its proposals would have a “positive effect on budget neutrality” without providing data to back up that claim, according to Joan Alker, executive director at the Center for Children and Families at Georgetown University. “These are complicated things that are going to require the state to monitor many aspects of peoples’ lives,” Alker said. “In addition to being bad health policy, they are very complicated and expensive to administer.”

Consumers brace for changes The uncertainty has left Arizona residents who depend

on Medicaid coverage unsure whether they will face stricter standards – or no coverage at all. Mark McCully moved from Ecuador to Peoria last year, in part because of Arizona’s expanded Medicaid program. McCully built a career in advertising and marketing, but he said he said he’s been unable to find a job after “getting locked out of positions because of my age.” He said he does not oppose Arizona’s efforts to seek a work requirement, noting that he’s pursued employment and filled out applications. But he also has health concerns, taking about a dozen medications daily to manage cardiac disease and diabetes. McCully said he would be willing to relocate to another state if it were a matter of maintaining insurance coverage. “People don’t put themselves in other people’s shoes,” said McCully, a Pittsburgh native. “When you get in these types of situations, every day is a question mark ... If I lose (coverage) here, I will have to make a decision what state I’m going to live in – or which country.” Ken Alltucker is a Watchdog News reporter who covers everything about health care from a consumer’s perspective – doctors, hospitals, insurance, policy, prescription drugs and those seemingly ever-increasing bills. He helps consumers navigate the complex world of health care and serves as a watchdog of government-funded health care. Originally printed May 6, 2017, reprinted with permission from The Arizona Republic.

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t started as just another day in diabetes clinic. I felt the way I typically did when I saw her double digit A1C. I imagined that when I entered the room, I would describe, once again, how poor her performance as a diabetic patient really was. I would warn her, once again, of all the tragedies that loomed due to her uncontrolled diabetes: the wounds, the amputations, the infections, the blindness, the dialysis, and much worse. But maybe this time, something would change. I would get through to her, and she really would become successful in lowering her A1C. I look back on the brand new internist I was then, assigned to work for the Indian Health Service (IHS) at a clinic on a remote Indian reservation in Arizona. Most of my patients struggled with uncontrolled diabetes. I would go through my checklist, trying to be a thorough and diligent provider. I would make sure that all their labs were completed and that I had dutifully explained all the results that needed improvement. Many of my patients spoke no English, only their Indigenous language. They lived without electricity and running water. They hitchhiked to their appointments because they either had no vehicle, or no money for gas. They endured the tragedies of rural poverty and told me stories about the family members who were killed since their last appointment. After years of hearing their stories, I grew to deeply respect their strength and fortitude. But not that day. That day, all I could see was another double digit A1C



and not the person struggling to hold it all together. My tone was cold and condescending as I scolded her for her failure to manage her diabetes. I will never forget what she said – “You always make me feel bad about myself. I don’t know if I can come to see you anymore.” Her words changed my entire practice. They made me look inside myself and ask what I was so angry and impatient about. Did I see her failure to meet the standards for diabetic control as my failure? Was the standard more important than the patient? I immediately apologized and asked her to give me another chance. I worked hard to be aware of my tone, to look for kinder ways to share news of poor diabetic control with her and all my patients. I looked for gentle ways to encourage her. I praised her for small improvements and was so excited when her A1C came down to 9. But that improvement was not sustained. In fact, for most of the 11 years that I served as her primary care physician, she did not meet the standards for diabetic control. On the surface, it might have seemed to chart reviewers that nothing was happening during her frequent visits with me and that I was a failure. I certainly felt that way at times. One day, though, she came in looking scared. She had been experiencing chest pain and was worried she had developed heart disease. She was so overwhelmed with anxiety that she could not speak about her fears to anyone… except me. All those years, when it seemed nothing substantial was going on during her frequent appointments,

we were building a relationship she could trust. Finally, after almost driving her away, I had earned her trust. She knew I would care for her body and her spirit with compassion. I had finally met her standard. As it turned out, that’s the standard that mattered the most. This is a lesson I have carried with me as I have dedicated my career to providing health care to American Indian and Alaska Native patients with the Indian Health Service (IHS). I currently serve as the Chief of Internal Medicine at the Phoenix Indian Medical Center (PIMC). My work is intently focused on building a 24-hour onsite hospitalist program, and on expanding medical specialty availability at our facility. I am also the Chair of PIMC’s Credentials Committee and am the national Chief Clinical Consultant for Internal Medicine for the Indian Health Service. Titles aside, I choose to work for the IHS because we are a mission driven organization, striving to realize the ideal of providing the highest quality health care for American Indians and Alaska Natives despite resource limitations. I feel fortunate to work alongside other staff who share this vision, and to work under leaders motivated by these shared ideals. The camaraderie I experience in the Indian Health Service is part of what energizes me when the challenges feel overwhelming. I know that I matter to the organization as a person, not just as a physician and leader. It is truly a privilege to be able to work in such a supportive environment.

Looking ahead, I am excited about the future of the Phoenix Indian Medical Center. We have recently seen the addition of multiple new services including onsite MRI availability, onsite neurology and cardiology services, and the addition of ENT and orthopedic surgery providers. There are plans to expand our subspecialist availability further to include nephrology and pulmonology, at a minimum. Having these services onsite enables us to provide a much more comprehensive level of services, particularly to patients without resources whom are among the most vulnerable. Subspecialist availability also improves the morale of our providers, who can get their clinical questions answered more directly and efficiently. These service additions, which occurred despite the challenges of limited resources and an intricate bureaucracy, are contributing to the bright future that I believe is in store for the Phoenix Indian Medical Center – truly, a team of which I am honored to be a part! Dorothy Sanderson earned her Doctor of Medicine from the Uniformed Services University of Health Sciences and completed her Internal Medicine residency at the University of Virginia. As a Captain in the U.S. Public Health Service, she has dedicated her career to serving American Indians and Alaska Natives with the Indian Health Service.

July 2017 | arizonaphysician.com


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ARIZONA PHYSICIAN | July 2017 © 2017 Rising Tide

Expanding Access Through Streamlined Process: A SIT-DOWN WITH

Sara Salek, MD BY DOMINIQUE PERKINS Article Photos by Denny Collins Photography April 2017 | arizonaphysician.com



his month we are addressing the topic of serving Arizona’s underserved populations – a constant struggle, and a significant effort across many organizations and services. We thought it only appropriate to sit down with Dr. Sara Salek, Chief Medical Officer for the Arizona Health Care Cost Containment System (AHCCCS), to discuss State programs, resources, and issues.

The very model AHCCCS was founded in 1982 – the first state-wide Medicaid managed care system in the nation. Structured to encourage competition and choice, AHCCCS is widely considered a top model for Medicaid programs nation-wide. Since its founding, the program has operated under a federal Research and Demonstration 1115 Waiver. Salek says this set-up, “Allows for the operation of a total managed care model and provides for increased flexibility for how we run our Medicaid program.” “AHCCCS selects contracted health plans via a highly competitive request for proposal process,” she said. “This health care model allows for member choice of health plan, management of health care networks, which are monitored on quality metrics, as well as managing overall healthcare costs.” Healthcare services include: • Acute health care services. • Services, family planning, immunizations, prescriptions, surgery, hospitalizations, emergency care, and transportation. • Behavioral health services. • Counseling, medication management, case management, peer support, residential services, and hospitalization. • Long-term care services. • Attendant care, assisted living, and skilled nursing facility care. The AHCCCS program includes over 60,000 health care providers serving members living at or near the poverty level. The system covers over 1.9 million Arizonans, over 50% of the births in the state, and two-thirds of the nursing facility days, based on projections for 2017, Salek said. AHCCCS resources reach state-wide. In fact, they are required to, Salek said, “For example, for Maricopa and Pima Counties, contractors who provide acute care services are required to provide PCP, pharmacy, and dental services so that 90% of their membership do not need to travel more than 15 minutes or 10 miles from their residence (unless accessing those services through a Multi-Specialty Interdisciplinary Clinic).” Each network and area has carefully followed standard of care and access. Salek also said that AHCCCS is currently in the process of updating their telemedicine policy to address the ongoing needs in rural communities.

Streamlining services In Arizona, behavioral health has historically been a “carved out” benefit - separately managed by health plans called Regional Behavioral Health Authorities (RBHAs). Due 24


to this structure, multiple health plans are involved in meeting mental health needs, and navigating the complex system is frequently a challenge and a barrier in obtaining care. This can be further complicated by concerns regarding medication adherence and stigma, and in some cases these complications and fears can also result in avoiding physical health care as well as mental health care. With the goal of creating a more streamlined system to address these issues, AHCCCS collaborated with other behavioral health partners to reduce some of these barriers. Beginning in April of 2014, approximately 17,000 members with Serious Mental Illness (SMI) were transitioned a single plan: Mercy Maricopa Integrated Care, to manage both their behavioral and physical health care needs in a “whole health” approach. The following year, in October of 2015, this model was implemented statewide through contracts with Health Choice Integrated Care in Northern Arizona, and Cenpatico Integrated Care in Southern Arizona. “Further health plan integration efforts are underway,” Salek said. “Integrated Contractors responsible for both the acute physical and behavioral health care needs of adults on AHCCCS (excluding adults determined to have SMI) and children on AHCCCS (excluding foster children covered under CMDP) will begin October 1, 2018.”






Health Plan

(physical health)


Health Plan/RBHA (physical & behavioral health)

(behavioral health)

Addressing homelessness While Arizona homelessness has decreased some in recent years, it is still a very real problem throughout the state. According to the Department of Housing and Urban Development’s annual report to Congress in November 2016, homelessness has dropped 30% since 2010.1 “As homelessness is a significant social determinant of health, our health plans work with their local community partners and their contracted network to address the unique needs of this population, including addressing access to primary care and housing resources,” Salek said of the AHCCCS approach to aid.

“Published studies demonstrate that the rate of emergency department utilization and hospitalization is higher among the homeless population compared to the non-homeless low-income population, making accessing these outpatient services and resources critical in improving overall health care outcomes and costs.” Specific programs are available through the RBHAs to support those who have SMI and are able to live independently. Assistance may include rent subsidy, supportive and transitional housing programs, home-repairs, and eviction prevention programs. “Independent living is supported with provider-owned or leased homes and apartment complexes that combine housing services with other covered behavioral health services,” Salek said.

Salek’s story Dr. Salek has been the Chief Medical Officer for AHCCCS since 2014. In this role, she provides clinical leadership to both the AHCCCS Division for Health Care Management, which oversees our health plans, as well as the Division of Fee for Service Management (DFSM), which includes the American Indian Health Program (AIHP). “In my role as CMO, I oversee both medical and quality management functions, which includes addressing member access to care issues and quality of care investigations,” she said.

On a daily basis, she also oversees pharmacy services, consults on grievance and appeals, and addresses billing and coding issues. “The current clinical initiatives my team is working on includes combating the opioid epidemic, improving the service delivery system for children and adults with autism spectrum disorder, and addressing the complex needs of children involved with the Department of Child Safety (DCS),” Salek said. Dr. Salek is a native Arizonan, born and raised in Tucson, Arizona. Her family was a powerful influence in her education, and stressed the importance of math and science from an early age. When she was 14 years old, Salek went to work as a candy striper at Tucson Medical Center, and her decision to pursue medicine was sealed. “Working in the hospital setting came second nature to me and I was exposed at this early age to all facets of humanity – kindness, compassion, hard work, and suffering,” she said. She completed her undergraduate degree in Nutritional Sciences at the University of Arizona, and then went to medical school at the The University of Arizona College of Medicine – Phoenix. Salek is board-certified in both adult and child & adolescent psychiatry. She completed her residency in adult psychiatry at Banner Good Samaritan Medical Center in Phoenix, Arizona, and also did a Child Fellowship through July 2017 | arizonaphysician.com


To make a report of suspected fraud, waste or abuse, please contact the AHCCCS OIG at

888-ITS-NOT-OK or 888-487-6686.

Children’s Hospital Boston, through Harvard Medical School. After Boston, Salek returned to Arizona and practiced clinically in adult and child psychiatry for a short while, before entering a different side of medicine – administrative. She worked as the Children’s Medical Director at the Arizona Department of Health Services Division of Behavioral Health Services. When her husband got a job for Stanford University, she went back to clinical practice for a while in Palo Alto, California, where she also served as the Addiction Consultation Team Medical Director for the Palo Alto Veteran’s Administration. Upon returning to Arizona, she began work with AHCCCS.

State resources & funding With such an expansive, complex program, many steps are taken to ensure proper use of resources. New programs being implemented, and new needs identified mean that every bit of funding counts. To guard against fraud, and other waste and abuse, the AHCCCS has an Office of the Inspector General (OIG), which is responsible for the integrity of the program. AHCCCS also accesses and contracts with data analytic vendors to counter fraud and other concerns, including: •

• •

HMS: Which provides regular data matches with commercial insurance carriers to determine third party coverage that can be used for coordination of benefits. Work Number: Which provides real time salary data for employers that account for over one-third of the employees in the state. EDI Watch and Medicaid Integrity Contractors (MIC): Which analyzes Medicaid claims data to identify highrisk areas including billing irregularities. Medi-Medi: Which identifies potential improper billing and utilization patterns for the Dual Eligible population (Medicare/Medicaid). Fraud Investigations Database (FID): Which lists all federal Medicare-related investigations. Other government databases: Including Social Security, ADES Base Wage data, Motor Vehicle Department, and the Arizona Criminal Justice Information System.

These security measures have proven very effective, according to Salek. “In 2016, AHCCCS realized over $1 billion in avoided and recovered costs as a result of coordination of benefits, third party recoveries, and AHCCCS OIG activities,” she said. “OIG supported the investigations of 62 successful prosecutions of either members or providers.”



Data such as this and other critical components are published on the AHCCCS website2 to ensure transparency, Salek said. “This includes our medical policies (AHCCCS Medical Policy Manual-AMPM), our contractor policy (AHCCCS Contractor Manual-ACOM), health plan contracts, health plan performance, health plan compliance-based actions, and contractor audited financial statements,” she said. Meeting an ever-growing need requires an ever-growing set of resources. New initiatives, partnerships, contracts, and programs make so much of this possible. Currently, AHCCCS is a $12 billion program annually. “We are required to provide a state match of 26% in order to draw down the federal funds for our program,” Salek said. “Annually, during the state legislative session, legislators finalize the annual State budget, which includes the allocation of funding for our program.” The 2017 legislative session has added a few services to the program, including an outpatient occupational therapy benefit for acute members, and restoration of the adult emergency dental benefit up to $1,000 annually. In May of this year, the Department of Health & Human Services Substance Abuse and Mental Health Administration (SAMHSA) awarded Arizona a grant of a little over $24 million over a two-year period, to combat opioid use disorder (OUD) and opioid-related deaths.3 These funds will allow AHCCCS to expand their existing strategies, which include community-based access to the overdose reversal drug, Naloxone; prescriber and patient education; opioid prescribing practices; and complex case management and care coordination. Plans are in place to create an opioid monitoring initiative to capture, report and share opioid-related data, a comprehensive needs and capacity assessment, and a state strategic plan to address the gaps in prevention, treatment and recovery support, Salek said. “Efforts will focus on increasing access to OUD treatment, expanding access to Medication Assisted Treatment (MAT) through stigma reduction and education, enlisting new MAT providers, ensuring 24/7 access to care points, increasing access to peer support services and increasing recovery support options,” she said. References 1. https://www.hudexchange.info/resources/documents/2016AHAR-Part-1.pdf 2. https://www.azahcccs.gov/ 3. https://www.hhs.gov/about/news/2017/05/31/hhs-announcesover-70-million-in-grants-to-address-the-opioid-crisis.html

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

On the personal side..

Dr. Salek and her family enjoying the evening sunset.

1. Describe yourself in one word. Dedicated. 2. What is your favorite food, and favorite restaurant in the Valley? I love all food – if I had to pick just one, it would definitely be pizza. Favorite restaurant is Caf` e Poca Cosa. 3. What career would you be doing if you weren’t a physician? Teacher. 4. What’s a hidden talent that you have that most wouldn’t know about you? I love to bake. 5. Best movie you’ve seen in the last ten years? Grand Budapest Hotel and Bridesmaids 6. Favorite Arizona sports team (college or pro)? Wildcats (basketball). 7. Favorite activity outside of medicine? Hiking—I love Pinnacle Peak. 8. Family? All my immediate family lives in Arizona – my parents and sisters are in Tucson and my brother is in Chandler. My sisters are both pharmacists and my brother is a pediatrician. I am married and we have a son named Xander.

July 2017 | arizonaphysician.com



The ArMA Annual Meeting of the House of Delegates kicked off on June 2 with the President’s Awards Banquet and the inauguration of the new President, Michael Hamant, MD, of Tucson. Dr. Hamant’s inaugural address appears in this edition of Arizona Physician. The President’s Banquet highlights the work of distinguished physician colleagues and community members. Here are the 2017 awards recipients. Sportsman Award: Mark Westervelt, MD, retired Family Physician, Camp Verde David O. Landrith Humanitarian Award: Kris Volcheck, DDS, MBA – Founder, Brighter Way Institute ArMA Distinguished Service Award: Cronkite News – Arizona State University, for HookedRx documentary Edward Sattenspiel, MD, Award: Robert Orford, MD, MPH – Mayo Clinic Scottsdale “Walk the Talk” Award: Arizona State Senator Kate Brophy McGee

ArMA/ADHS Public Health Service Award: Chic Older, EVP, ArMA Wallace A. Reed, MD Award: Thomas Grogan, MD – Founder, Ventana Medical Systems C.H. William Ruhe, MD Award: Mayo School of Continuous Professional Development, Mayo Clinic in Arizona 28


July 2017 | arizonaphysician.com



What Physicians Think: Scope of AHCCCS BY SHARLA HOOPER


hank you to those who took the time to respond to our survey on providing care to AHCCCS patients! A number of our participants also provided insights on aspects of clinical care while dealing with the AHCCCS care delivery system.

Quality of AHCCCS as a Medicaid program Of the respondents who participate in AHCCCS, 28.8% felt the system was superior to other state Medicaid systems. About 43% were unsure if AHCCCS was superior to other states. Several physicians were complimentary in their comments assessing the system – with reservations about the future of the program. States Adele O’Sullivan, “I think our AHCCCS plan allows us to provide excellent health care for the most vulnerable. My fear is that in the next years fewer

July 2017 | arizonaphysician.com


Do you treat patients covered under Arizona Health Care Cost Containment System (AHCCCS)?

71.3% YES

28.2% NO

How do you rate Arizona’s AHCCCS program to other states’ Medicaid programs?

Program challenges

17.5% BETTER

11.3% WORSE

41.3% NOT SURE


11.3% EQUAL


Are you concerned about how block grants might affect AHCCCS if the American Health Care Act is passed?





16.5% NO

will be covered, services will be harder for them to get, and if we have made any progress in narrowing the gap in health disparities we will give it all back.” According to Jonathan Weisbuch, MD, “The AZ AHCCCS is superior to ND, WY, MA, or CA in which I have worked.” Another respondent pointed to the differences in the way that AHCCCS is managed compared to other states, “1. It is helpful to keep in mind that AHCCCS is different from Medicaid. The fundamental purpose of AHCCCS is ‘health care cost containment.’ 2. The plan works well,” and saw a unique potential within the system, “3. I think everyone should be able to buy into AHCCCS – like the KidsCare program.” Anita Murcko, MD, write that AHCCCS is a “Well-organized and managed program; how to best integrate mental health services is key challenge.” Even those with positive initial feedback described areas for improvement, as one respondent describes, “More than other Medicaid programs I feel I am able to start the process of a good work up but am stymied by the lack of resources or the refusal of AHCCCS to approve a recommendation.”

One respondent pointed to encountering challenges enrolling in the system: “Becoming a network provider for Mercy Care remains the holy grail of AHCCCS participation. It remains notoriously difficult if not impossible to become contracted with them.” A significant portion of comments identified reimbursement as an area of concern. One respondent stated, “It’s a great and needed program, but the health care providers need to be compensated more.” Of our respondents, only 16.7% felt they were adequately compensated for treating AHCCCS patients. 69% felt that AHCCCS did not have enough mental health services or network capacity. The respondent comments linked these two components; without adequate or fair reimbursement, clinicians and providers drop from the system or avoid enrolling altogether. • “Finding sub-specialists in the area who are providers is becoming more difficult because of low reimbursement.” – Anonymous • “Low reimbursement, therefore lack of subspecialty referral.” – Fred Kogan, MD, PhD • “Compensation continues to be cut. List of docs to refer to very limited.” - Anonymous • “It is getting harder to refer patients to specialty providers as there is declining participation due to lower reimbursements.” - Cindy Meehan, MD Eve Shapiro, MD, offers that “AHCCCS and other Medicaid programs should reimburse physicians at Medicare levels at least.” And there are other aspects of administrative requirements that frustrate physicians. Charles Castillo, MD, writes that, “In general, the system works well. I get frustrated, however, when I try to perform minor surgical procedures in my office and we are denied payment because AHCCCS tells us it has to be performed in an OR. We are trying to save money for the system and end up appealing the denial in order to be reimbursed. Very frustrating.” Dr. Mary Hayes writes that “The Arizona Medicaid program is the only one that involves our practice and employees. The changes in the last twenty years have been the amount of

duplicate reporting to various entities, which in turn reports to the State, the decreased reimbursement, and the lack of member accountability.” Another respondent states that “As a colorectal surgeon I use some compounded medications and the AHCCCS pharmacopeia is limited and difficult to work around, thus we prescribe suboptimal medications in some cases.”

Does our state offer enough mental health services for Arizona’s underserved?


12.7% YES


Complex conditions and co-morbidities The patient populations served by AHCCCS often have complex conditions and co-morbidities due to a previous lack of access to health care. And that can be compounded by the system itself: “In treating an AHCCCS patient with a complex problem, there are tremendous hurdles to deal with that are time consuming and not always effective.” Another respondent cited pre-authorization concerns, simply stating: “Pre auths is AWFUL. VERY patient unfriendly.” Dr. Elizabeth McConnell describes the whole patient care necessary to improving AHCCCS patients’ lives, and states concerns about the system’s ability to guide this process: “AHCCCS is a program of enormous proportion which attempts to care for individuals caught in situations which demand not only healthcare but also social care and eldercare and child care and dietary care and conquering habits care and violence care and abuse care and neglect care and every other care that is inherent in good physical and mental health.... this program has very tiny guideposts…”

Engaging AHCCCS patients as participants in their care A number of comments described frustration with “no-show” AHCCCS patients and felt that there should be methods implemented to compel AHCCCS enrollees to be more invested in their health. It is a system inadequacy that “No penalty for patients [who] are chronic no shows for appointments and don’t give notification,” according to Fred Kogan, MD, PhD. Richard Harding, MD, writes, “I am happy to be a provider, however, if a patient does not appear for their appointment they should be half financially responsible. I have at least a 20% no show rate. My time is valuable as well…I should have the right to charge for irresponsibility.” An ED physician observed, “I think AHCCCS patients are more likely to head straight to an ER instead of waiting like everyone else for their office appointment. I think this is an unnecessary expense for the system.” This concern extends to patient compliance as well. One respondent said, “I believe AHCCCS is a quality Medicaid program. However, I think a small, income-based premium or copay should be instituted in order to encourage responsible utilization and understanding of coverage.” Ryan Stratford, MD states, “I think it is a disservice to patients to not require that they be responsible for some portion of their healthcare. Without responsibility, patients are unwilling to follow physician advice. Medicaid or AHCCCS patients are always much more difficult to treat because they do not actively engage in their own care.” Sharla Hooper is the Managing Editor for Arizona Physician and serves as Associate Vice President of Communications and Accreditation for the Arizona Medical Association.

69.9% NO

If you treat AHCCCS patients, do you feel reimbursement for services you provide is adequate?

11.5% NOT SURE



16.7% YES

48.7% NO

Is access to health care a right or a privilege?






Population Health Management A Model of an Integrated Service Delivery System BY OLE J. THIENHAUS, MD, MBA

Background The need to coordinate primary care and psychiatry has been recognized for many years. After all, the prevalence of chronic physical illnesses among persons with a diagnosed mental illness is much higher than in the population at large, accounting for a large part of the reduced life expectancy of these individuals. It is also well documented that primary care physicians prescribe, for instance, more antidepressants than psychiatrists. However, outside centrally managed systems like the U.S. Department of Veterans’ Affairs (VA), progress toward integration has been slow due to structural, administrative and financial impediments. Here in Arizona, the latest round of funding initiatives for Regional Behavioral Health Authorities (RBHA) in 2014 and 2015 provided an opportunity to design an integrated delivery system for AHCCCS beneficiaries, especially those with serious mental illness. The merger of the University of Arizona Health Network with Banner Health in Tucson 34


at about the same time provided the organizational depth and operational expertise to build an integrated clinic. In February 2016, the Whole Health Clinic opened its doors.

The Whole Health Clinic and population health The clinic is located in East Central Tucson and led by Clinic Director Lori Pierson and Chief Medical Officer Peter Klinger, MD. It currently serves a case load of about 500 patients. Eventually, it aims at a total of 1,500 individuals. On-site physician staffing consists of psychiatrists and family physicians, but thanks to the scope of the larger organization the entire tertiary care spectrum is accessible to patients as well. In addition, the clinic has a contingent of allied mental health and primary care professionals, including psychologists, nurses, recovery coaches (who function largely as case managers) and peer support specialists. The shared electronic health record, a unified treatment plan and daily interdisciplinary huddles make possible team

Below: A treatment team meeting at the Whole Health Clinic

care. Most important, there is continuous informal communication among the various professionals. The clinic is a demonstration project, showing how integrated team-based care allows to move in the direction of population health as the guiding principle. The renewal of service contracts is predicated not on the number of services provided or the frequency of patient visits. Rather, population health outcomes determine the long-term survival of the program. Outcome measures include parameters of social adjustment, such as employment status, as well as more traditional criteria like hospital admission rates and visits to the Emergency Department. The population-health orientation is novel enough to justify leadership by a dedicated population health specialist whose input is critical in continually adjusting the service line design. The population health specialist, in conjunction with other leaders, is in charge of a sophisticated patient registry and the monitoring of outcome measures.

Early psychosis intervention Serious mental illness can be conceptualized as a chronic illness. One component of the clinic is a service specifically engineered to address the needs of individuals early in the disease process, the Center for Early Psychosis Intervention or EPICenter. This service, which has a counterpart in Maricopa County as well, provides an individualized intense wrap-around service package for young people (aged 15 to 35) who are newly diagnosed with a major psychiatric disorder. Without intervention, such individuals are clearly at risk. They are more likely than their peers to lead unhealthy life-styles and, consequently, to develop metabolic diseases, obesity, cardiovascular and respiratory conditions. They are also at risk of progressing to sustained social dysfunction July 2017 | arizonaphysician.com


Case Illustration: Dominic is a 28 year old unemployed single man who has been living in Tucson all his life. He was referred to the Whole Health Clinic by his probation officer. He has a long record of admissions to mental hospitals, usually for suicidal behavior, and he also has poorly controlled type I diabetes. On top of it, Dominic uses pain medication “whenever I can get it,” following a long expired period of oxycodone prescriptions for peripheral polyneuropathy. Dominic met with a Peer Support Specialist who established that he was profoundly discouraged because his attempts to find a job had been unsuccessful: “As soon as they find out I’ve been in jail, I can tell, the game is over.” He was living in a shelter and had no money to “do anything.” The PSS initiated a few immediate steps, including a meeting with the recovery coach to arrange for transportation and start mapping out a plan for a more organized job search. She also walked Dominic over to say hello to the psychiatrist and the family physician both of whom would see him within the next week. With preliminary assessments by PSS, Recovery Coach, family physician and psychiatrist completed, the team met to discuss a plan of care. A tentative diagnosis of major depression, recurrent, along with opioid use disorder, and Diabetes Mellitus was documented. The family physician and the nurse stressed how much Dominic had complained of the pain and insisted that only narcotics helped. The treatment plan combined weekly therapy sessions with CADC-prepared social worker therapist with SSRI treatment and enrollment in the Clinic’s SMART Recovery group. A referral to the University pain management center was made. The following symptomatic outcome measures were chosen for monitoring: • • • • • •

PHQ-9 Hb A1c BMI Drug Abuse Screening Test (DAST) Health-related Quality of Life (HRQL) Analog pain scale

Goals: • Remission of mood disorder • Stabilization of diabetes • Sustained abstinence • Employment • Establishment of a socially anchored life *The story, all names, characters, and incidents portrayed in this illustration are fictitious. Any resemblance to actual persons, living or dead, or actual events is purely coincidental.



as evidenced by disability, loneliness, substance abuse, criminal behavior, higher rates of self-destructive behavior and high rates of ED utilization. The EPICenter engages its clients by putting them in an ownership role as far as their care is concerned. A novel mobile-device-based program (MyOwnMed™) puts in the hand of participants the ability to monitor their functioning in real time by accessing rating instruments, and to review test results, consultants’ recommendations and upcoming appointments. They are also enabled to communicate electronically with any member of their care team.

The next generation Training of professionals in a new delivery model is critical to any clinical enterprise that hopes to endure. As a training site for the University of Arizona, the Whole Health Clinic is involved in medical student education as well as the training of residents in family medicine and psychiatry. Psychology interns participate in the EPICenter and provide psychological testing to all individuals at the clinic when it is requested. Plans are under way to train nurses and pharmacists as well.

The big picture No matter where health care reform in this country is taking us in the future, an emphasis on population health and a move away from fee-for-service medicine are not


going to go away as defining features. The Whole Health Clinic is test-driving, as it were, several key elements to support that new orientation: The interprofessional group delivering team-care, the integrated electronic health record, the emphasis on aggregate outcomes, the engagement of the patient as an active owner of his or her treatment plan, and the emphasis on continuous communication among team members. The challenge to the individual clinician is the need to retain and foster our rapport with the individual in our office or our examination room, advocate for that individual’s needs and meet his or her expectations: This responsibility is not removed or lessened if the larger focus is on population health. Ole J. Thienhaus MD, MBA, is Chair of the Department of Psychiatry at the University of Arizona College of Medicine in Tucson. In 2012, he came from Las Vegas, Nevada, where he had been Chair of Psychiatry at the University of Nevada School of Medicine since 1996. Dr. Thienhaus is Board-certified in Psychiatry and Geriatric Psychiatry. He is the author of some eighty peer-reviewed articles and editor or author of four books. He holds an MBA from the University of Cincinnati College of Business Administration.

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early 40 years ago, a group of citizens shared a vision about a new way of caring for the dying. Led by the Rev. Q. Gerald Roseberry, the volunteers established Hospice of the Valley in 1977 – the first hospice in Phoenix, Arizona, and one of the first in the nation. They worked in rent-free space at the Maricopa County health department. Their goal was to support patients in their homes – offering medical, social and spiritual comfort – rather than isolating dying patients in hospital wards. As Maricopa County grew, so did Hospice of the Valley (HOV). And as hospice became more accepted nationwide, it was added as a Medicare benefit in 1982, establishing its place in the health care system with a secure financial foundation.

The community hospice Today HOV retains its community orientation and commitment to serve all, regardless of whether the patient has Medicare, insurance or financial means. Last year the total value of community services provided by HOV was $10.3 million, including nearly $8 million in charity care. The integration of end-of-life care into the healthcare system spawned a new medical specialty. In 2006, hospice 38


Value of charity care and other community services: $9.2 million $0.3 $1 $1 $6.9 million

Charity care Uncovered costs for AHCCCS patients Community health services In-kind donations

and palliative medicine was recognized by the American Board of Medical Specialties, which certifies physicians. Professional associations for nurses and nurses’ aides also offer certification for expertise in hospice and palliative care. The spectrum of palliative care has broadened to include serious illnesses prior to hospice eligibility. Community volunteers remain very much a part of hospice care. At Hospice of the Valley, some 2,500 volunteers provided 195,000 hours of service in 2015. Their contributions

include home and inpatient visits with patients; reading or singing to patients; providing respite for caregivers; brightening the day with pet visits or engaging in religious or spiritual practices with patients if requested. Volunteers also provide administrative office support; sew and stitch items; work in the agency’s thrift stores and make greeting cards. “Compassionate community members give valuable support to our patients and families in so many ways,” said Debbie Shumway, executive director of HOV. “In return it is our privilege to serve those who need care but face financial or other barriers.”

Charity care for those in need Donations, grants and gifts make it possible for Hospice of the Valley to care for people without insurance and to pay for extra services that aren’t covered by Medicare or insurance. Take the case of Jesse Gutierrez, who worked 33 years in construction. At the time he was diagnosed with throat cancer in April 2015, he had health insurance through his employer. But after he was off work for three months, he was fired. Since he was only 58, Jesse didn’t qualify for Medicare. “After that we had to go on Cobra,” said his wife, Julie. The Casa Grande couple paid $1,261 per month for health

insurance, but hospice care was limited to three months. After that HOV stepped in to cover the cost of Jesse’s care. A doctor, nurse and social worker made house calls. Medications related to the cancer diagnosis were provided at no charge. That included liquid morphine – more expensive than pills – because it was the only type of painkiller Jesse could swallow. For a week in July, Jesse stayed at a Hospice of the Valley palliative care unit in Gilbert at no cost to the family. “It is so hard to express in words what hospice has done for us,” Julie said. “I will never forget it, and my kids won’t either. If I hit the lottery today I would donate it all to hospice. They have been so good to us.” Donations and grants also cover HOV’s Pet Connections program, with 130 pet teams that visit patients and families throughout the Valley. The four-legged visitors bring smiles and evoke memories patients have of pets they used to have. Dogs, cats and even miniature horses make the rounds. Another service supported by donations and grants is Hospice of the Valley’s perinatal program for parents-to-be who have been told their babies most likely won’t survive birth. For those who do survive but aren’t expected to live long, Ryan House is available to families. “We felt so much love and care there,” said Seth Darnell, who stayed at Ryan House with his wife, Jennifer, and their July 2017 | arizonaphysician.com


infant daughter, Nora. Nora died peacefully in her parents’ arms two weeks after birth. Their extended family was there, as were a nurse and social worker from Hospice of the Valley. “We are grateful for the care,” he said.

Volunteers contribute to patient care Behind every hospice volunteer is a heart-warming back story. Most of them step forward as a way of expressing appreciation for care given to their loved one. Many have nurturing personalities. Some have medical backgrounds or scientific interests, including some students, even teen-agers. Three of Lee Benson’s four grandparents had dementia and hospice care. He got involved volunteering at HOV’s

Gardiner Home as a university graduate student majoring in biomedical informatics because it “seemed like a good way to give back.” Gardiner Home specializes in caring for dementia patients in an inpatient setting. Ann Kooi also volunteers at Gardiner Home. Her careers – intensive care/emergency room nurse, followed by paralegal work – plus her personal experience helping her sister care for their mother with Alzheimer’s disease – perfectly prepared her for the job. “I retired and was looking for something to do with the skills I had to apply,” she said. “My ex-husband had died at a Hospice of the Valley palliative care unit and I was impressed with the care given there. I wanted to give back.” Patsy Pearce is among Hospice of the Valley’s long-time volunteers, with 20 years of service. Last year she was presented the Hon Kachina Volunteer award, a statewide honor. She has served as a home care and palliative care unit volunteer, provides spiritual care to dementia patients and respite for family caregivers in the East Valley, gives community talks and educates prospective volunteers. As a young girl, Pearce cared for her grandmother at the family farm in Oklahoma. Anyone with a kind heart and listening ear can volunteer. HOV volunteers go through 24 hours of training over the course of a month to make them comfortable with caregiving. Those who wish to work in areas not involving patient care do not have to complete the group classes, but go through individual training related to their roles. For more information on volunteering, call 602-636-6336 or view hov.org. Beverly Medlyn is communications director for Hospice of the Valley. Email her at bmedlyn@hov.org.

Name John Eckstein, MD Volunteer Eckstein Center, Hospice of the Valley Why I do it Dr. Albert Eckstein, my father, was Hospice of the Valley’s first medical director. (In fact, he wrote articles for this magazine

about hospice care in the 1980s.) My wife Diane and I are honored to volunteer at the palliative care unit in Scottsdale that bears his name. He was my main mentor, as a person and as a physician. Volunteerism, philanthropy and service have always been important to our family.

What I do

At the Eckstein Center I do not volunteer as a physician. Diane and I go once a week in the late afternoon and early evening, doing what any volunteer does. First I go into the kitchen and make chocolate chip cookies. I make great chocolate chip cookies! (Not from scratch – the dough is already made, but I know the secrets for baking cookies just right!) The families, patients and staff all enjoy the cookies. We determine if any patient rooms need cleaning and restocking. We also clean and maintain the common areas. If a patient or family member requests a meal, we prepare it. Mostly we enjoy talking with patients and their families.

Best part of the “job” Talking and listening to patients and their families. If they comment about the facility, I tell them it is named

after my father. We also provide the history of HOV. If they ask what I do, I tell them I’m a physician, which may lead to questions and discussion. I keep my comments general, and never offer specific opinions about their particular problem or question any medical treatment or care. Mainly I listen. Since many families come from out of town, we may talk about their communities. There is no set agenda. We also enjoy talking with and observing the caring staff. Never in all my years of medical practice have I heard a negative or critical word about the care provided by Hospice of the Valley. The staff is exceptional. Bricks and mortar make a comfortable physical facility. The HOV staff creates the far more important caring and emotional experiences at the end of each patient’s life for both the patients and their families. Diane and I are so honored to contribute our small part. My father would be pleased.



Critical Path Institute: Advancing Therapeutics from Arizona for the World BY BRIAN POWELL



July 2017 | arizonaphysician.com


The Critical Path Institute leadership including president and CEO Martha Brumfield, PhD, (above), and executive director of the Critical Path to TB Drug Regimens initiative, Debra Hanna, PhD (right) work to educate the AZ community about C-Path programs and initiatives.


he Critical Path Institute may function unbeknownst to the general public and even to members of the medical community, but the trailblazing work it is doing today with diseases such as Alzheimer’s, Parkinson’s, multiple sclerosis and diabetes may have a dramatic impact on the types of conversations physicians and their patients are having in the future. Martha Brumfield, Ph.D., C-Path’s president and CEO, describes the Tucson-based nonprofit organization’s unique mission as one of advancing novel methodologies and tools through regulatory authorities for the purpose of expediting drug development. “We all want patients who need medicines to get them as soon as possible and we want those medicines to be as safe as possible,” Brumfield says. C-Path, which was founded in 2005, works collaboratively with the U.S. Food and Drug Administration, the pharmaceutical industry, and academia to create consensus science. The organization is independent and neutral and has gained respect as a trusted third-party in the work of drug development and the regulatory process for medical products, as well as for large-scale data sharing. “We are trying to change the paradigm. It’s one little piece at a time,” Brumfield says. “We have seen the same challenges again and again and the same approach again and again and we are not making enough progress. With these tools and methods, we can make better decisions, shorten the timeline and most importantly get effective and safe medicine to patients who need them, specific to their disease.”



A Tucson success The Critical Path Institute opened its office in Tucson 12 years ago with five employees. The organization was founded by Raymond Woosley, M.D., Ph.D., former vice president of the Arizona Health Sciences Center and dean of the University of Arizona College of Medicine-Tucson, in partnership with the FDA and University of Arizona. Startup funds came from the FDA as well as Science Foundation Arizona and the Phoenix-based Flinn Foundation, a grantmaker that aims to advance the biosciences in Arizona. Today, C-Path is in the midst of its second five-year grant from the FDA, and draws funding from the pharmaceutical industry on a unique fee-for-participation basis as well as foundations. Its annual budget is about $15 million, double the amount from just three years ago. The organization operates out of an office complex at the base of Tucson’s Catalina Foothills. C-Path has grown to 73 employees – including five who work remotely. Many are adjunct faculty members at University of Arizona, located about four miles away. There is no research or lab space at C-Path – although the organization does sponsor research elsewhere – but rather traditional office space for the experts in science, drug development, and the regulatory process who are running the organization’s 14 programs. Brumfield has been the President and CEO of C-Path since February 2013. She began working for the organization as a consultant in 2010 and then served as its director of international and regulatory programs. Brumfield previously spent 20 years with Pfizer Inc., most recently as senior vice president of worldwide regulatory affairs and quality assurance.

While C-Path works virtually with companies, researchers, and agencies from around the world, including the European Medicines Agency and Japan’s Pharmaceuticals and Medical Devices Agency, in the coming years it hopes to establish more face-to-face Arizona connections, like its recently announced partnership with the Phoenix-based Translational Genomics Research Institute to improve the treatment of bacteria-resistant tuberculosis around the globe.

Taking on tuberculosis The Critical Path to TB Drug Regimens, C-Path’s largest program, received a $1.1 million grant in May from the Bill & Melinda Gates Foundation that will enable C-Path and TGen to sequence at least 12,000 tuberculosis bacteria isolates from about 35 countries, including developing nations in Africa, Asia, Eastern Europe, and South America, over the next three years. The DNA sequencing, which will be done by TGen North in Flagstaff, will help identify drug-resistant patterns. Researchers worldwide will be able to see the results via C-Path’s data-sharing program with the hope it will lead to more precision-medicine treatment options for those suffering from the drug-resistant strain. Debra Hanna, Ph.D., who joined C-Path in 2011 after spending 11 years in the antibacterial research-anddevelopment unit of Pfizer Global Research and Development, is the executive director of the Critical Path to TB Drug Regimens initiative. Hanna says there are only about 10,000 cases of tuberculosis in the United States, but one-third of the global population carries the disease and about two million people die each year. Yet the standard pharmaceutical option is four decades old, and in most current cases, four drugs must be taken together for up to 24 months to kill the bacteria. “This is a disease of the developing world and of the poorest of the poor,” Hanna says. “There is very little investment in TB drug development, since there’s little money to be made, so you will see foundations, primarily the Bill & Melinda Gates Foundation, who are now funding companies to innovate in this space: to do the appropriate clinical trials, to get better drugs to patients, and to find ways to make that cost effective so the drugs can get to these parts of the world.” In Arizona, the drug-resistant varieties of tuberculosis impact Native American populations most significantly, and it is present in neighboring Mexico as well. “It will take the acquisitions of tens of thousands of more data sets, but when that volume of data is large enough, it’s a clear opportunity for this to drive clinical decision-making,” Hanna says.

Data Collaboration Center The addition of the TGen sequencing will enhance C-Path’s Data Collaboration Center, a pre-competitive environment which has more than 1,400 scientist and researcher participants from nearly 80 countries. C-Path integrates and aggregates data – from more than

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50,000 subjects to date – so that all data records are organized in the exactly the same way for each disease, whether Alzheimer’s, Parkinson’s, kidney disease, multiple sclerosis, Duchenne muscular dystrophy, or tuberculosis. Hanna says that when looking for new drug-development tools, or biomarkers, rarely is there enough data in any one institution – whether it’s academia, a pharmaceutical company, or government group – to fully validate a completely novel tool or biomarker. But now researchers can turn to the data at C-Path, which helps to validate the methodologies to a regulator’s standard. One example of the benefit of C-Path’s data collection is the development of a clinical-trial simulation tool for mild and moderate Alzheimer’s disease, which was endorsed by the FDA and EMA and applies computerized models to simulate “what-if” scenarios for clinical trials. “Those are the kind of tools we are trying to validate and get out there for everyone to use so they can make better informed decisions on trial design, which patients they should enroll, and how they are going to measure progression of disease,” Brumfield says.

C-Path programs The Critical Path Institute’s 14 programs, which include the data-sharing and tuberculosis projects, focus on both adult and pediatric clinical trials and outcomes. The Pediatric Trials Consortium, for instance, has a mission to create a sustainable infrastructure of trial sites for children. C-Path recently launched a spinoff nonprofit, Institute for Advanced Clinical Trials for Children, to make this a reality. Brumfield says the goal is to create sites nationally and globally. “This will provide an opportunity for Arizona physicians to participate, and could be an opportunity for them to be on the cutting-edge of medicine being evaluated in children,” Brumfield says. And it would provide C-Path another opportunity to work with physicians and researchers right here in Arizona. For more information about the Critical Path Institute, visit www.c-path.org. July 2017 | arizonaphysician.com


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