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

May 2017

Are You Getting Paid?

Physician reimbursement feedback pg. 30 Understanding the business: a conversation with

Michael Mills, MD pg. 23


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VOLUME 1, ISSUE 5 EDITOR-IN-CHIEF JAY CONYERS, PhD

jconyers@arizonaphysician.com

MANAGING EDITOR SHARLA HOOPER

shooper@arizonaphysician.com

ASSOCIATE MANAGING EDITOR DOMINIQUE PERKINS dperkins@arizonaphysician.com

PHOTOGRAPHY DENNY COLLINS

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LAYOUT & PRINTING PRISMA

Contents Physician Profile

Understanding the business side, trusting experts, and advocating for more control are keys to fuller reimbursements. A conversation of payment advice with Michael Mills, MD.

www.prismagraphic.com

ADVERTISING

information@arizonaphysician.com

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 12 30

Everything Doctors Need to Know About Bundled Payments Are You Getting Paid? Physician Reimbursement Feedback

15 40

Getting Paid is Complicated Dual MD & MBA Degrees Offer Medical Students Practical Industry Skills

In This Issue 4 What’s Inside

19 Legal: The Physician Employer

6 President’s Page

28 Event Photos: Physician Leadership Conference

8 Policy: Changing How We Pay 10 Congressional Corner with Kyrsten Sinema

34 Public Health Opinion: Systems solutions 42 Business: Policy Dividends May 2017 | arizonaphysician.com

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What’s Inside THE COMPLEXITY OF PHYSICIAN COMPENSATION

Jay Conyers, PhD

It’s very hard to practice medicine when you can’t control the prices you charge and can’t relate them to the cost of doing business. Ronald Feldman, MD

I

recently stumbled upon this quote by a gastroenterologist practicing in sunny Southern California. It’s poignant and sobering, and truly sums up the problem physicians face today. It hits on perhaps the most common concern physicians have – that someone else in the healthcare system determines how and when they get paid, and how much. Gone are the glory days of getting reimbursed exactly – or close thereto – for what a physician believes is the value of the care he or she delivers to a patient. The complexity of physician compensation has been consistently ratcheted up in recent decades, most notably with the ongoing migration away from a throughput model to one focused on value-based care. The physician piece of the ‘healthcare pie’ steadily dwindles year after year, and there doesn’t seem to be much that they can do to stop it. At least not if they choose to play in the sandbox where hospitals and third-party payers call the shots. Despite the roadblocks physicians face in today’s marketplace, more than half feel that they are fairly compensated. Sure, it’s hard to argue with the notion that physicians are well paid, with average annual compensation exceeding $200,000. However, it doesn’t mean it isn’t getting more and more difficult to actually get paid. The hoops physicians jump through these days to get reimbursed for care delivered reminds me of the experiments a colleague of mine conducted in his lab during my tenure as a research professor at a medical school in Texas. Dr. Pramod Dash was a collaborator of mine, a world-renowned neurobiologist who studies neuroprotection and cognitive function in rats with traumatic brain injury (TBI). My lab was trying to develop nanoparticle-based free radical scavengers, and we thought that perhaps our therapeutic agents would penetrate the blood brain barrier (BBB) and help mitigate inflammation and free radical damage.

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Dr. Dash’s setup would subject the rats to a water maze with a food reward, and the complexity of the maze was altered with varying degrees of injury and treatment. Rats subjected to a piston-driven cortical impact injury with no neuroprotective agent administered found the food less often than treated rats. They got progressively confused and disoriented, even more so as the force of the piston was increased. Those with protective agents, such as valproate, fared better and completed the water maze at a higher clip. It was an elegant experiment that clearly showed how protective agents could lessen the neurodegenerative effects of brain injury. Our healthcare system certainly is a maze. In this maze, physicians encounter the twin pistons of regulation and insurance policy. You can stretch the metaphor further and equate the business team with the neuroprotective agents. The people who assist physician practices with billing, coding, credentialing, collections, health plan enrollment, prior authorization, and the list goes on… Truth be told, no one is making it easier for physicians to get paid, and only those who adroitly navigate the changes are doing anything more than treading water (no offense to the rats). Unless you and/or your office staff keep up, you’re losing ground, as it seems a new regulation that cuts into reimbursement is always on the horizon. As Norm, the lovable bar adornment from the sitcom Cheers, once said, “It’s a dog eat dog world, and I’m wearing milkbone underwear.” Despite the challenges physicians face in getting paid for care delivered, not many people will sympathize with them. Unfortunately, the average American likely thinks physicians make good money and have little to no worries There’s an age-old argument that physicians have it made, at least financially. They live by the “work hard, play


congresswoman from the 9th Congressional District, and her thoughts on how potential changes to the ACA might impact our state’s residents. Our public health corner this month comes to you from Dr. Jonathan Weisbuch, who shares with us his concerns about our state’s health systems. For our feature articles, we bring you an overview of bundled payments, written by Lisa Erano, and an assessment of the complexities of reimbursement, authored by Arizona MGMA President and healthcare consultant Dr. Diane Brennan. We also have an article from MICA looking at its history of dividend payments and reducing liability premiums over the years. Lastly, we share with you an overview of the University of Arizona School of Medicine’s joint MD/MBA program for medical students interested in learning more about the business side of medicine. While the Tucson campus has been offering such a program since 2000, the Phoenix campus will begin offering the new joint degree this summer. Other typical content in this issue includes the monthly member survey and our physician profile. For the latter, we sat down with Dr. Michael Mills, physician executive director of Arizona Digestive Health’s Digestive Institute and clinical assistant professor at Banner University Medical Center, and asked him about compensation and reimbursement issues facing physicians today. We hope you enjoy learning more about Dr. Mills and his views of the payment landscape. Next month, we focus on our veterans, and look at ways we can improve their access to care. Undoubtedly, veterans have experienced considerable hardships trying to get adequate care at VA hospitals across the nation, and perhaps none more so than the local Phoenix VA hospital. We look at the issues they face, and how our physicians can contribute to the care they need. With that, enjoy this issue, and look for us again next month! Jay Conyers, PhD, is the Editor-in-Chief for Arizona Physician and serves as Executive Director of the Maricopa County Medical Society. *No rats were harmed during the writing of this article. **For those interested in seeing the full comparison of compensation, please visit http://www.bestmedicaldegrees.com/salary-of-doctors/.

Comments on Pay

hard” mantra, many say, and enjoy lavish vacations, homes, and toys that typical people can only dream about. Is there any truth to this? Of course there is, but it’s not to the extent that most people would think. For example, you’d be hard pressed to find someone who truly believes a high school teacher makes more than a physician, but I read a comparison** recently that equated the time and money invested by a physician throughout his lifetime, and compared it to that of a teacher. Adding up the hours spent completing a bachelor’s degree, medical school, and residency, an average physician spends 41,760 hours training for their profession. With most finishing residency around age 29 and working until they’re 65, it means a physician spends 36 years working, yet they work an average of 59.6 hours per week. As for the cost, most physicians finish their training with significant student loan debt, with numbers approaching $100,000 for undergrad and $200,000 for medical school. While exceptions exist, they pay off their loans similar to most Americans, making payments over a 10- to 20-year period. In the aforementioned analysis, this equated to a cost of $687,360 for someone to become a doctor, accounting for typical interest on $300,000 in student loans over a 20-year repayment period. So what about earnings? Using the average physician salary of $202,948, a typical doctor makes $5,410,428 over the course of their lifetime. Backing out the loan debt from training, earnings come in at $4,723,068 for a typical physician. A high school teacher, on the other hand, will earn $2,372,392 when combining salary and a typical education pension and backing out $186,072 in student loan debt. Not many people would be surprised to see that an average physician makes roughly $2 million more than an average high school teacher over the course of their professional lifetime. Where the analysis gets interesting is when earnings are normalized to hours worked. A typical high school teacher invests 6,400 hours training for their profession and works 65,360 hours over the course of their lifetime. Given their average lifetime earnings, this comes out to an hourly rate of $33.06. A physician, on the other hand, puts in 102,989 hours over the course of their career, and another 40,000 just getting to that point. Despite the roughly $2 million gap in lifetime earnings, a physician takes home an average of $33.03 per hour of work. If these numbers are correct, a typical high school teacher will make three cents more per hour than a physician. It’s an interesting analysis, but I don’t recommend trying to debate someone on the premise that a doctor makes less than a teacher. But still, compensation for physicians is as complex a subject as is particle physics. So what’s in this issue? For our policy corner, we have a great article penned by Dr. Jason Fodeman, former Pima County Medical Society member and current faculty member at the Drexel School of Medicine in Philadelphia. He looks at how more consideration should be given to reimbursing physicians for non face-to-face work. Our congressional corner features Rep. Kyrsten Sinema, Arizona

Look for quotes from our survey respondents throughout this May issue of Arizona Physician Magazine.

May 2017 | arizonaphysician.com

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President’s Page ARE YOU GET TING PAID?

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his magazine is devoted to various issues of physician compensation, which is a bit open-ended. But there is only one health plan proviso: Any new pay system can’t work if it’s built on an assumption that payers should fork over more cash for medical services. The healthcare system is already straining under high costs. I reiterate my position from my February article: the allocations to doctors relative to big pharma costs, hospitals, and long-term care have been steadily decreasing. This shrinkage in our share of the pie has led so many to come up with more creative ways to create efficiencies in healthcare delivery. As I am fond of saying, physicians are not the tail but the head – and yet we are somehow forced into this vice of cost containments, as if we are the abusers of the system! We are the deciders, not simply providers of healthcare. Without us deciding what is necessary for patient care, how is the system to run? The addition of midlevel providers in droves will not fill the gap. And, recently, it seems filling the gap is not the goal – rather, it is blurring the distinction between physicians and midlevels, thus equalizing payment for Relative Value Units (RVUs). I’m not against all providers getting paid, I just believe that we are being misled in where to seek out the inefficiencies. “Fee-for-service pays you for doing as much as possible,” Robert Doherty, from the American College of Physicians (ACP), said in 2007. “Capitation pays for doing as little as possible. And pay-for-performance skews to what can be measured.”1 Well, not all that is important in healthcare today can be measured. In 2013, the National Commission on Physician Payment Reform presented their findings to Congress, recommending that fee-for-service be eliminated due to problematic financial incentives, or at least weakened as the primary compensation model by adding supplementary quality metrics.2 The emergence of value-based-reimbursement – encapsulated in legislation like the Medicare Access and CHIP Reauthorization Act (MACRA) – requires the rewards and 6

ARIZONA PHYSICIAN | May 2017

John L Couvaras, MD

penalties of physicians for performance on quality and patient satisfaction scores. Medicare programs incentivize physicians to manage the risk of certain populations, or accept bundled payments for targeted procedures, rather than paying in the traditional way. Examples include the Comprehensive End-Stage Renal Disease Care Model, and the Medicare Shared Savings Program. To participate, hospitals and physician groups have developed provider networks, in some cases Accountable Care Organizations (ACOs), to make sure their patients have access to coordinated services. Alternative Payment Models (APMs) have been exploding in popularity, according to the Centers for Medicare & Medicaid Services (CMS). The Next Generation ACO Model provides doctors even more risk and rewards than under the Medicare Shared Savings Program. Still yet to arrive is MACRA, whose implementation was delayed until 2018. MACRA establishes two new payment tracks for physicians treating patients holding government-sponsored insurance: Clinicians in Advanced Alternative Payment Models can earn annual bonuses of 5%, but these are risk-based models. The majority of physicians will participate in the Merit-Based Incentive Payment System. On that track, physicians can earn plus or minus 4% of reimbursement in 2019, 5% in 2020, 7% in 2021, and 9% in 2022. In all of these pilot programs there is a belief that we are in this healthcare cost debacle due to misaligned incentives, and all the creative effort is focused on addressing this issue. But, as I mentioned at the beginning, the medical economic pie is out of proportion, and this should be the first consideration. The hospital and pharma lobbyists have blocked any meaningful legislation to limit such egregious disproportions. Pharmaceutical costs in the U.S. are multiples of those in other countries for the same medications. There has been no negotiation with CMS on big Pharma charges with regards to Medicare. Hospitals have rounded up the wagons, creating Physician-Hospital Organizations (PHOs) and ultimately positioning themselves to divide the economic pie through narrow network ACOs. The big medical insurance


Comments on Pay

companies, (UHC, Aetna, Humana, and the Blues, etc) are positioned not to take the risk of insurance, but act as a Third-Party Administrator (TPA). Over 50% of commercial plans in the U.S. are only managing/administrating the plans, but taking 18% or more of the premiums. Their ability to rewrite the plan benefits to reduce fees to the physicians increases profits to them and their shareholders. It is this “big business” aspect of medicine with companies and shareholders that is largely responsible for the costliness of healthcare in the U.S. Our country and government are so dedicated to promoting capitalism that corporations have been protected as “persons,” given “corporate personhood” to provide them the same rights and protections as a living person. Big hospital corporations or pharmaceutical companies are protected by this “personhood.” Any attempt to correct the misappropriation of medical payments to such corporations has been blocked, leaving only physicians and other providers to be the scapegoat for expensive healthcare. The administrative costs to the TPAs will equal, if not exceed the amount paid to physicians and other providers. This is wrong. This is immoral. This is the truth. Do you physicians know where you keep your latest draft of your in-network contract? I can assure you that when you call, they will not readily provide it. You should renegotiate your contract fee schedule often, and only agree to resign the new schedule if it is advantageous. Work with other professional negotiators, align with larger physician groups. Make sure your fee schedule is audited, comprehensive, and reflects the procedures you are currently doing. If not, a default code and reimbursement will apply. I am limited in what I can say or reveal, given the specific language in the contracts. As most of us know, we are not allowed to discuss our fees as this would be considered Antitrust. From this position, many of us have signed contracts which prohibit us from discussing almost the entire contract contents! How are we to get paid when we have no ability to discuss and understand what is meaningful? Even as we struggle to get paid for our efforts, it feels like

Medicine is not, nor will it ever be, an exact science. Accounting for the intangibles is going to be most problematic.

we have been reduced to panhandling, or picking up loose change to make up for the reductions in what we are paid. I hope this issue of Arizona Physician is helpful to many of you, and implore those of you who are not yet members to join the Maricopa or Pima County Medical Society, and the Arizona Medical Association. We all want to get paid well and on time for our efforts. We do agree that there are inefficiencies in the delivery of healthcare, but that physicians are the only ones best-suited to identify them or to create new means of finding and applying cures and therapies. I leave you with this last thought – in the words of Benjamin Franklin: “We must, indeed, all hang together, or most assuredly we shall all hang separately,” a wise investment for our state. John Couvaras, MD, FACOG, is the president of the Maricopa County Medical Society, and is board-certified in OB/GYN and reproductive endocrinology. He is the founder of IVF Phoenix, and has been providing fertility treatment services in the Valley for more than 25 years. Dr. Couvaras previously served as the Director of Reproductive Endocrinology and assisted reproductive medicine, and chairman of the department of obstetrics/gynecology at Paradise Valley Hospital. References 1. https://www.managedcaremag.com/archives/2007/12/ how-doctors-are-paid-now-and-why-it-has-change 2. http://physicianpaymentcommission.org/report/375:44-53

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Policy Corner CHANGING HOW WE PAY DOCTORS IS KEY

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s they were heading out the door, the Obama Administration decided to scrap a plan to change how Medicare reimburses physicians for administering drugs in their offices. CMS ultimately made the right decision as the changes would have jeopardized patient care and access to life-saving medicines. While patients are protected from this latest round of price controls, the perverse incentives of Medicare’s reimbursement system are still pervasive with the brunt being passed along to patients in the form of misutilization of resources, restricted access, lengthy wait times, and compromised care. One policy that has produced an array of unintended consequences is that Medicare has historically refused to reimburse physicians for non-face-to-face care.

While patients are protected from this latest round of price controls, the perverse incentives of Medicare’s reimbursement system are still pervasive with the brunt being passed along to patients in the form of misutilization of resources, restricted access, lengthy wait times, and compromised care. 8

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Jason Fodeman

Non-face-to-face work is an integral part of medicine and is particularly important for primary care doctors such as myself. It includes activities such as speaking with patients on the phone, emailing patients, following up lab results, talking with families, coordinating care, consulting with specialists, refilling prescriptions, and completing paperwork. Primary care physicians (PCPs) spend a considerable amount of time on these tasks. Research in The Annals of Family Medicine concluded that PCPs spend 39% of their work day outside the exam room working on patient related activities. A study in The Annals of Internal of Medicine discovered that every thirty-minute visit generated 6.7 minutes of additional work. These activities are essential to a well-functioning, patient-centered health care system. While lawyers, consultants, and accountants would get paid for this type of work, historically, physicians have not. Ironically, this policy designed to save money can have some costly implications for patients and taxpayers. It means some of these important non-face-to-face activities do not happen as they should or as patients would like. It also means when they do occur, they may happen at a higher, more costly setting than medically necessary. For example, this policy likely pushes conversations such as a follow up of lab results or follow up of symptoms that could occur over the phone or by email into an office visit. For patients this means they must take time off from work to go to the doctor. This wastes time on travel to and from the doctor’s office, waiting, and the length of the visit, which decrease worker productivity. It also takes away a valuable appointment slot from a patient who needs to be seen in person. At the same time, this policy likely pushes care that requires urgent subspecialty input that could be managed in the outpatient setting via phone consultation with a specialist or at an urgent specialist visit to the Emergency room. Research I coauthored, in the American Journal of Medicine explored non-face-to-face medical care and recommended three potential solutions. One possibility would be the creation of Current Procedural Terminology codes for


reimbursement and the unintended consequences it has for patients. The reimbursement of non-face-to-face work would be a good place to start. Jason D. Fodeman, MD, MBA is a practicing primary care physician. He specializes in delivery systems and health policy. Article originally appeared on The Daily Caller, dailycaller.com, January 25, 2017. References http://dailycaller.com/2017/01/25/changing-how-we-pay-doctors-iskey-to-fixing-our-healthcare-system/#ixzz4fII694O7

Comments on Pay

e-mail and telephone encounters. Another would be to let doctors bill insurers for the time devoted to non-face-to-face care. A third option would be to determine the average time per month that a doctor dedicates to each patient outside of the exam room and assign this a per-patient monthly value. The latter would likely be the simplest to implement while the second option would better meet the unique individual needs of patients. In recent years, CMS has dabbled in reimbursing physicians for non-face-to-face care, but its overly regulated, complex, and stringent approach has limited use and benefit. Reimbursing doctors for work that they do outside of the exam room is good medicine. It would lead to an increase of email and telephone encounters. This would decrease unnecessary trips to the doctor and eliminate visits that could be handled in other ways. It would also reserve office visits for those who truly need to be seen in person. This would improve patient access and more efficiently use resources. It would also foster a health care system that would be more satisfying for doctors and patients. It would likely attract more young doctors to primary care and also help to alleviate the primary care physician shortage. It could even save the taxpayers money. Medicare’s recent decision to drop the reimbursement changes was a win for patients. Hopefully, the new administration will look to reform the faulty physician

I am concerned that compensation models other than salary with annual reviews, which look broadly at how a physician is performing, will be skewed to drive the wrong care.

May 2017 | arizonaphysician.com

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Congressional Corner U.S. CONGRESSWOMAN KYRSTEN SINEMA

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s I travel around Arizona, I hear almost daily from families, seniors, and businesses about the uncertainty surrounding health care. Unfortunately, partisan gridlock in Washington currently prevents an honest, fact-based discussion from occurring. The Affordable Care Act (ACA) has been a mixed bag for Arizonans. On the upside, kids can stay on their parents’ plans until they’re 26, Medicaid expansion provides coverage to millions of hardworking low-income individuals who were previously uninsured, and individuals with pre-existing conditions can buy insurance at more reasonable rates. Uncompensated care has decreased, allowing greater stability and investment in health care for Arizonans in both urban and rural areas. Medical reimbursements and payments are now more closely aligned with health outcomes. On the downside, too many people are struggling to find affordable coverage and provider networks that provide adequate choices. Costs continue to rise and options for Arizonans in the individual market are insufficient and expensive. Our exchange isn’t working well. Instability in health markets creates uncertainty and pain for both families and businesses. Burdensome regulations create unnecessary challenges for small and large medical practices alike. Thoughtful fixes must be made, but a full repeal of the ACA without a reasonable replacement would be devastating for many Arizona families and for our state’s economy. The attempt by this House of Representatives to repeal and replace the ACA, the American Health Care Act (AHCA), is not reasonable and actually made the law worse for Arizona. After studying the text and analysis of the AHCA, I could not support it. It adds financial burdens to our state’s economy. It denies coverage and makes health care more expensive for too many Arizonans. Health care reform should control costs and improve quality and access to care for hardworking Arizona families. Under this plan, too many Arizonans, especially older Arizonans, lose coverage, or face higher premiums or 10

ARIZONA PHYSICIAN | May 2017

deductibles with less financial support for plans that cover less. The bill’s Medicaid repeal costs Arizona billions in health care funding and puts a multi-billion dollar hole in our state’s budget. This results in fewer working Arizonans, children, and seniors getting affordable coverage and increased costs for Arizona hospitals, families, and taxpayers. There are real challenges in health care that need to be fixed, but this bill makes the situation worse. Congress needs to stop and start over. Today, the AHCA stands before the Senate, where Senators have wisely said they will draft their own bill because of the AHCA’s irreconcilable flaws. Republican Senators have vastly different ideas of what health reform should look like, and outreach to Democrats remains nonexistent. It is unclear if Senate Republicans can coalesce around one bill, and if that bill, which will likely be significantly different to the AHCA, could pass the House. For healthcare reform to last, both sides must put partisanship aside and have a serious debate about America’s healthcare system – so we can keep what’s working and fix what isn’t. There are actions Congress and the federal government can take to stabilize the market. First, the administration should make clear that cost sharing reduction payments will remain in effect so Arizonans can afford the plans on offer. Second, Congress should examine allowing older Americans in the individual market to buy into Medicare Advantage plans, and provide effective financial or plan design incentives to encourage more eligible young people to enroll in individual market plans. Third, Arizona should explore waiver authority under the ACA to create a high risk reinsurance program that better manages the risks and costs within the individual market.


Each of these ideas, and many others, if considered in an open, honest, and transparent way, would lower premiums, increase stability, expand options, and could receive bipartisan support. We have had some important success. In 2015, my legislation, the PACE Act, introduced with Congressman Brett Guthrie (KY-02), to protect small and mid-size businesses from increased regulations and potential health premium increases was signed into law. We introduced and passed the PACE Act to maintain the current definition of the small group market and ensure stability for employers and employees. Our bill was signed into law before the scheduled change, allowing employees to keep their health insurance plans. Another area where we have bipartisan support is our work to repeal the Health Insurance Tax (HIT) – a burdensome tax that increases the cost of health insurance for seniors, families, employers, and employees. I introduced this legislation in the House last Congress, and we successfully won a one-year delay. I introduced our bill again this year with Congresswoman Kristi Noem (SD-AL), and we have received strong support from both sides of the aisle. I have sponsored legislation called the “Lower Drug Costs through Competition Act” to increase competition in the prescription drug market by encouraging the development of generics. I support increasing Graduate Medical

Education slots and reducing the crushing medical debt deterring individuals from entering medicine or practicing in underserved areas across our state. I will also continue to advocate for simplifying the frequently counterproductive reporting requirements that keep providers from spending more time with patients, and let doctors and patients make decisions that are in the best interest of patients. As other proposals come before Congress, I will support reforms that expand consumer choice, increase the quality of care and access to care, control costs, and strengthen the doctor-patient relationship. There is absolutely no reason that so many conversations in Washington have a partisan overtone. We know that that there are never just two perspectives; there are dozens. I will continue to focus on where we agree, and on finding new, effective ways to solve problems. This approach is more important now than ever before – especially as we address serious challenges like making health care affordable and accessible for Americans. Representative Kyrsten Sinema serves Arizona’s Ninth Congressional District and has been to appointed to House Committee on Financial Services. She served in the Arizona State House for six years and the State Senate for one year. She has earned her Master’s in Social Work, law degree and PhD from Arizona State University.

HEALING HANDS. BIG HEARTS.

Big Thanks.

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

May 2017 | arizonaphysician.com

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Everything doctors need to know about bundled payments

BY LISA A. ERAMO, MA

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any independent primary care physicians already work hard to coordinate care effectively; but, are they ready to further strengthen these efforts and work even more collaboratively with hospitals to improve outcomes? Doing so could bring additional reimbursement and a path to satisfy Medicare reimbursement reform requirements – but at what cost? And can physicians take small steps toward bundled payments before diving in completely? The decision requires an understanding of bundled payments and the opportunities they present for primary care physicians. This information, in turn, makes it easier to determine whether it makes financial sense to pursue a bundled payment arrangement with CMS in the future. The payment may cover inpatient care as well as pertinent outpatient services rendered for a defined period post-discharge. Think of it as an umbrella payment for an entire episode beginning with the acute event (e.g., hospitalization) and ending at a defined point in the patient’s recovery. CMS uses historical claims data to set a target price for each episode. When the total cost of care for the episode

falls below that amount, the risk-bearing entity receives the difference and can share the savings with the providers who helped coordinate care and contain costs during the episode. These providers, known as gainsharers, usually include independent physicians. When the cost of care exceeds the target amount, the risk-bearing entity alone repays the difference to CMS. Consider the example of a patient with congestive heart failure who is admitted to a hospital participating in a bundled payment arrangement with CMS. Upon discharge, an internal medicine physician sees the patient for three follow-up visits over a 90-day period. If the physician is in a gainsharing arrangement with the hospital, he or she could realize an additional $162.20 for this episode when savings are generated. That’s 50% of the fee schedule amount for the CPT codes that are reported. Gainsharing arrangements reward physicians for doing what they do best, which is keeping patients healthy, says Win Whitcomb, MD, MHM, chief medical officer at Remedy Partners, a firm that assists physicians and hospitals May 2017 | arizonaphysician.com

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participating in bundled payment programs. “This is what they do every day – prevention and management of chronic illness,” he notes.

1. Are local employer groups or payers moving toward

How to get experience with bundled payments

2. Might a gainsharing arrangement help strengthen the

If a physician already has a relationship with one or more hospitals participating in a bundled payment program, then it makes sense to establish a formal gainsharing arrangement with those entities. This legally binding agreement sets forth payment stipulations, including the percentage of additional reimbursement that physicians can expect when savings are generated. Gainsharing is not permitted outside of CMS bundled payment programs unless contractual agreements comply with Stark laws, the Anti-Kickback Statute and other requirements, says Whitcomb. Also, the CMS programs require that measurable quality of care is maintained or improved at the individual episode level before savings can be shared. Aside from the financial advantages, there are additional benefits of becoming a gainsharer, says Chad Mulvany, MBA, director of healthcare finance policy, strategy and development at the Healthcare Financial Management Association. For example, he says, a gainsharing arrangement lets independent physicians explore bundled payments without having to absorb any direct financial risk associated with exceeding the target price. This experience would also be useful if and when CMS adds more bundled payment options that provide a way for physicians to satisfy the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) while avoiding the reporting requirements of the Merit-based Incentive Payment System (MIPS). Becoming a gainsharer – and engaging with other physicians and hospitals to improve outcomes and reduce costs – also helps physicians prepare for whatever additional regulations may lie ahead, says Rob Lazerow, managing director at Advisory Board, a practice management consulting firm. “I don’t think you can ignore the context of what’s happening right now. [MACRA] is just the latest push toward more partnerships between hospitals and physicians,” he adds. One challenge of gainsharing is that it usually takes at least 10 months from the date of an initial hospitalization for CMS to reconcile costs and issue payments, says Whitcomb. This is a long time to wait when a physician anticipates additional reimbursement that he or she can reinvest in the practice, use for staff bonuses, or earmark for another purpose, he adds. Another challenge is that the episode might not generate any savings, in which case the physician would receive no additional reimbursement despite his or her greater care coordination efforts.

Getting started with gainsharing Mulvany suggests physicians consider three questions before deciding whether to participate in a gainsharing contract:

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episode-based payments? If so, becoming a gainsharer helps to prepare physicians for this shift. practice’s association with a hospital? Coordinating efforts to improve the quality of care and clinical outcomes benefits both the hospital and the practice.

3. What type of relationship does the physician ultimately

want with the local health system? Is he or she hoping to work more closely with it? If so, collaboration could lead to this desired relationship.

If a physician decides to move forward with gainsharing, the first step is to identify local hospitals to which they frequently refer patients and that are participating in a bundled payment arrangement. Target those that are part of the Bundled Payments for Care Improvement Initiative (BPCI) – a program with a waiver allowing the use of gainsharing. BPCI is most relevant to primary care providers because it includes 48 bundles representing nearly 200 diagnosis-related groups, many of which cover common medical conditions such as pneumonia, stroke, congestive heart failure, and acute myocardial infarction in addition to orthopedic, spinal, cardiovascular and general surgical procedures. (CMS provides a complete list of BPCI participants at http:// bit.ly/BPCI-episodes) Next, physicians should contact each hospital’s chief medical officer directly to indicate the practice’s interest in a gainsharing agreement. “Let them know that you’re a major influencer in what happens to patients during the post-discharge period,” Mulvany adds. Hospitals are usually open to conversations with physicians about how to collaborate and reduce costs, says Jonathan W. Pearce, CPA, FHFMA, principal at Singletrack Analytics LLC, a financial consulting firm specializing in bundled payment arrangements. That’s because hospitals bearing risk in the current BPCI model need to reduce costs post-discharge. Physicians who know how they can contribute to bundled payments are more likely to receive a welcome from the hospital, says Pearce. “The best thing that physicians can bring to the table is knowledge of what happens to patients post-discharge and an ability to increase the quality and cost-effectiveness of that process,” he adds. Whitcomb agrees. “If primary care physicians could provide timely access after the hospitalization or skilled nursing facility stay, it would make the performance of the bundle better by reducing readmissions and keeping people on the right trajectory as they recover from their hospitalization,” he says. Primary care physicians play an important role in the success of bundled payments, says Pearce, adding, “Physician engagement is absolutely critical.” Copyrighted 2017. Advanstar. 127983:0517SH


G E T T I N G PA I D I S C O M P L I C AT E D BY DIANE BRENNAN, DBH, MBA

May 2017 | arizonaphysician.com

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nsuring providers are paid is a priority for every practice manager. Getting paid has always been challenging, and today is no different – maybe even more complex. There are lost or denied claims, requests for additional documentation, questions on timely filing and more with health plans. But the newer concern involves the increasing patient responsibility in payment for services provided. The financial burden has shifted, and it is putting patients and providers at risk. You and your staff are likely seeing more patients with high deductible insurance plans requiring co-pays and co-insurance. This means it is critical to have office staff and systems that are aligned. Front and back office staff need to work together and processes for check-in, check-out, charge capture, documentation, follow-up and billing (for insurance and patient) need to be clear so they are easily understood and followed. As providers of healthcare, you want your patients to have what they need. That includes smooth and supportive interactions with you and your staff. Day-to-day challenges, misunderstanding why something is necessary, fear of conflict when asking for payment, and a myriad of other reasons that may or may not be related to the job, cause stress and result in poor communication and interactions with the patient. A case example: Susan is a 55-year-old female patient undergoing chemotherapy for breast cancer. She has a $5,000 annual deductible with her health plan, and she has a $45 co-pay each time she sees her oncologist. She makes sure to pay her co-pay at each visit. Susan and her spouse are exceptional in understanding their healthcare coverage and keep rigorous records of their expenses. On a recent visit to the oncologist, Susan was approached by one of the billing office staff about her payment plan. Susan was informed that one of her treatments was not covered until she meets her plan deductible. Sounds confusing, right? Susan was shocked by the revelation that a treatment she had been receiving for the past month was not covered. She was appalled as the billing person showed her an invoice for $2,500 that was considered patient responsibility. The situation devolved further as Susan burst into tears wondering how she would pay this and whether she could even continue treatment. While this conversation occurred in a small room off the patient waiting area, the entire waiting room could hear most of what was being discussed. No one was spared from emotional upset as fear, anger and sadness spread from patients to staff. This type of patient situation is not unique to specialty care. Patients and providers are continuously surprised by medication coverage, co-pays and cost sharing. Patients think their doctor should know, but things are not always clear – even when the most current plan information is available. Understanding what’s covered, what’s not covered, what needs authorized, etc. is more complex than ever. As healthcare professionals, we think patients should know their coverage and financial responsibility. While more patients are beginning to understand their part in the payment process, many still do not. When something

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FOUR THINGS YOU CAN DO TO STRENGTHEN YOUR PRACTICE

1 2

Listen to the patient.

What is the patient really asking? If you’re not provoked by an angry or upset patient, your staff will notice. Remember that they are watching you and will follow your lead.

Ensure your staff have the skills and desire to work with patients.

When patients call, don’t make it hard for them to get answers to their medical or billing questions. Billing questions can be challenging, as conversations about money often evoke an emotional response. Staff may need training on how to • collect the co-pays and deductibles with ease, • stay calm and diffuse conflict, and • stay engaged with the patient to understand the real concern.

3

Pay attention to communication and processes throughout your practice.

Notice what works or doesn’t work and encourage your staff to consider this as well. Don’t settle for how things have always been done, especially if you notice problems. Talk with your practice manager about how the front and back office team work together to ensure people and processes are aligned.

4

Promote accountability and a culture of caring.

Cultivate a culture of caring with your patients and with each other. You may already have this approach. How clear is this expectation with your team, your partners, the organization? Working together means understanding the impact we have on each other in ensuring patient satisfaction, collecting payment, and having a practice that is successful and financially sound.


goes wrong, a service or test is not covered and the claim is not paid, patients feel betrayed by the doctor and office. Patients trust and rely on you to take care of their health. While you can’t know everything, you can have systems and people in place to ensure patients have a way to communicate the challenge, work through options and begin to take a more active role in their health and financial responsibilities for care. As challenging as the healthcare environment may be, the good work that happens in caring for patients is a special responsibility that can easily be overlooked in the busy-ness of healthcare. Our healthcare system has evolved to increasing levels of patient responsibility for care and payment. Ensuring your practice has processes and people in place working together to manage through the complexity is necessary for financial success and sustainability. Dr. Diane Brennan is a healthcare consultant and leadership coach. She is the president of the Arizona Medical Group Management Association (www.AzMGMA. org). Diane is also co-author of Back Pocket Coach: 33 Effective Communication Strategies for Work & Life. For questions or comments, contact Diane at Diane@DianeBrennan.com.

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The PhysicianEmployer:

How to Stay Out of Trouble B Y S TA C Y G A B R I E L

A

s a physician, you wear many hats: healer, counselor, advocate and advisor. One hat most physicians would rather not wear is employer. That’s because managing personnel matters can be distracting, disruptive and sometimes unpleasant. But, most physicians, whether they like it or not, will employ staff who provide indispensable support to their medical practice. Faced with this reality, the prudent physician-employer will put in place employment practices aimed at avoiding employment issues. Although employment issues come in many shapes and sizes, the following are the most common areas where physician-employers get into trouble.

Classify your workers correctly When you decide to fill a position, the first priority is to determine if the individual hired to fill the position will be classified as an employee or independent contractor (“IC”). It’s tempting to classify as many workers as possible as ICs to avoid the expenses and obligations that come with employee status. For that reason, medical practices often engage staff as ICs instead of employees. However, to qualify as an IC the employer must prove the worker qualifies as an IC under the various IC “tests” adopted by federal and state agencies charged with enforcing employment laws, such as the IRS, Department of Labor and the AZ Industrial Commission. While the tests differ, they all fundamentally May 2017 | arizonaphysician.com

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turn on whether the worker is economically dependent on the employer and/or whether the employer controls the manner and means by which the worker performs services. Among the factors examined is whether the relationship is exclusive; whether the worker pays his/her own expenses and bears financial risk; whether the worker performs services that are otherwise part of the regular services offered by the employer (i.e., if the business is to provide medical services, is the worker engaged to provide such services). The burden to prove IC status is high and most working relationships fail the IC test.

Hire your employees correctly Assuming you are hiring an employee, it is prudent to verify the applicant’s credentials represented on the job application or resume before extending a job offer. After an offer is extended, it’s advisable to make the offer conditional on the new hire successfully passing a background check and drug screening. Additionally, the employer is required to verify the new employee is eligible to work in the U.S. by completing an I-9 form and, in Arizona, conducting an E-verify search. Consideration should be given to requiring new hires to sign an agreement restricting their ability to divulge or use confidential business information and engage in competitive activities both during or after their employment ends. In Arizona, there are limitations on a medical practice’s ability to impose a non-compete on a physician so careful drafting of the agreement is required.

Employment issues can quickly escalate into protracted legal disputes that drain resources, disrupt the efficient operation of your practice, and negatively impact employee morale. Pay your employees correctly Once an employee is hired, the physician-employer must ensure it is paying its employees correctly. There are generally two wage classifications: salaried (exempt) or hourly (non-exempt). Just like it’s tempting to classify a worker as IC, it’s also tempting to classify an employee as exempt to avoid paying overtime and the administrative burden of tracking time. But, once again, the desirable path is often not the correct path. Most employees do not qualify as exempt. To qualify, the employee must be paid at least $23,660 per year (the Department of Labor’s new rule increasing the minimum exempt salary to $47,476 per

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year was stayed by a federal court before it went into effect) AND the duties must fall within one of the narrow exempt classifications established by federal law. Physicians, physician assistants, and most RNs are exempt, but most office workers are not. If the employee’s duties fail the exemption test, he/she must be paid overtime for any time worked over 40 hours per week, even if the employee requests or consents to be paid salaried. Misclassifying an employee as exempt exposes the employer to unpaid overtime, double damages, and attorney fees. Additionally, a non-exempt (hourly) employee must be paid at least the minimum wage. Under Arizona’s recently-passed “Fair Wages and Healthy Families Act” (the Act), the minimum wage increased to $10.00/hour, effective January 1, 2017 and will increase each year in increments set forth in the Act, capping out at $12.00/hour on January 1, 2020. Thereafter, the minimum wage will increase annually based on cost living as measured by the consumer price index. Also, as of July 1, 2017, Arizona employers must provide all employees with paid sick leave. Employers with fewer than 15 employees must provide employees with 1 hour of paid sick leave for every 30 hours worked, up to 24 hours per year. Employers with 15 or more employees must provide 1 hour of paid sick leave for every 30 hours worked, up to 40 hours a year. The Act broadly defines the reasons employees may use sick leave and contains multiple rules regarding the accrual, taking and administration of paid sick leave.

Terminate employees correctly There is no formula for terminating an employee; each situation calls for a different approach. However, in most circumstances the discussion should be brief and to the point. Explain in general terms the reason for the decision and then quickly move the discussion to exit procedures, including transition of work duties, conversion of benefits, timing of final pay, and return of company property. If severance is being offered, the offer should be contingent on the departing employee signing a full release of claims against the employer.

Document the terms of employment correctly “Hand-shake” deals work great in an employment setting…until they don’t. When the employment relationship breaks down, disputes inevitably arise over terms of employment if those terms are not reduced to writing or if the written agreement is ambiguous. Bonus or commission arrangements are often the subject of such disputes since many employers fail to document what qualifies as a bonus/commission event, how the bonus/commission is calculated, whether any offsets are permitted, when the bonus/commission is earned and paid, whether the bonus/ commission is paid or forfeited upon the employee’s separation. Employers also get embroiled in legal disputes when they fail to specify in writing when and how paid time off benefits (such as sick leave, vacation and/or PTO) are accrued, and whether these benefits are paid out or forfeited upon separation. When it comes to documenting performance issues, physician-employers are often reluctant to address in any formal sense. It’s perceived as easier to ignore the issue altogether or address with verbal coaching. But, issuing a problem employee with a formal written corrective action notice can assist the employee understand the issue and reform his/her behavior. And, if that effort fails the existence of performance documentation also serves as compelling evidence to rebut a discrimination or wrongful termination claim. While documenting performance issues and the terms of employment can be a nuisance, it will pay dividends in the long run by helping the physician-employer avoid legal disputes.

In terms of final pay, Arizona law requires terminated employees be paid their final wages within a specified period of time. If the employee is involuntarily terminated, he/she must be paid final wages within 7 working days following the termination date, or the next pay period, whichever occurs sooner. Employees who resign must be paid by the next regular pay day. An Arizona employer is not required by law to pay out unused paid time off, unless the employer’s paid time off policy specifies otherwise or the employer has a practice of doing so.

Conclusion While patient care and treatment should always be your primary focus, ignoring your role as an employer is irresponsible and short-sighted. Employment issues can quickly escalate into protracted legal disputes that drain resources, disrupt the efficient operation of your practice, and negatively impact employee morale. Implementing the personnel practices described above will undoubtedly keep you out of trouble. Stacy Gabriel is the founder and managing member of a law firm focused on employment law matters. She regularly advises and represents both medical practices and physicians in negotiating employment contracts, drafting personnel policies, and resolving and litigating workplace disputes. She can be reached at stacy@gabrielashworth.com. May 2017 | arizonaphysician.com

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Understanding the Forest from the Trees:

A CONVERSATION ON BUSINESS & MEDICINE WITH

Michael Mills, MD BY DOMINIQUE PERKINS Article Photos by Denny Collins Photography

April 2017 | arizonaphysician.com

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D

r. Mills was drawn to medicine for a variety of reasons: the desire to help people as a career, an ongoing interest in the sciences, and even the encouragement of an aptitude test he took in high school. “My medical education story is interwoven with my desire to also understand the business of medicine, capitalizing on my entrepreneurial traits and strong work ethic recognized in my youth from various jobs, including delivering The Arizona Republic on my Schwinn kick-back 2 speed,” he said. After his undergraduate years at the University of Arizona, Mills headed to New Orleans for Medical School at Tulane. He concurrently took classes in the Tulane School of Public Health & Tropical Medicine, and received a Master of Public Health along with his medical degree. “This additional education shaped my view of healthcare delivery, understanding the forest from the trees,” he said. For his specialty focus, Mills found the perfect balance of surgery and medicine in Gastroenterology. He completed an internal medicine residency at University of Colorado in Denver, and his fellowship took him back to Arizona, in a combined program at Good Samaritan (now Banner University)/ Carl T. Hayden VA Health Care System, completed in Tucson at the University of Arizona in 1996. Mills began his career in academic medicine as faculty at the University of Colorado in Denver. After three years, he returned to his home state of Arizona to start his own solo practice, office sharing with Drs. Dave Drewitz and Fred Kenny, and then creating the Digestive Health Center of Arizona. His group joined others in the Valley in 2008 to form one of the largest GI supergroups in the country: Arizona Digestive Health. Mills keeps busy, between practice and other responsibilities which include serving as Medical Director of Phoenix Endoscopy, the Physician Executive Director of the Digestive Institute and Director of the Swallowing and REflux Center at BUMCP, and creating additional business. “I have enjoyed leadership opportunities in my practice and larger group, and with various organizations locally, regionally and nationally,” Mills said. While he enjoys wearing many hats, his greatest satisfaction still comes from helping his individual patients.

would take on all of the extra work and risk when they could get a steady paycheck, plus benefits, as an employee of a hospital system. Additionally, Mills said that we may be warning students and residents away from private practice. “Residents have always responded quickly to perceived trends in the healthcare marketplace, and they are being told that private practice will go the way of the dinosaurs,” he said. Another trend residents are responding to is the pay gap between primary and specialty care. “While I do not see a leveling of the pay grade between primary care and specialists, I suspect that primary care pay will be stable and specialist may see their revenue drop,” Mills said. “I believe that there needs to be a calling, a passion, about one’s own work, and to remove barriers for those who want a career in primary care, such as loan forgiveness, is money well spent.” Mills said he feels projected shortages of 60,000 to 90,000 physicians within the next 10 years are accurate, given the current number of graduating medical students and limited spots for training to replace the nation’s aging practicing physicians. Mills also expressed that primary care may be

Shortages “Hanging your shingle” is becoming an increasingly daunting proposition for young doctors. Between the expense required to begin a private practice, the existing debt of medical student loans, and the extra (and complicated workload) inherent in running a successful practice, it’s no wonder how some view that being your own boss may not be enough to offset the extra work and uncertainties. There are dozens of factors that must be addressed in private practice, Mills explained, including the difficulty of finding, hiring, and overseeing good staff; careful billing, collecting, and accounting practices; expensive office equipment and computer systems; compliance with government quality programs; and fewer insurance companies to negotiate rates. Students are asking themselves why they 24

ARIZONA PHYSICIAN | May 2017

Dr. Mills and his wife, Dena, enjoying a desert hike.


the best area where expanded utilization of well trained and overseen non-physician providers could ease the shortage. However, he maintains that physicians should and must fight to preserve their vital role in delivering care to patients. “We may find ourselves in a position to oversee a number of ‘midlevel’ providers, where we still can influence and impact best practices,” he said. “It is the inappropriate expansion of the scope of practice, such as pharmacists selling themselves as diabetic treatment specialists, where the battleground must be firmly hardened, advocating for our patient’s needs.”

Arguing quality Physician reimbursement is steadily moving towards a “value-based pay,” with supporters claiming that this will “move doctors’ focus from just quantity to that of quality.” Mills feels that this position is an insult to the oath of the profession overall. “Clearly, our profession’s ethics mandate that we put the needs of our patients before our own personal financial gain,” he said.

“Thus, it irks me when those who promote a change from the fee-for-service model – not taking into account our oath as professionals – claim that physicians do more things to patients in order to make more money.” Mills cited an address given by former President Obama in 2009 (aired on CNN and in many subsequent YouTube videos) regarding healthcare reform, in which he suggested that Ear, Nose & Throat surgeons performed tonsillectomies that could have been diagnosed as allergies to pad their pockets, and firmly stated that the belief that doctors are somehow naturally predisposed to “game the system” is wrong. Now, Mills acknowledges that not all of the blame can be passed. “We have no real mechanism in place for reprimanding the bad apples within our ranks who are not following our ethical code of conduct,” he said, adding that others in the healthcare marketplace are not bound by the physicians’ oath and are more likely to have their focus on the bottom line. Ultimately, Mills wonders, if the correct metrics are being used to define value and quality? “My biggest worry is that cost will become the only focus, with quality taking a back seat,” he said. As we have seen, most of the buzzwords in government healthcare policy seem to focus on physician reimbursement – Medicare Access and CHIP Reauthorization Act (MACRA), Merit-Based Incentive Payment System (MIPS), Alternative Payment Model (APMs), etc. While plenty of program fine tuning will occur, Mills is assured that they are here to stay. And, he said, quoting an article he wrote for Round-up Magazine, “You better play, or you’re gonna pay.” There is hope. The financial penalties and incentives place the reward of providing the highest quality of care at the lowest possible cost squarely on physician’s shoulders. “The silver lining is that this is our chance to positively impact the quality and cost of healthcare in the U.S. for our patients,” Mills said.

Negotiating value Out-of-network ‘surprise billing’ has generated quite a stir this year at the Arizona Legislature, where lawmakers have submitted a bill that would require physicians to negotiate directly with insurance companies, via an arbitration process. Mills said this is an issue that cuts both ways. Patients should have the choice of who they see and know if they are in or out of their network. Every physician should have the right to negotiate terms and accept an insurance contract, or stay out of the network. While he agrees that there should be no surprises, he said that such a broadbased legislation would put physicians in an even more compromised position. “If we do not have the right to walk away from a bad contract, or choose to not see patients with certain insurances, we lose our negotiating position,” he said. Most have forgotten why physicians discount their rates to be in-network: “To be listed (advertised/promoted) in their in-network May 2017 | arizonaphysician.com

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brochures and thus get more patients through the door,” he said.

Understanding the business With so many growing complexities and regulations, it has never been more important for physicians to understand the business of medicine. We asked Mills what advice he would give to physicians in practice groups or operating independently to maximize their reimbursements, and he offered three key points:

1. First, personally negotiate your contract with the payer.

Fully understand the terms, including your obligations and payment parameters (which hopefully include built-in annual increases). I have utilized a spreadsheet of my top 20 codes (by revenue) to create a weighted Medicare-base average for each contract, and know the percentage of my total business for each plan before heading back to negotiations. Having open and friendly relations with the payer representatives is helpful to arrive at win-win opportunities. Also the representative may leave the company but not the industry.

2. Second, have well-trained staff in your billing department with written financial policies and expectations. If you are a Medicare-accepting physician, you should treat every patient via the Correct Coding Initiative (CCI). Remember that “under coding” is viewed just as bad as “over coding,” so it makes sense to get it right the first time. Take a course in coding if you have not been taught along the way. Physicians are ultimately responsible for the codes that are billed, being subjected to fraud and abuse charges, large fines and even jail time. Open lines of communication are critical with your billing staff/billing company in clarifying charges. Silence is a bad sign. Most contracts require you to collect the co-payment prior to seeing the patient, and

clear communication in writing with the patient about their financial obligation is required. Review monthly your accounts receivable and aging reports as well as percentage of bad debt right-offs, good markers of your billing department’s success in collecting every dime that you are due. Personally approve bad debt write-offs.

3. Lastly, as those in private practice get paid with the

money left over after everyone else is paid, review your staffing and overhead expenses to see where savings may be possible. An efficient and a well-run office are paramount as we deal with decreasing reimbursements. Depending on the area of practice, you may be able to add new service lines at a better value to the patient and payer than otherwise is available in the marketplace. Always check with your attorney to determine if it is legal, and how the revenue must be treated in order to not get into trouble.

Mills also told how he has relied closely on the advice of experts such as his attorney (Bob Milligan) and accountant (Jim Fischetti) from the beginning of his practice journey, viewing those consultants as critical business partners to manage the complexities of contracts, healthcare law, retirement plans, billing and coding. “It’s hard enough to take care of patients at a high level, so get the best advisors that you trust, and follow their recommendations,” he said.

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On the personal side..

A Mills family outing: Hayden, Dena, Jessa, Dr. Mills, and Preston.

1. Describe yourself in one word. Driven.

6. Favorite Arizona sports team (college or pro)? Arizona Wildcats!!!

2. What is your favorite food, and favorite restaurant in the Valley? Food – Mexican (favorite: carne seca platter at El Charro in Tucson!) Restaurant – Elements at Sanctuary (corner table at sunset with my wife!)

7. Favorite activity outside of medicine? I spend most of my free time with my wife and kids, from family dinners and game night, to camping and family vacations. I enjoy golf and working out at the gym, and have a special place in my heart for the White Mountains in Arizona for fishing, camping, hiking, and just enjoying our great state. My wife and I try to take a special trip together once a year.

3. What career would you be doing if you weren’t a physician? My father was an attorney, and likely I would have pursued a career in law had I not found medicine. I pretend at times to be our free, “in house” lawyer when it comes to reviewing contracts and other documents. 4. What’s a hidden talent that you have that most wouldn’t know about you? I have always been into collecting things .... coins, dated railroad nails, stamps. Most would not know that I have a collection of over 4000 different beer cans from around the world! 5. Best movie you’ve seen in the ten years? Life of Pi (2012), stunning cinematography paired with a story of determination, faith, and the power of our minds.

8. Family? I married the love of my life, my high school sweetheart, a fourth generation Arizonan, celebrating our 28th anniversary this year! Dena and I are blessed with three amazing children. Preston (24) and Jessa (21) are studying business at ASU, with Hayden (14) entering high school this fall at Arcadia. My amazing mother, Jeannine, has been forever an inspiration to me in perseverance. I have two accomplished sisters, Michelle and Marcy, both attorneys. And I have the best in-laws I could have ever hoped for in Janet and Kent Webster, with fantastic brothers and sistersin-law as well. May 2017 | arizonaphysician.com

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Are you getting paid? What physicians think about payment issues...

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ARIZONA PHYSICIAN | May 2017


A

BY SHARLA HOOPER

s we use this edition to look at the complicated landscape of physician payment and reimbursement, we wanted to ask about physician perspective on how they experience these complexities. We thank everyone who participated in the survey and provided comments. Your input helped us create a picture of the challenges and frustrations that Arizona physicians encounter with payment models and reimbursement. Of those who participated in the survey, 58.8% were in specialty care and 31.1% in primary care. The significant majority of our respondents, 69.1%, were male, 30.9% female. It is easy to assume that solo independent practice physicians are more aware of the business intricacies of payment – solo practice physicians accounted for 29.9% of our respondents. About 20% were employed by a physician-owned group, and about 15% by a non-physician owned group. Another 18.7% were hospital employed. Of the 56.1% of respondents who feel they are not fairly compensated, • 18 were female (about 43% of total female respondents) • 56 were male (about 60% of total male respondents) • 21 were primary care (about 49% of primary care respondents), and • 49 were specialty care (about 61% of specialty care respondents). About 78% of all solo independent practice physician respondents feel they are not fairly compensated. Between 44 and 48 percent of respondents in physician-owned groups, non-physician owned groups and hospital employed feel they are not fairly compensated. Of the possible options for what presents the most significant challenges for payment and reimbursement, insurance/government reporting burdens and CMS policies including federal sequestration both were selected by 83.1% of respondents. Quality metrics based on patient compliance – and noncompliance – was selected by 67.7%; negotiating with payers, 64.6%. What about the financial burdens of medical education and clinical training? As a medical student respondent pointed out, “When the barriers for entry to the field are so great including average medical student debt of nearly 170k, followed by residency years with a moderate pay, and the time sacrifices demanded by the field, a large compensation must be waiting at the other side to help offset the investments.” The respondent’s reasoning was, if physicians face lower compensation in quality metric reimbursement models, there should be correlating decreases in the financial burdens imposed during their extensive training process.

Quality measures and the problem of patient compliance

Our respondents had numerous comments describing concerns about how quality standards are established and measured, and how they impact payment. Despite their misgivings, about 68.7% did agree, either fully or somewhat, that compensation should be more quality driven. On the other hand, 26.7% completely disagreed with the concept. Where are physicians in determining quality metrics and compensations? They need to be involved in the nascent formation of these objectives. Dr. Hamed Abbaszadegan states, “Administrators that are not associated with front line clinical care do not always see the challenges with the complexity of delivering health care. As a result, the associated quality metrics can be unachievable even though the ideas sound solid in the executive suite. This notion of linking quality to pay must be done with the direct feedback of physician leaders. Only with concurrence of physicians can this be accomplished successfully.” Physicians can be motivated by reasonable quality metrics, as Dr. Lilia Parra-Roide points out: “Most physicians have the best of intentions and would naturally improve performance in any area they are given believable, actionable and evidence based metrics. Payment strategies need to avoid placing extra burden on physicians that does not actually result in better outcomes for patients.” May 2017 | arizonaphysician.com

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Are you compensated fairly?

Are you primary or specialty care?

31.6%

PRIMARY

9.6%

Gender

YES

58.8%

SPECIALTY NEITHER

37.1% 56.1%

6.8%

NO

NOT SURE

20.1%

Employed by

PHYSICIAN-OWNED GROUP

18.7%

NON-PHYSICIAN OWNED GROUP

0.7%

69.1%

NOT SURE

30.9%

15.7% OTHER

Do you agree with metrics-related compensation tied to quality of care?

10.7% 26.7% YES

14.9%

NON-PHYSICIAN OWNED GROUP

29.9%

INDEPENDENT PRACTICE

Identify the top challenges regarding reimbursement CMS POLICIES, WHICH RESULT IN CONTINUING PAY CUTS TO PHYSICIANS INSURANCE/GOVERNMENT REPORTING BURDENS QUALITY METRICS BASED ON PATIENT (NON) COMPLIANCE AFFECTING PHYSICIAN PAY

NO

NEGOTIATING WITH PAYERS

58.0%

SOMEWHAT

4.6%

PRIOR AUTHORIZATION PROTOCOLS NOT SURE CONTRACT NEGOTIATIONS IN THE EMPLOYED PHYSICIAN MODELS

Would a shift to a qualitymetrics for compensation be successful? YES, IT WOULD ENCOURAGE A FOCUS ON QUALITY OVER QUANTITY NO, PHYSICIANS WILL NOT LIKE COMPENSATION WEIGHTED TOWARDS QUALITY IT WILL HAVE NO IMPACT ON HOW PHYSICIANS PROVIDE CARE NOT SURE

24.8% 27.9% 13.2% 34.1%

ICD-10 INTEGRATION

83.1% 83.1% 67.7% 64.6% 56.2% 29.2% 16.9%

Will the new 10.7 % 26.7% YES NO Geisinger Health System compensation model 19.1% THE MODEL WILL HAVE NO IMPACT ON QUALITY OF CARE succeed?

17.6%

NOT SURE


Several respondents shared strong suspicions about whether quality measures actually work: “There is no evidence that quality measures work. When calculated at the individual physician level, most docs have too few patients in any category to make valid comparisons.” And those metrics can be manufactured: “Some physicians are selecting patients with low co-morbidites and risk for surgery to improve their ‘complication’ rates.” The entity imposing the quality measures makes a difference. There is skepticism about measures created by insurers: “I don’t trust quality measures by insurers. Many insurers have proven they are not trustworthy with data they gather about physicians. Further, their models of quality have not been shown to be accurate indications of quality.” Patient compliance poses a serious complication to quality metrics that affect payment. “Basing it on patient satisfaction, a subjective matter, can be quite damaging for physicians who practice standard of care and highquality care,” Dr. Ross Goldberg observes. “Sometimes patients have to be told things they don’t want to hear, and they could respond by indicating poor satisfaction, which can negatively affect the physician, who was only doing their job and protecting the patient from harm.” This was cited in a specific example by another respondent, “I recently received a ‘bad patient satisfaction grade’ for refusing opioid medications to a patient.”

The role of prior authorization in quality

Prior authorization protocols were selected as a reimbursement challenge by 56.2% of respondents. Prior authorization requirements can delay care, sometimes indefinitely. One respondent sums it up, “The prior authorization process for even routine generic meds has become so burdensome that more time is spent on paperwork than with patients. I didn’t go into medicine to become an authorization clerk for an insurance company!” Another points out that when insurance companies deny payment for pre-authorized care, this affects how patients judge the quality of care.

A regulatory environment and burdensome reporting

A recent study published in Health Affairs (April 2017) examined time spent on face-to-face medicine versus computer-related activities. Conducted between 2011 to 2014, the study found that a quarter of physicians spent less than two hours per day with patients; and only a quarter spent more than four hours on direct patient care. It found doctors spent an average of 3.08 hours on direct patient care and 3.17 hours on desktop. And many of the desktop activities, such as care coordination and emailing patients, are not reimbursed but are of high value to the health care delivery system, where care coordination is vital to penalized items such as readmission rates. This was confirmed by a respondent who describes, “No compensation for work done when patient not in office. Consulting with other physicians, phone calls, reviewing records, etc.” Simply stated by one respondent, “We are so bogged down with charting and metrics, that it cuts into the time

that we could be contributing to patient care” – and the subsequent payments for that care.

Payment inequities & contracting

When considering several system models of physician payment, 36.6% of respondents felt that physicians will continue to deliver high-quality care with a salary based on national averages and no incentives in place; whereas 26.7% thought this type of model would fail. Asked about a model based on quality metrics tied to patient sign-up, there was a great of deal uncertainty about the potential for this model, 34.1%, and anticipation of its failure, by 27.9%. One respondent, having worked in both environments, prefers a model not dependent on incentives. She described herself as “fortunate to be in a work environment where all physicians are paid the same rate per hour and there are no productivity bonuses. I’m glad to not have to deal with concerns about gender-based pay inequality, or trying to rush more patients through the office to increase my wage. Could I be making more on productivity? Possibly, but I worked previously in an environment where my production bonus were frequently denied, despite being the second-most productive physician in the organization.” Knowing the market can increase physicians’ salary power within the employed model, as one respondent describes, “My employer increased our salaries by up to $50,000 when one physician found another job with Dignity Health that paid $50,000 more for the same amount of work. Fearing massive exodus, the employer increased the salaries. Physicians need to know the market value for what they do and should be more business savvy.” Contracting with insurers is also fraught with reimbursement peril, particularly in the case of a self-described independent practice anesthesiologist: “Many insurance companies refuse to contract with solo practitioner anesthesiologists. Then, we are asked to deliver care to people who have a plan for which we are not contracted, because there are no other anesthesiologists available for those cases. What next? Accept a payment from the insurance company substantially lower than that they put in their contracts with other physicians? The patient’s deductible and co-pay are usually withheld from the non-contracted anesthesiologist’s payment. Or, balance bill the patient? Or, maybe the insurance company will not pay anything, since we are out of network. Is this fair? The insurance company loves it – it saves them money.”

Bigger is not better

Over the last 15 years, we have seen increased consolidation in the health care system. Could the tide be turning though? One respondent states: “The system is rigged toward big institutions with the illusion of better, high quality care. New data are showing that small practices provide more efficient and quality care because they have greater control over the process and reputation builds their patient base.” Sharla Hooper is the Managing Editor for Arizona Physician and serves as Associate Vice President of Communications and Accreditation for the Arizona Medical Association. May 2017 | arizonaphysician.com

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PUBLIC HEALTH OPINION

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ARIZONA PHYSICIAN | May 2017


Thoughts on Current Health System Issues for Arizona B Y J O N AT H A N B. W E I S B U C H , M D, M P H

I

n Arizona, numerous health and public health related issues deserve consideration by all health professionals. The medical profession through its relationships at the Legislature and with the next administration, could have a significant role in shaping these issues.

1. Public health, environmental health, and forensic medicine1

a. The prevention of environmental hazards, assurance that disease outbreaks will be appropriately managed, and that unnatural and unusual deaths will be investigated and their causes identified, are all priorities of the state, which deserve increased support. b. More efficient organization of local health departments, with strong support from the state, is essential. Within this structure, an improved vaccination system, better disease reporting linked to providers, hospitals, schools, and industry, and a process to assure early recognition of any untoward event, natural or manmade, are all essential facets of a modern public health system. A critical element to improve population health is the reliability, availability and integration of important health and demographic data. These include, but are not limited to, vital statistics, hospital discharges data, Emergency Department utilization, ambulance runs, crash and trauma locations, reportable disease reports, domestic violence calls and occurrences, environmental pollution data, industrial injuries, health risk behavior prevalence, and other data relating to environmental, social and biologic aspects of disease, disability and death. A robust reporting system linked to prevention, academic research, and community education to change behavior will improve health status in Arizona. c. Efforts to prevent and eliminate environmental hazards, toxic releases, and lower workplace risks must be the joint responsibility of local health departments with state and national support. d. Linking Public Health with a statewide forensic Medical Examiner system coupled with the criminal justice system will be an asset for community health.2 Connecting the State Public Health Lab with genetics and toxicology labs at the medical schools and universities will help identify genetic and environmental causes during epidemics.

2. The State mental health system3,4,5

a. The shortage of psychiatric beds, nationally, is a serious problem (fewer than 20 beds per 100,000 population). In Arizona, however, the shortage is more severe. A few beds were added in 2004 with the rebuilding of the State Psychiatric Hospital in Maricopa County, but in 2014 the state had fewer than six beds for every 100,000 residents. To meet the demands of the emotionally disturbed, 350 beds are not enough. This deficiency is exacerbated by the fact that nearly one third of the 35 to 40,000 inmates in our state prisons and jails have serious psychiatric problems. Prisons and jails are not appropriate treatment facilities for the mentally ill, especially when in Arizona, these services are contracted out to private companies with inadequate mental health resources.6 Psychiatric resources in our medical schools could be used to meet needs of prisoners, children, adolescents, PTSD patients, addicts and others with behavioral problems. Integrating a system of care for patients of all ages with a range of emotional or disability issues, could be a goal for Arizona. b. The system to treat the “seriously mentally ill,” under Arnold v. Sarnes, which had been managed under an outside contractor, has recently improved with the development of the Mercy Health Care – Maricopa Integrated Health System program (MIHS).7 This new relationship should improve the services available for the population at risk, estimated to be about 6% of the adult population (~ 300,000 individuals). However, shifting mental health services from the Arizona Department of Health Services (ADHS) to the Arizona Health Care Cost Containment System (AHCCCS) may be of questionable value. The public health and mental health communities must monitor this program, informing the legislature if it is not succeeding. c. Building a statewide system of mental health services, meeting the needs of every resident with emotional ills, not only the “seriously” disturbed, is possible under the Affordable Care Act (ACA), provided it is retained. The ACA requires insurance companies to provide mental health, addiction, and other disability services. Using ACA resources to link the private mental health professionals to the psychiatric programs in our medical, osteopathic, naturopathic May 2017 | arizonaphysician.com

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ARIZONA PHYSICIAN | May 2017


and nursing schools would expand resources to meet the needs of all patients with behavioral, emotional and social health problems for all age groups, including troubled school children.

3. Maricopa County Hospital and Health System (MIHS), and other county systems

a. Maricopa County Hospital (MCH) has outlived its design; a recent evaluation of the system by a group appointed to review all MIHS services and facilities found that the hospital may be unable to meet licensure requirements in the near future. Admitting 18,000 individuals annually, and providing 100,000 out-patient visits, the hospital must either be replaced or have major renovations. The MIHS affiliated clinics also deserve renovation and improvement. The cost to replace the 500-bed facility is estimated to exceed $1 billion; in 2014, the voters of Maricopa County approved a $900 million bond issue to meet these needs. b. At the same time, however, the role of MCH as the University of Arizona College of Medicine - Phoenix’s major teaching facility was diminished when the University of Arizona contracted with Banner Health Systems to provide future resident training within the Banner Hospital System. Rebuilding the County Hospital, which no longer has a primary educational role in training students and residents, may not be an appropriate way to spend taxpayers’ money. The future of MCH may now be in doubt. The facility, in concert with the MIHS outpatient clinic system, currently serves over 200,000 individuals in Maricopa County, many of whom still have no health coverage, and look to MIHS as their medical home. Will they continue to receive the academic quality of clinical care, research, in a medical education environment they deserve? The future quality and numbers of trained professionals for the state of Arizona may depend on the answer to this question. c. Other county facilities may also require renovation in the next several years to provide quality care to the expanding numbers of patients insured under the ACA, especially in rural Arizona.

4. Hospital reimbursement

Providing the ACA survives, the population of insured individuals will grow, increasing demand for both primary care and hospital services. Under the ACA and other Federal and State programs, one-third of the costs of health services are covered. Medicare, Medicaid, the Children’s Health Insurance Program, the subsidies for the ACA exchange premiums provide nearly $3 billion to support Arizona hospitals and providers; all are necessary to preserve the quality of the system, especially in the many rural communities in the state. To keep hospitals viable while controlling costs, controversial innovations in reimbursement may be required. A state program to compensate hospitals based on appropriate per-diem payments rather than payments based on fees for every service provided may be considered.

5. Hospital improvements under the State licensure program

The Arizona Department of Health Services (ADHS) licenses over 80 hospitals with 13,000+ beds, a number which may be insufficient for our growing population over 7 million. To assure quality, cost and access to necessary beds as the population grows, ADHS may have to examine means to evaluate facility needs for renovation, expansion, and service augmentation. In older rural hospitals built many years ago with Hill-Burton funds, problems of age may exist. Renovations, new equipment, integration of regional services and additional professional resources may all be needed. These improvements may require resources not currently available, and may require an assessment by the state as to their need. Resource development for health services should be carried out under state leadership and strategic planning. Funds to improve facilities are always limited. Part of the licensing function of ADHS should be to help hospitals find resources and integrate services with other regional centers to improve the statewide health delivery system in Arizona. Every resident should have equitable access to healthcare when they are in need.

6. School health

a. Since 2001, the number of schools supporting a robust school health nursing program has declined, diminishing the quality and quantity of health services available to K to 12 school children. Arizona Public schools, with dwindling state funding, have cut many professional nurses. In other jurisdictions, DC and NYC, where school nurses function under the jurisdiction of Public Health Departments, reducing the number of school nurses did not occur, because nurses were not a part of the school administrative budget. When school RNs work for the PH Dept., additional resources are added to health agencies. RNs are available to PH when health crises occur. Arizona might consider this option as a way to expand physical and mental health preventive services for children, improve clinical services for students at school and on the athletic field. A state supported program for school nurses funded through public health would save the schools money, improve student health, reducing days lost to sickness and the need for off campus transport for some clinical issues. b. Professional school nurses, functioning under health department supervision with medical support from local or county physicians, would also be able to provide health education, preventive services, and offer professional support to students during the health crises that impact students of all ages. School nurses in conjunction with other members of the public health and clinical community can be valuable assets. They may be the first to recognize the first cases of a community outbreak. They also can provide appropriate age-level health education to our students. Health education provided by public health professionals will relieve the schools May 2017 | arizonaphysician.com

37


of this potentially controversial responsibility, while supporting the general school curriculum. c. Payment for these services could be drawn from multiple sources: some would come from the public school budgets, but most might be drawn from Federal funds, since some of the children would fall under CHIP or Medicaid criteria. For families whose insurance, under the ACA is covered by supplemental funds, the care provided by school providers (RNs and MDs) might be reimbursed through insurance carriers. d. Because school nurses and other medical providers would be under Public Health supervision, when they participate in the K-12, age appropriate school health curriculum, they would not be subject to the restrictions on content problematic for the school administration. Individual health counseling, provided by nurses would be defined by DPH health standards rather than topics limited by school administration policies.

7. Addictive substances, tobacco, marijuana, alcohol, etc.

a. With the introduction of Medical Marijuana into the Arizona medical milieu, the state Health Department along with the clinical community has become embroiled in a complex issue. With medical Marijuana now available, will legalization of regular marijuana not be coming soon? The management of cannabis and other potential addictive products will grow in importance. The education of children and teens to avoid these substances, and the development of programs to help those wishing to overcome their addictions are functions for ADHS and county health departments. Local police departments may also be involved as we move away from punitive to therapeutic responses to the use of addictive substances. The efforts to fight the opioid epidemic might engage all these local agencies. b. The anti-tobacco model is one on which others might be structured. The tobacco tax program to prevent tobacco use and assist smokers to quit the habit should be expanded, with the monies drawn away during the fiscal crisis, returned. This program will also have to address the growing use of e-cigarettes as a means to help smokers quit their habit, and prevent their use by teens. The use of the e-cigarette in non-smoking environments must be prevented if the power of the smoking ban is not to be diminished.8

8. Medical education, MDs, DOs, NDs, RNs, PAs, etc. The state supports two medical schools. It is the home of two private Osteopathic Schools of Medicine and one Naturopathic School. A large number of other professional programs educate nurses, PAs, and others. Arizona is growing above seven million people, a larger and larger number of whom will have insurance through the ACA Exchanges and the AHCCCS. Are we doing enough to expand the numbers of professional we shall need in the future? Are we using state resources judiciously to support professional education,

38

ARIZONA PHYSICIAN | May 2017

and keep our graduates in Arizona? Could we use state funds now serving the seriously mentally ill, prisoners, those on AHCCCS, and the homeless under contracts with private companies, to support our medical and nursing schools to meet the needs of these populations as part of their educational responsibility? Could these resources be used to improve disease prevention and optimize the quality of care these populations receive, as part of the professional education given our students?

9. Health professional reimbursement

To hold an adequate number of providers in the state, professional satisfaction must be assured. That satisfaction comes from quality of life, pleasure in the job, adequate reimbursement, and limited bureaucratic hassles. The state has a role in meeting some of these criteria. As noted above, 33% of professional reimbursements come from state and federally controlled monies, therefore the state should work with the professional organizations to assure appropriate compensation from these sources. The state also has the ability to allocate resources to help providers find optimal care for their patients regardless of the region in which they live. The hospital licensure process, and the licensing of providers can be used to assure appropriate resources are available when needed. The state can also influence all payers, not only Medicare and Medicaid, to be efficient and appropriate in reimbursing professionals, hospitals and clinics for the care they provide. Fees could be based upon agreements between payers and the medical associations, a system that works well in Canada. As suggested above, hospitals might be funded on a global reimbursement system based on facility average annual costs and annual bed-day utilization. Each hospital could be funded on the basis of an expected number of bed-days per month times the average cost per bed-day as determined by a biennial audit of total facility expenses.

10. Meeting the growing needs of the Affordable Care Act

The ACA stipulates that all citizens should ultimately be insured, and that all insurance carriers will provide a required list of services, including behavioral health, rehabilitation services, drugs, primary and secondary care, preventive care, contraception services, etc. The state must take responsibility to assure that insurance coverage meets these objectives, and that those with insurance are not prevented from getting the appropriate care they need as close to where they live as possible. This may require obligating insurers to provide links to rural areas through telemedicine, shared regional resources among providers, rapid transport when needed, etc. The ACA provides resources for public health agencies and other aspects of prevention in which the state can be a major player. Linking public health, environmental health, behavioral health, school health, and other appropriate community resources to improve the quality of life and the overall health status of the citizens of Arizona must be the ultimate


responsibility of state government, the legislature, and the elected officials in the many cities, towns and counties. To assure these outcomes, our citizens and our legislators must be educated. Health professionals must be engaged in the process, assuring the preservation of professional standards for quality, access, continuity, appropriateness, efficiency and effectiveness.

11. Veterans Health Services: recent information

Recent information demonstrates how the decline in budgetary resources both at the state and Federal level has diminished the quality of the care provided to veterans that was available ten years ago. This problem deserves review, with an eye toward adding resources here in Arizona to the VA Hospital in Phoenix and the Arizona Veteran’s Affairs Department.

12. Prisoner health reorganization9,10

The State of Arizona maintains several prisons, housing approximately 35,000 inmates. Maricopa County immures another 8,000 to 9,000 inmates on any given day. In the case of the state, several of the prisons are actually managed by an outside profit making contractor who brings in their own staff. The medical services for the entire system is provided under contract with an outside medical service company which provides physicians, nurses and other providers to serve the needs of the inmate population. This system is fraught with inadequacies, and has been subject to multiple lawsuits. Prisoners, under the Supreme Court decision in Estelle v. Gambel, and subsequent findings, have a Constitutional Right to receive adequate health services, comparable to what they might have expected to receive were they not incarcerated. Prisoners, both in the counties and in the state system deserve better health care services than they now obtain. A recent summary of these deficiencies at the state level was recently reported upon. Rather than contracting with out of state medical service contractors, the state could keep the $100 million now being spent to provide health care to Arizona prisoners, by contracting with the several medical schools in Tucson and Phoenix to serve the primary, secondary, and inpatient care needs of prisoners. In Massachusetts and Texas, where prison health services are provided through the medical educational system, costs are lower and quality better than in states that use out-of-state contract providers. Building a system of this organization will require leadership at the medical schools, at the state correctional department, and will require support from the legislative process.

Dr. Weisbuch is the former director of the Maricopa County Department of Public Health, and former Board member of the Maricopa County Medical Society. He’s also involved in Medical Education, and has taught at Southwest College of Naturopathic Medicine, and Arizona State University.

1. The Future of Public Health, Committee for the Study of the Future of Public Health, Division of Health Care Services, Institute of Medicine, National Academy Press, 1988. 2. Hargreaves, E. Public Health and Forensic Medicine, The Lancet, 172; 4434: 546-47, 22 August 1908. 3. The Critical Need for Mental Health Professionals Trained to Treat PTSD & Traumaic Brain Injury, American Psychological Association, www.apa.org. 4. Mental Health in America - Access to Care Data, http://www.mentalhealthamerica.net/issues/ mental-health-america-access-care-data. 5. Dowd, S., Covino, N. The Costs of Not Caring: How to Fix Our Broken Mental Health Care System, Huffington Post, the Power of Humanity, Healthy Living, Feb 10, 2016. 6. McNamara, P. ACLU Report calls prison medical care inadequate, The Arizona Star. 2014 Sept 11. 7.

Johnson, S.R. Bridging Medicaid’s Medical and Behavioral Care Chasm, Modern Healthcare, The Maricopa County Integrated Health System Newsletter, April 26, 2014.

8. Blanding, M. The E-Cig Quandry, Magazine of the Harvard T.H. Chan School of Public Health, Aug 16, 2016, https://www.hsph. harvard.edu/magazine/magazine_article/the-e-cig-quandary/. 9. Weisbuch, J.B., The New Responsibilities for Prison Health: Working with the Public Health Community, Journal of Prison and Jail Health, vol.10(1), pp. 3-18, Summer 1991. 10. Weisbuch, J.B., “Desmotology: The Practice of Prison Medicine,” Chapter 72 in Preventive Medicine, Maxcy and Rosenau, Ed Scutchfield, 1997 Edition. 11. Harris, C. ACLU Claims Widespread Health Care Problems in Prisons, Arizona Republic. 2014 Sept 12:Sect. A.

1977

2017

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Dual MD & MBA Degrees Offer Medical Students Practical Industry Skills BY MARIAN FRANK

A

s health care systems grow more complex, many medical students feel the need to understand the business side of medicine, from managing people, operations and budgets to building a strategic plan. Now, medical schools are offering their students an opportunity to gain valuable business skills while enduring the rigors of becoming a physician. With dual MD and MBA degrees, students can graduate with the skills to successfully manage a family practice, specialty group or lead a hospital. The University of Arizona College of Medicine – Tucson has offered a dual degree program since 2000, while the UA College of Medicine – Phoenix will begin offering an MD/ MBA program to incoming students in July. Glen T. Fogerty, PhD, interim dean of admissions and recruitment for the College of Medicine – Phoenix, said he has seen a growing demand for business classes from medical students. “They have been so focused on getting into medical school, now they are thinking of the next step,” he said. “Many see the changes happening in the industry. They see how the world of health care administration is being run, and they’re thinking about how they can be the most competitive, the most prepared for residency. We suggest to them our dual degree and certificate programs.” 40

ARIZONA PHYSICIAN | May 2017

In the MD/MBA program, operated in conjunction with UA’s Eller College of Management, students spend their first two years focused on MD classes. MBA core curriculum courses in areas such as finance, marketing and leadership development are offered during their third year. They complete clinical rotations in their fourth and fifth years. In addition to the MD/MBA program, the Phoenix campus offers dual degree programs in MD/MPH and MD/ PhD as well as Certificate of Distinction programs in Rural Health, Global Health and Service and Community Health. “MD students are looking for more options,” he said, “They’re thinking about how they can be well-rounded and they want to do something that will set them apart.” Fogerty, who previously served as director of recruitment for the MBA program at the W.P. Carey School of Business at Arizona State University, is the driving force in offering the program at the Phoenix Biomedical Campus. “The MD/MBA is a great fit for us,” he said, adding that medical students are A-type, driven students who see the need for service to medicine but also see the importance of building business skills. “Whether it’s health care administration, running a hospital, leading a medical group of doctors, those are the skills where an MBA pays off,” he said.


decision-makers and leaders who have a fundamental understanding of how to manage people, processes and budgets in a health care setting. As MDs advance in their careers, the unique combination of an MD/MBA offers them the skills and opportunity for a smooth transition into an administrative role, he added. “Having doctors who can understand and communicate the business side to leaders in the hospital or health care system is another way that our students can make a difference in the lives of the people in their community,” Morrison said. Marian Frank is associate director of Public Affairs for the University of Arizona College of Medicine – Phoenix. She previously worked as an editor and reporter for The Arizona Republic and Phoenix Gazette.

Comments on Pay

Now, the Eller College is on the same campus as the College of Medicine – Phoenix, as the business school recently moved its satellite campus from Scottsdale to downtown Phoenix. The UA College of Medicine – Tucson has offered a dual-degree program since 2010. Tanisha Price-Johnson, PhD, executive director of admissions for the college, said there is a small cohort of students in the program, but that interest in growing. Most students take the bulk of their MBA classes after their second year of medical school, but some choose to take them after they complete four, before matching into a residency program. “We had a lot of graduates who were practicing in their specialties, but they found that they didn’t have a business foundation, so we began partnering with the Eller College,” Price-Johnson said. The dual degree provides them opportunities to refine their leadership skills, helps them understand organizational structure and teaches them how to negotiate, build a business plan and share that plan with patients and other stakeholders, she said. Like the UA Phoenix medical school, which is a separately accredited college of medicine, the UA Tucson medical school offers MPH and PhD dual degrees as well as eight certificates of distinction. Steve Morrison, director of the Full-Time MBA program for Eller, said with the changing health care environment, it’s more important that there are administrators,

I am a big believer in tying pay to quality. However, I am concerned that how we measure quality is not an accurate reflection of good patient care.

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BY JAMES CARLAND, MD

I

n February 2017 MICA distributed $26 million in dividends to qualifying member policyholders. In 2016 it distributed $27 million. MICA has paid $390 million in dividends to its members over the past twelve years, and since inception, it has paid $575 million. For policyholders insured by MICA for thirty-six months or more, each of the distributions for 2015 and for 2016 represented a little more than 25% of a policyholder’s annual premium. How is this possible? The answer combines adherence to the company’s mission supported by its mutual structure along with its long-range planning and expertise in underwriting, risk management and claims management. MICA is a company that knows its purpose and has developed the operational and financial capability to safely fulfill its mission. MICA was formed by Arizona physicians when they had no other option. None of the commercial carriers would continue to insure medical liability. They said it was too expensive, too volatile and too unpredictable. Our purpose was then, and remains, to respond to the need to provide quality medical professional liability (MPL) insurance at an actuarially sustainable premium rate – not to take advantage of a market opportunity. Our founders wanted to make premiums as low as possible, but they also recognized the necessity to ensure that premiums were adequate to pay claims over the long term. A number of other insurance companies, formed a little before and for a number of years following MICA’s formation, focused solely on providing low premiums without adequate consideration of ultimate claims costs. When MPL claim settlements and jury awards came in years later and the funds that had been put aside to pay them were insufficient, those companies failed. MPL has a long tail of liability, meaning the ultimate cost of a claim often is not known for five or more years after it is reported. Moreover, many claims have defense costs that exceed the amount of a settlement or verdict. The goal of a well-managed MPL carrier is to estimate all of those future costs accurately . . . and that is done based on management’s assumptions and an actuary’s estimate and prediction based on established loss trends. A well-run MPL insurer will have knowledge of pending legislation and regulation in its state(s) of operation. It will have an understanding of the judges and court venues, prior rulings by the state Appeals Court and Supreme Court, and of the plaintiff attorneys – their strengths and weaknesses and their favored arguments and style. Its management and Board will actively seek legislation that brings clarity, consistency and rationality to the resolution of claims. A quality carrier will have invested time and effort to create collegial and mutually supportive relations with defense counsel,

because they work together on behalf of the policyholder. Annually, a well-run insurer will use this “knowledge of the territory” and with their actuary, will evaluate claim cost and frequency trends in order to estimate the ultimate costs of claims that will be paid in the upcoming years. Reserves are periodically revalued based on information accumulated regarding each claim still open and each claim closed. Reserves may, in the aggregate, increase (unfavorable development) or decrease (favorable development) in value. As each year passes, reserve development continues until all claims are paid and closed. That may take more than twenty years, particularly if there is a child’s claim involved. As part of ongoing financial management, the ultimate cost for each year is re-forecast and reserves are increased (strengthened) or reduced. The sum of reserve changes in all prior years plus the estimated reserves for the just-closed year are then compared to the reserve estimates from the prior year’s closing. Reserves are then strengthened, if development is adverse, or reduced, if development is favorable. Favorable reserve development results in the release of funds that can be used to acquire another insurer, create a subsidiary company, expand or improve operations, or, if an investor owned carrier, provide a dividend to its parent or to its shareholders. Or the company can allocate a portion to each of these activities. If the carrier is a mutual company, its “shareholders” are its participating policyholder members. Dividends are paid to its policyholders of record, thereby reducing the net cost of their MPL premium: a “member benefit” for those insured with a mutual company like MICA. The amount of money a mutual insurer has available for dividend payments depends primarily on the predictive accuracy of its original reserve estimate, an estimate based on prior loss trends and predicted future loss trends, compared to the ultimate cost when all claims for that report-year are fully paid. The actual payout of claims is heavily influenced by a number of factors, including changes in the overall climate, such as patient attitudes, tort reforms or loss of tort reforms, the effectiveness with which the company and its defense counsel resolve claims, and the ability of management to assume the risk of large losses and control operational costs. The last fifteen years in Arizona provide an excellent example of this process. Leading up to and into the early 2000s, claim costs were rising dramatically. For a number of years, MICA paid more in claims than it received in premiums, and reserves for a number of those years had to be increased. That resulted in actuarial forecasts of continued steeply rising claims costs. The same evaluation process occurred throughout the country leading to the discontinuation of MPL insurance coverage by The St. Paul Companies,


the bankruptcy of MIIX Insurance Company and the imposition by one carrier of a single year 94% rate increase for Arizona physicians. With little or no favorable reserve development, MICA ceased distributing dividends, implemented modest premium rate increases, and “made room” for hundreds of the physicians displaced by these events. During this very difficult period, working with organized medicine, MICA supported successful efforts to get the Arizona State Legislature to adopt (1) legislation requiring the submission of an affidavit of merit provided by a qualified physician, when a suit alleging malpractice was filed, (2) legislation defining the qualifications of a standard-of-care expert, and (3) legislation encouraging physicians and other healthcare professionals and entities to have a dialog with patients and families following an adverse outcome without concern that their words of sympathy or empathy would be used against them in a subsequent court action. Following the enactment of this groundbreaking legislation, lawsuit filings declined suddenly and dramatically. As forecast loss trends declined, reserves set aside based on the earlier assumptions were reduced. The vast majority of reserves that were subsequently released were returned to MICA members in the form of dividends: $60 million in one year alone, with $50 million the year immediately following, and $390 million over the last twelve years. And MICA was able to implement a series of six overall premium rate reductions in Arizona totaling 35%. Some argue in hindsight that a more accurate estimation of initial reserves would have meant lower premiums, but that would have entailed ignoring loss trends and making a

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 5

bet on future rate adequacy based solely on hope that future losses would never be greater than the initial loss estimate. More than one carrier has dissolved after making such a bet. What MICA does, what a well-managed, safe mutual insurer should do, is make its best fact-based, actuarially sound loss-cost estimate of future claim costs, and if claim costs ultimately prove to be lower than forecast, return unneeded and unspent premiums to its members in the form of a policyholder dividend: a combination of prudence and safety with the lowest ultimate net cost. That is, after all, in the long-term interest of MICA’s beneficial owners – its member policyholders – and is consistent with the original intent of MICA’s founding physicians.


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Proactive risk management programs can reduce the risk of a claim or suit. We offer many specialty-specific programs, as well as those that can be used by all medical practitioners. Our policyholders have access to MICA’s extensive selection of risk management tools, such as: office audits, online CME, monthly webinars, podcasts and weekly Hot Topic emails. Our dedicated risk management hotline is staffed during business hours by Risk Management Consultants who are available to answer any questions you may have about risk mitigation in your own practice. To learn more about the risk management tools that MICA provides and how you can become a member, visit our website www.mica-insurance.com or contact us at 800.352.0402.

Medical Professional Liability Insurance (602) 956-5276 (800) 352-0402 www.mica-insurance.com

Arizona Physician Magazine, May 2017