AzMedicine Spring 2016 by Arizona Medical Association

5 Tips to Minimize Prior Authorization Delays | Converting primary care to subscription-based care Spring 2016

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FROM OUR PRESIDENT Non Physicians expanding scope of practice, or the dumbing down of health care delivery........... 4 Physician Careers: Understanding the Market....................................... 8 The Impact of Equalizing Payment for Evaluation & Management Visits on Physician Practice Consolidation..................... 12

Retirement: All or None or Somewhere In Between?....................................... 20 Integrating Physical and Behavioral Health Information for Better Patient Care........................................... 24 Teaching Future Physicians the Business Side of Medicine............................... 26

Converting primary care to subscription-based care........................................ 14

HSAG VISTAS Quality as the Business Case for Medicine and Lowering Costs.......................... 28

5 Tips to Minimize Prior Authorization Delays...................................... 16

Farm to Hospital Concept Thrives at Cancer Treatment Centers of America............... 30

What Physicians need to know about leaving clinical practice if they may wish to return....................................... 18

w e n e R A M r A rship

e b m Me

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simone@azmed.org

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Spring 2016 | AZMedicine 3

FROM OUR

President

Non Physicians expanding scope of practice, or the dumbing down of health care delivery (Is medical school becoming obsolete?) “ You have to motivate yourself with challenges. That’s how you know you’re still alive.” — Jerry Seinfeld This year will again be a challenge for the practicing physician. Aside from all the insurance, government, and hospital issues I have outlined in past editorials, a new threat to patients and the delivery of excellent health care has emerged. Many nonphysicians are slowly trying to eclipse the reason why we exist – the delivery of expert care by a physician-led team. We have all spent many years in medical school and postgraduate training to gain the Nathan Laufer, MD, FACC depth of knowledge and experience to be able to practice our professions. We all try to deliver the highest quality expert care that our years of training has prepared us to do. However, dark clouds are on the horizon. There are a many non-physicians sitting in the wings trying to expand their scope of practice, without the commensurate education and training required. This will have the consequence of ‘dumbing down’ the delivery of health care to the citizens of Arizona. Some example of these groups are: psychologists who want prescriptive powers to use psychotropic drugs; optometrists who want to use lasers; chiropractors who want to be considered primary care physicians; estheticians who want to use lasers for skin care; 4 AZMedicine | Spring 2016

naturopaths who want prescriptive authority, and most recently, certified registered nurse anesthetists (CRNA) and clinical nurse specialists (CNS) who want full prescriptive authority and independent practice. In September 2015, the Arizona Nurses Association (AzNA) and their component associations filed for a major scope of practice change to the Nurse Practice Act that would impact in varying degrees four categories of advanced practice nurses (APRN):

There are a many non-physicians sitting in the wings trying to expand their scope of practice, without the commensurate education and training required. Nurse Practitioners (NP), Certified Nurse Midwives (CNM), Certified Nurse Specialists (CNS), and Certified Registered Nurse Anesthetists (CRNA). The original scope of practice expansion application and subsequent bill introduced was based on model legislation developed by national nursing associations. Following the release several years ago of an Institute of Medicine report calling for APRNs to Continued on page 6

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practice to “the full extent of their education and training,” the national groups have been shopping the legislation at the state level. In Arizona, this has been pushed as “consensus” model legislation, where the changes of all four categories are tied together in one bill. There is a disturbing trend here with the potential of further eroding the delivery of the best medical care in the world. In Arizona, NPs have had independent practice privileges since the mid-1980s. This includes complete prescriptive authority.

and complete prescriptive authority. Interestingly, a number of grandfathered CRNAs never went to university! We join AzSA in our concern with this request and we feel strongly it has serious patient safety implications. If these changes are granted as requested, we have been told directly by the CRNAs that they intend to open independent pain management practices. Our fellowship-trained physicians who practice pain management have testified that this is not a safe practice. And, it comes at a time where all of medicine is looking at an epidemic of prescription drug dependency happening across the country. As to Clinical Nurse Specialists, this one is a big question mark to many of us who have been directly involved with the nursing scope change application. We have met with the State Board of Nursing and even they seem to have a hard time clearly distinguishing between a CNS and a Nurse Practitioner. Information the Arizona Nurses Association has provided shows the potential for a wide disparity in the level of training a CNS would be required to have compared to that of a Nurse Practitioner.

I question the level of expertise the nursing board is required to have if they are going to allow nurses to venture into areas of practice for which they do not have the commensurate knowledge needed. Current statute requires that they have a collaborative arrangement with a physician and some NPs have felt this needs more clarification as it is causing them problems in being recognized by payers and health plans. A similar requirement exists for Certified Nurse Midwives (CNM) who are recognized by the American Congress of Obstetricians and Gynecologists (ACOG) for independent practice. They, too, are concerned with a better clarification of the term “collaboration.” Where our primary concern has emerged is with two other categories of nursing, Clinical Nurse Specialists (CNS) and Certified Registered Nurse Anesthetists (CRNA). For help with CRNAs we have turned to the Arizona Society of Anesthesiologists (AzSA) whose members work closely with CRNAs, in many different practice settings. In 2011, a major practice scope for CRNAs was considered in Arizona and current statute was accepted by both the CRNAs and the Arizona Board of Nursing as being appropriate and ensuring proper patient quality and safety. These groups of nurses are now seeking independent practice without supervision by a physician,

6 AZMedicine | Spring 2016

We have asked the Nursing Board why they are not using the existing pathway of Nurse Practitioners for this category of APRN as it would eliminate our major concerns about qualifications and patient safety. The training and experience of Nurse Practitioners in Arizona is well established and has been in place for 30 years. We have not received an answer to this question as it seems to be part of the entire package. The proposed bill deferred the training and education requirements to the nursing board. Any education and training requirements should be explicit in statute and not deferred to the nursing board. The nursing board does not have the medical expertise needed to make some of the critical decisions deferred to it by this bill. The bill grants some nurse specialties the right to practice medicine without comparable training and experience to that of a physician. THIS IS A DANGEROUS CHANGE. The nursing board does not have any physicians on it, and is only required to have one APRN. I question the level of expertise the nursing board is required to have if they are going to allow nurses

to venture into areas of practice for which they do not have the commensurate knowledge needed. In contrast, the Arizona Medical Board has at least one nurse on it! Should the nursing board not have at least one physician member and more APRNs who might be qualified to oversee the activities of the APRNs, rather than LPNs and RNs?

I have always said that the only constant is change. However, change needs to be progressive, not regressive. In this case, we don’t want change to adversely affect the high quality and safe medical care that has been delivered for years to the citizens of Arizona.

In both of these cases, CRNAs and CNS, it is the physician community that is put in the position of having to be the one to assess what is safe for patients. ArMA’s focus on patient safety has always been the only driving force. We are seeing “positioning” by these non-physician groups as the spill-over of the Affordable Care Act. The government promised health care for all, but didn’t necessarily promise good quality care. Apparently to some, unqualified care is better than no care. ArMA has developed a coalition to oppose the progress of this bill. Participants include: Arizona Medical Association, Arizona Osteopathic Medical Association, Arizona Society of Anesthesiologists, Arizona Chapter of American College of Physicians, Arizona Dental Association, Arizona Section of American Congress of Obstetricians and Gynecologists, Arizona Chapter of the American Academy of Pediatrics, Arizona Academy of Family Physicians, Arizona Psychiatric Society, Arizona College of Emergency Physicians, Arizona Chapter of American College of Surgeons, and Arizona Society of Interventional Pain Physicians. All physicians believe in a team approach to healthcare with each member of the team delivering the best care they know how and are qualified to provide. However, this does not include non-physicians and non-nurse practitioners becoming totally independent from the medical team. Unfortunately, with limited training, they don’t know what they don’t know! I have always said that the only constant is change. However, change needs to be progressive, not regressive. In this case, we don’t want change to adversely affect the high quality and safe medical care that has been delivered for years to the citizens of Arizona. I trust the state legislature will agree and not support SB1473.

This is my last editorial for AZ Medicine, as my president’s term will conclude at the end of May. It has been a privilege to represent the physicians of Arizona over the last year. I thank you for your support during my term and continue to be optimistic about the future of physicians and healthcare in Arizona despite these speedbumps. AM Nathan Laufer, MD, is the 124th ArMA President. Dr. Laufer is a cardiologist and the medical director of the Heart & Vascular Center of Arizona.

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Spring 2016 | AZMedicine 7

The Business Side of Medicine

Physician Careers: Understanding the Market Reprinted with permission of Doximity. This article originally appeared January 27, 2016 at http://news.doximity.com/entries/3060029.

Last year we unveiled Career Navigator, the first-ever comprehensive career resource that includes physician compensation estimates and

Joel Davis, VP of Hiring Solutions at Doximity

open job opportunities. Now, more than 35,000 Doximity members have anonymously shared their annual income with the greater physician community in an effort to bring more transparency to medical careers. For some, this insight has helped them better prepare for career moves and salary negotiations. Others have discovered new opportunities – either fulltime clinical positions, or

8 AZMedicine | Spring 2016

to supplement their current practice. For example, 50% of all physicians practicing in American Well’s telehealth group discovered the opportunity through Doximity. As physicians finalize their resolutions for the new year and plan the next steps for their careers, we want to share the latest insights our data scientists have gleaned from our compensation map. In this latest round of analysis, we examined the balances (or imbalances) between locations, academic versus clinical positions, and genders.

Location, Location, Location If you are looking for the maximum return on your extra decade of education, then where you practice matters. It turns out, cities where our data shows physicians are most interested in working — Los Angeles, San Francisco and Washington, D.C. — have average salaries significantly lower than the rest of the country. Physicians living in our nation’s capital, for example, had the lowest average salary across all specialties

If you are looking for the maximum return on your extra decade of education, then where you practice matters. — making a full 17% less than the national average for all specialties. Doctors in these metropolitan areas are most in-demand by employers based on recruitment activity on Doximity:

Highest paying states for primary care physicians (family medicine, internal medicine, pediatrics, OB/GYN): 1. Arkansas: $330,000 2. South Dakota: $305,000

1. Denver, Colorado

3. Iowa: $305,000

2. Louisville, Kentucky

Lowest paying states for primary care physicians (family medicine, internal medicine, pediatrics, OB/GYN):

3. Spokane, Washington 4. Las Vegas, Nevada 5. Colorado Springs, Colorado When it comes to average annual income, Minnesota and Indiana seem to fare the best – both are 13% over national average for all specialties. So, if you really want get the most return on your medical school investment, head to the heartland.

49. Delaware: $218,000 50. West Virginia: $205,000 51. District of Columbia: $192,000 Highest paying states for specialists: 1. North Dakota: $472,000 2. Wyoming: $433,000 3. Idaho: $429,000 Continued on page 10

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Continued from page 8

Average Compensation Densities for Academic & Non-Academic Physicians

Lowest paying states for specialists:

25%

49. Vermont: $299,000

20%

50. District of Columbia: $298,000

Physicians in Academic Medicine Pay the Price Academic medicine has always been one of the most important callings in healthcare. Not only do these physicians continue to mold the future of medicine with each class, but the with the impending physician shortage, they are responsible for making sure their cohorts are prepared to carry the growing caseload. And we have academic physicians to thank for making great strides in medical research.

Academic

% of Subpopulation

51. Rhode Island: $291,000

Cohort Type Non-Academic 15%

10%

0% $0

10 AZMedicine | Spring 2016

$500,000

$750,000

$1,000,000

Average Compensation

significantly by specialty. For example, academic cardiologists make on average 52% (or $150,000; p < .05) less than their non-academic counterpoints. Similarly, non-

As a whole, academic physicians make on average 13% less than their non-academic counterparts, and this varies significantly by specialty. However, devotion to teaching and research comes at a price. As a whole, academic physicians make on average 13% less than their non-academic counterparts, and this varies

$250,000

academic gastroenterologists make 41% (or $124,000; p < .05) more than academics in the specialty. Similar to the pay gap findings in gender, the procedural specialties tend

to make significantly more in non-academic careers. Additionally, while we don’t account for tenure or geography, it appears that academic physician earnings cluster around $250,000 and have less variability:

Male Vs. Female Physicians: Is There Pay Gap? Women now make up 34% of the physician workforce and half of this year’s medical school graduating class, yet inequalities persist in their careers. In September 2015, a study by Dr. Anupam Jena revealed women in academic medicine were 13 percent less likely to be promoted to full professor than men with the same qualifications. Another study suggested women are less likely to get research funding.

Our data tells a similar story: overall, male physicians tend to make an average of 21% more than female. Specialties with some of the largest gender pay gaps: Ophthalmology: males earn 36% more than their female counterparts (~$95,000 more per year; p < .05) Physical Medicine & Rehabilitation: males earn 24% more than females (~$80,000 more; p < .05) Cardiology: males earn 29% more than female cardiologists (~$97,000 more; p < .05) Specialties with some of the smallest gender pay gaps: Anesthesiology: males earn 12% more than female anesthesiologists (~$43,000 more; p < .05)

Average Physician Compensation by Gender & Age

Average Compensation

$360,000

Gender Male Female $320,000

to compensation trends with Career Navigator and pairing it with job opportunities in areas with unmet needs, physicians will be empowered to take control of their careers and get compensated fairly for keeping the country healthy. Physicians can explore the interactive compensation map at www.doximity.com/careers.

$280,000

Physicians’ Age

Overall, male physicians tend to make an average of 21% more than female.

physicians prepare for salary negotiations. We hope that by adding a bit of transparency

**Note: all salary estimates are based on self-reported annual income, not per unit of work. They were not controlled for part time vs full time work. Other than the academic vs. nonacademic comparison, all figures include both academic vs. nonacademic salaries. Gender pay by specialty is not weighted by subspecialty. AM

Because differences matter.

Radiology: males earn 13% more than females (~$49,000 more; p < .05) Family Medicine: males earn 14% more than females (~$30,000 more; p < .05) *This analysis does not account for any disproportionate subspecialization (e.g. more men pursuing a higher paying subspecialty such as interventional cardiology). At what point in their careers are men and women equally compensated? The difference in earnings between men and women seems to persist across the career timeline – the gap

closing only slightly as physicians approach retirement. While there are movements in the industry to close the gender gap in both academic and non-academic careers, the gender pay gap remains an issue.

Bringing Transparency To Physician Careers Compensation is nowhere near the primary motivating factor for many in medicine. However, the employment landscape is shifting: more physicians are selling their private practices to become employees of hospitals and large groups. Therefore, it is important that

Spring 2016 | AZMedicine 11

The Business Side of Medicine

Leveling the Playing Field: The Impact of Equalizing Payment for Evaluation & Management Visits on Physician Practice Consolidation Over the last 10 years, hospitals across the county and in Arizona and have been steadily merging and purchasing physician practices. In some specialties, more than 50 percent of physicians are now hospital-based employees

Paul Giancola, Esq. rather than owners of their practice. The trend in consolidation has been driven in part by the goals of the Affordable Care Act to encourage coordination of care and to reward value instead of volume. Another reason is that Medicare feefor-service pays hospital-based physicians more than officebased physicians for identical non-emergency evaluation and 12 AZMedicine | Spring 2016

management (E&M).

patient

visits

In 2013, the Denver Post reported on a vivid example of this phenomenon with a patient who received two cardiac stress tests: the first in the physician’s office; the second after the physician’s practice was purchased by a hospital. The first test cost $2,100; the second test cost $8,000, due to an added facility fee. Similarly, in 2013, the Medicare Payment Advisory Commission (MedPAC), an independent congressional panel that reviews Medicare, noted that a routine 15-minute office visit cost $72.50 at a doctor’s office, but $123.88 if billed as a hospital outpatient visit. MedPAC expressed concerns about the financial incentives for shifting services from physician offices to hospital outpatient departments. As a result, MedPAC recommended that payment variations for the same services in different ambulatory settings be

With a possible leveling of the playing field, this is a good time to revisit the advantages of physician practice consolidation. equalized. This recommendation was recently adopted by the United States Government Accountability Office (GAO) in its December, 2015 report to Congress entitled, “Medicare, Increasing Hospital-Physician Consolidation Highlights Need for Payment Reform.”

paid hospital outpatient departments than lower paid physician offices.

The GAO found that between 2007 and 2013 the number of vertically consolidated hospitals increased from about 1,400 to 1,700. Meanwhile, it noted that the number of vertically consolidated physicians almost doubled from about 96,000 to 182,000.

Because Medicare pays for the same physician E&M services at a higher rate when performed at a hospital outpatient department, it found that Medicare expenditures for outpatient services grew at a rate of 8.3% annually, increasing from 22.4 billion to 36.3 billion dollars. It noted that the difference in payment rates provides an incentive for hospitals to acquire physician practices and to increase healthcare costs.

Not surprisingly, it found that hospitals have more E&M visits performed in higher

The Centers for Medicare and Medicaid Services (CMS) does not have the authority

to equalize payment rates for E&M visits between outpatient departments and physician offices to achieve Medicare savings. Therefore, the GAO recommended that Congress fix discrepancy. To address the practice of hospitals acquiring physician offices and billing at higher reimbursement rates, President Obama proposed in his Fiscal Year 2016 budget to impose site neutrality for E&M visits. In the Bipartisan Budget Act of 2015 (BPA), a compromise was reached. The BPA establishes site-neutral payment policy for newly-acquired, providerbased, off-campus hospital outpatient departments after November 2, 2016. However, provider-based facilities acquired before the law’s enactment may continue to bill under the Hospital Outpatient Prospective Payment System. In contrast, any newly acquired physician practices after the date of enactment are prohibited from doing so for items and services furnished after January 2, 2017. The reaction to the BPA and the possibility future expansion of site-neutral payment policies has been fierce. Since the site-neutral policy became effective, hospital industry groups have argued to Congress that the compromise policy will financially harm hospitals, potentially cause outpatient departments at teaching hospitals to close,

impact charity care and cause some hospitals to close. It remains to be seen whether Congress will address existing hospital-based physician practices and other areas of inequality in site payments in future legislation. The potential savings involved would suggest that Congress will. With a possible leveling of the playing field, this is a good time to revisit the advantages of physician practice consolidation. The two primary reasons to consolidate are the economics of scale and the potential for improved contracting with payors, hospitals, and other organizations. The economics of scale include, among other things, efficiencies and cost savings in technology investment, risk management, marketing, joint purchasing, developing Stark compliant ancillary revenues, billing and collection, and benefit plans. The challenges, of course, are loss of autonomy, incompatibility, significant financial risk, and uncertainty of outcomes. A list of some of the issues to consider are featured in the inset. Not everyone wants to be employed by a hospital. Although solo or small practice may be a part of the past, physician practice consolidation is a viable practice option that likely has a bright future. AM Paul J. Giancola, JD, is a partner in the Healthcare Practice Group, Snell & Wilmer, LLP, Phoenix, Arizona.

Consolidation: Issues to Consider Getting Started • Letter of Intent • Mission Statement • Confidentiality Agreement • Cost Sharing Agreement / Capital Account • Feasibility Study • Timeline and Meeting Schedule • Accountant and attorney input

Due Diligence • Practice Assets /Liabilities • Leases for offices and equipment • List of payors • Malpractice policies • Software systems and EMR • Employees • Outstanding liens / loans • Benefit plans • Antitrust Issues • Fee schedules / Insurer payment information • No sharing of reimbursement, marketing, strategic plans and other competitively sensitive information during negotiations (may use third-party to aggregate data) • Buy-In Methodology

Business Plan • Financial Model of Post-Consolidation Practice • Proforma • Costs / Contributions • Impact on revenues • Short and long term • Line of credit for initial cash flow interruption

Structure • New Practice Entity • Limited Liability Company (LLC) or Professional Corporation (PC) • Governed by Operating Agreement or Bylaws • Board of Managers / Directors • Centralized decision making body • Voting representative of Group • Majority and supermajority rights • Withdrawal / buy-out • How are decisions made • Committees • Non-Competition Agreements • Consolidated billing, accounting and financial reporting • New Payor Contracts • Single billing number • Employs Physicians and Staff • Compensation Formulas • Shareholder / Member / Employee • Allocation of Revenues and Expenses

Spring 2016 | AZMedicine 13

The Business Side of Medicine

Converting primary care to subscription-based care As you may have noticed, U.S. healthcare is in a phase of extreme complexity. Perhaps paramount amongst the wave of changes taking place is the

performance; shared cost savings agreements, such as the formation of Accountable Care Organizations (ACOs); and pre-payments to providers to care for specific patient populations. The benchmarks used to set goals for many of these initiatives include the following: • Meaningful use guidelines (related to electronic medical record utilization)

Kenneth G. Poole, Jr., MD, MBA, FACP reform of insurance reimbursements from volume- to value-based models. Healthcare services in this country continue to be paid for primarily in a fee-for-service manner – the more one does the more one gets paid. However, both governmentbased insurance (Medicare) and commercial insurance companies alike are gradually implementing variations in the way they reimburse healthcare providers for medical services. Examples include bonuses for quality-related goals and outcome measures; payment modifiers for provider 14 AZMedicine | Spring 2016

• Goals set forth by the National Committee for Quality Assurance (NCQA) • Quality metrics set forth by the Healthcare Effectiveness Data and Information Set (HEDIS) • Physician Quality Reporting System (PQRS) guidelines While individual commercial insurance companies are rolling out their specified versions of value-based reimbursement models to different providers and provider groups, it is Medicare and Medicare Advantage plans who are leading this trend. That said, physician practices that service a substantial number of Medicare patients find themselves in a position where care for

Small, independent medical practices are finding themselves unable to comply with the myriad of new payer regulations and requirements an already relatively complex set of patients has become significantly more challenging and costly. It is not surprising that only large integrated delivery systems (or healthcare networks/ systems) and practice associations that possess robust, integrated electronic medical records and massive administrative forces are best able to comply with these regulations and considerable subsequent overhead costs. Small, independent medical practices are finding themselves unable to comply with the myriad of new payer regulations and requirements due to the lack of manpower, resources, and time. This has been the driving force behind the proliferation of large healthcare systems and the

mass acquisition of primary care practices. All over the country, hospitals are merging; what equates to healthcare system “franchises” are popping up in office parks and strip malls; and large healthcare systems are amongst the largest employers in metropolitan areas. However, even large healthcare systems are not immune to the complexity and cost challenges that come along with reimbursement reform, particularly on the primary care side. Thus, being equipped for the years ahead is a proving to be challenge for primary care practices of all kinds and sizes, and small medical practices and large healthcare systems alike are forced to choose 1 of 3 paths to successfully navigate this current:

Option 1 – deal with it, and play the game as-is. This is what most large healthcare systems are presently doing. Systems are developing in-house models of care and quality metrics that would likely satisfy the outcome measures of most insurance plans. They are also forming exclusive risk-sharing collaborations with insurance providers in an effort to directly cash in on the cost savings their efforts may yield. Accountable Care Organizations (ACOs) are one form of this. Option 2 – charge an administrative fee. Uncommon at the moment, this is something that may become popular in the coming year(s), particularly amongst popular, high-performing healthcare systems with strong name recognition. Under this model, systems in essence charge a yearly fee of several hundred dollars to patients in order to obtain primary care. Option 3 – decide that it is not worth the trouble. This is the option that has birthed the popular trend of concierge medicine and other subscription-based practice models. Instead of breaking the bank with the administrative and IT costs required to be in compliance with the myriad of evolving healthcare regulations many small practices are cutting down on their patient panel sizes, often times completely opting out of medicare, and

Subscription-based practices are an attractive alternative for the dwindling, yet still substantial, number of primary care providers who are not employed by large healthcare systems. then charging patients who chose to remain on board a substantial membership that can equate from one to several thousand dollars annually. In return, patients, or members, are given more individualized attention and improved physician access and provided with nontraditional, yet popular, medical services such as health coaches, fitness assessments, nutrition consultations, chef demos, spa-like amenities, and office bells and whistles.

processes and checklists, which many physicians find burdensome. As you may have noticed, U.S. healthcare is in a phase of extreme complexity. As insurance reimbursement reform evolves, many primary physicians are opting out of the traditional system to create their own lanes of payment in the form of subscriptionbased practice models. These

physicians should not be characterized as greedy, stubborn, or any less compassionate than others; they’ve simply concluded that the costs of complying with new insurance regulations are not worth the trouble. AM Kenneth G. Poole, Jr., MD, MBA, FACP, is a general internal medicine physician in the division of Community of Internal Medicine at the Mayo Clinic in Scottsdale, AZ.

Subscription-based practices are an attractive alternative for the dwindling, yet still substantial, number of primary care providers who are not employed by large healthcare systems. They are able to maintain complete practice autonomy, something very valuable to physicians. They also find themselves freed-up from administrative and government oversight and are able to continue to dictate operational details such as patient volume and the amount of time devoted to care. This contributes to a feeling that the provider is focused on individualized patient care and not administrative Spring 2016 | AZMedicine 15

The Business Side of Medicine

5 Tips to Minimize Prior Authorization Delays Reprinted with permission of the American Medical Association. This article originally appeared on the AMA Wire ® January 2, 2016, http://www. ama-assn.org/ama/ama-wire/post/5-tips-minimize-prior-authorization-delays.

By Troy Parks, AMA staff Is the prior authorization process disrupting your work flow and impeding your ability to provide quality care to patients? Use these five tips to relieve your prior authorization frustrations and better select a method that suits your practice. Prior authorization steals time from physicians that would be better spent with patients and increases practice costs. The process can pose roadblocks to patient care, delaying much needed services or stalling the delivery of a patient’s treatment. Practice management experts shared these tips to better manage this burdensome process and reduce its effect on patient care during an AMA webinar last week:

1. Check prior authorization requirements before providing services or sending prescriptions to the pharmacy.

Taking this step will help prevent delays to filling prescriptions, denials of claims and lost payments that can result from unmet prior authorization requirements. 2. Establish a protocol to consistently document data required for prior authorization in the medical record.

Uniformly following a protocol can help you avoid delays in patient therapy, prevent potential follow-ups with patients for additional information and minimize time spent on authorization. 3. Select the prior authorization method that will be most efficient, given the particular situation and available options.

A variety of prior authorization methods are available today, including standard electronic transactions, health plan portals, fax, telephone and secure email. A newly updated prior authorization toolkit from the AMA (log in) details the advantages and disadvantages of each method to help you make educated decisions for your practice. By selecting the method that best fits your practice, you can reduce work flow disruptions.

16 AZMedicine | Spring 2016

You can increase your chances of success in overturning a prior authorization denial by making sure all clinical information is included with the appeal, including any data that may have been missing from the initial request.

4. Regularly follow up to ensure timely prior authorization approval.

For prescription appeals, think about adopting electronic prior authorization technology to further streamline the process.

The prior authorization process is primarily manual. As a result, a request could be lost in one of the many steps. Track your requests, and follow up to prevent delays that can occur if information is lost or not received by payers.

Learn more about these recommendations by viewing the archived webinar (log in), the AMA’s prior authorization tip guide (log in) or the prior authorization toolkit (log in) to find an in-depth look at the current situation and what is being done to change it. AM

Overcoming prior authorization hurdles

Prior authorization required

5. When a prior authorization is inappropriately denied, submit an organized, concise and well-articulated appeal with supporting clinical information.

Prior authorization required

Spring 2016 | AZMedicine 17

The Business Side of Medicine

Physician Reentry: What Physicians need to know about leaving clinical practice if they may wish to return Physician reentry into clinical practice can be defined as returning to professional activity/clinical practice for which one has been trained, certified or licensed after an extended period.

Mary Ellen Rimsza, MD, FAAP Today, many physicians leave clinical medicine to pursue other interests, care for family or in order to manage health issues. However, if they decide they wish to return to clinical practice, these physicians may find it difficult to do so. For example, reentering physicians may find it difficult to obtain hospital privileges, renew their medical license, or obtain liability insurance because of this period of clinical inactivity.

18 AZMedicine | Spring 2016

The American Academy of Pediatrics (AAP) Division of Workforce and Medical Education Policy became interested in the issue over 10 years ago, in part because of the growing number of young women entering Pediatrics who might want to take a leave of absence to care for young children. The AAP soon discovered, however, that physician reentry was an important issue for all physicians in every specialty and age group. Recognizing the need to help physicians return to the workforce, the AAP started the Physician Reentry into the Workforce Project, which now has grown to include the American Medical Association (AMA), Federation of State Medical Boards (FSMB), and other specialty societies. Helping physicians who are clinically inactive return to the workforce is an especially important issue today because it has been estimated that 5 to 10% of US physicians < 65 years old are clinically inactive. Since there is currently

Since there is currently shortages in the physician workforce, addressing barriers to reentry for these physicians could help us alleviate our physician shortage. shortages in the physician workforce, addressing barriers to reentry for these physicians could help us alleviate our physician shortage. In order to assist these physicians, The Physician Reentry Project has created a website: http://physician-reentry.org/ to serve as a clearinghouse for resources and activities on physician reentry issues. On this site physicians who are thinking about leaving clinical practice or have already left practice can find resources to help them plan for their return to practice. In June 2015, The Physician Reentry into the Workforce Project developed a Webinar,

â&#x20AC;&#x153;Physician Reentry 101â&#x20AC;? (http://physician-reentry.org/ new-webinar-available-onphysician-reentry/). It is designed to help physicians understand what planning is needed before one leaves clinical practice, and what one needs to do in order to facilitate a return. Each state medical board sets its own requirements for reentering physicians. However, no matter where you decide to practice, the medical board, as well as employers, hospitals, and insurers will likely require you to provide proof that you are clinically competent to practice, especially if you have been out of practice for more than two years.

Your licensing board also may require you to provide a â&#x20AC;&#x153;reentry planâ&#x20AC;? before they renew your license. For example, you may need to provide a plan that demonstrates how you are going to refresh your clinical skills (eg. mini residency, CME, reentry program, shadowing other physicians). They may also require you to initially work in a supervised setting. Most physicians set up their own reentry plan but you can also enroll in a reentry program. A list of these programs is available on the Physician Reentry website. If you have not yet left clinical practice, but are planning to do so, one of the best ways to avoid problems with reentry is to make arrangements to

Reentering physicians may find it difficult to obtain hospital privileges, renew their medical license, or obtain liability insurance because of this period of clinical inactivity. continue some clinical activity. If your circumstances allow it, consider a working part-time rather than taking a leave of absence. If a part-time position is not feasible for you, might arrange to provide coverage for your former colleagues during their vacations, provide night call coverage, or do volunteer work in a free clinic. By continuing to do some clinical work, you will feel more confident about returning and also be able to provide licensing

agencies and potential employers with current references. In the past, it was assumed that doctors would enter clinical practice immediately after completing their residency training and then continue to practice for 30 to 40 years. Today, we recognize that many if not most doctors will have periods of clinical activity and this is just a part of our career trajectory.

No matter why you are leaving clinical practice, it is best to assume that you might some day you may want to return to practice and advanced planning can make your return easier. AM

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

Spring 2016 | AZMedicine 19

The Business Side of Medicine

Retirement: All or None or Somewhere In Between? A venture capitalist friend of mine once said to me, “Now that I am secure financially, I want to help humanity!”

Marshall B. Block, MD, FACP, FACE I responded, without thinking, by saying, “That is the difference between capitalists and physicians; when most physicians retire they want nothing further to do with humanity!”

20 AZMedicine | Spring 2016

I just thought that most physicians at the sunset of their careers have had enough and want out. I thought that most view retirement as a release from the pressure imposed from within to perform at very high levels so as to never to make a mistake by missing an abnormal lab or radiological result or a diagnosis. In addition, external regulations and controls imposed by our health care system either by insurance companies or oversight organizations, be they federal or local, further strains not only our professional life but also our social behavior, placing limits on what we can say to patients, how we can talk to them and sets boundaries that are thought critical to a healthy doctor-patient relationship.

Working in such an environment is very stressful and takes its toll after many years of practice. Because of decreasing reimbursement, we are facing increasing numbers of patients, each with their own set of peculiarities, which adds to the pressures of everyday practice. Coupled with greater expectations from patients and their increasing hostility and suspicion, this makes retiring something many look forward to with pleasure, thus fortifying my initial response to my venture capital friend. However, there are others among us who savor being a physician and overlook these difficulties. They want to continue to practice past the usual retirement age. For some, medicine is their life’s work.

For them there is no existence outside of medicine. They see themselves as physicians first and foremost and would lose their identity if they had to give up being a physician. In between these extremes are those that reach retirement and cannot fully retire for other reasons. Some are not financially secure enough to do so and must continue to generate income, albeit less than what they needed working full time. Others do not want to give up the “power” that comes with being in charge whether in the operating room or in the white coat. Money is not usually an issue for these physicians, rather self-respect and prominence is the motive. Other physicians have told me that they want to

be “needed” which is I suppose another way of saying that medicine helps them maintain their self esteem. Then there are the spouses of physicians who see their status in society as wrapped up in their spouses’ careers. I was told by one such spouse that once a physician retires at 65 years of age “ he becomes just another Medicare beneficiary” and as such loses social status. They in turn suffer the same fate so they influence their physician spouses to continue

I just thought that most physicians at the sunset of their careers have had enough and want out. over an extended period. I have arbitrarily chosen thirty years as the necessary period which one should have worked to be considered for special treatment as a “transitioning physician” (TP). Most employment contracts do not contain any verbiage to deal with the partial retirement of a

Having physicians work part time is not bad for the practice. It continues to help offset the overhead, albeit at a lower level then someone who works full time. In order to make it worthwhile to work part-time, the overhead must be reduced in some manner – otherwise the revenue generated by the

However, there are others among us who savor being a physician and overlook these difficulties. to practice to maintain their societal position. It is for these latter groups of physicians that this article is intended. How can you partially retire from full-time practice, maintain some income, and get the secondary gains you are seeking, be it love of medicine, need for social status, need for “power” or the need for self-esteem or a combination of all of them? Running a medical practice today is an expensive undertaking. Most medical practices run an overhead of almost 50% if not higher depending on specialty and size. In order to work part time in such a setting there has to be some consideration given to your contribution to the group

physician. It is therefore essential that every group should consider adding a section that deals with the TP. The biggest hurdle for any group in discussing this transition phase in a physician’s

part time physician will be consumed by the large overhead of the practice. After 30 years of paying full freight the TP should be given some special consideration. They are not in the same

divide overhead evenly while others divide it according to % of practice revenue generated. Others combine the two approaches using a fixed amount of the overhead (that part that anyone would need to practice regardless of volume generated) and divide the remaining overhead according to productivity. Using this approach, it is possible to devise an overhead figure that was less attached to a full time member of the group but low enough to make it worthwhile for the TP to continue to work. One can include a provision which states if the amount of revenue generated exceeded a set amount, the percentage of overhead allotted to the amount over the base amount would be greater, thus allow-

In between these extremes are those that reach retirement and cannot fully retire for other reasons. professional life has to do with the financial aspects of the transition on the practice as well as on the TP themselves. There are secondary gains from such an arrangement which need to be considered as they influence how the transition phase is perceived by the remaining members of the group.

category as the new three day a week partner where a long-term contribution to the success of the practice has not been demonstrated. Thus there has to be a different incentive for the TP than the new partner. Practices divide overhead in many different ways. Some

ing the practice to recover more overhead from the TP’s efforts. In this way the practice basically has an employee who is contributing something to the practice overhead and remains a valued member of the group, Continued on page 22

Spring 2016 | AZMedicine 21

Continued from page 21

attracting new patients not only to him or her, but also to the other members of the group. His or her name recognition has monetary value to the group and it needs to be recognized. There were other benefits that the TP makes to the practice which at first blush may not be envisioned. These also help offset the lower overhead which the TP was granted by the group. Depending on the type of practice, since the TP for the most part will not be taking call or making hospital rounds, the remaining providers will be taking on added burdens. They can be compensated for their time and effort by allowing each provider to bill for their services to the TP’s patients. Thus the TP’s patients began to gradually meet other members of the group as emergencies arise or problems are dealt with when the TP is not present. Since almost fifty percent of patients will leave a practice

The length of time allowed for this transition needs to be finite to help the practice plan for the future. after a named physician leaves that practice, this process may enable greater retention of patients for the members of the group after the TP completely retires. The remaining

The length of time allowed for this transition needs to be

The process of saying goodbye is a unique privilege that one has after a long-term relationship with patients. Enjoying the banter, the hugs, the tears, the laughter, and the memories that are shared during this process can be very rewarding. It is part of being a physician and it is part of the physicianpatient relationship that is so special. Not all patients feel happy for you. Most are more concerned about who is going to take care of them after you leave. A few really seem to be happy that you are going to be “free” of them. Most appreciate your care through the years.

members will recover some of their increased overhead during the transition phase later on as these patients generate added revenue to the practice.

The process of saying goodbye is a unique privilege that one has after a long-term relationship with patients. 22 AZMedicine | Spring 2016

When the day comes for the TP to fully retire, not only is the practice ready for it, so are his or her patients.

finite to help the practice plan for the future and to give the senior physician some reasonable expectation when his transition time is to end. It is essential for the PHYSICIAN to personally tell patients as they come in for their final visit that he or she is leaving and is choosing a replacement for them. A letter from the TP to their patients is a nice touch to reinforce their transition in the practice and can help in patient retention if they are in doubt on how to proceed.

Every practice needs to begin thinking about a transition plan and implement it in writing long before their most senior partner nears transition. Most physicians don’t think thirty years ahead, so it is incumbent upon the most senior members to educate their younger counterparts about the possibilities that lie ahead for all members of the group. Careful and considerate planning utilizing the wisdom of corporate accountants and lawyers will help to develop the best transition plan for each group. AM

Thank you Your membership ensures that we continue to successfully advocate on behalf of you and your patients. Spring 2016 | AZMedicine 23

The Business Side of Medicine

Integrating Physical and Behavioral Health Information for Better Patient Care Doctors and nurses have always been able to provide better care when they have more complete information on their patients. Never has more complete information been more important than today when health care providers face a future of value-based health care where

Melissa Kotrys, CEO, Arizona Health-e Connection payment is based on value and outcomes rather than the amount or type of services delivered. What’s more, where more complete information is especially critical is in managing the health of the one in five adults with co-morbid physical and behavioral health conditions.

24 AZMedicine | Spring 2016

Arizona Health-e Connection (AzHeC) has taken a major step toward providing more complete patient information with the AzHeC Board’s recent adoption of an approach and strategy for integrating physical and behavioral health data in the statewide health information exchange. This approach not only includes addressing state and federal laws regarding the exchange of physical and behavioral health data, but also the development of a unified communications and messaging strategy and a unified fee structure for both physical and behavioral health providers. The AzHeC Board eliminated Network participation fees for physical health providers as of October 2015, and now the elimination of participation fees has been extended to include community behavioral health providers. The value of more complete patient information and the importance of securely sharing information among physical and behavioral health providers can be readily seen in a look

Never has more complete information been more important than today at patients with the highest needs and costs. According to The Synthesis Report from the Robert Woods Johnson Foundation1, about five percent of the adult population accounts for half of all health care spending nationally. A significant part of this highneed population are the 34 million adults or 17 percent of the adult population that have co-morbid mental and medical conditions. In fact, numerous studies have found that comorbidity between medical and mental conditions is the rule rather than the exception. For example, people with diabetes or chronic asthma self-report depression at two to three times the rate of the general population, and persons with cardiovascular disease are at an elevated risk of having a lifetime anxiety disorder. A key to providing integrated

exchange of physical and behavioral health data is the ability to manage the state and federal laws that govern these two types of data. There are three basic sets of laws that apply: the Health Insurance Portability and Accountability Act (HIPAA), the federal substance abuse treatment privacy laws (42 CFR Part 2 in the Code of Federal Regulations), and Arizona’s health information organization (HIO) law. AzHeC’s integrated HIE strategy employs a hybrid approach that meets all state and federal legal requirements for patient notification and consent while affording all patient rights under the laws. The Network currently manages physical health data according to Arizona’s HIO law which provides patients notice of their right to opt-out of having their information

shared. If patients do not opt out, authorized providers are able to access the physical health information of their patients. Under the integrated plan, 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

The value of more complete patient information and the importance of securely sharing information among physical and behavioral health providers can be readily seen in a look at patients with the highest needs and costs. growth in Network participation, and adding community behavioral health providers to the list of those with no participation fees will spur even stronger growth. Since launching its new technology platform in April of 2015, The Network has grown from 33 participants to more than 100 participants by the second

quarter of 2016, and many of the newest participants are behavioral health organizations that have recently joined The Network. As with other initiatives throughout our history, AzHeC relied on broad community outreach and engagement to develop a

statewide strategy. Much of the information gathered over a period of several months helped to inform and design the plan and its implementation. In the end, not only was there broad community support for one statewide integrated health information exchange for physical and behavioral health information, there was also a consensus in the community that one system would provide the best care and the best outcomes for Arizona patients. AM Melissa Kotrys is the Chief Executive Officer for Arizona Health-e Connection (AzHeC) and the Health Information Network of Arizona. AzHeC operates the Arizona Regional Extension Center, which assists Arizona providers in achieving Meaningful Use.

1 “Mental disorders and comorbidity,” Goodell, S, Druss BG, Walker, ER, The Synthesis Project (Policy Brief No. 21), Robert Woods Johnson Foundation, February 2011.

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Spring 2016 | AZMedicine 25

The Business Side of Medicine

Teaching Future Physicians the Business Side of Medicine Physicians in the past may have been somewhat insulated from the red tape and business processes associated with health care. However, ongoing changes to medical coverage, payment systems, health policy and growing demands for transparency, better quality, cost and patient safety are now forcing care providers to closely examine and continuously improve medical practice. But are we properly trained to do so? Since the early 1900’s when the Flexner Report gave rise to better standards for medical education, there have been relatively few innovations in the curricula that is served up to aspiring physicians. And while this traditional model instills a strong foundation of biomedical sciences and hands-on clinical science, it wasn’t designed to prepare physicians to deal with the business complexities of medicine and the ever-evolving health care system. That is until now. Mayo Medical School, through the American Medical Association’s Accelerating Change

26 AZMedicine | Spring 2016

in Medical Education initiative and with the support of the Kern Family Foundation, is taking bold steps to better prepare the physicians and scientists of tomorrow for these challenges. Mayo Medical School is now one of the first in the nation to incorporate a third science – the Science of Health Care Delivery (SHCD) into its four year For Mayo Medical School students, medical education will include medical training learning how to implement care delivery models that improve value for patients. program through curriculum joint ly SHCD curriculum includInterim Dean of Mayo Medideveloped with Arizona State ing: Person-centered Care; cal School. “Our curriculum University (ASU), an innovaPopulation-centered Care; is meant to close the gap tive and highly regarded leader High Value Care; Team-based between medical education in education, research and Care; Health Policy, Economand the realities of clinical online learning. ics & Technology; Leadership. practice and patient care.” “Our goal is to give our future physicians the knowledge and tools they will need to truly understand and transform health care,” says Michele Halyard, M.D., Suzanne Hanson Poole Vice Dean and

The Science of Health Care Delivery is a discipline of analyzing, evaluating and implementing care delivery models that improve value for patients. There are six domains featured in the

The building blocks of the curriculum include areas such as systems thinking, social and behavioral determinants of health, health care policy, shared decision making, health economics, change

management and management science, biomedical informatics, and value principles of health care. Beginning with the graduating class of 2019, students will complete their medical degree through Mayo Medical School and also receive a Science of Health Care Delivery certificate of completion, co-delivered by Mayo Medical School and ASU. Students will have the personal option of pursuing a Master’s degree in SHCD from ASU, and can possibly accomplish the additional requirements during their four year training. “Our efforts to expand Mayo Medical School to a national footprint with campuses in Arizona, Florida and Minnesota will afford our students the opportunity to learn across multiple care settings and diverse patient populations,” notes Dr. Halyard. “This, combined with the knowledge they will receive through the SHCD curriculum, will hopefully set them apart as future physician leaders and prepare them to transform the challenging business and practice of medicine in the future.” AM Learn more about the new Mayo Medical School–Arizona Campus at http://www.mayo.edu/ mms/programs/md/ medical-school-campuses/ phoenix-and-scottsdale-arizona

Mayo Medical School – Arizona Campus Opens in 2017 In July, 2017, Mayo Medical School will open its doors to an inaugural class of 50 first-year medical students on the Mayo Clinic campus in Scottsdale, Arizona. The national school, with its original campus in Rochester, Minnesota and future third- and fourth-year program in Jacksonville, Florida, has one of the highest faculty to student ratios in the country. In 2015, Mayo Medical School was also recognized by U.S. News & World Report as one of the 10 most affordable private medical schools in the nation. This new Arizona campus showcases Mayo’s commitment to build the physician workforce in the Southwest. Mayo Medical School – Arizona Campus will begin accepting applications in June 2016.

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www.catalinarecruiters.com It’s about matching lifestyles, personalities and practice philosophies. Spring 2016 | AZMedicine 27

HSAG

Vistas

Quality as the Business Case for Medicine “ Quality is never an accident; it is always the result of high intention, sincere effort, intelligent direction and skillful execution; it represents the wise choice of many alternatives.” — William A. Foster By Howard Pitluk, MD, MPH, FACS & Mary Ellen Dalton, PhD, MBA, RN According to the Department of Health and Human Services (HHS), between 2010 and 2013, the reduction in hospital-acquired conditions resulted in 1.3 million fewer patient harms, saving an estimated 50,000 patient lives and approximately $12 billion in healthcare costs.1 As this report demonstrates, a safer healthcare system has occurred because programs aimed at improving patient safety and quality of care have become national priorities that are now mandated in the provisions of the Affordable Care Act (ACA). The ACA’s National Quality Strategy (NQS) calls for better individualized care, improved health for our communities, and lower healthcare costs through quality improvement.2 For more than 37 years, Health Services Advisory Group (HSAG), the Medicare Quality Improvement Organization (QIO) for Arizona, has made the implementation of quality healthcare for providers, patients, and communities the central focus of all we do. The savings documented in the above study are attributed to improved quality processes and provide a strong business case for quality improvement as an effective, evidence-based healthcare strategy that results in better patient outcomes, cost savings, and sustainability in the healthcare marketplace. The 2016 Centers for Medicare & Medicaid Services (CMS) Quality Strategy further strengthens this position as CMS moves from a passive payer for services to an active purchaser of healthcare based on solid, evidence-based research and data. This strategy aligns with the ACA’s shift of Medicare payments from volume to value.

28 AZMedicine | Spring 2016

As the largest purchaser of healthcare in the nation, CMS is promoting alternative payment models within Medicare Fee-forService (FFS) that reward quality care, improve health outcomes, and transform the healthcare system. By the end of 2016, 85 percent of Medicare FFS payments will be tied to these alternative payment models, increasing to 90 percent by the end of 2018.3 These CMS government mandates and initiatives play a pivotal role in healthcare quality improvement by enhancing partnerships in systems where providers are supported in achieving better healthcare outcomes by meeting quality goals, beneficiaries and consumers experience better quality of life, and patients who receive care are healthier and safer.4 To align with this changing paradigm, healthcare organizations and providers need to look at quality as a business model that takes into account the way payment to providers will be made going forward.

The Cost of Poor Quality By changing the healthcare system to one based on quality that can be measured and repeated consistently, we can eliminate waste and the cost inherent in bad outcomes and associated care. The difference between this actual cost and the cost that would have resulted if everything had been designed effectively and performed perfectly the first time is the cost of poor quality. When we receive poor quality services, it is usually an indication that something else is missing: lack of internal processes, miscommunication, and absence of accountability are just some of the root causes attributable to poor quality. Moreover, poor quality healthcare often results in patient complaints, dissatisfaction, and substandard outcomes which can lead to hidden costs in conducting business, such as reputational damage, lack of trust, and low employee morale. These failures also create unanticipated cost to the bottom line because of the effort necessary to find, fix, and often redo procedures that were done incorrectly the first time. To minimize the cost of quality, we need to look not only at doing the correct action (e.g., using an evidence-based best practice),

but also at doing the action correctly (e.g., conforming to standards) the first time.

Quality as Good Business Practice Maximizing patient safety through improved quality in a consistent and sustainable manner is the foundation of a sound business strategy, financial stability, and economic growth. Providing good quality care improves patient outcomes, eliminates waste and decreases cost.

Yet, providing good quality in healthcare as a business strategy is not a new concept. Philip Crosby, widely recognized as the â&#x20AC;&#x153;guruâ&#x20AC;? of quality management, introduced the notion that evidence-based quality care makes good business sense more than 50 years ago in his book, Quality Is Free. Crosby defined quality as the conformance to requirements, with the performance standard for healthcare quality being zero defects in our processes and the system for producing that quality being prevention.5 Nonconformance in healthcare processes (i.e., not doing it right the first time and/or not determining what defects may be inherent in our interventions) leads to poor quality and monies spent to correct what could have been prevented through conformance to evidence-based standards.6 Conformance allows for planning, process design, testing, and training. With this foundation, individual providers, as well as organizations, can develop and implement quality management programs, design processes that incorporate these programs, and develop and conduct training for employees and management.

Leadership, Quality, and Return on Investment Quality impacts performance by linking internal performance indicators that measure operational processes and systems (e.g., tracking early removal of a Foley catheter in an intensive care unit [ICU]) and external performance indicators that measure patient care outcomes (e.g., number of catheter-associated urinary tract infections in an ICU as measured by the standardized infection ratio and reported to CMS). These indicators have a direct effect on revenue and expenses and ultimately, return on investment.

serves as the link and leverage point between cost of care and quality of care. To make quality a business strategy, leaders at all levels of an organization need to embrace behaviors and practices that establish a culture which fosters work standards to improve quality. Leaders must put in place systems that enable ideal behaviors, implement scientific methods to ensure patient safety, and create a continuous learning environment in which problems are solved by those closest to the work.

Quality Strategy As healthcare policies and payer models change to reward quality and not volume of services, HSAG stands ready to assist providers in aligning their processes and workflows with the principles of quality. The practice of medicine is fundamentally based on these principles, which in the final analysis, makes quality as a business strategy synonymous with evidence-based care, and ultimately what we strive to achieve for the patients we serve. AM Howard Pitluk, MD, MPH, FACS, is Vice President, Medical Affairs & Chief Medical Officer; Mary Ellen Dalton, PhD, MBA, RN, is Chief Executive Officer. Andrea Silvey, MSN, PhD, Chief Quality Improvement Officer; and Dawn Williams, BS, Director of Communications, assisted with this article. 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. AZ-11SOW-XC-02232016-01

1 Efforts to improve patient safety result in 1.3 million fewer patient harms, 50,000 lives saved and $12 billion in health spending avoided. Available at: http://www.hhs.gov/about/news/2014/12/02/ efforts-improve-patient-safety-result-1-3-million-fewer-patient-harms50000-lives-saved-and-12-billion-in-health-spending-avoided.html. Accessed on January 30, 2016. 2 About the National Quality Strategy. Available at: http://www.ahrq.gov/workingforquality/about.htm. Accessed on February 16, 2016. 3 CMS Quality Strategy 2016. Available at: https://www.cms.gov/Medicare/ Quality-Initiatives-Patient-Assessment-Instruments/QualityInitiativesGenInfo/ Downloads/CMS-Quality-Strategy.pdf. Accessed on February 1, 2016. 4 ibid. 5 Management and Business Studies Portal: Philip Crosby: Zero Defects Thinker. Available at: https://mbsportal.bl.uk/taster/subjareas/busmanhist/mgmtthinkers/crosby.aspx. Accessed on: February 1, 2016 6 ibid.

Leadership plays a pivotal role in achieving and sustaining high quality within an organization, be it a hospital or physician office, and Spring 2016 | AZMedicine 29

The Business Side of Medicine

Farm to Hospital Concept Thrives at Cancer Treatment Centers of America “Farm to table” is a term more now commonly used at restaurants and farmers markets around the country, but what about “farm to hospital”? This relatively new concept enables hospital dining rooms to serve freshly picked and nutrient-rich vegetables to patients to help keep them strong during cancer treatment, and the concept was pioneered by Cancer Treatment Centers of America® (CTCA) at Western Regional Medical Center (Western) in Goodyear, Arizona. The hospital’s “Hope Springs Organic FarmSM” opened in 2012, and at the time, its 25 acres was the first and largest cancer-only, hospital-owned-and-operated organic farm in the United States. Over the past few years, and with the help of farming partner McClendon’s Select, the farm has grown to 69 certified-organic acres. “When CTCA first contacted me about providing produce for the hospital, I told them that our farm was at capacity and couldn’t take on any new clients,” Bob McClendon, proprietor of McClendon’s Select, recalls. “But they were persistent and invited me 30 AZMedicine | Spring 2016

to tour the hospital. What I saw at CTCA® was something very different. I saw a commitment to the patient, a comprehensive approach to treating the whole person. I decided right there we needed to be part of this healing process.” Today, the farm now includes 14 growing areas ranging in size from one acre to four acres each, a lagoon filled with 2.6 million gallons of water -- which is hooked up to a filtration system that serves as the water supply for the produce -- and it supplies fresh produce for the hospital’s daily culinary creations, including more than 100 different types of vegetables grown each year, eight varieties of citrus and four varieties of dates. “Not only do our patients tell us that they appreciate the option of eating produce picked at the peak of freshness, many of them enjoy the therapeutic benefits of helping plant and harvest the farm here at CTCA,” said Matt McGuire, President and CEO of CTCA at Western. “Whether it’s an innovative clinical treatment option, serving organic produce, or any detail in between, we want to do anything we can to help keep our patients strong in mind, body and spirit while they’re focused on fighting their cancer.” AM

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Adam M. Brodsky, MD Maricopa Director Henri R. Carter, MD Rural Director Bourck D. Cashmore, MD Rural Director Jacqueline A. Chadwick, MD At-Large Member, Executive Committee Gary S. Christensen, MD Rural Director Edward J. Donahue, MD Maricopa Director Ronnie K. Dowling, MD AMA Delegation Chair and Speaker of the House

Michael F. Hamant, MD Vice President, Executive Committee, and AMA Alternate Delegate Jennifer R. Hartmark-Hill, MD At-Large Member, Executive Committee Thomas H. Hicks II, MD AMA Delegate M. Zuhdi Jasser, MD AMA Delegate Nadeem A. Kazi, MD Rural Director Philip E. Keen, MD At-Large Director

Daniel M. Lieberman, MD Maricopa Director Robert J. Marotz, DO Rural Director Timothy M. Marshall, MD Pima Director Jeffrey T. Mueller, MD Immediate Past President, Executive Committee Robert R. Orford, MD At Large Director Traci Pritchard, MD Secretary Allison Rosenthal, DO At-Large Director Thomas C. Rothe, MD Outgoing Past President, Executive Committee Susan M. Whitely, MD Treasurer, Executive Committee

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

Peter C. Kelly, 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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MICA posts eleventh consecutive year of dividends. MICAâ&#x20AC;&#x2122;s history of dividend payments extends well beyond the last eleven years. In fact, since our founding in 1976, MICA has distributed over a half a billion dollars in dividends to its members.

Medical Professional Liability Insurance (602) 956-5276 (800) 352-0402 www.mica-insurance.com Dividends declared for a policy year reflect the Companyâ&#x20AC;&#x2122;s financial performance. Past performance does not guarantee future dividends.