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

Fall 2017

To Be or Not To Be‌ Employed pg. 26

Perspective on putting patients first pg. 23


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ARIZONA PHYSICIAN | Fall 2017


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ARIZONA PHYSICIAN | Fall 2017


VOLUME 1, ISSUE 8 EDITOR-IN-CHIEF JAY CONYERS, PhD

jconyers@arizonaphysician.com

MANAGING EDITOR SHARLA HOOPER

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ASSOCIATE MANAGING EDITOR DOMINIQUE PERKINS dperkins@arizonaphysician.com

PHOTOGRAPHY DENNY COLLINS

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LAYOUT & PRINTING PRISMA

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EDITORIAL BOARD MICHAEL BUGOLA, MD JOHN COUVARAS, MD MICHAEL DEAN, MD TIMOTHY FAGAN, MD MICHAEL HAMANT, MD TABITHA MOE, MD ROBERT ORFORD, MD WILLIAM THOMPSON, MD JAREN TROST, MD

Contents One Physician’s Choice

The struggle to put patients ahead of insurance payments that led Scott Bernstein, MD, to choose concierge medicine

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Features

New AMA Study Reveals  Are You Getting 20  30 Practice Owners Are No Paid? Revenue Cycle

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Longer the Physician Majority

What Physicians Think: Physician Employment Models

Management

an Physicians Maintain 33 CIndependence While Working as Part of a Large System?

ractice Managers: 36 PYour Partner in Private

arizonaphysician.com twitter.com: /AZPhysician facebook: /ArizonaPhysician instagram.com: /azphysician

Practice

In This Issue 4 What’s Inside 6 President’s Page 7 Congressional Corner with Raul ´ Grijalva 9 Community: A Border Hospital Perspective 13 Choosing the Right Path for Your Practice

16 Engaging with Patients on the “Demand-Side” of Opioids and Chronic Pain 22 Public Health: SCID Screening Begins 38 Maximizing Physician Success in MACRA 40 Community: Arizona Medical Eye Fall Unit 2017 | arizonaphysician.com 3


What’s Inside TO BE OR NOT TO BE... EMPLOYED

Jay Conyers, PhD

“By medicine life may be prolonged, yet death will seize the doctor too.”

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n Shakespeare’s Cymbeline, the King of Britain utters these words after hearing the news of the Queen’s death, conveyed to him by the court’s physician, Cornelius. What does this have to do with medicine, and this issue focusing on physician employment? Absolutely nothing, but I had to pluck a good quote from the Shakespeare archives given the title of this issue of Arizona Physician! Despite naming this issue after a famous quote lifted from Hamlet, this month’s content has nothing to do with revenge, murder, nor, for that matter, the Danish royal family. Rather, it touches on the decision looming over many physicians – to seek employment at a hospital, clinic, or large group or decide to hang a shingle and control your own practice. With each passing year, more and more physicians seem drawn to the former. What drives physicians down one path and not the other? Is it compensation, is it quality of life? Does it have anything to do with patient care? Of course, there’s no simple answer, and truth be told, it’s most likely a combination of factors. For some, it might be rooted in a desire to just focus on what he or she was trained to do – treat patients. Younger physicians seem more drawn to employment than their contemporaries were, especially given the ever-increasing business aspects of medicine that gobble up time. Navigating regulatory requirements, understanding EMR integration, streamlining billing and coding, and investing in human resources weren’t classes in anyone’s medical school curriculum. For others, the hassles of running a business don’t necessarily outweigh one’s desire to call his or her own shots – decide which patients they will see and how frequently, what they will order in terms of diagnostics, and how they’ll treat their patients. I’m not necessarily saying that employed physicians don’t have a say in how they practice medicine, but I think one could easily argue

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that a self-employed physician has considerably more autonomy when it comes to how they practice medicine. Each year, the industry examines trends in physician employment. Numerous reports are available, and most show that physicians are less and less likely to have an ownership stake in a practice. Year after year, the number of employed physicians and the hospital-acquired practices seem to trend upward. But what does the data actually say? A recent report in Modern Healthcare1 indicated that for the first time in our nation’s history, fewer than half of all physicians have an ownership position in a physician practice, according to the American Medical Association. From 2012 to 2016, physician ownership fell from 53.2% to 47.1%. The report also revealed that practice size continues to swell, as more and more smaller practices are merging with larger ones. Over the same time period, those practicing in groups with more than 50 physicians increased from 12.2% to 13.8%. So why the increase? The AMA study, derived from the Physician Practice Benchmark Surveys conducted every two years, points to a number of reasons for the growing trends. The increased financial burden of maintaining safety, quality, and IT compliance for a practice is an obvious contributor, but so too is the growth in Accountable Care Organizations (ACO) and their commitments to fully integrated care. Additionally, many health systems are soaking up physician practices at a break-neck pace in order to fine-tune their physician networks and address recent payment reforms that look more favorably at broader populations. And just last year, a Physician Foundation study,2 conducted by Merritt Hawkins (a nationwide physician recruitment firm), revealed some alarming trends that hint at the concerns over the employment shift. Their data shows that practice owners see 19% more patients than do employed physicians and are more familiar with Medicare Access and CHIP Reauthorization Act (MACRA). Does this


What is your experience with End of Life Care issues? Your participation in this important survey will help direct future resources for patients and physicians! Please complete the survey at https://www.surveymonkey.com/r/eolcareaz mean that employed physicians don’t know about MACRA? Likely not, but perhaps their lack of need to focus on the ‘business’ aspects of medical care make it less of a ‘must know’ topic for them. Lastly, the study points to the rapid increase in physicians speeding up retirement plans, leading to a physician shortage in many communities. There are clear and convincing arguments to both sides, for certain. I’m not going to convince anyone that one is right, and one is wrong. But hopefully, the contents of this issue will help inform you of the trends and the issues that might play into one’s decision to go down one path over the other. While we don’t bring you a physician profile with this issue, we do bring you a number of thought-provoking

articles. It’s a great issue packed with useful information. We hope you’re enjoying the new magazine platform, and look forward to receiving it! In the spirit of “The Bard of Avon,” I’ll close with a great quote about the similarities of the two arts. As the great Henry Grunwald once noted, medicine and poetry have one thing in common – the heart is the center and controls the mechanics of life. 1. h  ttp://www.modernhealthcare.com/article/20170531/ NEWS/170539971 2. https://www.beckershospitalreview.com/ hospital-physician-relationships/study-employed-physician-see19-fewer-patients-than-practice-owners.html

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President’s Page T H E P H Y S I C I A N PAT H

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his month’s theme is about the factors in a doctor’s decision to consider solo practice versus employment. Yet in this modern environment, the solo practitioner is becoming a unicorn. New doctors exiting training face pressures from both loans and the whipsaw political machinations which add greater uncertainty to the medical environment. We should reconsider our premise and differentiate employment between hospital/Accountable Care Organizations models and physician group and multispecialties. For older physicians who are seeking retirement in the next decade, any decision they make to stay or go into employment has little to do with high loans and startup costs of new practices. This group is struggling with the complexity of providing care, in an ever-changing managed care environment, and declining reimbursement and job satisfaction. The older self-employed physician, who is struggling to compete with the surge in hospital acquired practices, finds that his employed counterpart is paid more, and has greater time off and work-life balance. According to a Medscape 2014 poll1, more women choose to be employed than self-employed, while the reverse is true for men. The survey notes that this difference could be more related to age than gender, because a greater percentage of female physicians are younger, and more than twice as many doctors under the age of 40 are employed compared to those who are self-employed. Among doctors who changed employment statuses, 52% switched from employed to self-employed, while 29% of those who switched to employment came from self-employment. “Those who left an employed model in favor of selfemployment seemed more satisfied:” Among physicians who moved from self-employment to employment, about 49% of physicians say they are happier now, while 25% said they were less happy. By comparison, 70% of doctors who moved from employment to self-employment said they were happier, and just 9% said they were less happy.”2

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ARIZONA PHYSICIAN | Fall 2017

John L. Couvaras, MD

How the workplaces compare Physicians in the 2014 Medscape survey cited employment as a preferences for reasons related to “greater financial security,” “less paperwork,” and a “better life-work balance.” New doctors today may well encounter an expectation that they are going to be an employee and not ever consider the prospect of being a small business owner. When it comes to overall satisfaction, employed and self-employed doctors are about equally satisfied. Selfemployed doctors have control but not security; employed doctors have ditched the unpleasant management responsibilities but also have less control over their work lives. Yet both groups seem satisfied with their situations. What accounts for that? Quite possibly, each group gravitates towards the situation that is most in sync with their own personality or inner desires. Those who remain self-employed may have a stronger need to run their own practice, be in control, and not take orders. Those who enjoy employment may consider the lack of autonomy to be a definite downside, but not one that is critical to their ultimate satisfaction. The argument that new physicians don’t see themselves as business owners, hence their expectations to be employed, seems a bit like a self-fulfilling prophecy. We know the greatest employer of new doctors in the last four years has been hospitals. However, if new physicians were fully informed of other viable pathways to “ownership” and hence, self-employment, this would affect future polling results. With the shift in Medicare reimbursement to hospital-based physicians from the subsidized 140% of Medicare, and back to community standards, this option should become a greater choice for new physicians entering the market. Choices for doctors should not be a bad thing. Resources: 1. https://www.medscape.com/slideshow/ employed-doctors-6006080 2. https://www.advisory.com/daily-briefing/2014/03/13/ employed-or-self-employed-a-look-at-which-doctors-have-it-best


Focus On Border Health

Congressional Corner ´ M. GRIJALVA U.S. CONGRESSMAN RAUL

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rom tribal communities in the southern part of the State to seasonal migrant workers in Yuma, the border region is home to diverse communities that are unique in many ways. It is this uniqueness that oftentimes results in uncommon problems and consequently requires innovative solutions. Generally speaking, border populations have health needs that are greater than the rest of the United States due to several factors, including accessibility to facilities and providers, social determinants of health-related decisions, and culturally-appropriate care. While uninsured rates in border communities has dropped since the passage of the Affordable Care Act (ACA), the fact remains that they are in all aspects still medically underserved. This lack of accessibility is coupled with high poverty rates and a population that suffers disproportionately from chronic diseases. All of which produces an imbalance in care that needs to be addressed. Just as healthcare providers make an initial assessment on their patients, lawmakers should make a greater effort to better understand the health care challenges that rural and border communities face. Sixty-three percent of U.S.Mexico border counties are federally designated as Health Professional Shortage Areas (HPSA), meaning there is a lack of capacity and resources, not willingness, to properly address the medical needs of border citizens. The majority of these shortage areas are rural. Basic assets afforded to urban America like transportation, and choice in physicians and clinics, are much harder to come by in rural parts of the country. For instance, the City of Nogales, with a population size of over 20,000 falls under the care of one hospital and one community center. But where a challenge exists, there are exceptional individuals that rise to meet it. The determination and resilience of health care providers along the border goes unmatched. Programs such as Mariposa Community Health Center’s Healthy Start have reduced infant mortality by providing culturally-appropriate home visits to pregnant women in Santa Cruz County. Their Vivir Mejor program uses sound and culturally-competent education to increase healthy living behaviors – from food choices to exercise regimes – which

prevents diseases like high cholesterol and diabetes that disproportionately affect border regions. These types of programs provide the specialized and culturally-sensitive treatments that will act as an effective health intervention for the region. But many of these programs would not exist without federal support and qualified providers. While physician shortages are a problem across the nation, the border region faces the additional challenges of not only obtaining, but sustaining a workforce that can meet the needs of this unique population. That is one of the reasons I am proud of my vote for the Affordable Care Act (ACA). The primary function of the ACA is expanding access to health insurance for millions of Americans and paving the path to a health system focused on prevention instead of costly emergency room care. However, perhaps not as well-known are the law’s numerous provisions aimed at improving and expanding our health care workforce. For instance, the ACA permanently re-authorizes funding for the National Health Service Corps (NHSC) program, which provides scholarships and loan repayment for individuals that agree to practice in a federally-designated Health Professional Shortage Area (HPSA). For border communities, this could be the difference between having just a couple of doctors and being able to visit a wide range of specialists. Under the ACA, funding is also included for Center of Excellence (COE) programs that recruit, train, and retain underrepresented minority students, as well as faculty, at health professions schools. The goal is to expand our nation’s capacity to deliver a health care workforce that can address the needs of our racially and ethnically diverse population. It could be the difference between the patient who feels comfortable enough to share their medical history with a doctor who speaks their native language, and the patient that fails to share their history and as a result Fall 2017 | arizonaphysician.com

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Focus On Border Health develops a preventable illness. Addressing workforce shortages isn’t always a question of how – we could already be doing much more if other innovative programs included in the ACA were actually funded. For example, Section 10501 of the ACA established medical school grants that provide rural-focused training and recruit students most likely to practice in underserved, rural communities. Similarly, Section 5307 authorizes grants, contracts, and cooperative agreements for research, projects, and model curricula that provide training in cultural competency, prevention, public health proficiency and reducing health disparities. These provisions and similar programs have the potential to make great strides towards addressing the severe workforce shortage issues that plague the United States and especially the rural border regions, yet, neither program has ever been funded by Congress. The political will to step up and say, “these programs are worth it” must be there. At the end of the day, legislators face a choice of supporting programs that have been critical to meeting the needs of border communities or jeopardizing the progress that has been made thus far. The ACA has not been a solve-all approach for our borderlands, but from the Medicaid expansion to the Indian Health Care Improvement Act, it has filled an enormous gap in care. In Arizona alone, over 387,000 individuals gained coverage through the ACA. Sadly, prior to the passing of the ACA, Native American populations in Arizona and elsewhere had historically been neglected to the point where we should have been embarrassed as a nation. The Indian Health Service (IHS), which currently provides care to 2.2 million people, already lacks proper funding. The ACA permanently reauthorized care for Native Americans, while expanding programs for mental health, transportation and long-term care for this population.

Those are just some of the ways in which the ACA has made great strides, not to mention the more commonlyknown benefits, such as free preventative services, protecting those with pre-existing conditions, allowing children to stay on their parents’ insurance and reducing age and gender price rating, all which benefit border populations. That is why I find Republican efforts to dismantle the ACA so troubling. Improving our health care system is an on-going process. Yes, it is complicated and it should be, because the health of 300 million plus individuals requires more than a one- size-fits-all solution. Instead of ripping apart the ACA, Members of Congress should work together to improve upon it, just as history shows we have done with other landmark laws. We should focus on bringing down costs, reducing high deductibles, and increasing accessibility, including to diverse quality providers. I firmly believe health care is a right for all, not a privilege for the wealthy few. To overlook and oversimplify the diverse needs of border communities is a huge and costly disservice to the patients and constituents for whom we as physicians and lawmakers have vowed to protect and care. Raúl M. Grijalva has represented southern Arizona in the United States House of Representatives since 2003. In his time in Congress, he has risen to become the Ranking Member of the Natural Resources Committee, Co-Chair of the Congressional Progressive Caucus, a senior member of the Education and Workforce Committee and a longstanding member of the Congressional Hispanic Caucus. A lifelong public servant to his home community of Tucson, Rep. Grijalva spent 12 years on the Tucson Unified School District and 15 years on the Pima County Board of Supervisors before coming to Congress.

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ARIZONA PHYSICIAN | Fall 2017


Focus On Border Health

A Border Hospital Perspective:

Leading the Yuma Regional Medical Center BY DARIN FENGER

Fall 2017 | arizonaphysician.com

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Focus On Border Health

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roviding healthcare just 23 miles from the border with Mexico is a far bigger blessing than a challenge, even in today’s world of ever-changing laws and reimbursement policies. That’s the message of Dr. Robert Trenschel, President and CEO of Yuma Regional Medical Center (YRMC), who says he knows that his counterparts far from the border likely underestimate the many positive points of operating a hospital along such a unique spot on the map. “The border issues can be unique from an immigration perspective, but being in healthcare along the border is not as different as you might imagine. Plus, it’s certainly not the Wild West anymore,” Trenschel said, chuckling. “It’s actually not that different financially. Sometimes it’s actually better.” The hospital CEO said that while challenges such as reimbursement for uninsured patients may be a bigger challenge for YRMC, the benefits of being a hospital along the almost 2,000-mile-long U.S. border with Mexico are still far greater. “You may have less competition when you work along the border. You may have more patients who need your care, not fewer,” Trenschel said. “They may have payment sources that others may not. From my perspective, I think care on the border may actually be a little more financially advantageous for providers.” In addition to its close proximity to the border, YRMC serves as Yuma County’s only hospital. “We are the only major resource for 180 miles,”

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Trenschel said. “That is a huge factor. There is nowhere else for people to receive care.” YRMC reaches out to the Yuma field-worker community through numerous ways, including partnerships, community events and outreach. The hospital works with Campesinos Sin Fronteras (Farmworkers Without Borders) to provide educational and screening resources that are specific to types of cancer to field workers, for example. YRMC actively participates in and supports community outreach events that benefit field workers directly, such as Dia Del Campesino (Day of the Farmworker) and the Melon Festival. Through the hospital’s Workplace Wellness Program, YRMC also reaches out to The Growers Company – a major agriculture presence in Yuma County – to provide ongoing wellness education sessions, biometric screenings and early detection screenings. Other major advantages that are unrelated to the border include two major military installations in the area, and the fact that Yuma County draws an incredible average of 90,000 winter visitors during the cooler months each year. Trenschel stressed that while the culture along the U.S.-Mexico is obviously a unique mix of trends and demographics, the difference between the border region and the rest of the United States is becoming less and less. “Over the last 10 years, the country has just become much more diverse,” he said. “The population throughout the United States has become so diverse that I think most healthcare organizations face a lot of the similar issues. We


Focus On Border Health

may face them in a little more concentrated fashion.” YRMC’s relationship with the border is a tangible one, with many patients being Mexican-American or citizens of Mexico living in Yuma or traveling across the border to receive care. Of course, most Mexican citizens are here legally, while some have entered into the United States illegally. Trenschel said one of the biggest challenges for YRMC is not being reimbursed for care provided to anyone who lacks insurance or any form of coverage. “I think a significant portion of care that is not reimbursed comes across from Mexico. This is where we are affected more,” Trenschel said. “Obviously, from a financial perspective, if you have higher levels of uncompensated care that is an issue, because you have to provide care to everyone who walks into your Emergency Department due to the Emergency Medical Treatment & Labor Act (EMTALA).” He added: “Whether they are here legally or illegally, we care for everyone who comes to our door.” Some of that traffic across the border can benefit YRMC, however, especially for oncology, orthopedics and cardiology. “Mexican residents will come across for some, but not all of services. The primary care they can receive in Mexico is probably less expensive. Medications are also cheaper,” Trenschel explained. “They come across when they are injured very badly or need something that is not getting addressed across the border.”

He added that too many people underestimate the economic impact of Mexican residents seeking services in the United States. He stressed that it is a mistake to perceive Mexico as only a place of poverty. “Too often people stereotype Mexico incorrectly. The demand for cash-pay services that comes over from Mexico is definitely a good thing about being a border hospital,” Trenschel said. “It’s really about perception. Poverty is not necessarily always the case.” The bigger financial drain for YRMC is actually crossing the international border in the opposite direction. Statistics show that 30 percent of insured city and county employees with Yuma County receive their healthcare in Mexico. Trenschel called that figure a “concerning drain” on YRMC’s pool of insured residents. However, he quickly adds that he understands why some American citizens – even Mexican-Americans who were born in the U.S. – may choose to cross the international border to see a doctor. “Mexican providers are able to offer less-expensive care, so we are seeing an outmigration of insured patients across the border. Culturally, they simply may be more comfortable receiving care in Mexico,” Trenschel said. “Many of our physicians are foreign born, but not of Hispanic descent. Patients in Yuma who are of Mexican descent may prefer to see someone from the same cultural group. They have that cultural connection with their provider.” To help take that trend in a new direction, YRMC’s Fall 2017 | arizonaphysician.com

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Focus On Border Health Family Medicine residency program focuses part of its curriculum on teaching new generations of doctors about the special needs of multi-cultural care along the border. Since the residency program began several years ago, numerous young physicians have chosen YRMC for the chance to learn more about caring for under-served populations. For Trenschel, who is a Doctor of Osteopathic Medicine (DO), Robert Trenschel, DO, President and CEO delivering healthof Yuma Regional Medical Center (YRMC) care that is relevant, culturally sensitive and also financially viable for all parties involved is certainly nothing new. Trenschel’s career in healthcare has spanned working in Texas with its rich Mexican-American community to years spent in Florida serving patients of Cuban and Haitian descent. “In the public hospital arena, you always have higher concentrations of individuals who are either disenfranchised or who don’t have insurance,” he said. “Often that population can represent various ethnicities.” While the quality of care a patient receives is never impacted by their citizenship or cultural background, the approach to care should certainly be tailored to that patient’s specific cultural needs, Trenschel says. “The challenges are the cultural beliefs that a patient brings with them. That translates into their care, of course,” Trenschel said. “You are still going to provide the care that you need to provide, but you still need to know what those cultural beliefs are, so that the patient really hears you and makes that personal investment in their treatment, for example.” Cultural sensitivity is especially important when dealing with chronic disease management. “That’s where the rubber really meets the road. If someone comes in with a broken bone, they simply want it fixed,” Trenschel said, adding that such health needs revolve more around helping a patient make a behavioral change. “Diet plays such an important role because food traditions are so important across various cultures. How do you help them become healthier? It helps to understand 12

ARIZONA PHYSICIAN | Fall 2017

them as people and as members of a unique cultural group.” He added that whether the issue is diet or exercise, he has always believed that allowing a patient to hold onto a cultural belief will result in greater buy-in, which will always benefit the patient. “They know you are aware, that you care. It really builds a bond when they know that you care about their cultural beliefs,” Trenschel said. “Then patients are more open to receive whatever it is that you have to say, which really is in their best interest.” Clinicians must also speak patients’ language in a most literal way. “Having such a large portion of the population who speaks Spanish, then trying to have a workforce that mirrors that population, can be very difficult. However, we know that when you speak the language of the individual, you accomplish so much more. You don’t have to go through an interpreter,” Trenschel said. “There are also the cultural beliefs that will be better understood for the patients and their families. They are an important part of the care and education, too.” Despite the many clear advantages of working in healthcare along the U.S.-Mexico border, YRMC still must work to overcome incorrect perceptions. Trenschel said this can particularly come into play when medical professionals from other parts of the country or world are considering a move to Yuma, but really only know the region through movies or the news. “Sometimes it is a little more of a challenge in the border area in terms of the perception of safety. When I have recruited some physicians here, they have asked if it’s safe living so close to the border. It’s okay that they ask because they just don’t know,” Trenschel said. He added that he’s always more than happy to tell people about the quality of life in Yuma, Arizona. Trenschel says that when he and his wife moved to the community two years ago, it didn’t take long for them to fall in love with the town and truly consider it home. “I always tell those doctors that Yuma is very safe. I think it is a wonderful community and I enjoy living here,” Trenschel said. “I am always excited to tell people about Yuma. To me, YRMC really should be one of this area’s greatest ambassadors to the rest of the nation – and world. We know how happy we are to live and work here. Yuma just might be where that next doctor or nurse would truly love to call home.” Darin Fenger serves as the Corporate Communication Specialist for Yuma Regional Medical Center. Prior to joining the hospital’s Community Relations team, Fenger wrote for the Yuma Sun newspaper. His last position at the newspaper, after serving 14 years there, was features editor.


Arizona’s PMP Mandate: Choosing the Right Path for Your Practice BY MELISSA KOTRYS, CEO, HEALTH CURRENT

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early 800 Arizona residents died from opioid overdoses last year, a 74 percent increase in opioid overdoses since 2012. These are alarming numbers, and they were the key reason behind Governor Ducey’s declaration of a public health emergency regarding opioid abuse this past June. They are also the target of a new state law, effective October 16, 2017, that requires all prescribers to check a patient’s utilization history through the state Controlled Substances Prescription Monitoring Program (PMP) before prescribing an opioid or benzodiazephine drug. Arizona’s PMP law was signed by Governor Ducey in March 2017; however, the mandate to check utilization histories was delayed, allowing for an integration with the statewide HIE, Health Current, as well as integrations with provider electronic health record (EHR) systems. According to the legislation, the mandate was to go into effect the latter of October 1, 2017 or 60 days after the statewide HIE integrated the state’s PMP into the HIE. Health Current notified Arizona’s Board of Pharmacy that it had integrated the state database into the HIE as of August 17, 2017. As a result, the Board of Pharmacy posted a notice that the mandate goes into effect on October 16, 2017.

Checking a patient’s utilization history Prescribers should first become familiar with the requirements of the PMP mandate, as well as the exceptions

to the mandate. (Please see PMP Overview & Exceptions at healthcurrent.org/PMP Mandate). Before prescribers access the PMP, they must be registered with the Arizona State Board of Pharmacy (ASBP). This registration process also allows a registered prescriber to assign a delegate or delegates who are also able access the database, although they must use a separate log in. There are two types of applications that allow users to access the PMP. One is through the ASBP website. Another application allows the statewide HIE, Heath Current, and electronic health record (EHR) companies to integrate with the PMP and provide access to registered users. Here are the three ways that prescribers can access the PMP: • Access via the ASBP Website Users manually enter the prescriber name, license information and patient name to search utilization history. This application is available immediately, and it not only allows users to access Arizona patient utilization history, it also allows users to search other states for patient utilization histories. • Access via a Provider EHR A provider’s EHR must be integrated with the state PMP and prescribers must be set-up for access before they are able to access the PMP. Providers should check with their EHR vendor to find out about the availability, Fall 2017 | arizonaphysician.com

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timing and costs of this integration and set-up which could be significant. Once integration is complete, access through a provider EHR can be effective and efficient. • Access via Health Current, the Statewide HIE Health Current is integrated with the PMP as of August 17, 2017. This means that HIE participants who are connected to the HIE portal have a simple set up process to access the PMP. Arizona providers who are not yet HIE participants will need to join the HIE and then be connected to the portal in order to access the PMP. Access to the PMP via Health Current can be an effective and efficient option.

The value of checking utilization histories through Health Current While a Health Current connection offers an efficient workflow solution for accessing the PMP, there is much more to HIE participation. Today, the HIE contains clinical information on 7 million unique patients, with nearly 400 organizations participating in the HIE, including all major hospitals. For example, information on over 90 percent of all hospital inpatient admissions and emergency visits is available through the HIE. Participants save valuable time and resources with one connection to the HIE that eliminates the need to manage multiple connections to hospitals, reference labs and other providers. In addition to access to the PMP, there are many services that help integrate the secure sharing of patient information into provider workflows: • Alerts – real-time event notifications (admissions, discharges, ED visits, etc.) sent to providers based on a panel of patients that they wish to track. • Direct Email – secure email accounts that allow registered users to exchange patient protected health information. • Portal – secure web-based access that allows selected patient data to be viewed online. This includes access to the PMP Gateway. • Data Exchange – electronic interfaces between a provider’s EHR and other EHRs or patient tracking systems, including unidirectional and bidirectional exchange. • Clinical Summaries – comprehensive Continuity of Care Documents (CCDs) containing up to 90 days of a patient’s recent clinical and encounter information.

Choosing the right path for your practice There are several key considerations for prescribers in selecting the right option or options for access to the state PMP: • Workflow – Accessing the PMP through the statewide HIE or a provider’s EHR will offer a much more efficient workflow than the standalone process of accessing the PMP through the ASBP website.

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ARIZONA PHYSICIAN | Fall 2017

• Costs – There are no participation fees for community providers who participate in the HIE, and there is no cost to access the PMP through the ASBP website. However, there could be a cost as well as a time delay associated with the integration of a provider EHR with the PMP. • Timing – Access to the PMP through the ASBP website is available immediately, and access for HIE participants connected to the HIE portal is available with a brief set up process. For other options listed above, prescribers should check with their EHR vendor or a Health Current representative. While prescribers may need to access the PMP through the ASBP website as a short-term solution, they will want to carefully consider the right long-term approach for their practice. HIE participants should contact their account manager if they are interested in accessing the state PMP. Providers who are not yet participants in Health Current are able to find out about HIE participation and connecting to the PMP by contacting Health Current at: recruitment@ healthcurrent.org.

QUESTIONS? NEED MORE INFORMATION? Arizona Board of Pharmacy Prescription Drug Monitoring Program 602-771-2732 https://pharmacypmp.az.gov/ pmp@azpharmacy.gov Arizona Department of Health Services Clinicians Website on Opioid Prescribing (Arizona guidelines, links to CMEs, etc.) www.azhealth.gov/opioidprescribing Health Current Arizona Statewide Health Information Exchange 602-688-7200 https://healthcurrent.org/ info@healthcurrent.org Prescription Drug Misuse & Abuse Initiative Community Toolkit www.RethinkRxAbuse.org


PMP Compliance Checklist If you are unfamiliar with the components of the impending mandate, this PMP Compliance Checklist may be helpful in preparing yourself and your practice.

onfirm you are registered with the PMP, visit 1 Chttps://pharmacypmp.az.gov/; registration is already required by Arizona law.

7 Understand the EXCEPTIONS to the requirements:

a. The PMP does not need to be checked if the patient is:

arefully read the new law, SB 1283 (https://apps. i. Receiving hospice or palliative care for a 2 Cazleg.gov/BillStatus/GetDocumentPdf/442343) serious or chronic illness.

CUT ALONG DOT TED LINE AND KEEP FOR YOUR REFERENCE

and make sure you understand it.

ii. Receiving care for cancer, cancer-related illness or condition or dialysis treatment. Determine the optimal way to use the PMP in your practice, there are essentially three options: iii. Being administered the controlled substance. a. Use the PMP independently. iv. Receiving the controlled substance during the course of inpatient or residential b. Use the PMP with a data management treatment in a hospital, nursing care facility, program that can assist with analysis, push assisted living facility, correctional facility or alerts, automation, etc. mental health facility. c. If available, use the PMP with your electronic v. Being prescribed the controlled substance health record; access to the statewide for no more than a ten-day period for an health information exchange is free for most invasive medical or dental procedure that providers. results in acute pain. You may authorize delegates to check the PMP on vi. Being prescribed the controlled substance your behalf; however, they must use a separate for no more than a ten-day period for an log in. acute injury or a medical or dental disease

3

4

process diagnosed in an emergency setting that results in acute pain to the patient (does not include back pain).

5 2017, or when the PMP is integrated into the

The mandate will go into effect on October 1, statewide health information exchange, but it is advisable to begin using it sooner to minimize disruption.

the requirements for checking 6 Uthenderstand PMP:

a. Must check PMP for all new patients and continuing quarterly treatment for patients being prescribed an opioid analgesic or benzodiazepine. b. Prior to the prescription being written, prescriber must first review all Schedule II, III or IV medications prescribed for the patient in the proceeding twelve months.

vii. Being prescribed the controlled substance for no more than a five-day period, and the prescriber has already reviewed the PMP within the last thirty days and the patient had not been prescribed a controlled substance previously by another prescriber.

b. Practitioners may receive a one-year waiver due to technological limitations.

c. Practitioners are not responsible for checking the PMP if they are unable to request or receive data due to system failure.  Note: This checklist is a resource developed by the Arizona Osteopathic Medical Association and the Arizona Medical Association.

Fall 2017 | arizonaphysician.com

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Engaging with Patients on the “ Demand Side” of Opioids and Chronic Pain BY BEN BOBROW, MD

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ARIZONA PHYSICIAN | Fall 2017


T

he term supply side economics gained notice in the U.S. during a period of severe economic stagnation with extraordinarily high unemployment and high inflation. While the economic theory became popular in the 1970s, its roots can be traced all the way back to United States “Founding Father” Alexander Hamilton. Supply-side economics posits that supply is the key to economic prosperity and that consumption or demand is simply a secondary consequence. Economics, like medicine, is full of controversies and there is an opposing theory as to what primarily drives economies. In contrast to the supply side concept, demand side economics (credited to one of the most influential economists of the 20th century, John Maynard Keynes) argues that economic growth is primarily created not by supply but rather by demand for products and services. Economic and political viewpoints aside, while neither theory works perfectly in the real world, there is some value (and truth) to each model. A parallel becomes apparent when examining two inter-related major public health problems: opioid use/abuse and chronic pain (non-cancer pain lasting more than 3 months).

The challenge Since the 1990s, we have seen the use of opioids increase and despite significant increases in medical treatments (imaging, medications, and procedures) for back and neck pain, joint pain, headaches, and abdominal pain, population disability rates have not improved. Chronic pain now affects an estimated 100 million Americans and costs our nation roughly $635 billion a year in medical expenses and lost productivity.1 This places an unprecedented burden on our healthcare system and impedes our country’s ability to compete globally. More importantly, opioid misuse/abuse and chronic pain are destroying lives, families, and communities. The yearly number of overdose deaths related to prescription and illicit opioids has nearly quadrupled since 2000, and this increase parallels the striking growth in the quantity of opioid pain relievers we prescribed.2, 3 Chronic pain is the number one cause of long term worker’s disability. In contrast to other leading public health problems in the U.S., we (the medical community) have all, to some degree, been involved in getting to this point. The two public health problems of opioid use and chronic pain are intertwined. A recent national survey suggested that in 2015, 37.8% of adults (91.8 million people) in the U.S. used prescription opioids and that, among these, 16.7% reported a prescription opioid use disorder. Interestingly, 63.4% said they used opioids “to relieve physical pain” and 11.2% took opioids “to help them relax.”4 Evidence suggests that the vast majority (~75%) of people now using heroin, started after receiving an opioid prescription from a medical provider, most commonly for pain.5

Emphasis on the supply-side To thwart these public health harms, federal and state entities have implemented important and well-intentioned

prescription drug monitoring programs and policies aimed at curbing excessive and inappropriate opioid prescribing. These prescribing guidelines (analogous to the supply side of the equation) have dominated the professional and media conversations around how to mitigate the enormous morbidity and mortality we continue to see. To quote an exasperated DEA official at a recent public opioid reduction conference in Arizona, “We simply can’t play whack a mole with our opioid problem.” I agree with his sentiment, which is based on the reality that the opioid issue is now so pervasive that we should not delude ourselves into thinking we can simply create (and try to enforce) some prescribing policies and that this will somehow heal our pain and addiction. Rather, the two largest national public health epidemics of our generation, opioid abuse/overdose and chronic pain, are so closely linked that neither can be fixed in isolation. The reality is that it won’t be easy or quick. They require a more in-depth understanding and a sustained, systematic approach to both issues. Changing our national opioid and pain trajectories requires a paradigm shift in which we simultaneously focus our attention and resources not only on the supply side but also just as resolutely on the demand side. Effectively treating pain is foundational to Western medicine and has even been referred to as a “moral imperative.”1 In the wake of the dramatic prescribing reductions, the question millions of Americans (and their healthcare providers) are now asking is, “If no pain medications, what exactly are we supposed to do for our pain?” Simply not treating pain is not an option, but if practitioners fail to offer patients viable alternatives, the concern is that many will seek opioids from illicit sources. In fact, as prescriptions for opioids significantly decrease, we have already seen a significant uptick in the use of heroin and heroin-related complications.5

Why chronic pain is so hard to treat Despite considerable research, there is still much that needs to be elucidated about how to optimally treat chronic pain. This is in part because it is a profoundly subjective experience and challenging to quantify. Many believe that at least one major contributor to our failure to remedy chronic pain is that too many of us – providers and patients – fundamentally view (and treat) acute and chronic pain in similar ways, when they are in fact very different clinical entities. We know that chronic pain signals can remain active in the nervous system for months and even years after an injury. Sometimes pain even ensues in the absence of any identifiable injury. Advances in functional MRI brain imaging have demonstrated significant changes in both brain structure and neurochemical composition which are associated with chronic pain as well as depression, anxiety, and insomnia. Much of the pathophysiology of chronic pain may lie in these neurocognitive changes which cause the brain to “over sense” routine and non-threatening nerve inputs. Individual attitudes towards pain, particularly irrational fear, anger, catastrophic thinking, attention, and hypervigilance are predictors of the chronification of pain.6


Negative and maladaptive emotional states are very common in chronic pain sufferers and such neurocognitive corollaries can prevent a return to normal life, work, and enjoyable leisure activities. This in, turn, produces a cycle of further pain, inactivity, deconditioning, and low self-esteem. Nearly every specialty of medical practitioner recognizes this constellation of symptoms and has observed a poor response to conventional therapies that work to alleviate acute pain. All of this does not mean that chronic pain is somehow less real than acute pain. Rather it underscores that there is much more to chronic pain than only the biological aspect and that we need to view chronic pain (and opioid abuse) from a broader and more accurate biopsychosocial perspective. While the large emotional component to chronic pain and opioid use may seem like a barrier to effective treatment, it also creates therapeutic opportunities.

Helping patients change mindsets around opiates and chronic pain We have many opportunities immediately available to us to significantly improve our approach to treating chronic pain but two areas stand out. The first is improving patient self-efficacy – one’s confidence in one’s own ability to achieve intended results – around chronic pain and opioid use. Self-efficacy is established by life experiences in mastering skills and social persuasion that one has the competencies to succeed. Higher levels of self-efficacy have

In the wake of the dramatic prescribing reductions, the question millions of Americans (and their healthcare providers) are now asking is, “If no pain medications, what exactly are we supposed to do for our pain?

been associated with lower levels of pain and disability.7 Ample evidence also exists that self-efficacy plays a prognostic role for those with substance use disorders.8 As physicians, we have an immense (but often under-utilized) ability to impact our patients through the cornerstone of medicine: the patient-clinician relationship. On the surface, we collect data and relay disease and treatment information. However, on an emotional level, our dialogue has the potential to induce a sense of shared aims, trust, hope, empathy, caring, and comfort. All of

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ARIZONA PHYSICIAN | Fall 2017

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these “positive” sentiments combat the maladaptive ones and help improve the perception of pain and can motivate individuals to want to make necessary lifestyle changes. These are often referred to as mindsets of which there are generally two pertinent kinds.9 The first are mindsets around treatment efficacy and second are mindsets on the capacity to change. Infusing constructive mindsets that a treatment will be effective and that there is at least the potential for improvement are essential. For example, if the practitioner does not express confidence that pain self-management with increased appropriate activity can improve chronic pain and function, the patient senses this and is far less likely to want to try it. Instilling these mindsets may be as easy as providing information or refining how we frame things. For sure, in some cases, the process of changing a deeply entrenched mindset may be more challenging and involve a combination of efforts such as identifying and addressing the source of an immobile maladaptive mindset. However, some static mindsets can be changed with remarkably brief interventions – the right words at the right time. Yes, this takes some engagement and dialogue but it is much more effective (and safer) than many of the interventional treatments on which we have become reliant. I have seen that we often don’t try very hard at this, and sometimes we don’t try at all. The second opportunity is to more strongly encourage chronic pain self-management. Perhaps the most vital factor in managing pain is the role of patients themselves. As a profession, we have succeeded at medicalizing things which our parents and grandparents mostly shrugged off. Additionally, we frequently are complacent in patients being passive recipients of care, which in the case of chronic pain decreases their sense of control and yes, their self-efficacy. Pain self-management is an effective way to increase activity and energy levels, lessen disability and reduce the perception of pain. When people actively participate in things which give their lives meaning, this empowers them and builds self-confidence. This also promotes a sense of control over pain so that people feel as if “they have pain and not the other way around.” Arizona has made tangible strides in this direction. One notable development is the formal recognition of chronic pain as a chronic disease – similar to heart disease and diabetes. This helps people appreciate that like those other chronic conditions, chronic pain requires ongoing patient self-management. Recently, as part of the Governor Ducey’s call to reduce opioid deaths, the Arizona Department of Health Services’ Director, Dr. Cara Christ, with the input from a wide range of experts and stakeholders, launched a novel state public health program focused on helping people better understand and self-manage chronic pain without opioids.10 This type of innovative public health effort, aimed at increasing public awareness and utilization of safe, effective approaches to managing chronic pain and appropriate opioid use, is intended to be synergistic with practitioners having these crucial conversations with their patients. The result is people wanting to be active participants in their care and wanting to take less opioid medications as they

better grasp their capacity and their role in healing. The perniciousness of these epidemics requires multi-pronged and sustained tactics that engage all sectors of society including the public and focus not only on the supply side but also on the demand side of the problems. Different than previous major public health problems, we (the medical profession) played a central part in the progression of our current opioid and chronic pain problems. Now we all have a big role in helping turn things around. You can share and download Patient Chronic Pain Self-Management Resources designed to help patients and caretakers by visiting the ADHS website and searching for the term “Chronic Pain Management.” References: 1. Relieving Pain in America: A Blueprint for Transforming Prevention, Care, Education, and Research presents the IOM study – 2011 2. Paulozzi L, Jones C, Mack K, Rudd R. Vital signs: overdoses of prescription opioid pain relievers — United States, 1999–2008. MMWR Morb Mortal Wkly Rep 2011;60:1487-1492 by visiting the ADHS website and searching for the term “Chronic Pain Management.” 3. Han, Compton, Blanco, Crane, et. al., Prescription Opioid Use, Misuse, and Use Disorders in U.S. Adults: 2015 National Survey on Drug Use and Health. Ann Intern Med. 2017;167(5):351-352. 4. R  udd RA, Aleshire N, Zibbell JE, Gladden RM. Increases in drug and opioid overdose deaths — United States, 2000–2014. MMWR Morb Mortal Wkly Rep 2016;64:1378-1382 5. Theodore J. Cicero, PhD1; Matthew S. Ellis, MPE1; Hilary L. Surratt, PhD2; et al The Changing Face of Heroin Use in the United States A Retrospective Analysis of the Past 50 Years. JAMA Psychiatry. 2014;71(7):821-826 6. Lautenbacher S, Huber C, Schofer D, et al. Attention and Emotional Mechanisms Related to pain as Predictors of Chronic Postoperative Pain: A Comparison with Other Psychological and Physiological Predictors. Pain. 2010 Dec;151(3):722-31. 7. Dohnke B, Knäuper B, Müller-Fahrnow W. Perceived self-efficacy gained from, and health effects of, a rehabilitation program after hip joint replacement. Arthritis Care Res 2005;53:585–92 8. K  adden R, Litt M. The Role of Self-Efficacy in the Treatment of Substance Use Disorders. Addict Behav. 2011 Dec; 36(12): 1120–1126. 9. C  rum A, Zuckerman B, Changing Mindsets to Enhance Treatment Effectiveness. JAMA. 317(20):2063–2064, May 2017 10. http://azdhs.gov/prevention/tobacco-chronic-disease/chronicpain-management/index.php 11. https://thepainproject.com

Dr. Ben Bobrow is a Distinguished Professor of Emergency Medicine at the University of Arizona College of Medicine and Co-Director of the Arizona Emergency Medicine Research Center. He also serves as the Medical Director for the Bureau of Emergency Medical Services and Trauma System at the Arizona Department of Health Services.

Fall 2017 | arizonaphysician.com

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New AMA Study Reveals Practice Owners Are No Longer the Physician Majority 20

ARIZONA PHYSICIAN | Fall 2017


Physicians evenly distributed between owners and employees Fewer than half of patient care physicians had an ownership stake in their medical practice, according to a newly updated study on physician practice arrangements by the American Medical Association (AMA). This marks the first time that physician practice owners fell below a majority portion of the nation’s patient care physicians since the AMA began documenting practice arrangement trends. The share of patient care physicians with ownership stakes in a medical practice declined 6 percentage points to 47.1% in 2016 from 53.2% in 2012. In contrast, the share of patient care physicians with employed positions increased about 5 percentage points to 47.1% in 2016 from 41.8% in 2012. As a result, there were equal shares of physician employees and physician practice owners in 2016, while 5.9% of patient care physicians were independent contractors. The preference of younger physicians toward employed positions has had a prominent impact. Nearly two-thirds (65.1%) of physicians under age 40 were employees in 2016, compared to 51.3% in 2012. The share of employees among physicians age 40 and older also increased between 2012 and 2016, but at a more modest pace than younger physicians. “Patients benefit when physicians practice in settings they find professionally and personally rewarding, and the AMA strongly supports a physician’s right to practice in the setting of their choice,” said AMA President Andrew W. Gurman, M.D. “The AMA is committed to helping physicians navigate their practice options and offers innovative strategies and resources to ensure physicians in all practice sizes and setting can thrive in the changing health environment.” Whether physicians are owners, employees, or independent contractors varied widely across medical specialties in 2016. The surgical sub-specialties had the highest share of owners (59.3%) followed by radiology (56.3%). Emergency medicine had the lowest share of owners (27.9%) and the

highest share of independent contractors (24.8%). Pediatrics was the specialty with the highest share of employed physicians (58.3%). While the majority of patient care physicians (55.8%) worked in medical practices that were wholly owned by physicians in 2016, this majority decreased from 60.1% in 2012. Although this share is more than 4 percentage points lower than that of 2012, most of this change occurred between 2012 and 2014. Physician movement toward hospital-owned practices and direct hospital employment appears to have slowed since 2014. The share of physicians who worked directly for a hospital, or in practices with at least some hospital ownership, was the same in 2014 and 2016 – 32.8%. Despite challenges posed by a changing health care landscape, most physicians (57.8%) provide care to patients in small practices of 10 or fewer physicians. There were signs of a gradual shift toward larger practices. In 2016, 13.8% of physicians were working in practices with 50 or more physicians compared to 12.2% in 2012. The new study is the latest addition to the AMA’s Policy Research Perspective series that examines long term changes in practice arrangements and payment methodologies. The new AMA study, as well as previous studies in the Policy Research Perspective series, is available to download from AMA website.

About the American Medical Association The American Medical Association is the premier national organization providing timely, essential resources to empower physicians, residents and medical students to succeed at every phase of their medical lives. Physicians have entrusted the AMA to advance the art and science of medicine and the betterment of public health on behalf of patients for more than 170 years. For more information, visit ama-assn.org.

Distribution of physicians by ownership status and type of practice1 2012 Ownership status

Owner Employee Independent contractor

Type of practice

Solo practice Single specialty group Multi-specialty group Direct hospital employee Faculty practice plan Other 2

2014

2016

53.2% b 41.8% 5.0% b

50.8% a 43.0% a 6.2%

47.1% a 47.1% a 5.9%

100%

100%

100%

17.1% 18.4% 42.2% 45.5% a 24.7% 22.1% a a 7.2% 5.6% 2.8% 2.7% 5.9% 5.7%

16.5% b 42.8% b 24.6% b 7.4% a 3.1% 5.7%

100% 3466

100% 3500

100% 3500

Source: Author’s analysis of AMA 2012, 2014, and 2016 Physician Practice Benchmark Surveys. https://www.ama-assn. org/about/physician-practice-benchmark-survey Notes: 1Significance tests are for year to year changes, within category. ‘a’ is p<0.01 and ‘b’ is p<0.05. Indications in the 2012 column are tests for 2012 and 2014; in the 2014 column for 2014 and 2016; and in the 2016 column for 2012 and 2016. 2 Other includes ambulatory surgical center, urgent care facility, HMO/MCO, medical school, and fill-in responses.

Fall 2017 | arizonaphysician.com

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SCID screening begins in Arizona As of August 9, 2017, Arizona newborns are now screened for Severe Combined Immunodeficiency (SCID). This is great news. Arizona runs a higher incidence of SCID than other states. Incidence in the general population is 1 in 50,000 people, in Hispanics, it’s 1 in 25,000, and in certain tribes (Athabaskan), it’s 1 in 2,000. Arizona expects to identify a few children with SCID every year. Early identification of SCID, a genetic disorder characterized by the absence of T cells and antibody production, is key to good outcomes. Without treatment, recurrent infections lead to nearly universal fatal outcomes within the first year of life. Early stem cell transplantation can predict survival rates of 94%, and is available here in the state. Arizona will be analyzing T cell receptor excision circles (TREC) to screen for SCID, which with the right cut-offs, have a good sensitivity and specificity and can be performed on the state’s existing bloodspot cards. These test characteristics, in addition to the higher incidence and effective treatment in Arizona, make SCID a necessary addition to the panel. With phenylketonuria (PKU) being the first newborn disorder screened for in Arizona in the 1960s, and SCID now added as the 31st, Arizona is now an even safer place to be born.

Arizona’s newborn screening panel of 31 disorders

Endocrine Disorders (2) Congenital hypothyroidism (CH) Congenital adrenal hyperplasia (CAH)

Amino Acid Disorders (6) Phenylketonuria (PKU) Maple syrup urine disease (MSUD) Homocystinuria (HCY) Citrullinemia type I (CIT-1) Argininosuccinic acidemia (ASA) Tyrosinemia type I (TYR-1) Fatty Acid Oxidation Disorders (5) Carnitine uptake defect (CUD) Medium-chain acyl-CoA dehydrogenase deficiency (MCAD) Very long-chain acyl-CoA dehydrogenase deficiency (VLCAD) Long-chain L-3-hydroxyacyl-CoA dehydrogenase deficiency (LCHAD) Trifunctional protein deficiency (TFP)



22

Organic Acid Disorders (9) Isovaleric acidemia (IVA) Glutaric acidemia type I (GA-1) 3-Hydroxy-3-methylglutaric aciduria (HMG) Multiple carboxylase deficiency (MCD) Methylmalonic acidemia-cobalamin defect (Cbl A,B) Methylmalonic acidemia-mutase deficiency (MUT) 3-Methylcrotonyl-CoA carboxylase deficiency (3MCC) Propionic acidemia (PROP) Beta-ketothiolase deficiency (BKT)

Hemoglobin Disorders (3) Sickle cell anemia (Hb SS) S, beta-thalassemia (Hb S/ ß Th) S, C disease (Hb S/C)

Other Disorders (4) Biotinidase deficiency (BIOT) Galactosemia (GALT) Cystic Fibrosis (CF) Severe Combined Immunodeficiency (SCID)

Disorders not detected by bloodspot screening (2) Hearing Loss (HEAR) Critical Congenital Heart Defects (CCHD)

More information for Arizona providers about SCID testing, counseling and follow-up is posted at www.aznewborn.com. ARIZONA PHYSICIAN | Fall 2017


Why I chose a retainerbased concierge pract ice

BY SCOT T L. BERNSTEIN, MD, FACP Fall 2017 | arizonaphysician.com

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I

am a private physician in primary care, specifically Internal Medicine (adolescence through senescence), in Scottsdale, AZ. While I was in the third-party payer system, I was self-employed in a solo private practice. The third-party payer system conflicted with my practice style, and my ability to finance its operation and to have a reasonable quality of life. My fundamental style has always centered on a comprehensive, compassionate, individualized approach to patient-centered care. I integrate safe and effective therapeutic choices within the context of each patient’s lifestyle and unique condition. This approach is more demanding and time-consuming than the standard conventional practice, usually requiring that I move well beyond the limited 10–15 minutes that most primary care physicians who contract with third-party payers are able to share with each patient. Consequently, during the time that I accepted thirdparty payments, it became increasingly difficult to practice medicine. Billing and collection services consumed nearly 40% of my gross revenue. Reimbursement from insurance companies, including Medicare, shrank while the costs of running a medical practice continued to rise. I was working 80-110 hours every week attempting to continue my practice style of personalized healthcare. The paperwork and stress were crushing. The dilemma I faced became quite clear: how could I continue to put patients ahead of insurance payments, maintain my innovative, comprehensive approach to personalized care and still open the doors each day without dropping dead? In 2008, I completely opted out of all insurance contracts (including Medicare) and adopted a direct-pay retainer practice. In this practice structure, all of my patients are members, paying an annual fee for my services – vis-à-vis membership in my practice. I neither bill for nor accept any reimbursement from insurance companies. I limit my practice to 200 patients. My youngest patient is 19 and the oldest, 101. They include prominent physicians and attorneys, CEOs, entrepreneurs, academics and artists, as well as a spectrum of people from all walks of life. I also do pro bono publico care by mutual consent.

The practice structure I am still self-employed in a solo private practice. I share call for vacations and weekends with another physician who has a separate, similarly structured practice. I also have the privileges and responsibilities of owning (rather than renting) my office condominium. The balance of my work life and my family life continues to bring me increased personal joy. In addition, I now have the time to pursue my passion for mentoring and teaching the next generation of physicians at the University of Arizona College of Medicine-Phoenix (UACOM-P) as an Assistant Clinical Professor in the Community Clinical Experience course and the Doctoring course1. Since 20122, two healthcare professionals (a licensed massage therapist and a physician who specializes in physical medicine and medical acupuncture) have joined 24

ARIZONA PHYSICIAN | Fall 2017

me in providing a truly integrative approach to personalized patient care. They also own their independent practices and individually lease space and amenities from me, and do not contract with insurance companies. I have the same two employees I had when I converted my practice in 2008. We approach the operation of my practice as an integrated team, including the principles of continuous quality improvement (CQI) and a profit-sharing program. These features promote their vested interest in the practice - a work culture that benefits everyone. I am the captain of my ship. I am not under the dominion of an employer who could close down my practice or who could make working conditions intolerable. I answer only to my patients, my employees, my call partner and myself. If a patient chooses to leave my practice, a replacement is soon enrolled from a waiting list. I get to choose my schedule and working conditions. I am the primary decision-maker and ultimately the practice is run the way that suits my style and temperament. The cost of this privileged freedom is the added responsibilities of leadership and ownership, both of my practice and of my office condominium. Thus, the consequences of all decisions and outcomes are mine to embrace. It has never been easy for me to leave work at the office; I often spend extra time creatively thinking and researching a variety of issues related to patient care, other professional matters and the maintenance of my office suite property. I gladly accept this cost for the freedom I enjoy. While I am always “on call” with regard to the maintenance of the property, I have learned much about the care of commercial real estate and, for several years now, I have been on the board of the owners’ association of the 25-building office complex in which my suite is located and am currently its president. My current practice model has allowed me to engage in a number of additional responsibilities I could not have imagined taking on under my previous model.

Insulated from the ACA I have been insulated from the ACA, as my income is completely independent of insurance companies and government programs. In fact, when the ACA was adopted in 2010, I had a rush of new patient enrollments because of the increased awareness of the problems inherent in healthcare insurance. I anticipate that the current disputations in Washington, D.C. will result in no significant impact on my practice structure.

The physician-patient relationship My patients and I enjoy the unhurried, authentic patient-physician relationship that is the central joy of my practice. My primary technology for patient interactions continues to be the old-fashioned office visit. These appointments are generally scheduled for 45 minutes with ample spacing to allow for individual needs, so I rarely feel pressured for time throughout my day. Telephone appointments are also popular when a hands-on physical examination is not required. Additionally, we communicate


via secure messaging, and sometimes we use Skype or Apple’s Face-time with prior understanding and consent, as these applications have been considered not secure by government agencies.

The growth of the retainer-based model Related models are clearly growing. However, it is difficult to obtain accurate data on the number of similar practices – mainly because the organizations serving these practices have gone through changes, and thus the data has not been well curated. I anticipate that this situation will resolve over the next 6-12 months. Many practices that use the “concierge” moniker actually do bill insurance companies and enroll upwards of 500-600 patients per physician. And many of these practices also employ physician assistants (PAs) and nurse practitioners (NPs) to do a significant amount of the patient care. The literature has indicated that the number of self-employed physicians is declining, but those are physicians who have been in the third-party payer model. The number of self-employed physicians who have opted out of the third-party payer model, however, has been growing. I expect this trend will continue.

Work and family life balance The balance between work life and family life continues to improve as my practice has matured. I generally get

home from work around 6pm. My family life continues to grow in depth and joy, while I reacquaint with old hobbies left fallow and adopt new hobbies that were previously unapproachable. My work-life is happier. My employees are happier. My patients are happier. My home life is happier, and I have more time to pursue both professional and personal interests. Dr. Bernstein has served on the Board of Trustees of the American Medical Association and on the Board of Directors of the Arizona Medical Association. Practicing Internal Medicine in Scottsdale since 1996, he established a direct-pay retainer practice in 2008. Dr. Bernstein is also a Clinical Assistant Professor in the Department of Medicine at the University of Arizona College of Medicine-Phoenix and a Fellow of the American College of Physicians. http://phoenixmed.arizona.edu/education/md-and-dual-degrees/ md-program/curriculum/pre-clerkship-curriculum-years-1-and-2

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AZMedicine, Summer 2012, Volume 23, Number2. Accessible at http://scottsdaleprivatephysicians.com/AZ%20Medicine%20 Summer%202012.pdf

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ARIZONA PHYSICIAN | Fall 2017


What Physicians Think of Employment Models BY SHARLA HOOPER

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he American Medical Association (AMA) has been tracking trends in physician practice arrangements since 2012, with the implementation of their Physician Practice Benchmark Survey (PPBS). This approach has allowed them to fill a gap in identifying trends in physician employment; it offers the first nationally representative look at hospital ownership of practices from the physician perspective. It also provides unique data on physicians’ choices regarding single and multi-specialty practice. The AMA survey collects information on four aspects of physician practice arrangements: whether physicians are owners, employees or independent contractors with their main practice; the type of practice that they work in (e.g., single specialty group); the ownership structure of their main practice (e.g., whether owned by a hospital); and how many physicians are in their main practice. As we discuss elsewhere in this edition, the AMA’s 2016 Benchmark Survey showed a significant change in physician practice models: it marks the first year in which fewer than half of practicing physicians owned their own practices. However, a slight majority of physicians (55.8%) continue to work in practices that are wholly owned by physicians. Regarding practice type, single specialty practice remained the most common and accounted for 42.8% of physicians in 2016. Multi-specialty practice accounted for the second greatest share of physicians (24.6%). Our approach with our own survey was to follow up with Arizona physicians; we requested their insights on physician employment models and this trend away from practice ownership. Thank you to all who participated!

The role of age and gender The AMA survey discovered that younger physicians, defined as those under the age of 40, were more than three times as likely as older physicians to be employed by hospitals. Fourteen percent of the under-40 cohort was employed, while only 4.2% of physicians aged 55 and older

were employed. In addition to age differences there are also gender differences in ownership. In 2016, 36.6% of women physicians had an ownership stake in their practice compared to 52.2% of men. Two factors contribute to this difference: women comprise a greater percentage of the younger physicians. Additionally, women physicians tend to practice in specialties in which employment is more prevalent.

The model you wish you practiced in... We asked our survey participants to indulge in wishful thinking…and their responses revealed a trend toward physician independence. For those who were currently practicing, in administration, or academic, 22% saw having a partnership stake in a small group of physicians as most appealing, 18.5% identified solo private practice, and another 13% identified being an independent contractor as most appealing. We also asked our fellow/residents and medical student respondents in what model they anticipated practicing – overwhelmingly they chose “academic position” (37.5%) and “employed physician within a hospital system” (31%), with the next runner-up as “employed physician within a physician-owned large group practice” (12.5 %).

Autonomy versus security We asked our respondents to share their insights, particularly in the case of those who had worked in multiple employment models. In their responses, some expressed the appeal of autonomy and independence in medical decision-making found in private practice. As one respondent put it, “Private practice offered greater autonomy, but lacked contracting rigor enjoyed as part of a large hospital system owned group.” So, is private practice autonomy worth the trouble? Some were adamant about its superiority. “Private Fall 2017 | arizonaphysician.com

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3.75% 5.0% 7.5% 13.75% 11.25% 58.75%

Administrative physician Academic physician Fellow/resident Medical student Other (such as retired) Practicing physician

If you identified as a fellow/resident or medical student, which employment model do you anticipate pursuing? Employed physician within a hospital system

31.25%

Employed physician within a physicianowned large group practice

12.50%

Academic position

37.50% 6.25%

Independent contractor Not sure/Other Partnership stake in a small group of physicians Solo private practice Concierge/subscription practice

12.50% 0.0% 0.0% 0.0%

From the perspective of employment opportunities, do you feel the implementation of the ACA and the formation of ACOs has been:

37.50%

Generally good for physicians (better opportunities)

56.25%

Not sure/Undecided

6.25%

Generally bad for physicians (loss of autonomy)

practice is still a better model!” according to Dr. Jay Friedman. Dr. Dennis Thrasher wrote, “Thirty-two years in solo practice, and I’ve never regretted it.” Another respondent stated, “Small physician group practice has been very rewarding. It allows great flexibility and opportunity.” Private practice can be fraught with the potential detriments of business decisions, as Henri Carter points out: “Private practice and office management is a daunting prospect. It is very difficult for anybody and especially someone right out of training to competently hire personnel for billing and scheduling. Then there are contracts (Medicare/Medicaid at a minimum typically), office space, nursing staff, supplies, records/EMR, accounting/HR issues even cleaning staff.” Alternately, several employed respondents who had previously worked in private practice expressed the relief of being free from making business decisions. Stated one, “Working as an employed physician removes burden of insurance contract negotiations, hiring and firing of support staff and paying malpractice from my own pocket.” Another echoed this sentiment: “I have been in solo private practice and now work part time as independent contractor for a hospice. I do not miss concerns regarding getting paid, keeping on top of insurance.” Several respondents who were in practices that transitioned to larger system buy out shared their experience: “I initially started at a private practice as an employed physician. No partnership track, minimal benefits. Since our practice was bought by a hospital, I have had many positive changes; increase pay, productivity bonus, 401k, better medical insurance and disability coverage. It’s been great.” And one described positive effects in their clinical circumstances: “I work in a mature employment model and previously owned my own practice. There is no comparison in the benefits of having a well-structured system to support the clinical practice, instead of trying to run a business on top of a clinical practice.” On the other hand, employment might present reduced authority over patient care. One respondent was adamant: “I will never work as an employee again. I will never again let an MBA try to tell me how to practice medicine and what is best for my patients.” The complaints against working in a hospital system employed model yielded a consistent theme – the loss of autonomy: “Was employed by large model and found it onerous, heavy-handed, arbitrary. Pay and vacation were reasonable, but worst professional experience in my life.” This respondent described several areas where control disappears: “Employment by a large health care system subjects the physician to compensation decreases at the will of the employer. Also, as an employed physician there is little to no control over your support staff. The quality of support staff can be very poor and physician input regarding personnel and work flow is often ignored.” When questioning or challenging issues, employed physicians can also find themselves the target of retaliation: “I am currently employed by a national group. The concept is great, the execution is appalling. We claim we are


patient focused but our actions are otherwise. Bringing this to the attention of leadership, essentially calling them out results in retaliation and economic sanction.”

What about the patients? Physicians who saw employment as detrimental repeatedly cited concern for the impact on patient care. Dr. James Langley wrote, “After 40 years of busy private solo practice, I [worked] as a Locums in a private practice for another physician. [It] was outpatient only, not Hospital, no surgery, loss of contact with patient after hours entering system through ER, then a Hospitalist then I got them back. No continuity of comfort technically and the emotional bond with the patient as “their Doctor” is fractured and lost. Very sad and disappointing though I can see the system now gives Doctors more time to rest and be with family and not taxed with running a practice and all that involves.” Dr. Michael Bugola shared that “Having been a partner in a very large medical group (where the average physician has little more influence than an unrepresented employee), I can attest to the remarkably uneasy feeling of being in a position of tremendous medical responsibility with little administrative authority. The patient suffers when medical decisions are (either directly or indirectly) made by (at times intentionally) aloof administrators driven by other priorities.” Stated one respondent, starkly, “Once you are employed by a hospital or health plan you lose control of your patients.” Another found a bright spot among the tangle of quality requirements in employed models, “…On the flip side, good for overall patient care, physician has another check to ensure all bases are covered with patient care.” As one employed respondent put it, “[I have] only worked in an employed model within an academic medical center, which has suited me well overall. That said, one model won’t fit everyone and it’s good for the market to maintain several viable employment types.” Sharla Hooper is the Managing Editor for Arizona Physician and serves as Associate Vice President of Communications and Accreditation for the Arizona Medical Association. Resources Kane, Carol K. “Updated Data on Physician Practice Arrangements: Physician Ownership Drops Below 50 Percent.” AMA Policy Research Perspectives. 2016. https://www.ama-assn.org/sites/ default/files/media-browser/public/health-policy/PRP-2016physician-benchmark-survey.pdf. Kane, Carol K., and David W. Emmons. “New Data On Physician Practice Arrangements: Private Practice Remains Strong Despite Shifts Toward Hospital Employment.” AMA Policy Research Perspectives. 2012. https://www.ama-assn.org/sites/default/files/ media-browser/premium/health-policy/prp-physician-practice-arrangements_0.pdf

Why do you think younger physicians might find being employed more appealing? Freedom from worry about managing practice requirements and meeting regulations

93.75%

More amenable to work/life balance

81.25%

Working in a team care environment

43.75%

Freedom from managing insurance contracts

81.25%

Reflects the experience of growing up in an HMO and ACO environment

25.00% 6.25%

Other

The AMA recently found that less than half of patient care physicians had an ownership stake in their medical practice. Do you find this surprising?

12.50% Somewhat surprising

87.50%

Not at all surprising

Which of the following employment models do you find most appealing? Employed by a hospital system Employed by a physician-owned large group Serving in an academic position

14.81% 11.11% 9.26%

Partnership stake in a small group of physicians

22.22%

Solo private practice

18.52%

Concierge/subscription practice Independent contractor Not sure/Other

5.56% 12.96% 5.56%


Are You Getting Paid? Value-based care is coming, and a key to success is Revenue Cycle Management. BY ELIZABETH MEYER

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hen it comes to health systems and practice management, there’s one thing you can always count on: change is inevitable. A perfect example of this is already underway – the monumental transition from fee-for-service to value-based care. This complex shift in health care is presenting considerable challenges to healthcare organizations, and particularly to their financial processes. The good news? There is one key component that can make all the difference: Revenue Cycle Management (RCM).

Why Revenue Cycle Management (RCM)? As part of the fee-for-service to value-based care transition, health systems will need to migrate their employed physicians and owned practices over to compensation plans that support three goals: improving the experience of care; improving the health of populations; and reducing costs of health care. If a health system continues to compensate employed physicians based on the old fee-for-service model, it will be incredibly difficult to successfully achieve these three goals without a realigned compensation model. In addition, if you don’t align compensation incentives with the goals of reform, you are at a higher risk for penalties, due to the overutilization of acute care or diagnostic services often encouraged by the old-school approach of volume-based care. RCM is a key component to making these transitions successful. Ultimately, if a healthcare organization lacks 30

ARIZONA PHYSICIAN | Fall 2017


As part of the fee-for-service to valuebased care transition, health systems will need to migrate their employed physicians and owned practices over to compensation plans that support three goals: improving the experience of care; improving the health of populations; and reducing costs of health care.

Fall 2017 | arizonaphysician.com

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efficiency, has a poorly trained staff or is ineffective in denial management, it will most certainly lead to a negative bottom line. But here’s the bright side. If a streamlined financial process is in place, the revenue cycle will be a healthy one, which means you’re getting paid.

What exactly is revenue cycle management? The easiest way to describe RCM is that it’s the financial circulatory system of a healthcare organization: claims processing, payment, and revenue generation. It includes all clinical and administrative functions that contribute to the capture, management and collection of patient service revenue. So how do you create a healthy revenue cycle? Ideally, by making sure that from the moment a patient makes an appointment to when the last bill is paid, nothing goes wrong. That sounds daunting, but it’s doable if you focus on completing the following steps correctly, one at a time: • Scheduling/pre-registration • Insurance/benefit verification • Point of service registration counseling collections • Encounter utilization review and case management • Charge capture and coding • Claim submissions • Remittance processing and rejections • Third party follow-up • Payment posting, appeals, Accounts Receivable Management and patient collections

Two key metrics for revenue cycle management Ready for some sobering industry statistics? Research indicates that approximately 15% of claims are never paid due to billing errors, and up to 50% of re-submitted claims are never paid. How do you know if your organization is in trouble? There are two key RCM metrics to consider: Accounts Receivables. While it varies by specialty, accounts receivables “over 120 days” should only represent 15% (10% is ideal) of your average monthly billings. Days in Accounts Receivables. You should average under 45 days, but under 30 days is ideal. Although there are a number of reasons why these two key metrics reflect poor performance, you should focus on the following three areas: Excessive Accounts Receivable. Make sure you: • Separate accounts receivables by insurance and patient balances. • Separate the different insurance payer types, and understand how their payer specific guidelines affect your accounts receivable management. • Identify key offending payers prioritized by amounts outstanding. • View monthly reimbursement trends for each payer. Inaccurate codes. Improve accuracy by routinely scrubbing codes before submission. 32

ARIZONA PHYSICIAN | Fall 2017

Claim rejections and denials. Diagnose rejects and denials by conducting a complete denied claims analysis in order to identify patterns.

Claims and good practices One of the biggest issues that negatively affect revenue is denied claims. In fact, according to the Government Accountability Office, up to one in four claims are denied. Why does this happen? Claims are denied for a variety of reasons, but some of the most common are because: • An insurer considers the care a patient received to be medically unnecessary. • A beneficiary may have received care outside of his or her network without realizing it. • A name was spelled incorrectly. • A number was inconsistently entered between two or more parties, creating a data freeze of sorts. Fortunately, there are two areas within the financial process that can positively reduce the number of denied claims. 1. Verification stage. The claims reimbursement process begins as soon as a patient first makes an appointment with a physician’s office or healthcare provider. A strong emphasis must be placed on recording accurate patient data, including insurance information and provider eligibility. 2. Claims correction. It is crucial to send a clean claim the first time. It is worth taking the extra 30 to 60 seconds per claim to thoroughly scrub it for initial submission, rather than an average of 15 minutes per claim because it was denied.

How do you make all this happen? Creating and implementing a healthy revenue cycle isn’t easy. Keeping up with all the normal, day-to-day tasks that go into running a successful healthcare organization is already a challenge. The transition to value-based care will require more from your staff, whether you’re a multi-location hospital network or a private practice. Revenue Cycle Management is one of the most critical processes that organizations need to master for success in these changing times. You must work diligently and methodically to review suspended claims and analyze where holes or gaps exist with things like compliance, errors, and timeliness. Using resources available to you, like medical software and outsourced billing services, can help make sure you’re ready. Elizabeth Meyer is the Director of Operations for ACOM Medical Billing, and leads a Gilbert, Ariz. based team in best practices for Revenue Cycle Management. With over 30 years of experience in all medical specialties, Elizabeth is a recognized expert in ensuring her private practice and hospital clients are paid quickly and correctly. Contact Elizabeth at: info@ACOMBilling.com; www.ACOMBilling.com; or 1-888-545-2610.


Can physicians maintain independence while working as part of a large system? BY HEIDI MOAWAD

Fall 2017 | arizonaphysician.com

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O

ver the past five years, there has been a major shift in physician practice models, with fewer doctors working in the small, physician-run practices that were considered standard in years past. More and more physicians are becoming part of large hospital systems than ever before. Often, being part of a large hospital system means working as an employed physician, which has some fundamental advantages and some inherent disadvantages. Doctors who are employed by large hospital systems do not have the same degree of independence as self-employed physicians, which can be a tough concept for physicians who do not want to have to answer to a ‘boss.’ However, while affiliation with a hospital system is becoming the trend for many doctors, full-time employment or disheartening lack of profession independence is not the only option. In fact, the reality of physician employment arrangement can involve a grey area that combines working for or within a large hospital system with varying degrees of independence. And there are almost limitless options in terms of what constitutes independence.

Setting clear boundaries Eric Tait, MD, MBA, is a primary care doctor in Houston, Texas, who went into his employment negotiation with IASIS Healthcare in Houston with the objective of working as an employed physician while also maintaining his previously built outside business contracts as well. He says that the key to his own negotiation process was rooted in his understanding that “primary care physicians are valuable to a healthcare system” and that his worth to his employer as a primary care physician gave him valuable leverage. Prior to joining IASIS, he had already built an investment partnership in an independent practice association (IPA), which is a partnership between physicians and insurers. When he agreed to a contract that allowed IASIS, his employer, to collect revenue from his clinical work and pay him a salary, he made it clear upfront that he would not share any of his IPA partnership rights with his employer. While this arrangement certainly sounds fair to most physicians, the reality is that many doctors have been dragged into (and lost) legal battles with employers who have claimed legal rights on physician revenue from outside business ventures, ranging from expert medical witness testimony to ownership in diagnostic facilities. Tait advises physicians to “insist upfront on establishing walls between outside work and the reach of employers.” This advice is quite different from the trap that many physicians fall intowhich is ignoring or even hiding business arrangements, and then running into problems with employers after outside work is discovered. Tait also urges physicians to recognize that even as employed providers, they still have rights to own businesses in healthcare.

The best of both worlds Maria Armstrong, MD, a physical medicine and rehabilitation physician who practices in Medina, Ohio, has

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ARIZONA PHYSICIAN | Fall 2017

worked as a medical director for a rehabilitation hospital while maintaining control of several aspects of her practice. As a medical director, she works as a contractor, preserving power over a number of facets of her professional setting; yet, working in the inpatient setting, she also enjoys a number of the benefits that come with being part of a hospital system. For example, as part of a hospital system, she explains, “I work with excellent nurses and staff, but did not have to hire or train the team.” She also uses the hospital medical record system, and did not have to set up her own, which many private physicians do. She says that the freedom to practice medicine in the way that is best for her patients, without the pressure of making healthcare decisions based on an employer’s profitability, is what she considers the most valuable aspect of her independence. As a contractor, Armstrong believes that she has more control over her hours than she would have had as a fully employed physician. One important aspect of achieving work life balance while working independently lies in building strong work relationships with other doctors, and Armstrong has not ignored that vital component of professional life. Armstrong explains that the key to achieving her work arrangement depended largely on her ability to network and partner with other independent doctors to work out a coverage schedule that is fair and at the same time tailored to each doctor’s needs. This would not be an easy task if Armstrong and her colleagues were all employed by a boss who was allocating responsibilities and compensation. However, Armstrong believes that “the independent model of practice may not last for long” and she sees that doctors are becoming part of larger organizations. She says that maintaining independence comes with a different type of responsibly, and explains that she pays for her own medical malpractice insurance, medical billing service, practice management service and health insurance. She says that buying health insurance for herself and her family is the costliest aspect of not being fully employed and she believes that this factor may be among the leading reasons that many physicians choose to be employed by a healthcare system over self-employment.

Choosing the right fit Paul DeChant, MD, a family physician working as deputy chief health officer, Simpler Consulting, part of IBM Watson Health says that choosing which health care system to align with is a vital part of balancing the combination between employment and independence. DeChant advises physicians “to be a part of a medical group that has strong leadership and good relationships with the system. Ensure your values are shared by the system and its leadership.” DeChant says that a system led by physicians may be the key to a good working environment “because there is better opportunity for physicians in a large system to practice with control over their professional and personal lives. Having physicians leading the organization helps ensure it has values aligned with the values physicians develop in


their education, training and practice.” DeChant’s says that the benefits that come with being part of a large healthcare system are “more financial security in a volatile marketplace, better contracting with payers, better infrastructure support – PI processes to improve performance, personal HR benefits, support staffing without hassle, and integrated EHR.” Yet, he also points to a number of negatives, such as, “more scrutiny regarding performance metrics and a lack of control over personal/professional if poorly managed.”

A range of possibilities The increasing complexities when it comes to payer negotiations and regulatory compliance in healthcare have caused overhead costs to swell for doctors in clinical practice, making the practical advantages of being part of a large hospital system more appealing for many doctors. Yet, the relatively limited degree of independence associated with a traditional employment model causes some physicians to question the wisdom of accepting employment arrangements. DeChant explains, “there will be fewer independent physicians in the future. There is a growing movement of Direct Primary Care in which primary care physicians are opening independent small practices serving a limited number of patients and eschewing contracts with payers. This may grow to some degree.”

More and more physicians are becoming part of large hospital systems than ever before. Often, being part of a large hospital system means working as an employed physician, which has some fundamental advantages and some inherent disadvantages. But, doctors can find numerous types of set ups, and each individual physician values different aspects of independence in the professional setting. It takes some strategic planning early in the process to be able to maintain independence while at the same time partnering with a large hospital system. And ultimately, success in getting what you ask for is largely dependent on how much you are in demand as a physician and whether your professional needs are well matched with the needs of the hospital system. Copyrighted 2017. Advanstar. 127976:1017SH

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Practice Managers: Your partner in private practice W BY CHIP HARDESTY

hen I was a child growing up in a small Florida town, our family doctor was Dr. Tedford. He practiced medicine and was a small business owner. His office had mint green walls and smelled of pHisoHex. He probably drove a Buick. He wasn’t a pediatrician or a surgeon but he administered my immunizations and removed my tonsils. Dr. Tedford never had to deal with much government interference. Medicare and Medicaid were new, EMRs were on Star Trek, and HIPAA was only a glimmer in Ted Kennedy’s imagination. We filed our own insurance claims and Aetna paid them promptly. The business of medicine has changed dramatically but 36

ARIZONA PHYSICIAN | Fall 2017

the physician’s desire to practice medicine has not. I am struck by the fact that the primary reason physicians choose to remain independent is the freedom to practice medicine as they see fit. This has undoubtedly become more difficult as insurance and government requirements and regulations have only added hours to the day reducing time spent with a patient. In a recent study in the Radiology Business Management Association Bulletin,1 it was reported that the average doctor spends 8.7 hours per week on administration; that’s about 20% of a work week! The need for help in managing the insurance company and the government regulations that make the business of practicing medicine onerous is obvious


and is driving the exodus from private practice. Multiple studies have shown that job satisfaction is approximately equal among those in private practice and those employed by hospitals, academic medicine, health plans and larger integrated systems. Interestingly, one of the same studies2 also found that 70% of those who returned to private practice after a period of employment were happy with the decision compared to 49% for those who returned to employment after private practice. Employment might be the answer for some as it seems to provide a more secure opportunity given the challenges within healthcare. But, there are other models for those who want to be physician owned. The Medical Group Management Association (MGMA)3 reports best practice data annually and there continue to be successful independent solo and group practices operating across the country. One of the keys to success is having a practice manager as your partner. The Arizona Medical Group Management Association (AzMGMA)4 offers more local opportunities for practice management resources and connections. It is costly for doctors to remain solo or independent group practitioners but a good collaborative relationship with a strong practice manager can relieve the small practice of the most burdensome administrative tasks allowing maximum influence over treatment of patients. Another option is joining with other physicians to contract with, or own, a management services organization (MSO) where the physicians collectively hire professional

managers to take on the administrative burden of corporate compliance, contract negotiation, and whatever the latest metric hurdle the bureaucrats from Washington, D.C. throw our way. Models exist where the clinical decisions, as well as locations, hours, staffing, equipment, and referred specialists remain with the individual doctor. Each type of practice model has pros and cons. Only you can decide which best works for you. Whatever you decide, make sure you get to know your practice manager. Practice managers are there to manage the day-to-day operations, work through challenges, be involved in strategy, and help ensure there are systems and processes that support your patients and practice so you can do the work you went into medicine to do. While healthcare is a hot topic and there will not likely be an easy solution, there are opportunities to improve what happen for patients and providers as we continue forward. We hope you will encourage your practice managers to be part of the AzMGMA community. Girzhel, S. â&#x20AC;&#x153;RBMA Bulletin.â&#x20AC;? 2017. Kane, Leslie. Medscape. 2014. 3 Learn more at www.mgma.org 4 Learn more at www.azmgma.org. 1 2

Chip Hardesty has over twenty-five years of experience in healthcare. He is the Chief Operating Officer of Radiology Ltd in Tucson. He has served on the AZMGMA board as Legislative Representative and is also a Past-President. Chip can be contacted at chip.hardesty@radltd.com.

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he Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) promises to reshape how Medicare pays physicians under the Quality Payment Program (QPP). Yet, a survey of 1,000 practicing physicians who have been involved in practice decision-making related to QPP shows that fewer than one in four physicians feel well prepared to meet its requirements in 2017, according to a survey by American Medical Association (AMA) and KPMG LLP, the U.S. audit, tax and advisory firm. Over half of the leading physicians believe MACRA’s requirements are “very” burdensome, according to the survey. MACRA encourages physicians to adopt value-based payment models in healthcare that connect Medicare’s reimbursement to quality and performance reporting. The law went into effect this year with “pick your pace” options for those required to participate in the QPP. Of those physicians responding to the survey, 56% plan to participate in the Merit-based Incentive Payment System (MIPS) in 2017, a payment system with variable incentive payments or penalties based on certain quality and efficiency measures, while 18% are expecting to qualify for higher and more stable payment as an Advanced Alternative Payment Model 38

ARIZONA PHYSICIAN | Fall 2017

(APM) participant. The AMA/KPMG survey was released today at the Eighth Annual Alternative Payment Model (APM) and Accountable Care Organization (ACO) Summit, and found that a majority (51%) of surveyed physicians who are involved in practice decision-making are somewhat knowledgeable about MACRA and the QPP and only 8% describe themselves as “deeply knowledgeable” about the program and its requirements. In addition, 90% felt the reporting requirements were “somewhat” or “very” burdensome, with the time required to report performance being the most significant challenge, followed by understanding requirements, how MIPS performance is scored, and the cost required to accurately capture and report performance. Physicians in smaller practices (four or fewer providers) and those without experience in existing value-based reporting systems were significantly more likely to view requirements as “very” burdensome and feel less well prepared for longterm financial success. “This survey showed that about a third of respondents are unlikely to meet the basic standard of one patient, one measure, no penalty. To help physicians meet that standard, the AMA developed and deployed resources to


guide physicians toward compliance. Our resources include a step-by-step video on minimum reporting requirements to avoid a penalty in 2019 and a payment model evaluator that offers a brief assessment of where a practice stands,” said AMA President David O. Barbe, M.D. “In just 10 steps, physicians can successfully meet the standard under MACRA. Those who are prepared to report more data can realize rewards for improvement and for delivering highquality, high-value care.” “Aligning physician incentives with quality and other performance targets will lead to greater rewards for physicians and better healthcare for patients.” said S. Lawrence Kocot, National Leader of the Center for Healthcare Regulatory Insight at KPMG. “While progress has been made in preparing physicians for the move from volume in the fee for service payment model to value in alternative payment models, it is important that we do even more to assist physicians with the transition.” KPMG contributed its technology, actuarial and regulatory knowledge and skills to assist the AMA in the development, build, and launch of its Payment Model Evaluator to empower physicians with actionable knowledge about MACRA and to help physicians assess their likely eligibility for MIPS or as an Advanced APM participant. Future AMA efforts will build on the experience of this useful educational tool.

AMA program and campaigns The AMA is launching a program to help physicians comply with MACRA to avoid penalties that can hurt Medicare revenue to physicians by as much as 4% in 2019 and climb to 9% in 2022. In addition, the AMA is launching the “One patient, one measure, no penalties” campaign to help physicians avoid penalties tied to MACRA by helping them meet reporting requirements. Learn more at https:// www.ama-assn.org/qpp-reporting.

About the American Medical Association The American Medical Association is the premier national organization providing timely, essential resources to empower physicians, residents and medical students to succeed at every phase of their medical lives. Physicians have entrusted the AMA to advance the art and science of medicine and the betterment of public health on behalf of patients for more than 170 years. For more information, visit ama-assn.org.

About KPMG LLP KPMG LLP, the audit, tax and advisory firm (www. kpmg.com/us), is the independent U.S. member firm of KPMG International Cooperative (“KPMG International”). KPMG International’s independent member firms have 189,000 professionals, including more than 9,000 partners, in 152 countries.

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ARIZONA OPHTHALMOLOGICAL SOCIETY FOUNDATION

Arizona Medical Eye Unit BY JEFF EDELSTEIN, MD

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“I have been volunteering for Arizona Medical Eye Unit (AMEU) clinics annually since 1988 and find the experience rewarding. The patients are extremely grateful that Arizona Ophthalmological Society (AOS) members take time out of our practices to help them. Those that come to AMEU Clinics leave with a sense of peace and comfort about the health status of their eyes. They are particularly impressed how we offer quality care from a trailer and the speed that we can get them referred to sub-specialists for needed care that may have otherwise been delayed or missed entirely.” – JEFF EDELSTEIN, MD, CHAIR, AOSF

A brief history of The Arizona Lions’ Medical Eye Unit The story begins with the Oddfellows and Rebekahs, worldwide groups that began as English fraternal organizations in the 18th century. They are non-sectarian and apolitical humanists who approached the Department of Ophthalmology at University of Arizona (UA) in 1974 with the idea of creating a mobile eye unit. The goal was to improve access to medical eye care in rural Arizona. The Oddfellows and Rebekahs raised funds for an endowment to build and maintain the Arizona Medical Eye Unit (AMEU). In 1976, ophthalmic technician Martin Lian was enlisted to help with trailer design and to develop eye clinics in rural Arizona. The project was immediately successful, requiring additional ophthalmologists. The Arizona Ophthalmological Society (AOS) membership quickly agreed to volunteer their time to help the AMEU allowing the program to expand. In 1978, Greg King became Director of the AMEU. Greg worked with rural community health centers to develop eye clinics that included Indian reservations where diabetic eye disease is rampant. In 2005 the AMEU, including Director Greg King, were transferred from UA to the Arizona Lions’ Vision Center as the mission better aligned with the Lions’ goals.

Mission statement The AOS Foundation (AOSF) is a 501(c)3, whose mission is to improve access to eye care for underserved populations in Arizona. Through use of a medical eye unit, the AOSF provides financial support for medical eye exams, patient education/awareness about eye disease and donated eyeglasses. AOS members have volunteered their time to staff the AMEU since its inception. The primary focus of the AOSF is to deliver high quality medical eye care for rural and under-served communities that may have limited or no access to an eye physician. To this end, the AMEU works with local community health centers, health fairs, school vision screenings, rural hospitals, homes for the elderly, and with multiple Indian Tribal Reservations throughout Arizona. For patients that need medical or surgical follow-up, the AMEU refers to the most appropriate nearby ophthalmologist. The goal of the AOSF is to ensure all Arizonan’s have

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 8

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access to medical eye care to reduce the burden of eye disease and improve their quality of life. Since 2008, the Arizona Lions’ Vision Center has collaborated with the AOSF to provide support staff and to help manage the unit. As a component of the Arizona Community Foundation, a non-profit 501(c)3 organization, the AOSF was created to continue the mission of the AMEU.

Physician and patient experience The AMEU runs between 50-70 clinics per year, serving approximately 20-30 patients per clinic. The patients are mostly adults, but children are also served. We are planning to expand our clinics to examine children that failed school vision screenings, in conjunction with VisionQuest 2020, a group founded by Arizona pediatric ophthalmologist, James O’Neil, MD. My colleague and immediate past-president of the AOS, Charles Schaffer, MD, has served as a volunteer on the Medical Eye Unit. He states, “It’s gratifying to hold clinics in a remote area for an appreciative group of people. Typically, these are high-pathology populations where the exams and early intervention serve both the patient and the community-at-large.” I am usually in Holbrook where we see locals, police, and diabetic individuals from Navajo County. At my last clinic, in early August, I treated a patient who was blind in one eye; after some questioning, I discovered he had non-inflammatory anterior ischemic optic neuropathy after taking Viagra. He was unaware of the connection, and maybe I saved him from having an event in his only remaining eye! A number of patients recently jotted down their responses to the question, “what does the AMEU mean to you?” According to one patient testimonial, “I think the service that is provided is a great service to smaller communities and it really helps people in these areas. We are very lucky to have it.” Another patient wrote, “I am so grateful for the Lions club putting this eye exam on for people who can’t drive to another town for the eye doctor. They are very helpful, passionate and reasonable. The doctors are very professional and kind.”

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Fundraising and the future of AOSF Thus far, the Arizona Lions and the AOSF have raised funds to replace the original trailer with a newer, safer AMEU and state-of-the-art ophthalmic equipment. Our goal is to continue fundraising to expand the program and its mission well into the future. The AOSF holds a fundraiser every fall. All proceeds benefit the AMEU. We welcome all who wish support the AOSF and the AMEU’s work. More information on the events, tickets and donations are available at the AOSF website, www.aosfoundation.org. Jeffrey Edelstein, MD, is Founder and Chair of the Arizona Ophthalmological Society Foundation (AOSF) and has been a volunteer for the Arizona Medical Eye Unit (AMEU) for his entire career. His private practice as an Oculoplastic surgeon has been based in Arizona since 1987, currently in Chandler. He serves on the Arizona Ophthalmological Society Board of Directors, as a Health Policy Consultant to the American Academy of Ophthalmology and is a member of the AMA RVS Update Committee (RUC). This year, he received the Melvin Jones Fellowship Award from Lions International for his humanitarian work with the AOSF.


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Fall 2017, Arizona Physician Magazine  
Fall 2017, Arizona Physician Magazine