A combined publication of the Arizona Medical Association, Maricopa County Medical Society, and Pima County Medical Society
Veteran Healthcare: thoughts from physicians who served pg. 30
Healthcare with heart: working in the VA with
David Biglari, DO pg. 23
ARIZONA PHYSICIAN | June 2017
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VOLUME 1, ISSUE 6 EDITOR-IN-CHIEF JAY CONYERS, PhD
MANAGING EDITOR SHARLA HOOPER
ASSOCIATE MANAGING EDITOR DOMINIQUE PERKINS firstname.lastname@example.org
PHOTOGRAPHY DENNY COLLINS
Contents Physician Profile
Caring for our State’s veterans is a work and a calling of the heart. We talk with VA cardiologist with David Biglari, DO.
LAYOUT & PRINTING PRISMA
EDITORIAL BOARD GRETCHEN ALEXANDER, MD MICHAEL BUGOLA, MD JOHN COUVARAS, MD MICHAEL DEAN, MD TIMOTHY FAGAN, MD TABITHA MOE, MD ROBERT ORFORD, MD WILLIAM THOMPSON, MD JAREN TROST, MD
arizonaphysician.com twitter.com: /AZPhysician facebook: /ArizonaPhysician instagram.com: /azphysician
23 Features 15 20
Are Non-Opioid Therapies More Desirable Than Opioids for Chronic Pain? Educating Phoenix VA Health Care System Physicians
Physicians Who Have Served: What They Think of Veteran Health Care Spreading Out, Serving More
In This Issue 4 What’s Inside 6 Pima County Perspective 10 Policy: Surprise Billing Curtailed 13 Congressional Corner with Martha McSally 17 Public Health: Opioid Report
28 Event Photos: MCMS Health Law Forum 34 Community: TAPI 38 Community: Backpack Buddies 41 Business: PCMH Program Deliver
June 2017 | arizonaphysician.com
What’s Inside C ARING FOR OUR VE TER ANS
Jay Conyers, PhD
To care for him who shall have borne the battle and for his widow, and his orphan. Abraham Lincoln
he above quote is what greets you when you walk through the front entrance of the U.S. Department of Veterans Affairs (VA) headquarters in Washington, D.C. These words were first spoken by President Abraham Lincoln during his second inaugural address, in early March of 1865, and preceded the end of the American Civil War by a mere three months. The VA was not established until threescore and five years later, but the words spoken by the president resonated with many, and now adorn the very institution designed to care for those who served to protect our country. Since the Civil War, we have sent our nation’s young men and women to fight for freedom in countless conflicts around the globe. Many are fortunate enough to return home unharmed. Many others do not. Some battle the scars – both physical and mental – for years to come. Our VA system, with its nearly 400,000 employees and hundreds of hospitals and clinics scattered across the country, cares for many of those who served. This includes my father, who served during the Vietnam War yet never saw battle, and my father-in-law, who was actually shot down as medical evacuation pilot rescuing wounded GIs. I never served, but every day I am thankful for those who have, and still do. I first got a glimpse of how we care for our veterans when I accompanied my then boss, Dr. Ward Casscells, on a tour of the Walter Reed Medical Center in Bethesda, MD. From 2003-2007, Dr. Casscells was my division chief at the medical school where I held a faculty position. He was an inspiring mentor and an accomplished cardiologist, and felt the need to serve his country in the midpoint of his life, joining the U.S. Army Reserves at age 52 (truth be told, he needed countless waivers to attend boot camp, given his loss of hearing and prior prostate cancer diagnosis). After boot camp, Dr. Casscells was stationed in Iraq,
ARIZONA PHYSICIAN | June 2017
serving as a special advisor to the Iraqi foreign health minister, and later at the Pentagon in Washington, D.C. Shortly after returning to Houston, Texas following his active service, he was nominated by President George W. Bush in early 2007 for the post of Assistant Secretary of Defense for Health Affairs. This was a big job, much larger than his seemingly small role as an academic clinician. At the time, the hot topic in the media was the Walter Reed scandal, which culminated in a series of articles published by The Washington Post in February of 2007 detailing years of patient neglect and unsatisfactory living conditions for our nation’s wounded soldiers receiving treatment at the hospital. Also, it was reported that the Department of Veterans Affairs was seeing an alarming increase in the number of veterans suffering from severe PTSD, which later become known as the signature wartime injury for the Iraq and Afghanistan conflicts. I had the pleasure of helping prep Dr. Casscells for his Senate confirmation hearings that spring and accompanied him on numerous visits to congressional offices and military hospital sites around our nation’s capital. It was evident, at least to me, that our veterans and wounded soldiers weren’t receiving the best possible care. Waiting rooms were jam-packed, gurneys were lined up in the hospital hallways, and the rooms we visited – with countless veterans missing limbs and either blind or deaf as a result of his or her Humvee encroaching on a buried landmine – smelled of mildew and had paint peeling from the walls and ceilings. Despite the poor conditions, one thing was apparent – the men and women caring for our wounded soldiers and veterans were truly committed to helping those who risked their lives for our freedom. The passion they exuded was palpable, and their dedication to serving our servicemen and women was undeniable.
As you might expect, the Walter Reed scandal was front and center during Dr. Casscells’ confirmation hearings, and he conveyed to the committee his resolve to improve the care our wounded soldiers and veterans received. He was confirmed on April 12, 2007 and immediately went to work. He recognized that the incompatibility of the electronic health record (EHR) platforms – namely, the VA’s VistA and the DoD’s AHLTA – was a major roadblock to improving care as soldiers moved to veteran status. He dedicated his time in office to integrating the two, asking for the respective agency secretaries to commemorate a MOU (memorandum of understanding) that would affirm their commitment. Unfortunately, Dr. Casscells never got to see the integration of the two EHRs during his time in office, nor prior to his untimely death in late 2012. Yet all was not lost. It took a full decade, in fact, for the idea to become a reality, when in March of this year, the Department of Veterans Affairs finally decided to move away from its self-developed VistA system, with Secretary Shulkin deciding to pursue a commercial product. Just this month, an announcement was made that Cerner, the same company overhauling the DoD’s AHLTA system, would replace the outdated EHR for the VA. What will the end result be? For one, it should streamline the transfer of records from active duty to veteran status, so that physicians caring for our nation’s veterans – including those at the Tucson and Phoenix hospitals – will have a better idea of the medical history of each veteran. And it will also improve the sharing of records between VA
and non-VA facilities, as the VA contemplates outsourcing more care as it works to rebuild its own infrastructure. Truth be told, fixing the EHR system isn’t the only solution, but it’s a move in the right direction. This month, we profile Dr. David Biglari, an interventional cardiologist at the Phoenix VA and Banner Health System. His dedication to treating his patients is unwavering, even down to his lead apron adorned with camouflage and the American flag. We hope you enjoy his story! We also bring you our third installment of the student essay content, with a wonderful piece by Michelle McQuilkin, a fourth year student at the University of Arizona College of Medicine – Phoenix. Our congressional corner this month is penned by U.S. Representative Martha McSally, herself an Armed Forces Veteran. We also have a great article describing the education opportunities for physicians working as part of the Phoenix VA system, and many other pieces that look at the current state of veteran health. Next month, we focus on serving Arizona’s underserved, and sit down with Dr. Sara Salek, Chief Medical Officer for our state’s Medicaid program, AHCCCS. Until then, please join me this month in saluting those who serve and have served our country. Jay Conyers, PhD, is the Editor-in-Chief for Arizona Physician and serves as Executive Director of the Maricopa County Medical Society.
HEALING HANDS. BIG HEARTS.
Blue Cross Blue Shield of Arizona values the contributions and efforts of Arizona physicians in caring for our members.
June 2017 | arizonaphysician.com
Pima County Perspective DIFFICULTIES OF VE TER AN HE ALTH C ARE
was asked to offer an opinion regarding some of the difficulties the Veterans Administration (VA) faces in delivering timely and quality care to the 9.1 million veterans who are eligible for care under that system today, myself included. I must admit that I am not a VA provider although I was employed by the VA for five years as a surgical resident. The opinions I express are my own and are not a reflection of any federal agency or authority. During my tenure as the Mobilization Assistant to the Assistant Secretary of Defense, Health Affairs, I sat in on many a high level meeting regarding VA Health Care at the Department of Veterans Affairs in Washington D.C. The history of how and why the Department of Veterans Affairs was created dates back to the Lincoln Administration and is very interesting. I myself am a veteran, having served for almost 29 years and having deployed on four occasions to Iraq and Afghanistan. My brother is a veteran, as is my father, so these issues are very real and personal to me. Congress recently enacted and President Obama signed into law the Veterans Access, Choice, and Accountability Act of 2014 (Public Law 113-146) (“Veterans Choice Act”), as amended by the Department of Veterans Affairs (VA) Expiring Authorities Act of 2014 (Public Law 113-175), to improve access to timely, high-quality health care for Veterans. Under “Title II – Health Care Administrative Matters,” Section 201 calls for an Independent Assessment of 12 areas of VA’s health care delivery systems and management processes.
Assessing and reporting The bipartisan Fixing Veterans Health Care Task Force report (a worthwhile read) was released in February 2015; the task force was chaired by Bill Frist (R), who represented Tennessee in the Senate from 1995 to 2007, was Senate majority leader from 2003 to 2007, and Jim Marshall (D), who represented Georgia in the House from 2003 to 2011. Frist and Marshall mentioned that they joined this task force because they believe in the VA’s mission. They go on 6
ARIZONA PHYSICIAN | June 2017
Jim Balserak, MD, MPH, FACS, FACE
to say that in learning about the history of the agency and its many iterations, it was easy to see how the VA’s current configuration, “grew out of legislation passed to address immediate needs and competing election cycles.” They propose that the best way to “fix” the VA is to focus on Abraham Lincoln’s promise, “to care for him who shall have borne the battle,” not the agency that dispenses his benefits. The VA engaged the Institute of Medicine of the National Academies to prepare an assessment of access standards and engaged the Centers for Medicare & Medicaid Services (CMS) Alliance to Modernize Healthcare (CAMH)1 to serve as the program integrator and as primary developer of the remaining 11 Veterans Choice Act independent assessments. CAMH subcontracted with Grant Thornton LLP, McKinsey & Company, and the RAND Corporation to conduct ten independent assessments as specified in Section 201, with MITRE conducting the 11th assessment. Drawing on the results of the 12 assessments, CAMH also produced the Integrated Report in this volume, which contains key findings and recommendations. CAMH is furnishing the complete set of reports to the Secretary of Veterans Affairs, the Committee on Veterans’ Affairs of the Senate, the Committee on Veterans’ Affairs of the House of Representatives, and the Commission on Care.1 This report was the result of a perceived crisis of care delivery and leadership within the VA Health Care System after the Inspector General launched investigations of the Phoenix VA hospital – accused of concealing exorbitant patient wait times to see providers which in some cases were felt to be the root cause of many patient deaths and innumerable declines in the health and safety of thousands of others in an investigation that ultimately expanded to 26 VA care facilities nationwide.
Healing the wounded This intense pressure can be linked to numerous factors. I served as a trauma surgeon working in Baghdad, Iraq on two occasions. I was the Chief Surgeon at the Joint Theatre Hospital, Bagram Air Base, Afghanistan. I was the Critical
Care Air Transport Team Lead taking wounded soldiers, airmen, sailors, and Marines from the downrange battlefield to Landstuhl Regional Joint Hospital at Ramstein Air Base Germany, then forward to facilities in the continental U.S. Let me say without any doubt that the health care our men and women receive is comparable to no other, boasting the greatest life and limb salvage rates from the most horrific classification of wounds, physical and mental, in the history of battlefield injury. Because of this dramatic increase in immediate trauma care, more of our service men and women survive battle injuries from which they otherwise would have succumbed in the Vietnam conflict and any war prior. Currently, 16 are wounded for every one killed, compared to 2.6 soldiers wounded for every one killed in Vietnam. When soldiers do come home, their injuries can be more profound and the care required more involved. Thousands suffer from post-traumatic stress disorder (PTSD), many are multiple-limb amputees, and even injuries that seem to leave no external sign can have a severe impact, including traumatic brain injury (TBI). Meanwhile, many of the VA’s technical patient management systems are out of date, leading to considerable duplication, delays and errors. The proposed budget for the VA – which enrolled 9.1 million veterans of the estimated 21.9 million living U.S. veterans – in fiscal year 2015 was $158.6 billion, according to a May 2014 Congressional Research Service (CRS) report. The Report also notes that in 2015 the V.A. “anticipates treating more than 757,000 Operation Enduring Freedom (OEF), Operation Iraqi Freedom (OIF), and Operation New Dawn (OND) veterans.” Between fiscal years 2011 and 2014, the number of VA enrollees increased 6.3%.2 The Department of Defense (DoD) estimates that more than 50,000 service members have been wounded in action during the Global War on Terror conflicts, but that figure does not fully capture mental health needs or still-emerging disabilities. A 2013 CRS3 provides a detailed look at all casualty statistics and spells out the extent of the mental health injuries. A 2014 survey by The Washington Post and Kaiser Family Foundation of Iraq and Afghanistan veterans found deep dissatisfaction with current levels of government care. The Iraq and Afghanistan Veterans of America (IAVA) issued a 2014 report exploring the troubles with the V.A. claims backlog and detailing the experiences of service members.4 I myself was involved in speaking with and studying the problems of health care access and delivery to dozens of soldiers within the Arizona National Guard Medical Hold Battalion who had returned from faithful duty and service in these conflicts but who were lost within the system through no fault of their own. Many had their lives put on hold for over five years because of a system failure. Jobs were lost, families were divided and destroyed due to a system failure of medical redeployment upon return home from tours of duty.
Changing for today’s paradigm The independent assessment of the challenges within the VA Health Care System is a 168-page document with numerous addendums and attachments that focused on the following key areas:
A. B. C. D. E. F. G. H. I. J. K. L.
Demographics Health Care Capabilities Care Authorities Access Standards Workflow – Scheduling Workflow – Clinical Staffing/Productivity Health Information Technology Business Processes Supplies Facilities Leadership
Personally, I feel a key element for reform of the VA should be taken from Principle #2 from Veteran’s Healthcare Reform principles: Refocus on and Prioritize Veterans with Service Connected Disabilities and Special needs. Specifically, “Healthcare for America’s Veterans should be earned either through a service-connected disability or military retirement based on a certain length of honorable service – it is not, as some misrepresent it to be, an automatic entitlement for everyone who served.” That all being said, I believe this report has tremendous merit. The underlying issue, which was alluded to in the Task Force report, is that the original VA’s foundational principle (to care for service connected disabilities) is fundamentally flawed in today’s paradigm of care. Policy-wise, legally, legislatively, and otherwise, the Veteran is entitled to care for service-connected disabilities only; anything else is space-available care. If this language sounds familiar to a TRICARE beneficiary, it should, as it was how the Military Health Service (MHS) used to care for our retirees prior to the evolution of TRICARE. Prior to TRICARE the beneficiary had two options: 1.
They were entitled to free health care as long as they lived next to a Military Treatment Facility (MTF).
2. And then it was space-available care if no appointment available or the beneficiary paid a 22% co-share with the Civilian Health & Medical Program of the Uniformed Services (CHAMPUS) (which preceded TRICARE in the MHS) if you did not live near an MTF. And space-available care for the non-service connected illnesses basically means patients will not be seen in any reasonable time.
Considering VA reform Some key elements to VHA reform I believe should be considered: 1.
Focus on service-connected care only. You can’t have good quality of care and continuity of care if you are entitled to be seen for only certain medical conditions (service-connected) and not others. For example, a physician can see a veteran for a service-connected knee issue but not for the veteran’s non-service connected health concerns such as hypertension, diabetes or heart disease. And if the veteran chooses to do so within the VA, then it often turns into space-available care with tremendously long waits, which as we know is not good June 2017 | arizonaphysician.com
quality care. We must either clear out space-available care and resource in order to make room for actual entitled care (service connected) with current resourcing, or as a Nation decide to resource the full spectrum of care beyond service-connected disabilities through an insurance program which would require the Veteran to have insurance coverage for non-service connected disabilities care. The veteran would therefore have to pay (very modest payments) now for health care that has continuity/better quality and therefore the VA can shift away from the episodic space-available care paradigm. This is a quality issue, not a cost issue. It also would allowed the MHS to resource the Active Duty Military Health Service end-strength footprint to meet the training, garrison, war fight, and contingency requirements. It was a DoD business decision based on the line’s commitment to resourcing active duty end-strength but also driven by quality of care.
2. Offload primary care. The VA current sits at a
very critical inflection point just as the MHS did with TRICARE in the mid-late 80’s: a resourcing end strength issue that was based on quality/continuity of care. The VA has the opportunity to offload primary care with a trade-off for quality/continuity of care in the veterans’ respective communities. The VA could pay for the portion of all “service connected” care and all else (remainder of the percentage) is borne by the veteran’s responsible co-share of whatever insurance program/ premiums that a future transformation could create.
3. Privatize or build capacity. As far as hospitals/
medical centers, the VA and the Veteran have two options: a.
Privatize inpatient care
Execute a market analysis of current veteran’s hospitals servicing areas. Remember, the original vet hospitals were where the WWI vet populations were located and then the WWII vet locations also (probably not much different). But the demographic locations of veterans have changed with an all-volunteer force. That needs to be taken into account: inventory and then a strategic/fiscal reset. Hence the newest VA hospitals now being built in the “new” vet demographic population areas: Las Vegas, NV and Orlando, FL.
4. GME funding. One thing that has to be taken into
consideration in regards to VA hospitals/medical centers/specialty care centers (spinal/poly-trauma/ amputee/etc.) is that by law, the VA’s mission is to train America’s physicians with Graduate Medical Eduction (GME) programs. If you privatized inpatient/specialty care, then you also would have to federally incentivize or fund private hospitals to support/augment GME. And you know how hard that is to do in today’s environment with the current federal health care reimbursement paradigm. So a second order effect of privatizing inpatient care would be for the Federal government to come up with a transformational program to offset the GME funding.
ARIZONA PHYSICIAN | June 2017
5. National strategic reserve. On a strategic level,
one could argue that the VA’s large Medical Centers, Poly-Trauma Centers, and specialty care centers (spinal/ poly-trauma/amputee/etc.) are a “national strategic reserve” and might just merit continuing to underwrite this national reserve capability (cost of “national” readiness). But we would need to insure that these facilities are geographically located in the areas of greatest need.3
Pouring more money into the VA current infrastructure operating model is flawed. A union-based non-incentivized work force won’t allow the VA to move forward in the direction they need and require in order to deliver the highest quality and most cost-effective care to the veteran. So the fundamental question: do we keep throwing money at the current VA organizational construct and make incremental changes to a flawed system (reform and failure) or do we have the courage to do something transformational like the DoD did with the overhaul of the MHS and the advent of TRICARE in the 1990’s?
Frustrations and faults While it has been over two decades since I provided care at a VA facility, I recall one frustrating aspect very well: the federal employee worker unions that exist within the VA System obstruct care. I will keep the names of these current VA Health Care providers’ names confidential but I kept hearing a few common themes. The first was that these worker unions have become much too powerful and politically influential and obstruct means for agile change within the VA Health Care delivery model. I remember at the time being limited in the number of surgical cases we could perform in any given operating room (OR) for no valid reason. I recall one OR employee telling me that is was not within their employment contract to do any more cases on a daily basis other than a minimum standard. This does not imply that workers in the VA system do not care about their service to veterans; it implies that the culture over time has generated an environment that has handcuffed health care delivery. There are thousands of VA workers who are truly committed to providing excellence to our veterans. Another glaring frustration stated was the wide gap and disconnect between provider staff and clerical staff, which inhibits effective scheduling and care delivery to the veteran. Within the VA system, administrators and schedulers answer to an entirely different chain of command and therefore, there is no real ability to improve efficiency. The problems within the VA system in the above categories are much too vast to pick apart individually but I will suggest what I believe to be a possible solution to the care problems both within the MHS and the follow-on care received in the VA health care system. In my former military career, my tendency to speak my mind has gotten me sideways with a few prominent people within the Pentagon and the Defense Health Agency for not playing the party line. Anytime government becomes too heavily involved in health care delivery it becomes much too costly and much too politically charged to affect
Currently, 16 are wounded for every one killed, compared to 2.6 soldiers wounded for every one killed in Vietnam. When soldiers do come home, their injuries can be more profound and the care required more involved. change. Every private party, lobby and interest group has the ear of a congressman, a senator, which makes effective and efficient change within a short time period impossible. If anyone out there believes that government involvement in health care delivery is good for health care or the beneficiary, then, respectfully, you have not been directly involved in processes.
Committing to a solution In my opinion, the way we fix veterans’ health care and provide access to health care that is of high quality and value and provides the best patient experience is to privatize it, and to privatize it very carefully. To publically endorse such a proposal in the political arena would be self-inflicted suicide and although a very plausible solution, no “public servant” would ever have the fortitude or endurance to propose such a thing. One would never last very long within the Washington Beltway if one were to speak of such a blasphemous solution. To privatize VA health care means that everyone becomes accountable and it introduces a much-needed competitive shot in the arm and an incentive-based solution to getting veterans into exam rooms and operating rooms when needed. Right now a surgeon at the VA can do three cases a week or 25 cases a week and their salary remains the same. It is human nature not to work any harder than you need to in order to affect the same outcome. It boils down to incentive-based health care delivery at all levels, from leadership to providers, and downward to the administrative and support level tiers of service. With bonuses and incentives based on throughput, quality, and veteran satisfaction, the system will simply perform better. Take the politics and union workforce out of it and develop a unified chain of command that reports to one ultimate CEO. The VA system is a very special place where our veterans go not only for health care, but to be among others who have served, who understand the sacrifices required to serve, and to have a comradery with fellow soldiers, sailors, Marines, and airmen who understand the emotional struggles attached to their sacrifice. The VA is a place where the veteran feels safe, despite the frustrations.
Suicide rates among veterans over the past 15 years have skyrocketed to levels that the DoD and MHS still are having a hard time understanding, despite aggressive programs to identify and assist those at risk. I believe that it is important to maintain the VA in name and founding principles, but not under the current administrative, employee contract and health care delivery models. It should be mentioned that the VA does more for veterans than provide health care. The Department also: 1.
Is the 10th largest life insurance provider.
2. Provides oversight of a compensation and benefits program to over 5 million veterans. 3.
Provides education assistance to over 1.1 million students.
Offers a home mortgage program with a portfolio of over 2 million active loans guaranteed by the VA.
Supports the largest national cemetery system, projected to inter over 132K veterans and family members in 2017.
I do not believe that throwing money at the system is the solution if the foundation and framework under which the system operates is inherently weakening. We continue to throw money at broken processes without analyzing how to improve upon it and without making very hard and difficult decisions as to how to repair and rebuild it and we still sadly believe that bigger government is better government. The VA problem is one example of many multi-billion dollar federal programs are not working and not effectively exercising and optioning taxpayer dollars as well as we have entrusted them to do. One thing you can do. When you see that older veteran wearing the gold-braided purple cap, the Vietnam veteran or Iraqi of Afghanistan veteran, take just a few moments to walk over and thank him or her for their voluntary service to a grateful nation. It is the less than 1% of citizens in this country who voluntary take an oath to serve it and to serve and protect the 99% who are never fortunate enough to wear the uniform and truly understand what it takes and requires to begin and to complete that journey that qualifies that person as a true veteran. We owe them that, at a bare minimum. Dr. Balserak is a member of the Pima County Medical Society, and past recipient of the organization’s Lifetime Achievement award.A retired Brigadier General, Dr. Balserak most recently served as Air National Guard Assistant for Mobilization and Reserve Affairs, Office of the Assistant Secretary of Defense. References 1. Independent Assessment of the Health Care Delivery Systems and Management Processes of the Department of Veterans Affairs Volume I: Integrated Report 2. https://fas.org/sgp/crs/misc/R43547.pdf 3. https://fas.org/sgp/crs/misc/R41921.pdf 4. The U.S. Veterans Affairs Department and challenges to providing care for service members: Research roundup 5. Interviews and commentary and responses from very high-level officers within the DOD and MHS who requested anonymity June 2017 | arizonaphysician.com
Policy Corner BAL ANCE BILLING CURTAILED BY NEW A Z L AW
ver the last few years, a chorus of news reports has brought to the attention of state legislatures what is now widely recognized as the “problem” of “surprise medical out-of-network bills.” This is a term commonly used to describe charges arising when an enrollee of a health plan receives care and a medical bill, from a health care provider who does not belong to their health insurer’s provider network. These bills are typically for medical services that are rendered at an in-network health care facility or at the request of an in-network physician. The enrollee is then billed by the out-of-network provider for the full amount of the charge that is in excess (the balance) of the reimbursable amount under the enrollee’s health plan. In contrast, in-network providers are generally prohibited from balance billing a patient under their contracts with the plan. This “problem” usually arises when the patient’s in-network provider obtains out-of-network providers to participate in the patient’s care. The most common out-of-network providers are anesthesiologists, radiologists, pathologists, surgical assistants, and emergency department on-call specialists. The issue has grabbed the attention of state legislators because in addition to news reports, many legislators have had constituent complaints and personal experiences with a surprise bill. The prevalence of a surprise bill is being studied. A 2011 New York Department of Financial Services study of 2000 complaints found the average out-of-network emergency bill was $7,000, of which insurers paid 46% with the enrollee responsible for the remaining amount. Similarly, for non-emergency in-hospital care, the New York study found that on average out-of-network assistant surgeons billed $14,000, while insurers paid on average only 13% of the bill. The study found that on average radiologists billed $5,400, while insurers paid on average 46% of the bill. A 2013 Texas study found that between 41% and 68% of the billed charges for emergency related physician services at in-network hospitals were submitted by out-of-network physicians. The New England Journal of Medicine reported in November 2016
ARIZONA PHYSICIAN | June 2017
By Paul J. Giancola
that 22% of patients who visited an emergency department received a surprise bill from an out-of-network provider. A number of states, including California, Colorado, Connecticut, Florida, New York, Illinois, Indiana and Texas, have responded by enacting laws specifically limiting balance billing by out-of-network providers under certain circumstances. New York has the most comprehensive state law protection against surprise bills.
Components of a “surprise bill”
The surprise bill usually involves two components. The first component is the difference in patient cost-sharing between in-network and out-of-network providers. For example, in a plan that provides coverage for in-network and out-of-network providers, an enrollee might owe 20% of “allowed charges” (the reimbursement allowed by the insurer regardless of the amount of the billed charge) for in-network services and 40% of allowed charges for out-of-network services. An enrollee may also have a plan deductible that will impact the amount of enrollee cost sharing on a bill. The second component of a surprise bill is the “balance bill.” Network contracts typically prohibit providers from billing enrollees for the difference between the allowed charge and the billed charge. Because out-of-network providers have no such contractual obligation, enrollees can be liable for the balance bill in addition to any cost-sharing, including deductibles that might otherwise apply.
Senate Bill 1441
The Arizona legislature responded to surprise bills when it passed and Governor Ducey signed, on April 24, 2017, S.B. 1441. The bill amends Title 20 of the Insurance Law, Section 20-3102 by adding Article 2 “out-of-network claim dispute resolution.” S.B. 1441, introduced by Sen. Debbie Lesko, defines a “surprise out- of- network bill” as a bill for a health care service, laboratory service or durable medical equipment (collectively “services”) provided in a network facility by a provider that is not contracted. The enrollee may dispute the amount of the bill by a dispute resolution process the starts
with a teleconference followed by final binding arbitration, if requested and certain criteria are met. The highlights of the new law include:
Disclosure notice of right to dispute resolution (“notice”)
• The Arizona Department of Insurance (“DOI”) in conjunction with health care licensing boards, will develop a notice that outlines an enrollee’s right to dispute a bill. • Insurers must include the notice in each explanation of benefits to enrollees that involves covered services rendered by an out-of-network provider. • A provider, on request, must provide the notice to the enrollee. • The DOI will post information on its website for consumers regarding: – what constitutes a surprise bill; – how to try to avoid a surprise bill; and – how the dispute resolution process may be used to resolve a surprise bill. • The Notice must inform an enrollee that: – the provider is not an in-network contracted provider; – the estimated total cost to be billed; – that if the enrollee or their authorized representative signs the disclosure, the enrollee may have waived any rights to dispute resolution.
Criteria to qualify as a surprise bill
• The services were provided for an emergency condition at a network facility; or • The services were not provided due to an emergency condition; however, the provider either did not disclose the notice or did not provide it within a reasonable amount of time before the services were provided; or • The services were not provided due to an emergency condition and the enrollee or the enrollee’s representative chose not to sign the notice.
• The insurer, as part of the teleconference, will provide the amount of the enrollee’s cost sharing requirements under the enrollee’s health plan based on the adjudicated claim. • The enrollee must participate in the teleconference; the enrollee has the option of participating in the arbitration. • The insurer and provider must participate in both the teleconference and the arbitration. • If either the insurer or the provider fails to participate in the teleconference, the nonparticipating party will be required to pay the total cost of the arbitration. • If the dispute has not been settled or a party has failed to participate in the teleconference, the DOI will initiate the process to appoint an arbitrator.
Criteria to initiate arbitration of a surprise bill
• The enrollee must pay or make arrangements in writing to pay to the provider the total amount of the enrollee’s cost sharing due for the services contained in the bill; • The enrollee must pay to the provider any amount received from the enrollee’s insurer as payment for the out-of-network services; and • The insurer, if applicable, must pay its out-of-network services allowable amount due to the provider.
• The arbitration will be held within 120 days of the request for dispute resolution in the county in which the services were provided, and it may by agreement be conducted over the telephone.
Criteria to initiate a dispute of a surprise bill
• The surprise bill must meet one of these requirements to qualify for dispute: – the enrollee has resolved any health care appeal against the insurer following the insurer’s initial adjudication of the claim; – the amount of the bill for which the enrollee is responsible after deduction of the enrollee’s cost sharing requirements and the insurer’s allowable reimbursement is at least $1,000. • The enrollee may request dispute resolution of a bill by submitting a request on a DOI prescribed form. • The DOI, on receipt of the request, will notify the insurer and provider.
• The DOI, in an effort to settle the bill before arbitration, will arrange an informal settlement teleconference within 30 days after receipt of the request.
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• The arbitrator determines the final amount the provider is entitled to receive as payment. • The arbitrator may consider various factors submitted by the parties in evaluating the amount of the bill, including the following: – the average contracted amount that the insurer pays for the health care services in the county where the services were performed; – the average amount that the provider has contracted to accept for the services in the county where the services were performed; – the amount that Medicare and Medicaid pay for the same services; – the provider’s direct pay rate, if any; – other information in determining whether a fee is reasonable and not excessive, including the usual and customary charges for services that were performed by a provider in the same or similar specialty, and provided in the same geographical area; and – any other reliable databases or sources of information on the amount paid for the services in the county where the services were performed. • All pricing information confidential. • The insurer and provider share the costs of the arbitration equally; the enrollee is not responsible for any portion of the cost of the arbitration. • The insurer must pay its portion of the payment resulting from the teleconference or the amount awarded by the arbitrator within 30 days of resolution of the claim.
Balance billing prohibited
• The enrollee is responsible for only the amount of the enrollee’s cost sharing requirements (defined as coinsurance, copay and deductible requirements) and any amount received by the enrollee from the enrollee’s insurer as payment for out-of-network services. • A provider is prohibited from issuing any additional balance bill to the enrollee for the service.
• The bill does not apply to the following: – health care services that are not covered by the enrollee’s plan; – limited benefit coverage as defined in statute; – charges for services subject to a direct payment agreement; – plans that do not include coverage for out-of-network services, unless otherwise required by law; – state health and accident coverage for full-time officers and employees of the State of Arizona and their dependents. • Each year DOI is to provide a detailed report to the Governor and the Legislature on the resolution of surprise bills, including the frequency of requests, results, requests by specialty, insurer, geographic area, and average percentage by which surprise bills were reduced. • The law becomes effective on January 1, 2019. 12
ARIZONA PHYSICIAN | June 2017
Comments S.B. 1441 was originally modeled after Texas’ law – the major components of which are an informal teleconference between the patient, the provider, and the health plan. In Texas, teleconference resolves 94% of qualifying surprise bills. For the small number of remaining bills, Texas provides an escalating sequence of dispute resolution with mediation followed by arbitration. Throughout the 2017 Legislative Session, the Arizona Medical Association (ArMA) led the effort by organized medicine and worked closely with specialty societies to educate lawmakers, and to prevent negative unintended consequences and burden on physicians and patients. S.B. 1441 reflects an uneasy and technically complex compromise between insurers and providers. The benefit for providers is that it provides a mechanism to quickly resolve and obtain reasonable compensation for services soon after the services have been billed, rather than having to pursue the patient and the insurer for payment. The highlight for providers is that for those enrollees who pursue arbitration, the price of admission is to first resolve the patient’s cost sharing (either paid or to be paid under a fee agreement) and the insurer’s out-of-network allowable. Many providers have been frustrated by insurers who pay the patient their out-of-network allowable, but the patient does not pay it to the provider. When accessed by the enrollee, S.B. 1441 prevents this from happening. In addition, it requires the insurer pay the provider the applicable out-of-network payment. Anecdotal evidence suggests that many providers consider payment of such amounts by the patient and the insurer to be a “win.” Moreover, insurers indicated during negotiations on the bill that avoiding a costly arbitration and resolving claims typically results in a willingness to offer the provider at the teleconference an amount that while less than the billed charge is more than the in-network contracted rate. If the bill is successful, it is because all parties have the incentive to resolve surprise bills without incurring the time and expense of arbitration. There may, however, be unanticipated consequences. For example, will the bill impair the free market and force physicians to contract with insurers and accept insurance rates? Or will some physicians decide to stop providing services at in-network facilities such as hospitals because they cannot obtain adequate and timely payment? Lastly, the bill as written is merely a framework. The DOI must still formulate regulations to implement the bill. The implementation of the bill is delayed until January 1, 2018, allowing for legislative changes if deemed necessary. ArMA will be engaged in the rule-making process and representing physician concerns prior to final implementation. Stay tuned; time and experience will ultimately tell the story of the benefits and unintended consequences of the bill. Paul Giancola, JD is a partner at Snell & Wilmer. His practice is focused on healthcare compliance, transactions, and regulatory matters for healthcare organizations and physicians. Mr. Giancola served as legal counsel for ArMA during the advocacy work on S.B. 1441 in the 2017 Legislative Session.
Congressional Corner U.S. REPRESENTATIVE MARTHA McSALLY
s a female veteran who has been deployed six times to Afghanistan and Iraq, I have seen my fellow female veterans do extraordinary things for our country. We compete alongside men during rigorous training, we climb into the cockpit of fighter jets, we have survived exploded improvised explosive devices, we have deployed with Special Forces, and we have neutralized missile threats. As a former squadron commander myself, I can confidently say that women are equally as effective warfighters as men. Unfortunately, the veteran’s care they receive is far from equivalent to their male counterparts. Women are the fastest growing population in both the military and veteran communities. According to a review conducted by the Department of Defense (DoD), more than 280,000 women have stepped up to defend their country by joining the military since 9/11. In 2001 women made up 6% of the veteran population; by 2020 women are expected to make up 11% of the veteran population. Given this rise of women in service, it is unsurprising that the VA has seen an 80% increase in female veterans seeking treatment since 2002. Unfortunately, the VA is still adapting to effectively meet the health care needs of these female veterans. Many Department of Veterans Affairs (VA) facilities and military medical care providers cannot provide basic medical services for women, such as prenatal care, gynecological care, or mammograms. The Southern Arizona VA Health Care System (where I get my health care) has been a leader in this area, creating a separate unique space for female veterans to receive specialized care in a safe environment. Unfortunately, this is not the norm. The Government Accountability Office (GAO) found that about 27% of VA medical centers and health care systems lacked an onsite gynecologist and 18% of VA facilities providing primary care lacked a women’s health primary care provider. Aside from difficulty accessing basic women’s care, women are not given customized disability care. For example, prosthetic devices for women who have lost limbs frequently don’t fit properly because the prosthetic design, support, and medical care is based on male physiology, according to a recent report by Disabled American Veterans. One in five women enrolled in VA health care screen positive for Military Sexual Trauma (MST) – meaning they
have experienced sexual assault or repeated, threatening sexual harassment during their military service. In spite of this staggering number, 31% of VA medical centers in the U.S. cannot offer adequate treatment and support for MST. Female veterans struggle with mental health disorders just like male veterans, but the VA and DoD have difficulty providing gender-specific peer support, group therapy, and specialized inpatient mental health care designed to meet the needs and preferences of women. Additionally, female veterans have higher rates of unemployment and homelessness than male veterans. In fact, women are the fastest-growing demographic of homeless veterans in America today. Female veterans are six times more likely to commit suicide than women in the general population. This is absolutely unacceptable. As a nation we need to fully recognize female veteran’s contributions and sacrifices. When someone raises their right hand and pledges to defend their nation, even with their lives if necessary, our country makes a covenant with them. We pledge to be there for our veterans when they return from the battlefield. We pledge to make sure they have the care and benefits they fought for and deserve. We owe them respect and the chance to heal and successfully transition home. I’ve worked to hold the government accountable to make the changes needed to get our veterans the care they need. Women who have sacrificed limbs for our freedom deserve a well-fitting prosthetic, at the very least. That’s why last fall I voted for legislation that provided the VA with $675,366,000 for medical and prosthetic research and development, specifically for female veterans. Women who have been sexually violated in service deserve resources for recovery. I introduced the PRIVATE Act to crack down on the violations that cause such trauma by protecting troops from nonconsensual sharing of intimate media by other military members. Women who have put their life on the line for others should be supported so that they don’t take their own June 2017 | arizonaphysician.com
life. That’s why I cosponsored the Female Veteran Suicide Prevention Act, which President Obama signed into law in 2016, to require the VA to identify the mental health and suicide prevention programs that are the most effective and result in the best outcomes among at-risk women veterans. Women who have put their lives on the line should be able to access basic gender-specific care. That’s why I cosponsored the Women Veterans Access to Quality Care Act to direct the VA to ensure that all VA medical facilities have the structural characteristics necessary to adequately meet the gender-specific health care needs of veterans at such facilities, including privacy, safety, and dignity. Women who have given their all for our nation should not come back from combat only to sleep on the streets. That’s why I cosponsored the Reduce Homelessness for Female Veterans Act to direct the Department of Housing and Urban Development (HUD) and the VA to oversee a survey of homeless female veterans to study the driving forces behind female veteran homelessness. Above all, women must have access to timely health care. That’s why I’ve worked to improve the Veterans Choice Program to increase access to health care for veterans – especially those in rural areas like Cochise County, by giving them the option of receiving care from non-VA services in their community. These are incremental steps in the right direction, but there is still much work to be done. On mental health, the VA can strengthen their partnership with veteran service organizations that work with veterans suffering mental health issues and survivors of sexual assault. On homelessness, the VA must collaborate with local social service agencies, especially in rural and small communities,
to ensure that female veterans receive vouchers, such as those made available through the HUD-VASH program (for which I have advocated for robust funding), and all the comprehensive services available to them. On access to women’s care, the VA Secretary must hire more female health care professionals and address facility inadequacies to provide the specific health care needs of female VA patients. On Military Sexual Assault, the VA must increase outreach initiatives so veterans are aware of the care they can receive to cope with MST. On the Veterans Choice Program, VA and non-VA female service providers must coordinate to ensure both increased access and continuity of care. I have personally fought to improve treatment of women in the military throughout my entire career – whether it’s a woman’s ability to fight in combat, choose not to wear an abaya, or command a squadron. As Representative for Arizona’s Second Congressional District, I will continue to advocate for women – this time in improved health care treatment so our female heroes receive the care and treatment they deserve. Congresswoman Martha McSally represents Arizona’s 2nd Congressional District in the U.S. House of Representatives, where she serves on the Armed Services and Homeland Security Committees and as the Chairwoman of the Border and Maritime Security Subcommittee. She is a Distinguished Graduate of the U.S. Air Force Academy and was the first woman in our nation’s history to pilot a fighter plane in combat and command a fighter squadron. During her 26-year military career, she served 6 deployments to the Middle East and Afghanistan-flying for 325 combat hours in the A-10-and led oversight of counter-terrorism operations in Africa. She retired in 2010 as a full Colonel.
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ARIZONA PHYSICIAN | June 2017
Are non-opioid therapies more desirable than opioids for chronic pain? BY TRACEY WALKER
pioid medications achieve no better results than non-opioid medications for long-term treatment of chronic back pain and osteoarthritis pain, according to researchers from the Minneapolis VA Health Care System. Findings of the study were presented in April at the SGIM 2017 Annual Meeting, in Washington, D.C., and is said to be the first completed randomized controlled trial of long-term opioid therapy for chronic pain. “This study is pertinent to managed care executives because opioid therapy is widely prescribed and not as effective as non-opioid pain treatment options,” says Erin Krebs, MD, the chief author, who holds appointments at the Center for Chronic Disease Outcomes Research, Minneapolis VA Health Care System. The randomized study of 240 veterans compared opioid therapy versus non-opioid medication therapy over 12 months. Patients treated for back, hip, or knee pain at VA primary care clinics were identified through searches of the electronic medical record and screened by telephone for eligibility. Patients with chronic back pain or hip or knee osteoarthritis pain of at least moderate severity despite analgesic use were eligible. Eligible patients who consented and completed a baseline assessment visit were randomized to either the opioid therapy arm or the non-opioid medication therapy arm.
Multiple medications available on the formulary were included in each arm. Both interventions (opioid therapy and non-opioid therapy) were delivered using a telecare collaborative management model, with pain medication management provided for 12 months; medications were tailored to patient preferences and adjusted within the assigned treatment arm to achieve improvement in pain and individual functional goals. Outcomes were evaluated by masked assessors at three, six, nine, and 12 months after enrollment. The primary outcome was the Brief Pain Inventory (BPI) interference scale, a patient-reported measure of pain interference with function. The BPI severity scale was used to assess pain intensity and a checklist of adverse symptoms was used to evaluate side effects of medication therapy. “We found no significant advantage of opioid therapy compared with non-opioid medication therapy over 12 months,” Krebs says. “More patients treated with non-opioid medications had significant improvement in pain. Patients treated with opioid medications had more medication side effects. In the context of prior studies that have documented higher rates of serious harms among patients receiving opioid therapy, our findings support the recent CDC recommendation that non-opioid therapies are preferred over opioids for chronic pain.” June 2017 | arizonaphysician.com
The study also found: Pain-related interference with function did not differ between opioid and non-opioid medication arms. • Mean BPI-I scores at 12 months did not differ between opioid (3.4) and non-opioid (3.3) arms (P=0.584). • The proportion of patients with clinically important improvement in pain-related functional interference did not differ between opioid (59.0%) and non-opioid (60.7%) arms (P=0.722). Pain intensity improved more in the non-opioid medication arm than in the opioid arm. • Mean BPI-S scores at 12 months were worse in the opioid arm (4.0) than in the non-opioid (3.5) arm (P=0.034) • The proportion of patients with clinically important improvement in pain intensity was lower in the opioid (41.0%) arm than in the non-opioid (53.9%) arm (P =0.007). Patient-reported medication side effects were worse in the opioid arm than in the non-opioid arm. • The mean number of medication-related adverse symptoms was higher in the opioid arm (1.7) than in the non-opioid (0.8) arm (P =0.040). Managed care executives can help by increasing access to and encouraging use of evidence-based chronic pain
therapies, in addition to discouraging overuse of long-term opioid therapy, according to Krebs. “This study used a pharmacist care manager to deliver the effective non-opioid medication management intervention,” she says. “Improving integration of clinical pharmacists into primary care to assist with pain medication management would be an important contribution to improving clinical care.” Based on the study, Krebs offers the following take-aways: • For long-term treatment of chronic back pain and osteoarthritis pain, non-opioid medication therapy is superior to opioid therapy for both pain and side effects. • This study is directly relevant to decisions about starting long-term opioid therapy. This study did not examine treatment options for patients who are already on long-term opioid therapy. • This study used collaborative telecare medication management by a clinical pharmacist in both treatment arms. This model of collaborative telecare medication management is effective in improving pain medication management and highly applicable to managed care settings. • A prior study published in JAMA of this model found that it doubled the rate of pain improvement compared with usual care. Copyrighted 2017. Advanstar. 127887:0617SH
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ARIZONA PHYSICIAN | June 2017
Opioid report highlights dangerous trend in overdose deaths Opioid Ep
2016 report shows opioid death rate as the highest in ten years
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consume s 80 % of th e global op ioid supply
Arizona 4 out of 5
new hero in users st art by misusing prescripti on painkillers
More th an 2 day from Arizonans die ea an opioid overdos ch e Arizona a
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opioid pill prescribe s were d in 2016
someone he Arizona Department of Health Services addicte prescrip t io n painkil d to enough fo (ADHS) today released its latest data on r every Arizonan lers to have opioid overdoses in Arizona showing the 2.5 week a supply highest number of deaths in ten years. In 2016, 790 Arizonans died from opioid overdoses. The trend shows a startling increase of 74 percent over the Drug ove rdoses * past four years. more liv take es than car “Opioids are powerful painkillers that are crashes in Arizona highly addictive,” said Dr. Cara Christ, director In the last of the Arizona Department of Health Services. 5 years, “We know most people using opioids for pain 86% do not intend to become hooked or underof person s who died from an op stand the potential for death.” ioid relate d For more ca us e were usin informat g ion: azheal The 2016 opioid report shows an average multiple th.gov substan ces of more than two Arizonans die each day as the result of an opioid overdose. Over half of the 1,497 drug overdose deaths last year were due to opioids as the primary cause of death. Opioids include heroin as well as prescription medication. The number of from opioid overdoses were analyzed. The 2016 deaths were heroin deaths alone has tripled since 2012. geocoded to identify the location. “This data provides detail on the effects opioids are having on our community,” said Dr. Christ. “This significant Key findings from the report include: increase in deaths is alarming and our response will require everyone in our community working together including • An average of two Arizonans die each day from an opioid doctors, nurses and other healthcare professionals, first overdose. responders, and community members.” • Opioid overdoses and deaths are steadily increasing each For the 2016 Arizona Opioid Report, ADHS linked and year with 2016 showing the highest number of deaths. analyzed vital records data, hospital discharge data, Arizona • In 2016, 790 Arizonans died from an opioid overdose. State Trauma Registry data, and the EMS reporting system. • Heroin deaths have tripled since 2012. Opioid death trends in demographic groups were compared • In the past decade, there were 5,932 people who died from 2006-2016. Historical patterns of encounters at hospifrom opioid-induced causes. tals and with trauma care systems for individuals who died
June 2017 | arizonaphysician.com
• Arizona opioid death rates start to rise in the late teens and peak at age 45-54. • The opioid death rate drops significantly above the age of 65. • There is a significant impact on the healthcare system. Opioid-related hospital encounter rates have increased by 300 percent over the past decade. • Arizonans are requiring more doses of naloxone to reduce opioid overdose deaths. • While the majority of deaths occur in metropolitan areas, rural areas have the greatest challenge in responding to opioid overdoses. “This data shows the opioid epidemic is a significant public health issue,” said Dr. Christ. “State agencies are working with stakeholders to turn the tide by preventing prescription opioid drug abuse through appropriate prescribing practices, expanding access to treatment, especially medication assisted treatment, and reversing
Everyone plays a role in combatting the opioid epidemic: • Help us educate family, friends, and others at risk of overdosing about the importance of naloxone and the critical steps to take if overdose happens. • Talk with your children and convince them to steer clear of drugs and alcohol by staying active with healthy alternatives to drug use. • If you are pregnant or thinking about becoming pregnant, talk with your doctor about the medications you take. • If you suffer from chronic pain, talk with your doctor about non-opioid treatment options for pain management. • If you have a loved one who is misusing or abusing opioids, seek help, and talk with your doctor or
New Reporting of Opioid Overdose and Naloxone Use
ADHS Public Health Emergency: Opioid Overdose Epidemic
Following Governor Ducey’s declaration, an Enhanced Surveillance Advisory has been issued to track opioid morbidity and mortality.
Governor Ducey has declared a state of emergency in response to the opioid abuse epidemic in Arizona. More than two Arizonans die every day due to opioid overdose. As part of the Governor’s emergency declaration, ADHS will be providing recommendations on elements for required enhanced surveillance of opioid overdoses and deaths, and naloxone administration dispensing and reporting.
Required reporting within 24 hours of the items below went into effect June 15, 2017. Required Reporters include the following: • Healthcare professionals licensed under A.R.S. Title 32 & 36, including physicians, are required reporters. • Administrators of a healthcare institution or correctional facility • Medical examiners • Pharmacists • Emergency Medical Services/Ambulance agencies (first response agencies, ground and air ambulance agencies) • Law enforcement officers Health conditions to be reported by healthcare professionals licensed under Titles 32 & 36, including physicians: • Suspected opioid overdoses • Suspected opioid deaths • Neonatal abstinence syndrome Reporting System Required reporters, including physicians, must use MEDSIS, for reporting the above listed health conditions. MEDSIS is the communicable disease reporting system, and it has been amended with new reporting fields. MEDSIS Training is available at www.azhealth.gov/ opioidtraining. Need to set up a MEDSIS account? Contact MedsisHelpDesk@siren.az.gov.
overdoses through naloxone.”
ARIZONA PHYSICIAN | June 2017
There must be a reduction in dangerous opioid use in Arizona. Clinicians are urged to apply the practices in the Arizona Opioid Prescribing Guidelines (Acute/Chronic Pain) or the CDC Guideline for Prescribing Opioids (Chronic Pain). • Consider non-opioid pain treatment alternatives first; opioids are not the first-line therapy for most chronic pain. • If initiating opioids, use the lowest effective dosage and limit initial prescriptions to 7 days (per AHCCCS Policy) or 3 days (per CDC Guidelines). • Check the Arizona Controlled Substances Prescription Monitoring Program prior to prescribing opioids. • Take a detailed medication history. Avoid combined use of opioids and benzodiazepines, and advise patients of the risk of adverse events. • Co-prescribe naloxone to patients at higher risk for overdose, including history of overdose or substance use, opioid dosages ≥50 MME/day (calculate) or concurrent benzodiazepine use. • To help Arizona meet the demand for opioid treatment, clinicians can also consider becoming a buprenorphine –waived provider. An eight-hour buprenorphine training course is required.
pharmacist about prescribing the overdose reversal drug naloxone. You could very well save that loved one’s life. A complete copy of the 2016 Arizona Opioid Report may be found online at http://azhealth.gov/opioid. Information and help are available for substance abuse problems at http://substanceabuse.az.gov.
The award-winning, nationally recognized Arizona Department of Health Services is responsible for leading Arizona’s public health system including responding to disease outbreaks, licensing health and childcare facilities, operating the Arizona State Hospital, and improving the overall health and wellness of all Arizonans.
Resources Arizona’s Declaration of Emergency: https://azgovernor.gov/sites/default/files/related-docs/opioid_declaration.pdf Arizona Clinical Guidelines and References: http://www.azdhs.gov/audiences/clinicians/index.php#clinical-guidelines-and-references-rx-guidelines Online Arizona CME – Safe and Effective Opioid Prescribing while Managing Acute and Chronic Pain: http:// www.vlh.com/AZPrescribing/ CDC Opioid Guide Mobile App: https://www.cdc.gov/drugoverdose/prescribing/app.html Nonopioid Treatments for Chronic Pain: https://www.cdc.gov/drugoverdose/pdf/alternative_treatments-a.pdf AHCCCS Opioid Rx Policy: https://www.azahcccs.gov/shared/Downloads/MedicalPolicyManual/300/310V.pdf Arizona Controlled Substances Prescription Monitoring Program: https://pharmacypmp.az.gov/ Calculating Total Daily Dose of Opioids (CDC): https://www.cdc.gov/drugoverdose/pdf/calculating_total_daily_ dose-a.pdf Buprenorphine Training Course: https://www.samhsa.gov/medication-assisted-treatment/training-resources/buprenorphine-physician-training
June 2017 | arizonaphysician.com
Educating Phoenix VA Health Care System Physicians BY LAURA TEMPLEMAN; DANIEL BLACKMAN PA U L CO U PA U D, E d D ; S H A K A I B R E HM A N , M D
ARIZONA PHYSICIAN | June 2017
ealth Care Systems within the Department of Veteran Affairs (VA) have a culture of encouraging employees to engage in continuous learning and professional development to accomplish the VA mission of providing the highest quality care to our Veterans. Many of the medical issues our Veterans face are not as common throughout the vast majority of the American population; hence our continuing medical education (CME) is geared toward Veterans’ issues to help prepare medical professionals to provide more effective care for Veterans. The Phoenix VA Health Care System (PVAHCS) has a main campus in downtown Phoenix and has ten Community Based Outpatient Clinics (CBOCs) located throughout central Arizona with the purpose of providing care to Veterans closest to where they live. We serve more than 90,000 unique Veterans, and in the past year delivered more than 1 million outpatient appointments. PVAHCS offers outstanding educational programs enabling physicians and other health care professionals in providing superior medical care. PVAHCS has a distinguished history of teaching physicians, nurses and other allied health professionals the latest, most advanced medical and surgical practices. We strongly believe that the needs of the Veteran come first. Therefore, we are committed to developing and maintaining distinguished educational activities to enhance and enrich medical knowledge and improve high quality care to our Veterans. The PVAHCS CME program focuses on dissemination of latest research knowledge, which ensures that clinicians are equipped with the most timely and relevant information available. We also offer sessions on laws and policies affecting our Veterans and physicians. For example, CME grand rounds were offered on recently passed laws related to the Veterans Choice Program. PVAHCS has a dedicated CME program to promote continuous improvement in patient health care by providing physicians and other health care professionals with high
quality, evidence-based educational activities. With the overall goal of improving physician knowledge and competency and enhancing performance in practice, the PVAHCS began providing continuing medical education in 2008 for our providers. The CME program started out small – with just one program for Primary Care Providers – but has now grown to seven programs. Our current focus areas now consist of Primary Care, Psychiatry/Mental Health, Patient Safety and Quality Improvement, Neurology/Traumatic Brain Injury, Tumor Board, Designated Women’s Health, and Pain Management. These programs are live courses, but also offer audio and video streaming as well as Lync online broadcast for those who cannot attend in person. There are up to 112 live activities offered throughout the year. In 2016, PVAHCS was proud to grant 74 CME credits to a total of 1,281 physicians and 652 other learners. In 2015, 1,168 physicians and 642 other learners earned a total of 63 hours of CME credits. PVAHCS offers thousands of Veteran-focused, accredited CME training opportunities at no cost to PVAHCS physicians through its web-based Talent Management System (TMS), which is accessible to all physicians 24/7 from anywhere in the world. We also provide reimbursement for physicians to attend the national, cutting-edge CME conferences and other expenses for continuing professional education. The PVAHCS CME program has achieved the Accreditation with Commendation, the highest level of recognition offered by the Arizona Medical Association (ArMA). Laura Templeman is Co-chair and Coordinator of the PVAHCS CME program (and is also a Training Specialist); Daniel Blackman is Designated Learning Officer (served in US Army); Paul Coupaud, EdD, is Chief of the Communication Department (served in US Air Force); and Shakaib Rehman, MD, is Associate Chief of Staff for Education and chair of the PVAHCS CME program.
Below is a breakdown of our seven live CME programs: 1
2 3 4 5 6 7
Primary Care CME Grand Rounds: 1st and 3rd Wednesday of the month from 8 to 9 a.m. The Primary Care CME Grand Rounds is also broadcast to clinicians at the Northern Arizona VA Health Care System. Psychiatry / Mental Health: 1st Wednesday of the month from 8 to 9 a.m. Patient Safety/Quality Improvement: 4th Thursday of the month, from 12 to 1 p.m. Neurology/TBI: 2nd Friday of the month, 8 to 9 a.m. Tumor Board Conference: 2nd and 4th Friday of the month, 7:30-9 a.m. Designated Women’s Health Program: 4th Wednesday of month, 8 to 9 a.m. Pain Management Programs: a. Pain Lectures, 8 to 9 a.m. 2nd Tuesday of month b. Pain Champions from 8 to 9 a.m. the 3rd Friday of month c. Pain Management, a 4-hour quarterly lecture on specified dates June 2017 | arizonaphysician.com
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The world of the heart:
THOUGHTS ON C ARDIOLOGY AND C ARING FOR ARIZONAâ€™S VETER ANS WITH
David Biglari, DO BY DOMINIQUE PERKINS Article Photos by Denny Collins Photography
April 2017 | arizonaphysician.com
r. David Biglari dwells in the world of the heart – both literally and figuratively. As a cardiologist for the Phoenix Veterans Affairs Health Care System (PVAHCS), he spends his time caring for Arizona’s service men and women returned from active duty, giving back for their acts of selfless service.
Admiration for sophisticated machines When David Biglari was only 11 years old, his family experienced a scare when his mother was diagnosed with an inoperable coronary artery disease. Later, it was decided she did not actually have the disease, but it was this experience that Biglari said planted the earliest seeds of his interest in medicine. His interest continued throughout his early school years, with human physiology particularly capturing his attention in high school biology classes. “I was always mostly fascinated by the human machinery and how each part worked in concert with others,” he said. “And as long as each part did its job well, things rolled smoothly as a whole, just like any other sophisticated machines.” He completed his undergraduate and graduate studies at the University of California, Los Angeles, graduating with a Master of Science, and PhD in neuroscience. He attended medical school at Midwestern University, in Glendale, Arizona. After graduating, he moved to Henry Ford, Michigan, where he began a residency in neurological surgery. However, one year into the program, Biglari decided to switch his specialty focus to cardiology, and he returned to Arizona to complete his internship and residency at the University College of Medicine - Phoenix. He also completed several fellowship training programs in Phoenix – in Cardiovascular medicine, and interventional cardiology.
VA from the start Aside from the year spent in Michigan in neurosurgery, Biglari settled immediately into practice in Arizona. Currently, he is a complex cardiac interventionalist and co-director of the cardiac rehab center at the PVAHCS. “My skillset involves performing minimally invasive, percutaneous cardiac, peripheral and structural heart procedures,” he said. He and his team have helped develop the cardiac interventional program, which is set to go live later this year. Aside from his clinical and administrative duties, he is also involved in teaching and training medical students, interns, residents, and fellows in the field of cardiology. Biglari was drawn to a career with the VA after getting acquainted with the patient population during his training, and is honored to feel such genuine care for those he works with and cares for. “I did 50% of my training at VA medical centers,” he said. “It is a privilege to serve those who served us. Joining the military is a selfless act and those who answer this calling, truly put themselves and their families in harm’s way.” By serving them, Biglari feels as though he is “giving back” to a group who have given so much. When he first joined the PVAHCS cardiology program there was a 24
ARIZONA PHYSICIAN | June 2017
particular need for his specialty – percutaneous cardiac complex procedures. And he has had a home ever since.
The best care With much public and political debate over the options available to veterans when it comes to medical care, several topics are at the forefront, one being whether veterans should have access to care at institutions other than VA hospitals and clinics, while still maintaining their VA coverage and services. Biglari believes that veterans deserve the best medical care money can buy, and feels that those fighting on both sides of the argument share that view – it’s just a difference of opinion in how to carry it out. “In my opinion and experience from both VA and the private sector, our Veterans get the best care through the VA network,” Biglari said. The coherent and comprehensive care network of the VA is not matched in any other system, he believes. And, while certainly most any doctor has the well-being and best interest of their patient in mind, Biglari asserts that those who work at VA medical centers have a deep-rooted belief in their mission, and are truly devoted to serving those veterans in need. Dr. Mills and his wife, Dena, enjoying a desert hike. Frequently veterans have occasion to access healthcare on both sides – necessitating coordination between the VA
and non-VA providers. “I think the VA does everything in their power to have coordinated care with the private health care sector in times when Veterans are referred for care,” Biglari said. “I cannot say with certainty this is reciprocated by the private sector.” In his own experience working across systems, Biglari noticed there are often delays in communication – transferring medical records and health summaries. While certainly no system is perfect – all have issues and shortcomings – in the end everyone needs to do what they can to contribute to quality veteran care. “What matters is how we as a society come together to improve health care delivery for all Americans,” he said. Of course the best care for veterans is not limited to treating physical ailments. With the prevalence of post-traumatic stress disorder (PTSD) present in those returning from active duty, it is more important than ever for veteran care facilities and systems to have robust and effective mental health branches. Fortunately, increased research as well as recent world-wide awareness campaigns have pushed for a more open and accepting discourse concerning mental health. Biglari is confident in the VA’s dedication to the prevention, identification, and treatment of mental diseases. While the field of care does not fall within his specialty – which he described as “the world of the heart” – Biglari has seen this emphasis evident since the early days of his training.
“In the last two-three years, I have seen a tremendous surge of efforts in this arena,” he said. “Numerous psychiatrists have come on board, the overhaul to the hotline call system, and the rapid acute care within the Emergency Department and outreach programs for Veterans with mental health needs,” were some efforts he listed. These changes signify one of many positive approaches the VA system takes to ensure top quality veteran care. Biglari describes continuous efforts to improve and expand in all areas, even including parking. “State of the art technologies are made available for the providers to enable them to provide the latest proven diagnostics and therapies,” he said. “The direct example of this is the program we have been building to create one of the most advanced cardiac intervention laboratories in the VA system, and Arizona.” Another way the VA is working to expand care is by utilizing technology to provide more home-based, and telemedicine approaches. In fact, Biglari says these are cornerstones for some major conditions that we treat. “My heart failure patients certainly benefit from these services and often request for extending them out,” he said. The VA has long been a pioneer in expanding care outside the walls of a clinic or hospital. In Phoenix, the VA has a mobile medical unit (MMU) fully outfitted with state-of the-art equipment and mobile exam rooms, ensuring that June 2017 | arizonaphysician.com
distance will not interfere with care. In addition to more standard mobile medical equipment, the MMU is also stocked with multiple tablet computers, so that veterans seeking care in the mobile unit can connect for sessions and evaluations with providers based in the VA in Phoenix at any time.
Challenges Certainly every healthcare system, large or small, faces challenges. The VA has challenges unique to their calling, and does not face some of the same barriers as other institutions. For one thing, the VA does not have quotas to meet, or other financial obligations or incentives. “Our main goal is only to provide the best of care for individual patients based on their needs through the latest evidence-based medical science,” Biglari said. With less pressure, Biglari feels blessed to spend more time with each of his patients, listening to their stories, and ensuring they are well taken care of. This is fortunate, since he lists the biggest challenge for veteran care as sorting through the fragmented care path the veterans have followed in and out of VA, private, and community service systems – systems that don’t always do the best job communicating with one another. Healthcare throughout America has been crippled by interoperability issues between health records systems. Differences in systems across fields makes record sharing, transfer, and tracking a constant struggle.
While Biglari has experienced the frustration of waiting for records, he says this is not really an issue of care. Caring for veterans, wherever they receive their care (whether VA or Department of Defense or the private sector) is still a priority. He describes the differing electronic record struggles as society’s issue to solve. Another issue society is grappling with is homelessness, especially among veterans. “Caring for the homeless in any system is always more challenging, as it is more rewarding,” Biglari said. The main challenge for healthcare with those experiencing homelessness is a lack of routine follow-ups, and a compliance with medications and other therapies. The challenge of caring for homeless vets is no different, although Biglari says the VA in fact has solid support structures in place to help with compliance and follow-ups for vets experiencing homelessness, essentially ensuring they get the care they need. Dominique Perkins is the Associate Managing Editor for Arizona Physician and serves as the Communications Coordinator for the Maricopa County Medical Society.
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ARIZONA PHYSICIAN | June 2017
On the personal side.. Dr. Biglari, his wife Ciara, and their son enjoying the Arizona outdoors.
1. Describe yourself in one word. Determined.
5. Best movie you’ve seen in the ten years? The Departed
2. What is your favorite food, and favorite restaurant in the Valley? We enjoy exploring around the state for restaurants new to us. We are always on the hunt for hole-in-the-wall places where one can find the best foods and secret recipes of every town and city hidden away.
6. Favorite Arizona sports team (college or pro)? The Cardinals (preferably the Kurt Warner’s Cardinals).
3. What career would you be doing if you weren’t a physician? I truly enjoy what I do day in and day out. I have no doubt it was my calling to be a healer of the hearts. If for some reason I were held back from doing this, I probably would end up as a producer or sound engineer. 4. What’s a hidden talent that you have that most wouldn’t know about you? I was in a Rock band when in high school, long hair and everything. I played the Bass guitar. I am a die-hard fan of Pink Floyd, Dire Straits and Jethro Tull bands. My adolescent and early adulthood really were shaped partly by influences from these bands.
7. Favorite activity outside of medicine? Spending time with my family is the most joyous activity for me. We love going to cities all across AZ and exploring. We love driving up to our favorite city, Jerome, and spending the day. When not with the family, I love riding my bicycle across the wide-open spaces of the Valley, exploring record stores and antique shops for treasure hunting. 8. Family? My wife Ciara, and I met in medical school, she graciously gave up a very successful practice to care for our family. We love living in AZ and raising our family.
June 2017 | arizonaphysician.com
The Mohty family enjoying the program
Drs. Cynthia Stoddington, Robert Dixon, Tanja Gunsberger, and Lee Ann Kelley mingling before the program
On Thursday, May 18, MCMS members gathered in the Society courtyard for an energetic discussion on some of the most pressing health law concerns facing today’s physicians. The Health Law Forum was the first of its kind hosted by the Society, and we look forward to many more. MCMS members submitted questions in advance to a panel of several of Arizona’s leading health law experts. Robert J. Milligan, JD, LLM, shareholder in Milligan Lawless, P.C., served as moderator, and also lent his voice of experience to several of the questions. We’re very grateful to our panelists, Anne Ronan, JD, from the Arizona Center for Law in the Public Interest; Susan N. Goodman, RN, JD, partner at Mesch, Clark, & Rothschild; and Paul Giancola, JD, partner at Snell & Wilmer. And, of course, a huge thank you to our long-time partner, MICA, for sponsoring the event. Mild May temperatures held steady, and the weather was perfect. Guests enjoyed drinks and delicacies provided by Tasteful Event Serving. Denny Collins photographed the evening. Please visit the Society Facebook page for the full album, and be sure to keep an eye open for future events E VENT PHOTOS BY DENNY COLLINS PHOTOGR APHY
Panelists responded to questions submitted by guests in advance, as well as live questions during the program
Drs. Robert Orford and Michael Mills listening to the discussion
Dr. John Middaugh
Questions covered topics such as liability, hipaa, licensing, pre-authorization, and other concerns.
Physicians Who Have Served: What They Think of Veteran Health Care BY SHARLA HOOPER
s we use this edition to review aspects of veterans’ health care, we sought physician perspectives and opinions of the Veterans’ Administration (VA) health care system. We thank everyone who participated in the survey and provided comments, which were invaluable in shedding light on the experience of training, delivering, and receiving care with the VA system. For this write up, we focused on comments provided by physicians who have either received and given care within the VA system.
Training at the VA Those who received training at the VA consistently appreciated working with the veteran population. “I have thoroughly enjoyed my time working at the VA and truly appreciate the opportunity to work with our nation’s veterans,” wrote Katie Marsh, a medical student. Anita Murcko, MD, shared, “Important parts of my training took place at VAs. It was at a VA that I first felt respect and independence as a physician. There is no private or academic setting that matches the VA experience.” But training in the VA also shed a light on the complexities and inadequacies encountered within the system. One respondent wrote that while they did not work in Arizona VA facilities, “[I] did train in VA facilities during medical school and residency. There I witnessed care which ranged from heroic to substandard, often in the same institution.” Dr. Steven Beck shares, “I have personal experience with the VA health care system as a medical student and resident in the 80’s and early 90’s. I’m also a USAF active duty veteran. Anyone who has experience working within the VA system knows it’s been broken for a very long time. Although there are many excellent, devoted people working within the VA system, there are also those who would have been dismissed years ago if in the private sector (including general staff, administrators and providers). Our veterans deserve much better. The system needs to be cleaned out, overhauled and vets given access to care outside the VA system whenever necessary.”
Private practice and community care of veterans Accessing care outside of the VA was facilitated several years ago through legislation establishing the Veterans Choice Program, which allows veterans to seek alternative 30
ARIZONA PHYSICIAN | May 2017
care if they live more than 40 miles from the closest VA facility. A number of respondents saw value in this system and its ability to counter inadequacies in the VA system related to access. Dr. Elizabeth McConnell points out that “The care is slow. There are few specialists. Access to excellent mental health programs is limited. Overall the VA is considered an excellent source of health care but accessing the system is difficult…I’m a big supporter of the VA and support improving its role in health care of all citizens most importantly those who serve our country.” Christian Risser, MD, wrote, “The number of vets and the volume of services they need has far exceeded the physician staffing at VA facilities for years. The consequence has been and still is long waits for appointments and care, especially in the specialties and sub specialties…I believe that [Veterans Choice Program] should be expanded to allow veterans free choice of available providers even within 50 miles of VA facilities. As a retired Air Force flight surgeon of 28 years, I was offended by my local facility’s referring of my fellow veterans to one favored group to the exclusion of myself and other qualified providers. I believe that I and my fellow veterans deserve free choice of providers through the TRICARE program.” Geography is an important factor for veterans living in the rural communities of Arizona. As Dr. Ron Clark describes, “Yuma county has large veteran population that is logistically too far away from Tucson or PHX to be required to travel and should have direct access to Tri-care participating physicians.” Dr. George Griggs pointed out that while certain types of care related to combat are best provided by the VA, other care can be more effectively provided in the private sector, “After 20 years as a USAF physician and 21 years as staff physician at two different teaching VA hospitals I have strong feelings about the importance of VA hospitals… [however] Private care should be an option for those living at a great distance. Women’s health issues, particularly OB and many GYN problems could be more effectively treated in the private sector. Most of those issues would not be service connected. Combat-related PTSD should be managed by the VA not the private sector.” This is reiterated by Anthony Yeung, MD, “I have successfully treated veterans referred to me by the VA. The
June 2017 | arizonaphysician.com
What restrictions should exist for veterans accessing VA health benefits?
Those who served in combat
5.9% Not sure
All veterans who served (other than dishonorable discharge)
Those diagnosed with a service-connected disability
How should the VA allocate future investment? Allocate funding to purchase outside care (non-VA providers) Balance investments in its own clinical operations with outside care Only allocate funding to improve existing clinical operations Not sure
21.6% 61.8% 8.8% 7.8%
Which provisions of the SAV Act best ensure veterans access to mental health services?
None of these
57.4% Creating a centralized website
18.8% Not sure
Program review by 3rd party investigators
Collaboration with non-profit mental health organizations
VA does not have the expertise to treat all the conditions they are mandated to treat. Physicians and surgeons known by the VA or Tri-care will get excellent care through direct referral to independent private providers with good track records who continue to distinguish themselves in the community.” However, the coordination of care between private practice and the VA system can be complicated. One respondent shared that, “As an outpatient private practitioner, I no longer work at the VA. Unfortunately, I see too many patients who complain of difficulty being seen in a timely manner at the VA and who also express frustration regarding the quality of care they receive. I also have a patient that moved from Tucson and still has physicians at that VA. If he wants to keep the physicians he likes, he has to stay at that VA, which means that he has to get bloodwork drawn there. I’ve had difficulty getting tests done while he is off steroids because he can’t get down there during those times.” One respondent made the argument to in fact consolidate federal health care systems like Medicare and the VA. “The United States already has an infrastructure to care for two populations: Veterans and Seniors on Medicare…Why not turn this into a true federally-funded entity? Send all Vets and Medicare recipients to VA hospitals and, instead of closing and reorganization VA catchment centers, rebuild the infrastructure and enlarge it. Then, the Medicare patient, whose funding is paid by taxpayers, would still have the same care, funded by taxpayers--but cared for by VA physicians,” offers Jay Crutchfield, MD.
Veteran health issues While it is common to see media coverage of combat-related health issues in veterans, several respondents identified the concern for preventable health issues due to cultural aspects of armed service. Leland Fairbanks, MD, shares that, “In all my early clinical training experience at VA Hospitals and later working relationships with VA Hospital Doctors & nurses at Phoenix VA Medical Center, I was struck with the distressingly large number of Veterans who were heavily addicted smokers, and Heavy Drinkers after discharged from military duty where smoking was a virtual expected part of their culture. There were many cases of alcoholic liver disease, and frequent bleeding gastric ulcers. Most older Veterans were on oxygen tanks to breathe because of COPD, Heart disease and many cases of lung cancer…” Dr. Fairbanks argues that a “way has to be found to remove the tobacco disease promoting culture from the US Uniformed Services and Veterans to reduce the huge extra tobacco disease treatment load and related extra costs burden placed on the understaffed VA Medical Centers.” Other physicians corroborate this as part of their own training experience. Thirty years ago, “The majority of illnesses were alcohol and tobacco related and inflicted illnesses. Aside from the dopamine driving effects of these substances, which are addictive, this is really a bio-psychological issue of PTSD,” observed John Couvaras, MD.
Quality of care for veterans While roadblocks remain to accessing care, a number of survey respondents stated their confidence in the actual care provided within the VA system. Dr. Rekha Shah reports, “I was working as Volunteer clinical physician in GI dept and the care provided in the dept was excellent.” Dr. Charles Gannon, states, “When I worked at the Tucson
VA hospital I found the quality of medical care was quite good. Generally, the knowledge and motivation of the medical professionals and supplementary personal were very good.” A veteran and provider, Dr. Fred Kogan states, “The physicians & nurses are extremely dedicated. The big problem is within administration and the remuneration they receive for meeting their goals.” Several other respondents reiterated this concern for the role of administration and oversight of the VA system. Writes one, “VA provides excellent care. Providers are excellent. Typically, administration and bureaucracy impair Veteran care as well as provider hiring and retention. This is the problem. Administrators are totally out of touch with patient care.” Dr. Andrew Kaplan argues, “Government employees cannot be held to accountability and standards the way private sector employees can.” Teresa Pavese, MD, writes in more detail of administration inadequacies, “VA facilities are infamous for cutting corners, brief, less than adequate screening exams with less qualified subordinate ancillary care providers, cutting back on diagnostic testing and implanting appropriate treatment in a timely fashion. When surgery is needed, long wait lists are involved sometimes postponing medically urgent needed surgery until it is too little and too late.” Additionally, there is some concern about undermining the leadership role of physicians within the VA system. Charles Otto, MD, a veteran, writes, “The recent attempts by the VA system to lessen the oversight of health care delivery by physicians is disturbing. For our veterans to receive quality health care it is necessary that the providers with the most education and training remain in charge of that care. This is especially true in the high acuity setting of in-hospital and emergency care. The operating room is not the place to reduce physician input to acute care as in the recent proposal (fortunately withdrawn) to allow nurse anesthetists to practice independently.”
Have you ever trained or practiced at a VA hospital or clinic?
Sharla Hooper is the Managing Editor for Arizona Physician and serves as Associate Vice President of Communications and Accreditation for the Arizona Medical Association.
Are you a veteran?
Does improved access for women veterans come from VA leadership or Congress?
10.9% 5% 8.9% VA leadership
Congressional action External veteran groups working with the VA
VA health information technology Several respondents pointed to the innovative and up-to-date electronic medical record system used within the VA. Hamad Abbaszadegan, MD, writes, “The Phoenix VA is the capital of the health information technology innovation world. It is sad that the cloud of wishing failure from our media blinds the eyes of seeing the truth.” Elizabeth McConnell, MD, describes the effectiveness and potential of the VA EMR system. “Online focused monthly questionnaires of veterans that require direct interaction of the veteran with computers that screen the answers and direct the patient for concerning issues may be the best use of computer technology. In my own [external] practice, I have found the health records created by the present EMR system available to be poor at best but there exists an opportunity for the VA to make the government’s EMR which is the best in the United States and upgrade it use the internet as a resource for the veterans to input more detailed information about themselves. Update that information with the monthly questionnaires and allow not only access but use of that EMR to the private sector physicians and hospitals. This would save everyone a lot of money and could potentially be used by all U.S. citizens.”
A combination of all three
Should veterans be able to seek covered treatment outside of dedicated VA facilities?
Should Congress require the DoD and VA to integrate their EHRs?
SURE June 2017 | NOT arizonaphysician.com
The Arizona Par Partnership tnership for Immunization Celebrates 25 Years of Significant Impact BY J O E Y R O B E R T PA R K S
ARIZONA PHYSICIAN | June 2017
he Arizona Partnership for Immunization (TAPI) and its many partners have had in the last 25 years, keeping Arizonans healthy and safe from vaccinepreventable diseases, is astounding.
Major measles Between 1989 and 1991, the United States experienced a major outbreak of measles which mostly affected preschool-aged children. The U.S. Center for Disease Control and Prevention (CDC) encouraged all 50 states to develop strategies to immunize 90% of American children up to two-years-old by 2000. In October 1991, the Arizona Department of Health Services (ADHS) developed an ambitious infant immunization plan. That plan became The Arizona Partnership for Infant Immunization (TAPII) in 1992. Only 43% of Arizona’s two-year-olds were fully immunized in 1993 against preventable childhood diseases like measles, mumps, polio, and whooping cough. Thanks in large part to Arizona physicians, it’s now over 90%.
Instrumental individuals To advance childhood immunizations in Arizona, Betty Bumpers, the First Lady of Arkansas, gained the support of Ann Symington, the First Lady of Arizona. Mrs. Symington served as the Honorary TAPII Chair and worked as a member of the coalition in its early years. The president of the America Medical Association (AMA) and the first CEO of the Phoenix Children’s Hospital, Dr. Dan Cloud, a retired pediatric surgeon was recruited as Chair of the TAPI Steering Committee in 1992. ADHS and TAPI reached out to the Arizona community and a partnership across the state was developed, including: State and County Public Health Departments, professional organizations, managed care plans, community health centers, hospitals, hospitals, HMOs, nonprofit community health and social service agencies, fire departments, medical organizations (like the Arizona Academy of Pediatrics, Arizona Medical Association, Arizona Osteopathic Medical Association and Arizona Association of Family Practice), pharmaceutical companies, businesses, media (such as The Arizona Republic and Arizona Broadcasters Association), businesses (such as Bank One and McDonalds), daycare centers, Head Start programs, the Junior League, the Urban League, the Phoenix Suns, and even the faith community. As Douglas Hirano, MPH noted in the 1998 American Journal of Preventive Medicine, “TAPII has been a successful public and private partnership for a number of reasons: private sector participation, a single and measurable goal, vision and leadership, a strong emphasis on assessment, a broad-based membership, community ownership, Governor’s Office participation, health plan involvement, and full-time project staffing.”
Awesome accomplishments An immunization registry, the Arizona State Immunization Information System (ASIIS), was established with the support of the medical community and the
leadership of First Lady Symington and public policy guru David Landrith. Arizona physicians rely on ASIIS to determine the vaccines a child needs and to help keep families up-to-date on age-appropriate vaccinations. As technology became integrated into medical practices, TAPI recognized the need to educate people who worked in physician offices and clinics. Training on Immunization Practices (TIPS), an education and training program, was created for medical office staff throughout the state. This year, TIPS training kicked off on May 23 in Phoenix. Registration is available at www.TAPI.org. WhyImmunize.org was established by TAPI to assist physicians and their patients when questions arise about the value of vaccines. The website provides medical and scientifically valid information about the risks and benefits of vaccines, and includes free resources and education material for medical professionals and community partners. Last year, over 100,000 items were distributed throughout Arizona and beyond. And TAPI has developed a reputation as an innovator. When the rules for publically funded vaccines became more restrictive and TAPI noted that insured patients were having difficulty finding a place to receive vaccines, a new project was launched to bill for vaccines provided by county health departments. The reimbursements (above staffing costs) are returned to county health departments and are used to support vaccine safety net programs throughout Arizona.
Doctors and community commitment make a difference After Dr. Cloud passed away in the summer of 2010, TAPI looked for another physician known in the community and they found Dr. A.D. Jacobson a willing successor to Dan Cloud. Physician leadership was critical because of all the partners TAPI works with. “It’s been a great volunteer opportunity,” said Dr. Jacobson. “Other than a few people like Executive Director Debbie McCune Davis and Program Director, Jennifer Tinney, everyone on the board is a volunteer. Probably another hero of the group, actually, is Jim McPherson.” Jim McPherson is a champion of raising awareness in the community. “I’ve been a cheerleader, and also a nag. A nudge in some ways,” he said. This pays off in big ways, “because in the past four or five years, ADHS created a map of the percentage of students exempted from getting immunizations for religious or personal reasons. If a large percentage of a school isn’t immunized, the other students could contract a disease because of the unimmunized students. That’s called ‘herd immunity.’ As a society, we protect each other because 90 to 95% of us are immunized.” “A lot of the success of TAPI is that it’s a partnership,” said Dr. Dan Aspery, a longtime member of TAPI’s Steering Committee. Dr. Aspery is a family physician by training and Vice President of Health Services and Medical Director for Blue Cross and Blue Shield of Arizona for 19 years. He’s extremely well acquainted with immunization and understands their importance. He’s also a community leader who June 2017 | arizonaphysician.com
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gets the information out with real enthusiasm and passion. “I was asked by Jim McPherson to help with TAPI,” said Dr. Aspery. “I knew Jim from Utah where he was doing public relations for FHP Health Care and I was one of the Medical Directors. The value of immunizations is tremendous. It’s protective. It’s one of the best things we can do preventive-wise.” “Meningitis is probably the most significant disease that everyone knows about for kids attending college and living in dorms. HPV is another. Until a few years ago HPV wasn’t prioritized and our state’s coverage rate was pretty dismal. We need to focus on the teenage population into the mid-twenties.”
Big improvements. Big awards. TAPI has established a tradition of recognizing innovation and excellence. The Arizona Big Shot Awards are handed out in April of each year to people who’ve done outstanding work to promote health and vaccines. TAPI honors healthcare providers who demonstrate a high level of excellence immunizing their patients. The Daniel T. Cloud, MD Outstanding Practice Infant Award acknowledges providers and practices who have 90% of their two-year-old’s up to date with a full array of vaccines. Also, the Daniel T. Cloud, MD Outstanding Practice Teen Award celebrates physicians and practices who’ve shown that their 12- and 13-year-old patients are fully immunized with the three recommended adolescent vaccines. The CDC honors a Childhood Immunization Champion. This year Jim McPherson was honored at the dinner on April 19 and given the Immunization Champion award by the Centers for Disease Control and Prevention for his 25 years of dedication to the cause.
Physicians are key to the whole delivery system. It’s important that physicians, in their offices, continue to maintain that relationship with parents and their children to provide that preventive care they need. They’re the ones who translate the immunization schedule and explain it to parents. The fact that the physicians in this Arizona community are the ones who stepped up to address the immunization problem says a whole lot. Medical leadership has been key to moving the solution to this problem forward. “I think what the future holds for TAPI,” said Dr. Aspery, “is to continually add partners to TAPI to move immunization rates up, because they’ve stagnated a little bit. Part of it is funding and part of it is increasing our exposure, also focusing even more on adolescents and adults, so they are not at the bottom of the pile.” “The physician community was there from the very beginning,” said TAPI Executive Director McCune Davis. “Even before TAPI was a real thing, they’ve always made sure Arizona families have access to disease preventing health care strategies. That’s really the point of TAPI’s 25th Anniversary. It’s celebrating our community leaders who step up to protect our community. The voice of physicians make a difference. They took on the responsibility and took ownership of this project to make a real positive difference in the health of all Arizonans.” That’s a pretty amazing thing.
Tapi and today’s challenges
Jim Goodwin - Owner
Arizona still has diseases outbreaks we shouldn’t see. Like measles and mumps. “We shouldn’t see that, but we do,” said Dr. Jacobson. “You get in to certain populations where people are uninformed about vaccines. There are pockets of people who spread what they hear and come to think that immunizations are bad.” “There were a lot of reasons the immunization percentage increased dramatically in Arizona when TAPI came into play,” said Dr. Jacobson. “TAPI was able to provide providers many useful tools they could use to communicate the benefits of immunizations. For example, talking points on immunization hesitancy. “There was a small study done in 1998,” said Dr. Aspery, “and it was published in The Lancet, the British equivalent of The New England Journal of Medicine, where a British physician reported that immunizations cause autism. The study was eventually retracted, but the damage was done. The horse had left the stable.” The false news frightened parents, and though debunked, continues to spread through social media. Physicians spend a lot of time reassuring parents about the safety of vaccines.
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June 2017 | arizonaphysician.com
Backpack Buddies BHHS Legacy Foundation and Legacy Connection join with other community organizations to bring essential items to Arizona’s high-need children. BY KAREN WERNER
n Arizona, one in every four children lives in poverty, severely impacting their ability to learn and succeed in school. Legacy Connection helps to break that cycle by giving thousands of students in the state the opportunity to start the school year with confidence. Legacy Connection collaborates with local organizations to support a wide range of programs, providing thousands of Arizona children with the essentials they need, but that their families can’t afford. One such program is Back-to-School Clothing Drive’s “New Clothes, New Beginnings” distribution, a one-stop shopping oasis that takes place each July. There, more than 10,000 elementary schoolchildren from low-income families from dozens of Arizona schools receive everything from a new backpack filled with school supplies to new shoes, clothes, books and dental care – all the necessities to start the new school year with self-esteem. This year’s event will take place July 17 to 20 at Grand Canyon University Arena. The event traces its roots to 1967, when the Salt River flooded and washed out many of the migrant camps along the riverbank. A group of women supported by “The Order of True Sisters” and other Phoenix agencies banded together to raise money to create handmade back-to-school clothes for the children of the migrant families. Fifty years later, Back-to-School Clothing Drive still strives to provide for students from Phoenix and its surrounding areas. Students who participate come from families living at or below the poverty level. So for many of these kids, these are the first new clothes and shoes they’ve ever owned. “It’s like Christmas in July for these children,” said Jerry Wissink, president and CEO of BHHS Legacy Foundation and Legacy Connection. “By providing this assistance for them, they’ll be able to go back to school and not worry about how they look. That will help them concentrate on what they really need to be concentrating on – and that’s learning.” “Many of the kids don’t know what to expect when they get here, and when they do and they realize it’s all for them, you can see their faces light up,” said Karl Gentles, Back-toSchool Clothing Drive’s executive director. “That’s a big deal for these kids that literally don’t have a lot to start with. The impact we’re making on the individual child is immense.” The impact is not limited to Maricopa County. On July 19, at Mohave High School in Bullhead City, the Mohave Valley Clothe-a-Child Foundation will present the Tri-State 38
ARIZONA PHYSICIAN | June 2017
Legacy Backpack Buddies “Dress Kids for Success” event for Bullhead City, Mohave Valley and Topock elementary school students. The organization will hold a second event on August 9 for Laughlin, Nevada and Needles, California elementary school students, as well as all area Head Start students. All told, these events serve up to 3,000 kids. Legacy Connection also supports the Assistance League of Phoenix Operation School Bell Delivering Dreams Bus, a
Two Ways to Help 1) Donate Money – and BHHS Legacy Foundation will Double it! You can help Arizona kids start school with confidence, and help them pursue their dreams and contribute to our shared future, by making a donation to Legacy Connection. An $80 contribution to Legacy Connection provides $400 worth of clothing and supplies to a child in need. And donations to Legacy Connection programs are matched by BHHS Legacy Foundation, which means a $400 gift becomes $800, which goes directly to clothing an Arizona child in need. Plus, when you give to Legacy Connection, you can take advantage of the Arizona Charitable Organization Tax Credit. A $400 contribution to Legacy Connection means decreasing your Arizona tax bill – or increasing your refund – by $400. Your gift ends up costing you nothing! And your donation – plus BHHS Legacy Foundation’s matching funds – will benefit the programs Legacy serves. Visit bhhslegacy.org or call 602-778-1200 to donate today. By making a gift, you’re not only transforming a child’s life, you’re strengthening Arizona’s future. 2) Donate Services Back-to-School Clothing Drive relies on more than 2,000 volunteers to make the “New Clothes, New Beginnings” event happen for the 5,000 students who will be onsite at various times during the week of July 17. Volunteers are needed for every aspect of the event, including stuffing backpacks, registering and welcoming students, and escorting students through each department as a Personal Shopper. If you’re interested in volunteering, visit backtoschoolclothingdrive.com/volunteer for information and to choose a volunteer time slot.
mobile dressing center stocked with shoes, clothes, books, school supplies and hygiene kits. The bus travels across the Valley to schools with a high percentage of children living in poverty, outfitting thousands of kids in need. “We buy all new clothes, nothing used,” said Linda Killmer, board treasurer of Assistance League of Phoenix. “When the experience is over they literally float and hop off the bus with smiles on their faces, they’re so happy.” The Delivering Dreams Bus is the only one of its kind out of 120 Assistance League chapters throughout the country. It is on the road from Tuesday to Friday every week that schools are open, serving more than 80 schools during a school year. And everything is provided to the children for free. “It’s not just clothes. It’s self-esteem. It’s confidence. It’s feeling like everybody else on campus,” said Adria Renke, president of Loyola Academy and Brophy College Preparatory. “This is a whole new me for these kids.” Thanks to the partnership with BHHS Legacy Foundation, the Assistance League of Phoenix has been able to increase the number of children the Delivering Dreams Bus serves. “We couldn’t do what we do without the partnership with Legacy, but even still, we’re reaching just a fraction of the children who need the help,” said Brenda Sperduti, Assistance League of Phoenix CEO. In addition to these program, Legacy Connection supports the Student Attire for Education (SAFE) Program, which allows elementary schools and human-service organizations to buy new clothing and more from an online store at affordable prices. It also provides backpacks for the WeekEnd Hunger Backpack Program, which provides non-perishable food and snacks on Fridays to kids affected by chronic hunger, so they can eat at home on the weekend and return to school on Monday nourished and ready to learn. Through programs like these, Legacy Connection makes a real impact on the lives of Arizona children. But none of it would be possible without the support of generous donors. BHHS Legacy Foundation CEO Jerry Wissink calls a gift today an investment in tomorrow, saying, “If we can take care of quality of life for these families and their children, they’ll grow up and be successful, and be able to support themselves going forward.”
About BHHS Legacy Foundation BHHS Legacy Foundation and Legacy Connection share a joint mission to enhance the quality of life and health of those they serve. They do this by funding grants to healthrelated nonprofits, nurturing collaborative partnerships, and raising funds through Legacy Connection for grant funding to support community organizations that work to promote good health. Both Legacy Foundation and Legacy Connection work in the Greater Phoenix area and the northern Tri-State region, including Bullhead City, Fort Mohave and Topock in Arizona, as well as Laughlin, Nevada, and Needles, California, to bring about long-lasting improvements to the safety and success of children, families and seniors, as well as the communities where they live. To learn more about BHHS Legacy Foundation, visit bhhslegacy.org.
June 2017 | arizonaphysician.com
Spreading Out, Serving More BY MICHELLE MCQUILKIN
s an Arizona native who grew up in a military family, the care of our veterans holds a special place within my heart. My grandfather lived in the Arizona State Veterans home right next to the Arizona Veterans Affairs Hospital, and I spent a lot of time there as an adolescent. When my grandfather spent time in the VA Hospital, I saw his experience through the eyes of a family member. This is something I took for granted at the time, as I had no idea I would one day be caring for patients in the same hospital. Now, I am beginning my fourth year of medical school. I have had the honor to complete two of my third year clerkship rotations at the Phoenix VA hospital. During my time I saw an interprofessional team of medical providers who worked towards a common goal of serving those who have served us. If I could identify an area of improvement, it would be to expand the Phoenix VA medical system. Each day the clinic schedules were full, sometimes that meant we would stay late just to squeeze in another patient that needed to be seen. However, there was not enough time in the day to see everyone. In short, we have a large veteran patient population here in the Valley with not enough resources and individuals to provide timely care. There are some changes coming to the VA hospital in the near future. In particular, the primary care outpatient clinics currently located in the hospital are to be moved to a different site. There are already some primary care and specialty clinics located off of the main campus. I worked at one of the satellite clinics during my psychiatry rotation. This small clinic offered multiple specialties all in one location to serve the local community. I would suggest establishing these clinics in more locations throughout The Valley, as it would bring primary care back to the community. By establishing more of these satellite clinics we can make care more accessible to veterans. In time, I believe the expansion of community clinics will help the underlying problem that the VA faces. However, this change cannot help those in need currently. Until an expansion is implemented, it is prudent that we provide our veterans with an alternative option for care. I propose that the VA medical system opens an application for local providers to apply to care for veterans through the VA, but see patients at their current office; offer a competitive payment system for providers; and provide a VA employed medical scribe that is familiar with the VA electronic medical record. The medical scribe would help document the patient interactions to decrease the burden on a provider to learn a new system. In time, we will make the Veteranâ€™s Affairs Medical System operate to meet the needs of our current and future veterans. As a medical community we will work to serve those that have served our country. Michelle McQuilkin is an Arizona native who grew up in Chandler, Arizona. As a first generation college student she attended Arizona State University and obtained a Bachelor of Science in Biochemistry. While working as a medical assistant during college, Michelle found that her passion was in serving others through direct patient care and was accepted to the University of Arizona College of Medicine Phoenix. While both of Michelleâ€™s older brothers served overseas in Iraq, she partnered with the Chandler Service Club to send over 80 Christmas stockings to soldiers who were in the hospital in 2007. Currently, Michelle is in her fourth year of medical school and is busy planning her wedding for next spring to a local veteran she met in chemistry class during her freshman year at ASU.
ARIZONA PHYSICIAN | June 2017
PCMH Program Delivers Healthier Patients and Happier Providers BY JAMES NAPOLI, MD, MMM, CPE
roviding high-quality care is multifaceted and requires everyone in the healthcare field to think differently. At Blue Cross Blue Shield of Arizona, we are committed to finding approaches that will enhance the patient experience while reducing the cost of healthcare. We believe it’s important to harness new models of primary care, such as Patient-Centered Medical Homes (PCMH), to make healthcare better for all Arizonans. In fact, we’ve been helping physicians evolve their practices to a value-based setting for several years and we are seeing a difference in the outcomes. Patients are healthier and more engaged, and practices are becoming more productive and efficient.
The PCMH model The BCBSAZ PCMH program embraces a pay-for-performance model, emphasizing evidence-based quality care and documented outcomes. When we launched our PCMH program in 2011, we focused on four chronic conditions. We have since expanded it to include the big six – asthma, diabetes, congestive heart failure, chronic obstructive pulmonary disorder, hypertension and coronary artery disease. As a provider, it’s important to manage the total patient by addressing condition management, social and behavioral
health, and maintaining a healthy and productive lifestyle. BCBSAZ collaborates with our PCPs through our care management program that helps patients with complex conditions navigate through the medical system and achieve their personal health goals. Those are the types of outcomes we all want. But this level of care requires a commitment from you. Patients with chronic conditions often require more time than normally allotted for a routine office visit. By providing financial incentives that reward best clinical practice, BCBSAZ enables patients to have better access to providers and gives providers the flexibility to spend extra time with patients, when appropriate and needed to manage the patient’s overall condition. At BCBSAZ, we agree you should have those resources. We provide access to a BCBSAZ care manager to help in managing patients with very complex conditions. We also share best practices throughout Arizona to make offices highly organized while using evidence-based care standards, ensuring adequate access to care and delivering coordinated services. We use analytic tools to track these conditions and share the data with providers to help align their practice with our population health management goals. (See sidebar for more registry details.) June 2017 | arizonaphysician.com
BCBSAZ Resources for PCMH Participants
Registry to record data on chronic disease care plans – A web-based registry allows PCPs to easily record data related to each of the chronic disease care plans. Training on the PCMH system – All PCPs and their staffs can learn how to use the PCMH registry system. Progress reports – To assist the PCP in measuring their progress, the program includes reporting tools. Care Manager assistance – PCPs have access to the no-cost services of a dedicated BCBSAZ care manager to help in managing complex patients. Incentive payments – At the conclusion of the one-year reporting period, PCPs may be eligible for incentive payments based upon achievement of goals as outlined in the care plans.
Numbers don’t lie Nearly 1,400 primary care physicians and almost 500 mid-level providers throughout the state have signed on to BCBSAZ’s PCMH program. That covers more than 215,000 of our members, including more than 46,000 with a chronic illness. We started with a focus on patients needing help in managing a chronic condition, but we’re working with providers to enhance care coordination for all patients. That’s because patients can benefit from the program even if they don’t have a chronic condition. In fact, according to the latest data comparing PCMH to non-PCMH practices, utilizing the difference-in-differences statistical methodology, over a two-year period, PCMH patients experience: • 31.3 percent fewer ambulatory-sensitive hospital admissions • 25 percent fewer ER visits • 12 percent fewer hospitalizations • 8.3 percent greater generic dispensing rate It’s not just patients who are happy, either. Providers in the program have expressed their pleasure with the quality interactions they have with their patients. They are focused on providing exceptional care and seeing the results in many of their patients’ health. “Since joining the BCBSAZ PCMH program, we seem to be more thorough as a team in checking necessary criteria, covering specific patient education items and meeting minimum standards on a very reliable basis,” says PCMH participant Marv L. Erickson, M.D. “Our office practice has also become more predictable at following up on items and following through with specific required tasks.”
Helping providers succeed The benefits of the PCMH model are clear. Still, some hesitation to participate is understandable. After all, we’re talking about a shift in the medical practice operations. That’s why at BCBSAZ, we emphasize collaboration and have a team dedicated to helping our providers succeed. 42
ARIZONA PHYSICIAN | June 2017
That begins by meeting each individual practice where it is. Then we use baseline data to set incremental goals. At the conclusion of the reporting period, PCPs may be eligible for incentive payments based upon achievement of the goals that are outlined in the care plans. We seek ongoing feedback and engage with our providers regularly, and if practices need more help, we ascertain why and assist them. Best of all, we’ve found that as we continue to raise the bar, our PCMH physicians successfully meet the targets and earn their incentives. We consider the PCP key to care delivery, but we’re not stopping with primary care. We also understand that complex patients require specialized care, so we’ve developed a specialist PCMH program for OB/GYNs. To date, we have more than 300 providers in this program. Healthcare is in the midst of a transformation. There’s no denying that. And it’s a shift that requires innovation and teamwork to allow providers to better serve their patients and insurers to better serve their members. Indeed, moving our industry forward and advancing the mission of quality care compels us to work together. Let’s start now.
Join the PCMH program At BCBSAZ, we are committed to working with providers who are share our vision for patient-focused care. To learn more about our commitment to move health forward and our PCMH program, call 602-864-4360. As the Senior Medical Director, Provider Partnership & Care Transformation for Blue Cross Blue Shield of Arizona (BCBSAZ), Dr. James Napoli leads a team focused on provider collaboration to create innovative models designed to advance healthcare quality, improve the health status of members, and improve care efficiency. He is Board Certified in Internal Medicine with over a decade of clinical experience in hospital medicine and physician leadership roles. Dr. Napoli holds a Masters of Medical Management degree from University of Southern California, a Doctor of Allopathic Medicine degree from Medical College of Ohio and a bachelor’s degree from The Ohio State University.
Arizona Physician (USPS 020-150) is published 12 times per year. It is a combined publication of the Arizona Medical Association, Maricopa County Medical Society, and Pima County Medical Society, 326 E Coronado Rd., Phoenix, AZ 85004. Periodicals postage paid at Phoenix, AZ. Postmaster, send changes to: Arizona Physician, 326 E Coronado Rd., Phoenix, AZ 85004. No part of this magazine may be reproduced or transmitted in any form or by any means without written permission by the publisher. All rights reserved. Volume 1, Issue 6
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June 2017 | arizonaphysician.com
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ARIZONA PHYSICIAN | June 2017
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Published on Jul 10, 2017