AzMedicine Fall 2016

ArMPAC General Election Endorsements | Public Health in the Palm of Your Hand Fall 2016

Published for Arizona Physicians

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Emerging Trends in Medicine

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Emerging Trends in Medicine

Fall 2016 | Volume 27, No. 3 www.azmed.org | facebook.com/azmedicine

Clinical Informatics: Creating the Future of Healthcare Delivery................... 8

Physician leadership in a team-based environment..................... 18

Direct-to-Consumer Marketing: 20 Years Later......................................... 10

Dispensing Naloxone to Prevent Overdose Deaths....................... 25

New Medicare Telehealth Services......... 12

Medicare’s new plan for paying doctors: 10 key takeaways.......... 26

A New Model of Innovation in Primary Care Comes to Arizona ............ 14 Cardiovascular Care, Heart Hospital Reinvention on Dual Track for Advancement............. 16 FROM OUR PRESIDENT Excellence in medical education .......................4

Public Health in the Palm of Your Hand.................................. 30

HSAG VISTAS The Legislation of Health Policy in America............22

ArMPAC General Election Endorsements............................29

Arizona Medical Board Medical Consultants Needed!

IT IS OUR MISSION to protect the public safety through the judicious licensing, regulation and education of physicians and physician assistants.

MEDICAL CONSULTANTS ARE THE BACKBONE OF OUR MISSION BECOME PART OF THE TEAM! Visit our website: www.azmd.gov under Medical Consultants Orientation or Email: omc@azmd.gov

Fall 2016 | AZMedicine 3

FROM OUR

President

Excellence in medical education At the June 2016 House of Delegates meeting, the resolution “Critical Issues Facing Arizona Medical Education” was passed in response to concerns raised by members following the resignation of seniorlevel deans at the University of Arizona College of Medicine – Phoenix. The resolution urged the Arizona Board of Regents (ABOR) to conduct an independent investigation into this leadership exodus, so that any necessary corrective action could be taken in order to ensure the advancement of accreditation and continued educational excellence of the Colleges of Medicine in Phoenix and in Tucson. ABOR requested that we provide a statement at a public hearing in August. Included in that statement were ArMA’s recommendations on excellence in medical education. The following column provides amplification of the points outlined in our August 5 hearing comments. At the time of this article going to print, ABOR is conducting an independent investigation.

In order to answer the question “What is excellence in medical education,” we must first ask ourselves “What is excellence in medical practice,” for the primary goal of medical education must be to produce physicians who are skilled clinicians. A medical school focused on producing physicians who are affable and efficient technocrats and “information managers” has failed in its core mission of teaching students to become effective and humanistic practitioners of the art of medicine.

Identifying the traits possessed by excellent physicians cannot Gretchen Alexander, MD be accomplished without considering the needs of our patients—their lives are most profoundly impacted by whether or not we are well-trained and therefore, they are ultimately our profession’s most important judges.

We must also ask ourselves--what do our patients want and need us to be? The needs of our patients are not that mysterious—in fact, they have been rather well described over the years. Patients need physicians to be knowledgeable, compassionate and curious—not only intellectually interested in the clinical issue presented by the patient, but possessed of a personal interest in the patient as a unique human being.

4 AZMedicine | Fall 2016

When our patients are ill, or worried about a troublesome symptom, these are the qualities they seek in a physician, and as long as our profession is able to continue to nurture these characteristics through excellent medical training, our patients will receive good care, and they will be powerful allies as we advocate for them in an evolving healthcare system.

How can we ensure that our profession continues to develop these qualities in our trainees?

And what are the qualities of a medical school that will most efficiently and reliably produce that type of physician?

We suggest that the following principles of excellence are essential for high-quality medical education: • Educational Integrity The school’s primary mission must be universally understood to be the education of exceptional physicians. Relationships between the school and outside entities must be managed effectively so as not to compromise the educational integrity of the curriculum or the school’s mission.

• Rich Clinical Training In their last 24 to 36 months of medical school, students learn about becoming physicians by caring for patients in a variety

Patients need physicians to be knowledgeable, compassionate and curious – not only intellectually interested in the clinical issue presented by the patient, but possessed of a personal interest in the patient as a unique human being.

of settings, primarily hospitals, under the direct supervision of senior physicians. Effective medical schools provide their students access to a wide variety of training sites which offer opportunities to work with diverse patient populations across a broad range of clinical environments and physician mentors. For students to most successfully pursue residency training spots after graduation they must have opportunities to rotate through programs that offer post-graduate training, where the contacts they make can facilitate favorable residency training placement.

• Diversity Healthcare disparities must be addressed through diversity training and initiatives to recruit minority students. A medical school truly dedicated to excellent patient care must also make a genuine commitment to partnering with public institutions to provide clinical training in settings where all students will work with underserved populations and develop a thorough understanding of those patients’ needs and vulnerabilities.

• Balance between Research and Education Research opportunities for students and faculty must be developed in a manner that supports the school’s mission of clinical

education as well as advancement of the science of medicine.

The LCME states that “those skilled in teaching and research in the basic sciences must maintain awareness of the relevance of their disciplines to clinical problems1.” The faculty of an excellent medical school will include physician-researchers whose work attracts funding through external grants. Monies from these grants may be used for salary support for the researcher and associates, supplies, travel, and salary support for selected senior officials of the school. Although there are indirect benefits to teaching and patient care, it is important to remember that the research activities of the school must complement the educational mission. The school must be meticulous in providing equal financial and institutional support to both types of activities.

• Culture of Respect One of the more regrettable traditions of medical education is our harsh treatment of our trainees, and of each other. Students who are socialized in this type of environment are less likely to treat their patients with respect once they are in clinical practice. A learning environment where faculty, administrators, students and non-physician professionals interact in a supportive and collaborative manner is more likely to foster high standards of professionalism among its trainees. Students who receive support, and see their mentors supported, during their training are more likely to internalize these positive values and Continued on Page 6

Fall 2016 | AZMedicine 5

Continued from page 5

become clinicians who care for their patients in a compassionate, collaborative manner.

• Effective Leadership The Dean of a medical school must be able to oversee faculty, manage an effective curriculum and organize clinical training sites that will best meet the educational needs of the students.

It is imperative that the Dean understand how to accomplish these tasks in a manner which will produce excellent physicians. A review of the list of the top five U.S. medical schools for NIH grant funding in 2014 reveals that the dean of each school has completed full residency training, as well as fellowship training (additional clinical training following residency).

In our opinion, for a dean to have completed his or her own full residency training, attained specialty board certification and to have practiced some form of patient care are core qualifications to lead an excellent medical school.

Medical schools with these core competencies will have prepared their graduates for the rigors and complexities encountered in residency and patient care, and will have fostered clinical and intellectual curiosity for the lifelong learning required by their profession.

• Operational Efficacy As healthcare systems evolve, our medical schools must adopt business principles that will allow them to be sustainable in the 21st century, and train students who are knowledgeable regarding business aspects of medicine including management. As such, an excellent medical school should be managed by senior leaders according to corporate best practices2 including: • Complete organizational understanding of problems and proposed solutions prior to execution of changes • Recognition of employees as knowledge workers who can provide critical input into process improvement • Expectation for managers to have first-hand knowledge of work being produced • Empowerment of employees to voice contrary or dissenting opinions • Promotion of managers from within the organization through investments in mentorship and employee development.

In closing, I return to the premise that medical education must have a high level of integrity supported by autonomy. Patients need their physicians to be knowledgeable, compassionate and curious.

It is our belief that a medical school which adheres to the core principles of educational integrity, rich clinical training, diversity in recruitment and clinical training, correct balance of research and educational priorities, culture of respect, effective leadership and operational efficacy will graduate physicians with the exemplary traits desired by their patients. Medical schools with these core competencies will have prepared their graduates for the rigors and complexities encountered in residency and patient care, and will have fostered clinical and intellectual curiosity for the lifelong learning required by their profession. AM Gretchen Alexander, MD, is the 125th ArMA President. Dr. Alexander is an attending psychiatrist at the Department of Psychiatry at Maricopa Integrated Health System and District Medical Group. Dr. Alexander delivered her inaugural speech, from which this column is derived, at the ArMA President’s Banquet on June 3, 2016.

References

Generally speaking, a Dean of the caliber required to lead an excellent medical school will be desirous of significant autonomy in the creation and execution of the school’s educational programs. In order to attract and retain the most highly qualified individuals to lead the school, the school’s governance structure must provide the dean with appropriate responsibility and authority for medical school matters.

6 AZMedicine | Fall 2016

1 International Association of Medical Colleges: LCME Accreditation Standards. http://www.iaomc.org/lcme.htm: pp1-14.

2 Takeuchi, Hirohata et al. “The Contradictions That Drive Toyota’s Success,” Harvard Business Review, June 2008

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Emerging Trends in Medicine

Clinical Informatics: Creating the Future of Healthcare Delivery For this edition of AZ Medicine, I sat down with the program directors and fellows of the UA’s Clinical Informatics Fellowship after the inaugural program year to understand emerging trends in this exciting and evolving subspecialty.

Our conversation highlighted insights from the program’s first year.

The Clinical Informatics Fellowship at the University of Arizona College of MedicinePhoenix was launched July

Jennifer Hartmark-Hill, MD 2015 by founding Program Director, Howard Silverman, MD, MS, and Associate Program Director, Soumya Panchanathan, MD, MS. Family Medicine physicians Dr. J. Edward Maddela and Dr. Umar Iqbal were the first cohort of fellows of this

8 AZMedicine | Fall 2016

two-year ACGME accredited program sponsored by Banner University Medical Center and the Phoenix VA Healthcare System.

Clinical Informatics, as defined by Dr. Panchanathan, is “the study of how people acquire, manage, process and use information. It isn’t as much about the technology— the things we can do with the data use the technology. But, it’s about ‘what is the information we can acquire?’ and ‘how can we use it best in the service of patients?’”

She adds that appropriate implementation of technology in the healthcare setting allows “the computer to do what the computer does best, and free up the human clinician do what the clinician does best— decision-making, empathy

Appropriate implementation of technology in the healthcare setting allows “the computer to do what the computer does best, and free up the human clinician do what the clinician does best.” and [building] the relationship with the patient.”

Dr. Iqbal is grateful for the program which has given him “formalized training in informatics” and a “high level view of how informatics works at many institutions.”

Fellows learn at major teaching sites including the Phoenix VA Health Care System, Banner - University Medical Center Phoenix, Dignity Health, Maricopa Integrated Health System, Phoenix Children’s Hospital and The University of Arizona College of Medicine Phoenix (COM-Phoenix).

Dr. Maddela adds that he

feels “very fortunate to enter the field at this time, because there’s so much potential, so much growth, so much to do for patients and populations.”

For example, “Veterans Like Mine” is a national project in the VA system using the CPRS/VistA electronic health record software that will impact care provided to patients in Arizona. This project aims to link relevant patient data to analyze patterns in care delivery to recognize and analyze patterns of decision-making. Dr. Iqbal says this will allow clinicians to “see what your peers did in similar situations. This

automated decision-support is based on how we practice rather than clinical trials.”

Those clinical trials, he adds, “may not have been conducted yet to answer the questions for the patient sitting in front of you.”

So, given the potential that informatics has for powerful clinical decision-support tailored to unique physician and patient needs, can clinical informatics propel knowledge from precision medicine into patient care of the future?

Dr. Silverman says that while clinical informatics “decision-support will be able to integrate data from precision medicine data to support individual patient care, this is the ‘easy’ part …knowing what a mutation means for an individual patient is the hard part.” He states that “there are more societal and ethical questions that need to be worked through first.”

One intriguing opportunity, according to Dr. Panchanathan, could emerge from being able to “import the genome data” from a given individual patient into the EHR. The clinician could then, “on the spot, query if there exist any mutations that affect a medication about to be prescribed.”

She cites the example of codeine, which clinicians avoid using in children, “because the ultrafast metabolizers are likely to have adverse effects at normal doses. But if I had the genomic data that I could query to see that for this child

Umar Iqbal, MD

it’s safe—it’s a very good medication.”

Beyond patient-centered data is the promise for population health.

Dr. Panchanathan relates that “informaticians are currently looking at data at the census tract level” including creative sources such as environmental data, county health factor rankings, social media trends and many more data streams in order to predict risk factors and incidence of illness or injury. “I think this is where the future is,” she says, using “social determinants of health . . . [to] keep people out [of the hospital] and keep people well, in their homes—a combination of telehealth and population management.”

In Arizona, the challenges remain for innovators working to facilitate interoperability of health data systems.

One novel approach to improving patient safety through data sharing across systems may come through “vendor-agnostic apps,” according to Dr. Silverman.

J. Edward Maddela, MD

Soumya Panchanathan, MD, MS

Howard Silverman, MD

Dr. Maddela recently attended a “Connectathon” and was able to witness this type of innovation in action. In this event, he described how “healthcare professionals team up with software developers to study a use case or novel idea for an app that can integrate with standard EHRs.”

(including patients, through patient portals), process (optimizing workflow) and platform (the technology).” He is appreciative of the fellowship for “training physicians to be future leaders” in these areas.

For example, an app was created to allow clinicians to set automated reminders to patients’ phones to remind them when to take medications. Patients could then press a button to acknowledge when the medication was taken, creating a “bidirectional” information flow. This can then, in turn, be pulled into the realm of big data for pattern analysis and predictive modeling.

To learn more about the University of Arizona College of MedicinePhoenix Clinical Informatics Fellowship, please visit: http://phoenixmed.arizona.edu/bmi/ education/fellowship

However, Dr. Maddela emphasizes that the emphasis of clinical informatics “is less about technology and more about people...and quality of care.”

For more information

Dr. Silverman adds that the goal of the clinical informatics program “is to produce a well-trained clinician informaticians to do this well to create efficient, safe, valuedriven care.” AM

He notes the need for transformation of health systems and “appropriate integration” of the “3 P’s” of “people

Fall 2016 | AZMedicine 9

Emerging Trends in Medicine

Direct-to-Consumer Marketing: 20 Years Later Direct-to-consumer (“DTC”) advertising of prescription drugs and devices by pharmaceutical companies has been in effect for almost 20 years.

In addition to the billions spent in marketing directly to physicians, pharmaceutical companies spend billions of dollars per year (5 billion in 2015), to tell patients and potential patients why they

Drug Administration (FDA) required that advertisements provide a detailed list of potential side effects to consumers.

DTC advertising most commonly appears on television, internet websites, radio, and print – magazines, brochures, billboards, newspapers. Ads generally fall into three categories: • “Product-claim” – specific name and claim – i.e., Viagra, Humira.

Paul Giancola, Esq. should take certain drugs.

In 2015, one quarter of the money spent was to advertise only five drugs. (I’m sure you can name them). Not surprisingly, the most advertised drugs are heavily prescribed and reap the biggest profits.

DTC advertising of drugs became legal in the United States in 1985. However, until 1997, the U.S. Food and 10 AZMedicine | Fall 2016

• “Help-seeking” – do not recommend a specific drug, but discuss disease or condition, such as allergies, diabetes, asthma, osteoporosis, and high cholesterol.

The ad usually includes the name of the company, and encourages the consumer to talk to their doctor.

• “Reminders” – give the name of the drug, and assumes the audience – physicians and consumers – are already aware of the drug’s use.

Over the years, the debate about DTC advertising has largely focused on whether it provides useful information to consumers, resulting in better

Not surprisingly, the most advertised drugs are heavily prescribed and reap the biggest profits. health outcomes due to disease awareness, or if it encourages expensive overuse of the costliest drugs.

At one end of the spectrum, physician’s organizations, such as the American College of Physicians (APA), believe that DTC advertising is inappropriate and undermines the physician – patient relationship leaving patients confused and misinformed about drugs.1 Recognizing that DTC is here to stay, the APA and the American Medical Association (AMA) encourage physicians to take an active and critical role in ensuring that DTC ads improve the communication of health information and contain accurate information on risks, benefits, and costs.2

FDA Regulation The FDA has the authority to

regulate “product claim” ads.

Such ads must present a drug’s benefits and risks in a balanced fashion, and should not be false or misleading. Print ads must also include a “brief summary” about the drug that includes the risks listed in the prescribing information.

Broadcast ads, however, must only address the drug’s most important risk (“major statement”) and either provide all the risks listed in the prescribing information or a variety of sources for viewers to find the prescribing information for the drug. Such sources may include a doctor, website, toll-free number, or magazine print ad.

Help-seeking ads are not generally regulated, as they are not considered drug ads.

However, the FDA does regulate them if they suggest

or recommend a specific drug.

Similarly, reminder ads are not regulated, unless they offer drugs with serious risks, such as those with a boxed warning, or if the ad provides or suggests information about the drug’s risks and benefits.

State Regulation and Sunshine Act The FDA regulates national advertising. Because of the FDA, there is little legislative space for states to address DTC. A few states, however, have laws that address DTC advertising, marketing, and doctor detailing. Such state laws typically contain disclosure and reporting requirements. However, with the passage of the “Sunshine Rule” or “Open Payments” rule, pharmaceutical companies now must report payments or other transfers of value to physicians for drugs and devices covered by Medicare and Medicaid.

Impact on Patient Care Surveys of physicians cited by the FDA 3 indicate that patients who saw DTC ads asked thoughtful questions, were more involved in their healthcare, and had better discussions with their doctors.

Physicians, however, did not believe that such ads conveyed information about risks and benefits equally well.

Nevertheless, according to the FDA, only eight percent of physicians felt “very pressured” to prescribe a specific brand-name drug when asked.

However, in other surveys,

Surveys of physicians cited by the FDA indicate that patients who saw DTC ads asked thoughtful questions, were more involved in their healthcare, and had better discussions with their doctors. physicians have reported that advertising induced demand made them more likely to prescribe the brand-name drug requested.4

Physician Obligations The AMA Ethics Opinion states that: • Physicians must maintain professional standards of care when prescribing; • Physicians should engage in a dialogue to assess the patient’s understanding of the treatment; • Physicians should not be biased against advertised drugs; • Physicians should resist commercially induced pressure to prescribe drugs that may not be indicated; • Physicians should deny requests for inappropriate prescriptions, and should educate patients as to why, and the different treatment options;

• Physicians should be vigilant to ensure that DTC does not promote false expectations, and to consider reporting such DTCs that do not follow the applicable FDA regulations.

Summary DTC of drugs are now as common as beer and car commercials. However, in contrast to beer and cars, a prescription from my physician is required to obtain a DTC product.

being prepared to discuss evidenced-based studies on the benefits and risks of such drugs.

Physicians must, however, always remain vigilant to only prescribe drugs that are medically indicated for a patient regardless of the pressure brought to bear on their medical judgment by patients and advertisements. AM Paul J. Giancola, JD, is a partner in the Healthcare Practice Group, Snell & Wilmer, LLP, Phoenix, Arizona.

1 See, Direct-to-consumer prescription drug advertising, American College of Physicians, a position paper (2006).

2 Id. AMA opinion 5.015 – Directto-Consumer Advertisements of Prescription Drugs, AMA Code of Ethics (1998).

3 See, FDA. The Impact of Direct-to-Consumer Advertising, Information for Consumers, UCM 143562, Oct. 23, 2015. http:// www.fda.gov/Drugs/ResourcesForYou/Consumers/ucm143562. htm 4 See, Gellad & Lyles, The Impact of Direct-to-Consumer Advertising of Pharmaceuticals, Am. J. Med. 2007, Jun; 120(6), 475-480.

DTC advertising is without question both successful and profitable. This means that pharmaceutical companies will continue to increase DTC to both stimulate demand and profits for their drugs.

Physicians, however, are ethically required to remain objective patient advocates.

Accordingly, physicians should be educated and prepared to discuss the pros and cons of specific drugs, particularly those that are powerfully advertised. This may include Summer 2016 | AZMedicine 11

Emerging Trends in Medicine

New Medicare Telehealth Services The number of physicians providing telehealth services is growing. Several factors are driving this growth, including increasing hospital system consolidation other arrangements in which rural physicians have

Register Vol. 81, No. 136, July 15, 2016) summarizes this year’s requests and lists the services that it will add to its list of those eligible for Medicare payment when provided via telehealth and those that it will not.

To be eligible for payment, the service must be on the list of Medicare telehealth services and meet all of the following additional requirements:

Marc Leib, MD, JD easier access to consultation by other physicians via telehealth.

Another factor driving this growth is that new procedures are routinely added to the list of services approved for telehealth.

Each year the Centers for Medicare and Medicaid Services (CMS) receives a number of requests to add to its list of services for which Medicare will pay when those services are provided via telehealth.

The recently published Medicare Physician Fee Schedule Proposed Rule (Federal

12 AZMedicine | Fall 2016

• The service must be furnished via an interactive telecommunications system.

• The service must be furnished by a physician or other authorized practitioner.

• The service must be furnished to an eligible telehealth individual.

• The individual receiving the service must be located in a telehealth originating site.

When these conditions are met, Medicare pays a facility fee to the originating site and makes a separate payment to the distant site practitioner furnishing the service.

CMS has specific criteria to evaluate requests for additions

to its list of telehealth services.

In summary, services are added when either a) they are sufficiently similar to other services that are already on the list, or b) if not similar to other services on the list, adding the service would significantly benefit Medicare patients.

CPT codes added to the list of telehealth services beginning January 1, 2017 include: • CPT codes 90967, 90968, 90969 and 90970, which collectively describe ESRDrelated services provided for less than full month duration. CMS notes that even though these services may be provided via telehealth, the required clinical examination of the catheter access site must be furnished face-toface “ hands on” (without the use of an interactive telecommunications system) by a physician, CNS, NP, or PA. This can be done at the telehealth originating site.

• CPT codes 99497 (advance care planning services, first 30 minutes) and add-on code 99498 (advance care planning services, each additional 30 minutes).

The Proposed Ruledoalso shared.

If patients not lists opt those codes that CMS received out, authorized providers are requests add to the the list but is able to toaccess physical declining to do so, including: health information of their • A long list of codes describing patients. observation services, includUnder the 99218, integrated plan, ing 99217, 99219, behavioral health data is under “restricted access” which means that in order to comply with 42 CFR Part 2, a provider can request patient consent to access restricted data and then access the data with affirmative patient consent. In addition, as long as a patient has not opted-out of having their information shared, emergency access to restricted data is available by a provider electronically affirming that an emergency is taking place.

The Network’s current technology vendor has the capability to restrict access to certain types of information, so no new technology will be required to operate this new strategy.

Closely related to the roll-out of AzHeC’s statewide integrated HIE strategy, AzHeC has recently collaborated with Mercy Maricopa Integrated Care, the regional behavioral health authority (RBHA) for Maricopa County, to implement a Network crisis portal to support the behavioral health crisis countywide.

It is anticipated that this crisis portal will be extended to RBHAs in the northern and southern areas of the state later this year.

The elimination of participation fees for community providers has resulted in strong

99220, 99224, 99225, 99226, 99234, 99235 and 99236.

to the list of telehealth services. CMS believes there are subtle physical and behavioral responses may not be apparent via telehealth.

The value of more complete • Emergency department visit patient information and the codes 99281, 99282, 99283, importance of securely 99284 and 99285.

• Numerous codes describ• Critical care evaluation and sharing information among ing physical therapy, management codes 99291 occupational therapy, physical (critical care first 30-74 and behavioral and speech-language minutes) and add-on code health providers canservices be were pathology 99292 (critical care each added to the list of additional 30 minutes). readily seen innot a look at telehealth services. One However, CMS recognizes majorhighest reason CMS has not patients with the there may be some benefit to added any codes describing a patient requiring critical these services to the list is needs and costs. care services to have critical care consulting services via telehealth in addition growth in Network participato the critical care services tion, and adding community provided by an in-person behavioral health providers physician. CMS has created to the list of those with no two new HCPCS codes participation fees will spur describing those consulting even stronger growth. Since services (see below). launching its new technology platform in April of (96101 2015, • Psychological testing The Network has neuropsygrown from and 96102) and 33chological participants to more testing (96118than 100 participants bynot theadded second and 96119) were

that physical therapists, occupational therapists and quarter of 2016, and many of speech-language patholothegists newest are notparticipants authorized are behavioral health organizapractitioners of telehealth tions thatthe have recentlystatute. joined under Medicare The Network.

As described above, CMS is As with twoother creating new initiatives HCPCS throughout our codes describing history, critical AzHeC relied on care consulting services broad for a community outreach and patient requiring critical care engagement to be develop services that may provideda

via telehealth.

GTTT1 statewide strategy. Much of describes the initial consultathe information gathered over tion and of GTTT2 a period several describes months subsequent consultations. helped to inform and design These codes critical the plan and describe its implementacare services that tion. consultation In the end, not only are in addition to in-person was there broad community critical provided support care for services one statewide directly to the patient. integrated health information exchange for Although the physical majority and of behavioral health information, physicians do not provide telethere was alsoit ais important consensus health services, in the community that one to be aware of additions to system provide the list would of services thatthe canbest be care and the provided in best that outcomes manner. for As Arizona that list patients. expands, AM more physicians will have the ability to Melissa Kotrys is the Chief Executive those Officer services for Arizonaand Health-e provide may Connection (AzHeC) and the Health choose to do so to expand their Information Network of Arizona. practice opportunities.

AzHeC operates the Arizona Regional Extension Center, which assists Arizonarule providers The proposed canin be achieving Meaningful Use. accessed at https://www.gpo. gov/fdsys/pkg/FR-2016-07-15/ 1 “Mental disorders and comorbidipdf/2016-16097.pdf, Section ty,” Goodell, S, Druss BG, Walker, ER, The Synthesis Project IIC on page 46179. AM

(Policy Brief No. 21), Robert Johnson MarcWoods Leib, MD, JD, isFoundation, an February 2011. anesthesiologist, attorney and past president of ArMA.

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Emerging Trends in Medicine

A New Model of Innovation in Primary Care Comes to Arizona Despite recent advances to expand health care coverage through the Affordable Care Act, over 60 million Americans (or 1 in 5) lack adequate access to primary care. Poor access to high-quality primary care has led millions of

Farshad Fani Marvasti, MD, MPH

Americans to seek emergency services for care that they could have received from their primary care physician.

There are numerous reasons for our current access issues. Fifty years ago, more than half the doctors in America practiced primary care; today, less than one-third of physicians are in primary care. Lower salaries than specialist colleagues, the proverbial “hamster wheel� of high-volume patient care and administrative bureaucracy

14 AZMedicine | Fall 2016

have made primary care a much less appealing path for many physicians.

If current trends continue, the United States will face a primary care shortage of 65,000 physicians by 2025.

Phoenix ranks #7 in the country when it comes to critical primary care shortages, with as many as 2,486 patients per primary care doctor, making it more difficult for patients to get access to care in a timely manner.

In short, our primary care health system is broken and in need of urgent repair.

Enter One Medical. Founded about 10 years ago by Dr. Tom X. Lee, an internal medicine physician and former CMO of Epocrates, One Medical seeks to reinvent primary care for both patients and clinicians.

One Medical is a membershipbased model that accepts most insurance plans including Medicare. Patients enjoy longer visit times, as One Medical providers see 35% fewer patients daily than typical primary care practices. This enhances the communication and relationship-building that

If current trends continue, the United States will face a primary care shortage of 65,000 physicians by 2025.

are critical to quality primary care.

One Medical provides a novel solution to address the fundamental challenge of access in primary care. Open scheduling rubrics allow patients to obtain same-day appointments, and a virtual medical team of clinicians is available for patients to address urgent medical concerns 24 hours per day, 7 days a week.

A recognized technology innovator, One Medical has its own proprietary EMR system that was developed by primary care clinicians, who continue to contribute to the design and ongoing evolution of this system for better population health management and day-to-day clinical care for patients.

The company also offers many digital health capabilities, including a robust mobile app that lets patients get care on the go.

One Medical Group is now the fastest growing national primary care network in the country, with offices in major markets such as San Francisco, Los Angeles, New York City, Boston, Chicago, and Washington, DC. In partnership with Dignity Health, One Medical Group opened its first office in Phoenix on March 1st, 2015. Two other offices were opened soon after in south Scottsdale and Gilbert with a 4th office opening this month in north Scottsdale.

One Medical in Arizona has experienced great initial success, with 5-star Yelp ratings, high customer satisfaction

scores in all offices, and recognition by Arizona Business Magazine as the Best Medical Company in Arizona for 2016.

Innovative models like One Medical represent a beacon of hope for patients seeking accessible, affordable, and high-quality primary care. AM Dr. Farshad Fani Marvasti served as the inaugural District Medical Director for the Arizona Market of One Medical Group, opening and developing its first 3 offices that have grown to serve over 10,000 patients in just over 1 year. As a practicing physician, he has received special recognition for having the highest patient satisfaction and net promoter scores in his network. Dr. Marvasti currently serves as the Medical Director in charge of clinical partnerships and strategy at One Medical to optimize the impact of this innovative primary care model as it grows to be a part of an integrated delivery system. In addition to this role, Dr. Marvasti is active in medical education and clinical research serving as the Director of Public Health, Prevention and Health Promotion at the University of Arizona College of Medicine Phoenix and as the Medical Director for the College of Health Care Solutions Healthy Lifestyles Research Center at Arizona State University.

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Fall 2016 | AZMedicine 15

Emerging Trends in Medicine

Cardiovascular Care, Heart Hospital Reinvention on Dual Track for Advancement If there was ever a time to be practicing medicine, that time is now.

Despite sweeping changes in the way healthcare is delivered, our industry is moving forward at a rapid pace, with

During the past two decades, similar advances have been made in treating patients with strokes, atrial fibrillation and other complex cardiovascular conditions. The good news is that there undoubtedly will be many new watershed moments.

As cardiovascular medicine races forward, so, too, does work at Abrazo Arizona Heart Hospital.

Timothy Byrne, DO new medical discoveries and a flood of technologies that are helping people live longer – and better.

This is particularly true in the fight against heart disease.

After all, who would have thought that revolutionary statin drugs could help cut cholesterol levels in half or that complex, lifesaving heart valve procedures could be performed without opening a patient’s chest?

16 AZMedicine | Fall 2016

When it opened under the direction of Dr. Edward Diethrich in 1971, the iconic Arizona Heart Institute made history as the site of the first heart and lung transplants in our state. Abrazo Arizona Heart Hospital in conjunction with the Institute has been an incubator for breakthrough research and a training ground for physician specialists throughout the world.

Now, Abrazo Arizona Heart Hospital is undergoing a clinical and business reinvention to continue the legacy of cardiovascular care in Arizona and the Southwest.

During the past two decades, similar advances have been made in treating patients with strokes, atrial fibrillation and other complex cardiovascular conditions.

During the past year, Abrazo Community Health Network has invested millions of dollars in people, programs and services. Abrazo Arizona Heart Hospital works closely with Abrazo Arrowhead Campus, which is a growing hub for cardiovascular care in western Maricopa County.

As part of this investment, Abrazo Arizona Heart Hospital established six specialty institutes for the treatment of everything from abnormal heart rhythms to aortic, valvular, congestive heart, and coronary and vascular diseases.

As in other areas of medicine, the development of new therapies in cardiovascular care is driven largely by randomized, controlled trials. As such, the hospital has stepped up its involvement in research, currently participating in 16 trials at Abrazo Arizona Heart Hospital and another two at Abrazo Arrowhead Campus. This includes a study to demonstrate the safety and effectiveness of a parachute implant for heart failure due to ischemic heart disease; a comparison of surgical vs. an endovascular approach in patients with critical limb ischemia; and Transcatheter Aortic

Valve Replacement (TAVR) procedures on low-risk patients using the first and only next-generation recapturable, self-expanding TAVR system of its kind available in the United States.

Abrazo Arizona Heart Hospital is performing new procedures, forging new partnerships and collaborating with physician groups outside of metropolitan Phoenix. Plans to establish a much-needed cardiology fellowship program also are in the works.

Education for caregivers and patients is a priority, too. Earlier this year, the hospital led a two-day education symposium and live cases on TAVR for cardiologists nationwide, and the hospital is reprising its popular public forums with live surgeries, heart health information, a physician

Q&A and patient storytelling on Sept. 23.

Like the reinvention of Abrazo Arizona Heart Hospital, developments in cardiac care show no signs of slowing down, with new approaches

in the treatment of valvular heart disease, along with even better ways in managing heart failure, stroke and other conditions on the horizon. AM Disclaimer: Timothy Byrne, DO, FACC, is Market Medical Director for

Interventional Cardiology for Abrazo Community Health Network. He is not an employee, agent or representative of Abrazo Community Health Network. He is solely responsible for the provision of his medical services to patients. Abrazo Arizona Heart Hospital is a satellite of Abrazo Arrowhead Campus.

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Fall 2016 | AZMedicine 17

Emerging Trends in Medicine

Physician leadership in a team-based environment As Sun Tzu said in the ancient writing in The Art of War, “In the midst of chaos, there is also opportunity.” The state of healthcare could be considered in midst of chaos, and there is no better time than now to take the opportunity and

Diane Brennan, DBH

be a physician leader. I don’t mean physicians in medical administration or executive roles. Physicians who choose to pursue leadership roles in healthcare organizations are important. But the real keys are those of you in clinical practice, seeing patients, working with the staff, and being leaders of your teams1.

The medical practice environment and the healthcare team are different today than even just a few years ago. And we’re on a trajectory for more change

18 AZMedicine | Fall 2016

as healthcare delivery and payment systems continue to evolve - regardless of what you believe about the Affordable Care Act. No matter what size or type of health care system you’re in, there are likely some challenging moments.

I believe physicians are why we will be able to make changes in the system - not one entity like the government, not the payers, not even your administrator. This has to be a team effort, a partnership that begins with returning the focus back to the patient.

Leading a team does not mean being a “gatekeeper,” an approach some may recall from the managed care era.

And if it feels reminiscent of that era, talk about this with your medical director or administrator to work through the obstacles.

Developing and working with an effective team has the potential to yield positive benefits for you as well.

Imagine leading a caring and committed team with members that are knowledgeable and accountable in their work.

Have you ever been part of a team like this? I have had this experience, and I can tell you

that being part of or leading a high performing team makes a difference not just in the work you do but also in your life.

Team-based care is a shift from you having to do it all, to creating a team that supports you in the delivery and management of care for your patient. Patients get to know and trust the team members, because the team becomes an extension of you. This may be different from what happens today, and shifting to this type of approach doesn’t happen overnight.

Team-based care aligns with the Institute for Healthcare Improvement Triple Aim2: • improving the patient experience (team members are committed to supporting the patient, responding to questions and being accountable for their work)

• improving the health of populations (measuring and managing patient progress and using what you learn to enhance care and communications) • decreasing per capita costs (using resources effectively and efficiently to support patients)

What does this really mean?

Being a leader is not about your title, it’s about you.

How you show up with your patient, how you engage with your entire staff - not just your medical assistant or nurse or receptionist. The care team is expanding. There are many more non-physician providers in today’s primary care and specialty practices. In addition to physician assistants and nurse practitioners, there may be RN care managers, social workers or behavioral health

The medical practice environment and the healthcare team are different today than even just a few years ago.

professionals, pharmacists, nutritionists and other patient support providers within your organization or associated with an Accountable Care Organization (ACO) or insurance plan.

Team-based care supports communication and collaboration across providers and specialties and becomes the norm rather than the exception for a patient3. The patient is at the center of the team and a partner in his or her care.

The primary care provider leads the team, assigning tasks and responsibilities to other care providers and members supporting the patient.

You might say, “We do that” or “We try to do that, but the system or the health plan or care management or the patient get in our way.” Perhaps some of you already use more of a team approach, but more often what

I’ve experienced as a consultant and as a patient, is while the intent is there, the follow through is not. It’s not for lack of trying - it’s more about how caring and concerned physicians are in wanting patients to do what they know is best. You

have long held the role of being in control and at the center of the team in the traditional medical model - directing the patient and the team, and dealing with the problems as they arise. It’s how things have worked for many years, and it’s no longer sustainable for many reasons. You and your patients need better support. Team members need clear roles and responsibilities to contribute their best in delivering that support.

What else can you do?

Get to know the team members beyond your immediate group. How can these other professionals, such as the care managers or social workers, support your patient and be part of the team? Allowing others in to support you or your immediate team is a change, and this can be challenging. But it is doable, and it has the potential to improve patient outcomes and make your life easier over time.

Continued on Page 20

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Fall 2016 | AZMedicine 19

Continued from page 19

Being a leader means helping others to understand what you expect. It is not uncommon to assume that others should know what you expect based on brief instructions or observations, and it’s important to remember that they may not fully understand. You are someone of authority and even if you’re the most approachable individual, your staff may be afraid to ask questions or share information. You have influence and opportunity to set the tone for how the team works together.

How can you do this?

Your team has the potential to be an amazing support for your patients, you, and each other. Four strategies you can use to encourage teamwork and follow through are: • Appreciate your people, individually and collectively, for the work they do.

In appreciating others we acknowledge their value in the situation or relationship.

Challenge yourself to notice what you can appreciate about someone, even if it’s difficult. And challenge your team to develop the practice of appreciation for your patients and each other as a habit as well.

• Listen for understanding.

As a physician, you usually have the answers, so it’s likely you are used to listening for when to respond or give an opinion. You might try listening to understand.

20 AZMedicine | Fall 2016

Team-based care supports communication and collaboration across providers and specialties and becomes the norm rather than the exception for a patient This is sometimes called listening without an agenda.

It’s an exercise to try in work and personal life and to notice what you learn.

• Be clear on expectations.

This is a tough one as it’s easy to think you’ve provided clear direction.

People nod yes and move on - yet they may not really be clear on what’s expected.

You might ask staff to repeat back their understanding of what they heard from you to make sure you’re both on the same page. Notice their expressions and body language. Eyes are a great way to tell if someone is on board.

• Ask for assistance.

Remember you are not alone. Your colleagues may be experiencing some of

the same challenges. You might work collectively with your team and practice administrator to improve processes internally and with health plans. I realize working with health plans to improve processes can sound like a stretch, but if you/we don’t raise the issues and try, nothing will change.

There is no exact cure or magic wand to heal healthcare. Your practice administrator or office manager are intimately familiar with the challenges and changes within healthcare.

Actively engage with these individuals as part of your team. Recognize that you have more influence and power in creating change than you might have thought. Know that change is a process, and

Your team has the potential to be an amazing support for your patients, you, and each other.

it takes work. And remember the wisdom of Sun Tzu, “In the midst of chaos, there is always opportunity.” AM Dr. Diane Brennan is a healthcare consultant and leadership coach based in Arizona. She is also co-author with Alexandra Ross of Back Pocket Coach: 33 Effective Communication Strategies for Work & Life. Diane currently serves as the president-elect of the Arizona Medical Group Management Association. For questions or comments, contact Diane at diane@dianebrennan.com For more information on AzMGMA visit www.azmgma.org

1. Angood, P. & Birk, S. (2014). The value of physician leadership.

(Special Report: White Paper).

Tampa, FL: American College of Physician Executives. Retrieved from http://www.physicianleaders.org/docs/default-source/ special-reports/the-value-ofphysician-leadership.pdf 2. Institute for Healthcare Improvement. (2016). IHI Triple Aim Initiative. Retrieved from http:// www.ihi.org/Engage/Initiatives/ TripleAim/pages/default.aspx 3. Schottenfeld, L., Petersen, D., Peikes, D., Ricciardi, R., Burak, H., McNellis, R., & Genevro, J. (2016). Patient-centered teambased primary care. (AHRQ Publication No. 16-0002-EF).

Rockville, MD: Agency for Healthcare Research and Quality.

. . . b e l i t r e t d i l m t ol d A

It’s time to renew your ArMA Membership!

602.347.6907 simone@azmed.org Online at azmed.org Sign in required. Questions? Call 602.347.6914

Fall 2016 | AZMedicine 21

HSAG

Vistas

The Legislation of Health Policy in America “ So this was a bipartisan effort with Republicans and Democrats coming together to do something that’s smart and common-sense.

And my hope is, is it becomes a habit.”

—President Barack Obama, Remarks by the President Before Signing MACRA

By Howard Pitluk, MD, MPH, FACS & Mary Ellen Dalton, PhD, MBA, RN According to the U.S. Department of Health and Human Services (HHS), the Patient Protection and Affordable Care Act’s (ACA’s) coverage expansion has allowed 16.4 million uninsured people to gain health insurance coverage—accounting for the largest reduction in the uninsured in 40 years.1 For Arizona, this meant a 3.74 percentage point reduction in the number of uninsured in 2014.2 3 The ACA has also expanded Medicaid in Arizona, allowing more than 280,000 individuals to obtain this coverage since the state opted into the Health Insurance Marketplace.4 This past year saw the passage of another seminal piece of legislation, the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA), which sets the stage for the total overhaul of physician payment into a merit-based, quality-driven system that rewards value over volume of services. But this historic legislation does not exist in a vacuum.

To better appreciate the ramifications of these landmark health policy changes, it is instructive to reflect back on the history of healthcare legislative reform in America and the impact Congress and various administrations have had on the present-day healthcare system.

The History of Health Policy It is not commonly appreciated that legislative proposals for federal healthcare reform go back as far as the mid-19th century when the Bill for the Benefit of the Indigent Insane passed both houses of Congress but was vetoed by President Franklin Pierce, who maintained that social welfare was the responsibility of individual states and not the federal government. In the early 20th century, while 22 AZMedicine | Fall 2016

It is instructive to reflect back on the history of healthcare legislative reform in America and the impact Congress and various administrations have had on the present-day healthcare system. the United Kingdom and much of Europe were enacting national health insurance programs, the United States was moving in the opposite direction with suspicion of centralized, government-run insurance being considered the precursor to what the American Medical Association (AMA) at the time labeled “socialized medicine.”5 In place of government programs, employers offered small-scale, inexpensive local insurance plans to their workers, a precursor to the third-party payer system that emerged in the 1920s and 30s.

When President Franklin Roosevelt proposed including a publically funded healthcare program into his pending Social Security legislation, the idea was again vehemently opposed by the AMA as “compulsory health insurance” and was removed from the Social Security Act before its passage. This became an established opposition doctrine for the next 30 years. In place of government insurance, individual hospitals and communities moved into the healthcare insurance business by offering their own insurance programs, the first of which was formed at Baylor University in Dallas, Texas, and became the model for Blue Cross.6 Other hospitals and physician groups began selling policies to employers, which provided coverage for physician services who then collected

premiums and sold them to their employees, the largest of these becoming Blue Shield. During World War II, the legislation of federal wage and price controls led to employers offering health insurance as a way to circumvent these wage restrictions and attract new employees. This practice became the foundation of the third-party payment system, which replaced direct, out-of-pocket payment by individuals.

With the end of the Second World War came legislation that included the Hill-Burton Act, which dramatically increased the number of U.S. hospitals by providing federal funds for new hospital construction and remodeling of existing facilities.7 In 1949, as part of his Fair Deal, President Harry Truman tried implementing, through legislation, a universal healthcare plan for all Americans, which was opposed by many of the private insurance groups and led to its exclusion from the bill. In 1951, legislation making employer-paid premiums a tax-deductible business expense solidified third-party payment by insurance companies as the primary means for healthcare access.

President Lyndon Johnson, recognizing the shift in public opinion taking place in the early 60s, rolled out his “Great Society” legislation in 1965 that had as its centerpiece the implementation of the Medicare program. Despite stiff opposition by insurance companies and the AMA on grounds that it made healthcare compulsory, represented “socialized medicine,” and would lower the quality of care, the Great Society legislation passed with Harry Truman becoming the first registered Medicare recipient.8 In 1970, no fewer than three separate universal coverage national health insurance bills were proposed, but none were enacted. However, two years later, President Richard Nixon signed the Social Security Amendments of 1972 extending Medicare benefits to people with severe disabilities and end-stage renal disease, regardless of age.9 The laws encompassing healthcare access underwent few changes during the next four decades although many attempts were made to legislate health policy reform.

In 1993, President Bill Clinton tried to pass his own version of a comprehensive universal healthcare plan for all Americans (the Health Security Act) based on an enforced mandate for employers to provide health insurance coverage to all of their employees.

Although containing many ideas that would eventually become part of the landmark 2010 ACA, organized opposition by many in Congress, as well as physician groups and insurance companies who characterized the plan as overly bureaucratic and restrictive, eventually led to loss of support by President Clinton’s congressional backers.10 The midterm elections of 1994 brought to power the first GOP-controlled Congress in both houses since 1953, effectively ending the Clintons’ plan for federally mandated universal Continued on Page 24

Fall 2016 | AZMedicine 23

Continued from page 23

healthcare coverage. (Hillary Clinton had become the face and the voice for healthcare legislative reform.) However, during President Clinton’s two terms in office, two important pieces of healthcare legislation were passed: The Health Insurance Portability and Accountability Act (HIPAA) and the Children’s Health Insurance Program (CHIP), which was renewed in the recently passed MACRA legislation.

Health Policy Today Today, the ACA and MACRA are helping build a stronger, more sustainable Medicare Program by making prescription drugs more affordable, covering preventive services

The Medicare Program is also sustained, in part, through legislation that created the Quality Improvement Organization (QIO) Program that now has two main entities: (1) Beneficiary and Family-Centered Care QIOs that provide beneficiary protection through clinical case review, and (2) Quality Innovation Network (QIN)-QIOs, focused on quality initiatives for providers and patients. As the Medicare QIN-QIO for Arizona, California, Florida, Ohio, and the U.S. Virgin Islands, Health Services Advisory Group (HSAG) works with healthcare providers to maintain quality by helping implement legislative change, and creates value for those who administer and receive healthcare through our quality improvement pro-

Today, the ACA and MACRA are helping build a stronger, more sustainable Medicare Program with no deductible or copay, and implementing tougher screening procedures and penalties utilizing new technology to stop fraud and abuse.11 The Centers for Medicare & Medicaid Services (CMS), the largest health insurer in the nation, has also adopted a quality strategy that aligns with the ACA by transitioning from a passive payer to an active purchaser of healthcare and services.

24 AZMedicine | Fall 2016

grams, further protecting the Medicare Trust Fund.

Going forward, the new healthcare landscape established through these legislative reforms requires strong partnerships between patients, providers, and payers to be successful. Today’s legislation is based heavily on feedback from physicians, medical societies, and academic institutions, rooted in ideas that go back generations

Today’s legislation is based heavily on feedback from physicians, medical societies, and academic institutions and vetted by the myriad reformers who came before us.

HSAG remains committed to ensure providers and patients understand how these new laws affect them and offer assistance and services that strengthen our nation’s healthcare system. AM

4 5 Years Later: How the Affordable Care Act is Working for Arizona.

Available at: http://www.hhs.gov/ healthcare/facts-and-features/ state-by-state/how-aca-is-working-for-arizona/index.html#.

Accessed on: May 19, 2016.

Howard Pitluk, MD, MPH, FACS, is Vice President, Medical Affairs & Chief Medical Officer; Mary Ellen Dalton, PhD, MBA, RN, is Chief Executive Officer. Dawn Williams, BS, Director of Communications, assisted with this article.

6 Ballard DJ, Spreadbury B, Hopkins RS. Health care quality improvement across the Baylor Health Care System: the first century. Proceedings (Baylor University Medical Center).

2004;17(3):277–288.

This material was prepared by Health Services Advisory Group, the Medicare Quality Improvement Organization for Arizona, under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. The contents presented do not necessarily reflect CMS policy. Publication No. QN-11SOW-D.1-06292016-03

7 Intro to HSR e-class: Module 2: Brief History of Health Services Research. 2007, Nov. 2. Available at: https://www.nlm.nih.gov/nichsr/ihcm/02history/history16.html.

Accessed on: June 28, 2016,

1 5 Years Later: How the Affordable Care Act is Working for Arizona.

Available at: http://www.hhs.gov/ healthcare/facts-and-features/ state-by-state/how-aca-is-working-for-arizona/index.html#.

Accessed on: May 19, 2016.

2 2015’s Rates of Uninsured by State Before & After Obamacare. Available at: https://wallethub.com/edu/ rates-of-uninsured-by-state-before-after-obamacare/4800.

Accessed on: June 28, 2016 3 Kaiser Family Foundation. Survey of Non-Group Health Insurance Enrollees. Available at: http:// kff.org/private-insurance/report/ survey-of-non-group-health-insurance-enrollees. Accessed on: June 28, 2016

5 Forrest A. Walker, “Americanism versus sovietism: a study of the reaction to the Committee on the Costs of Medical Care,” Bulletin of the History of Medicine 53 (4): Winter 1979, 489–504.

8 Medicare Is Signed Into Law. (n.d.). Available at: https://www. ssa.gov/history/lbjsm.html. Accessed on: June 28, 2016.

9 Legislative History: 1972 Social Security Amendments. Available at: https://www.ssa.gov/ history/1972amend.html. Accessed on: June 28, 2016.

10 Harry A Sultz and Kristina M. Young, Health Care USA: Understanding Its Organization and Delivery, 7th ed., Jones & Bartlett Learning, Sudbury, Mass., 2011, pp. 35–37, 230–232.

11 5 Years Later: How the Affordable Care Act is Working for Arizona.

Available at: http://www.hhs.gov/ healthcare/facts-and-features/ state-by-state/how-aca-is-working-for-arizona/index.html#.

Accessed on: May 19, 2016.

Emerging Trends in Medicine

Dispensing Naloxone to Prevent Overdose Deaths On May 12, 2016, Governor Doug Ducey signed legislation to expand access to naloxone in order to curb fatal overdoses. House Bill 2355 allows licensed prescribers to prescribe, dispense, and distribute naloxone directly or through

Haley Coles

a standing order to a person at risk of an opioid overdose, their friends and loved ones, and any person who may be in a position to assist.

The law allows for certain liability protections that previously did not exist for third party prescribing of naloxone, and the only requirement is that you instruct the individual to summon emergency medical services either immediately before or after administering naloxone.

Arizona had the tenth highest overdose death rate in the nation in 2014, with over 1200 lives lost to accidental overdose.

The majority of overdose deaths involved a prescription opioid or heroin, highlighting the need for greater naloxone availability, among other prevention strategies, in combating this major public health issue.

Naloxone distribution beyond first responders is shown to decrease overdose deaths in communities by as much as 37-90%. It is crucial that it be available and accessible.

Naloxone is a safe opioid antagonist that restores breathing by dislodging the opioids from the opioid receptors in the brain temporarily. It is not a controlled substance, it has no addictive or psychoactive properties and it has few side effects. It has no effect on people who do not have opioids in their system.

Individuals who regularly use opioids may experience withdrawal symptoms when given naloxone, particularly if higher doses are administered.

These withdrawal symptoms,

Physicians are well-positioned to increase access to naloxone and promote opioid safety though unpleasant, are not life threatening, while the respiratory depression that occurs in opioid overdose can be fatal without prompt intervention As respected and knowledgeable physicians, you are well positioned to substantially increase access to naloxone and promote opioid safety. It takes a multi-faceted approach to end overdose fatalities, and educating patients on opioid safety with naloxone is a proven and effective step. You can truly make a difference in the lives of Arizonans. Thank you for all you do! AM Haley Coles is E.D. of Sonoran Prevention Works. She has worked in the field of drug user preventive health since 2006 both in Arizona and Washington. She sits on several state-level advisory groups for the prevention of HIV and overdose, and teaches overdose prevention curriculum to different agencies throughout the state. She can be reached at hcoles@spwaz.org or 602-388-9870.

To review the new law: www.azleg.gov/ legtext/52leg/2r/bills/ hb2355h.pdf Naloxone product guide: www.prescribetoprevent. org/wp2015/wp-content/ uploads/Naloxone-productchart.16_01_21.pdf Educational handouts for naloxone recipients: www.prescribetoprevent. org/patient-education/ materials/ More resources, such as a prescribing and dispensing guide: www.prescribetoprevent. org/prescribers/palliative/

Emerging Trends in Medicine

Medicare’s new plan for paying doctors: 10 key takeaways Reprinted with permission from the April 28, 2016 Daily Briefing, a publication of the Advisory Board.

By Eric Cragun and Rivka Friedman CMS released its long-awaited proposed rule for new value-based payment programs under the Medicare Access and CHIP Reauthorization Act (MACRA).

The law will fundamentally change how Medicare pays physicians and other clinicians who participate in the program. It will establish a two-track system for Medicare reimbursement: one, called MIPS, for providers who are reimbursed largely through fee-for-service, and an alternative payment model (APM) track for physicians who take on a significant portfolio of APMs. The Advisory Board will have much more to say on the MACRA proposal (more on that below) as we digest the 962-page rule, but here are 10 early key takeaways.

1. The rule underscores the complexity of MACRA. While CMS has made a valiant effort to keep implementation streamlined, the sheer number of elements in MACRA requires lengthy, complex rules.

2. CMS has heard the call to streamline this rule and minimize the burden on participants.

Despite MACRA’s complexity, it is clear that CMS is making a concerted effort to preserve simplicity and flexibility for providers. For example: • The MIPS quality category will require providers to report just 6 measures, fewer than required under the existing Physician Quality Reporting System (PQRS); • The MIPS cost category measures come from claims data, allowing CMS to calculate performance independently; • The EHR use category—now known as “Advancing Care Information”—moves away from an all-or-nothing approach, and promises more customizable measures; and • CMS defines two approaches to meeting the alternative payment models (APMs) threshold—based on either revenue at risk or number of patients attributed under risk.

The Field Guide to Medicare Payment Innovation on advisory.com

26 AZMedicine | Fall 2016

3. MIPS will push medical groups of all sizes to invest in reporting and tracking performance on PQRS. MIPS requires PQRS performance accountability for groups of all sizes.

Previously, reporting alone would satisfy PQRS requirements and small groups were not subject to the value-based payment modifier program. For all providers, MIPS means more accountability for PQRS performance than they’ve had in the past.

4. CMS set a high bar on requirements for APM track.

Under the agency’s criteria for payment models to be eligible for the APM track— which CMS calls “Advanced APMs”—the Bundled Payments for Care Improvement (BPCI) Initiative, the Comprehensive Care for Joint Replacement (CJR) Model, and Track 1 of the Medicare Shared Savings Program (MSSP) all will not qualify.

Meanwhile, MSSP Tracks 2 and 3, Next Generation, and Pioneer—which all require downside risk—will qualify.

Less surprisingly, CMS confirmed that only Part B (traditional) Medicare payments will count toward the Advanced The Field Guide to Medicare Payment Innovation on advisory.com APM threshold. Payments from Medicare Advantage plans can count toward the “Other Payer” threshold beginning in CMS will notify entities of 2017 APM status in mid-2018 2021, but only if those payments are made through models that for adjustments to be made in 2019. Thus, if entities aren’t meet Advanced APM requirements. Notably, the rule does not confident they will qualify for APM track, it seems as though address whether CMS will allow Track 1 ACOs to switch MSSP they will need to report under MIPS in 2017 in case they don’t tracks mid-participation agreement to join an Advanced APM. qualify.

5. CMS expects most eligible clinicians to be in MIPS. Because of the high bar set to qualify for the APM track, CMS projects that only 30,000 to 90,000 clinicians will be in the track. An estimated 687,000 to 746,000 physicians will be in MIPS. 6. Most clinicians qualifying for the APM track will do so as a group.

CMS proposes to determine qualification for the APM track at the entity level for all clinicians who are on the APM participant list for that APM. 7. The proposed rule reflects a belief and expectation that medical home models have potential to drive significant value for Medicare.

The rule includes strong MIPS rewards for providers participating in medical home models through the Clinical Practice Improvement category. CMS also proposes creating a special pathway by which medical home models, including the Comprehensive Primary Care Plus (CPC+) program, can qualify as advanced APMs.

9. Performance periods are rapidly approaching.

As with other payment initiatives, CMS would base payment adjustments for both MIPS and APM tracks on performance periods two calendar years prior to the adjustment. That means—in both tracks—performance in 2017 will determine payments for 2019.

10. The rule’s complexity (and its high stakes) are likely to elicit concern and comments from various stakeholders.

Finalizing these regulations in time for performance periods to begin in 2017 poses a monumental task. It helps that the quality and resource use measures in MIPS have largely been around for a few years (through PQRS and VBPM). But MIPS will involve more providers than previous programs, and providers will have to make decisions about APM participation before the final rule is set. Stakeholders facing payment changes and uncertainty about those changes are likely to want their perspectives heard. Depending on how CMS addresses those difficulties, much could change between this proposal and the final implementation. AM

8. Providers must decide whether to submit MIPS data before they know if they will qualify for APM track.

CMS will not notify providers about their status for the APM track until after the MIPS performance period. For example, Fall 2016 | AZMedicine 27

The Arizona Medical Association Political Action Committee (ArMPAC) supports local, Arizona candidates who have demonstrated their support for medicine and the health of Arizonans.

To ensure the election of thoughtful, medicine-friendly candidates, support ArMPAC through personal contributions and by volunteering your time. ArMPAC is open to contributions from Arizona physicians, their families, significant others, and to those interested in supporting medicine-friendly candidates.

Contribute today at http://www.azmed.org/donations/

Interested in becoming more involved?

Contact Pele Fischer, VP of Policy & Political Affairs at ArMA pele@azmed.org or (602) 246-8901

28 AZMedicine | Fall 2016

ArMPAC General Election Endorsements

Help your local candidates get elected!

The Arizona Medical Association Political Action Committee (ArMPAC) exists to support local, Arizona candidates who have demonstrated their support for medicine and the health of Arizonans. The ArMPAC Board of Directors, led by Chair Gary Figge, MD, has considered the Arizona general election candidates and endorsed medicine-friendly candidates.

After deliberation, the Board recommends the candidates listed below as deserving support in the general election on Tuesday, November 8.

Federal Elections U.S. SENATE

Arizona’s Legislative Elections DISTRICT 1

John McCain (R) U.S. CONGRESSIONAL DISTRICT 4

Paul Gosar (R) U.S. CONGRESSIONAL DISTRICT 6

David Schweikert (R) U.S. CONGRESSIONAL DISTRICT 7

DISTRICT 14

DISTRICT 24

Karen Fann (R), Senate

Gail Griffin (R), Senate

Katie Hobbs (D), Senate

Noel Campbell (R), House

Drew John (R), House

Lela Alston (D), House

DISTRICT 4

Ken Clark (D), House

DISTRICT 15

Charlene Fernandez (D), House DISTRICT 5

Heather Carter (R), House

Bob Worsley (R), Senate

DISTRICT 16

Doug Coleman (R), House

Regina Cobb (R), House DISTRICT 8

Ruben Gallego (D)

Frank Pratt (R), Senate

U.S. CONGRESSIONAL DISTRICT 8

David Cook (R), House

J.D. Mesnard (R), House

Thomas “TJ” Shope, (R), House

Jeff Weninger (R), House

U.S. CONGRESSIONAL DISTRICT 9

Kyrsten Sinema (D)

DISTRICT 9

Randall Friese, M.D. (D), House DISTRICT 10

David Bradley (D), Senate Stephanie Mach (D), House DISTRICT 11

Vince Leach (R), House

Catherine Miranda (D), Senate Reginald Bolding (D), House Rebecca Rios (D), House

DISTRICT 18

Bob Robson (R), House

Steve Farley (D), Senate

Michelle Udall (R), House DISTRICT 27

DISTRICT 17

Steve Yarbrough (R), Senate

Trent Franks (R)

DISTRICT 25

Jill Norgaard (R), House DISTRICT 20

Kimberly Yee (R), Senate DISTRICT 21

Debbie Lesko (R), Senate DISTRICT 23

John Kavanaugh (R), Senate Jay Lawrence, (R), House

DISTRICT 28

Kate Brophy McGee (R), Senate Eric Meyer, M.D. (D), Senate Kelli Butler (D), House Mary Hamway (R), House Maria Syms (R), House DISTRICT 30

Robert Meza (D), Senate

The importance of supporting medicine friendly candidates, both financially and by voting, cannot be understated. It is vital to the practice of medicine and the health of your patients to elect candidates that will become legislators with whom the Arizona Medical Association (ArMA) works with in future legislative sessions. We urge you to vote for these candidates who have supported medicine. Interested in learning more about getting involved and helping candidates get elected?

Contact Pele Fischer at pele@azmed.org or (602) 246-8901.

Mark your calendars for the following key voting dates and deadlines: October 10 Voter registration deadline for General Election

October 12 Early Voting begins for General Election

November 8 General Election

Fall 2016 | AZMedicine 29

Emerging Trends in Medicine

Public Health in the Palm of Your Hand Lisa Villarroel, MD, MPH, Medical Director, Bureau of Epidemiology and Disease Control, Arizona Department of Health Services Responding to emerging public health threats like Ebola, Zika, measles, and spiking influenza requires close communication between clinical medicine and public health. Public health needs to get crucial information to Arizona providers, and providers need a quick way to get local awareness or the public health department on the line.

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Download the 5-star reviewed app at the AppStore or Google Play today.

30 AZMedicine | Fall 2016

Supervising Editor Jennifer Hartmark-Hill, MD

AzMedicine Advisory Council Marshall B. Block, MD Ronnie Dowling, MD Rebecca Fega, MD Kelly Hager Michael F. Hamant, MD Jennifer Hartmark-Hill, MD M. Zuhdi Jasser, MD Phil Keen, MD Marc Leib, JD, MD Mary E. Rimsza, MD Allison Rosenthal, MD Jeffrey A. Singer, MD Ronald P. Spark, MD

President

2016-2017 Board of Directors

Rebecca Fega, MD Resident Physician Director

Robert M. Aaronson, MD At-Large Director

Gary R. Figge, MD AMA Delegate

Gretchen B. Alexander, MD President, Executive Committee

Howard B. Fleishon, MD Maricopa Director

Miriam K. Anand, MD At-Large Member, Executive Committee

Ross Goldberg, MD At-Large Member, Executive Committee and AMA Alternate Delegate

Suresh C. Anand, MD Maricopa Director

Tanja Gunsberger, DO Maricopa Director

Daniel P. Aspery, MD AMA Delegate

Dale W. Guthrie, MD At-Large Director

Timothy H. Beger, MD At-Large Director

Kelly Hager, Student Director

Adam M. Brodsky, MD Maricopa Director Henri R. Carter, MD Rural Director

Michael F. Hamant, MD President-Elect, Executive Committee, and AMA Alternate Delegate

Executive Vice President

Bourck D. Cashmore, MD Rural Director

Jennifer R. Hartmark-Hill, MD Secretary, Executive Committee

Chic Older chicolder@azmed.org

Gary S. Christensen, MD Rural Director

Thomas H. Hicks II, MD AMA Delegate

Managing Editor

John Couvaras, MD Maricopa Director

M. Zuhdi Jasser, MD AMA Delegate

Michael Dean, MD Pima Director

Nadeem A. Kazi, MD Rural Director

Ronnie K. Dowling, MD AMA Delegation Chair, Executive Committee, and Speaker of the House

Philip E. Keen, MD At-Large Director

Timothy C. Fagan, MD Pima Director and AMA Alternate Delegate

Nathan Laufer, MD Immediate Past President, Executive Committee

Gretchen B. Alexander, MD

Sharla J. Hooper, MA Associate VP, Communications sharla@azmed.org

Peter C. Kelly, MD At-Large Director

Marilyn K. Laughead, MD Vice Speaker and Parliamentarian, House of Delegates Marc L. Leib, MD AMA Alternate Delegate Robert J. Marotz, DO Rural Director Jeffrey T. Mueller, MD Outgoing Past President, Executive Committee Robert R. Orford, MD At Large Director Traci Pritchard, MD Vice President Allison Rosenthal, DO At-Large Director William J. Thrift, MD Rural Director Susan M. Whitely, MD Treasurer, Executive Committee

Design/Layout Scott Smiley, Mangus Media sgsmiley@mangusmedia.com

Advertising For questions regarding advertising, please contact: Simone Lustig, Associate VP of Membership and Development (602) 347-6907 simone@azmed.org

R. Screven Farmer III, MD At-Large Director

AzMedicine is published four times a year by the Arizona Medical Association (ArMA) for Arizona Physicians.

It contains articles of interest to the medical community, covering socio-economic, political and scientific information.

The views and opinions expressed are the authors’ and do not reflect those endorsed by ArMA. ArMA does not guarantee or endorse the products or claims advertised.

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Send address changes to: AzMedicine 810 W. Bethany Home Road Phoenix, AZ 85013-1699 (602) 246-8901 • (800) 482-3480 • FAX (602) 242-6283

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Fall 2016 | AZMedicine 31

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