INSIDE: The 2016 ArMA Legislative Report Summer 2016
Published for Arizona Physicians
www.azmed.org
A New Era in Health Policy
HEALING HANDS. BIG HEARTS.
Big Thanks.
251907-16
Blue Cross Blue Shield of Arizona values the contributions and efforts of Arizona physicians in caring for our members.
A New Era in Health Policy FROM OUR PRESIDENT Physician Engagement for the 21st Century ........... 4 ArMA 2016 Annual Meeting...................................... 8 The Life Cycle of a Resolution: Resolution 04-16 ................................................... 10 Profiles in Policy Leadership.................................. 23 Your legislators are on social media. Are you?................................................................. 25 The politics of physician credentialing................... 28
Summer 2016 | Volume 27, No. 2 | www.azmed.org | facebook.com/azmedicine
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
Summer 2016 | AZMedicine 3
FROM OUR
President
Physician Engagement for the 21st Century: How Your Medical Association Can Help As a fourth generation physician, I grew up in the 1960s part of an extended family in which public service and self-sacrifice were core values. At the dinner table, I heard tales of my great-grandfather’s adventures as a medical missionary in China, and how, while working in Egypt in the 1930’s, he deliberately infected himself with schistosoma haematobium in order to bring schistosomiasis into the U.S. to be studied in vivo at New York University. “Good doctors don’t worry about how much money they make” I was told. Family conversations revolved around medical missions to Africa, editing journals and medical school administration. Implicit in my medical socialization was the understanding that a social contract exists between doctors and society: we are expected to altruistically, competently, and in a moral and ethical fashion work not only to heal our patients, but Gretchen Alexander, MD for the public good. In return, we expect professional autonomy and the privilege of self-regulation, reasonable financial rewards, and a functioning healthcare system.1 And yet, over the course of the last two or three decades, we have seen that social contract be used to hold us accountable not to our patients but increasingly to corporate entities whose aims relate more to income, profits and shareholder value than to patient care. The reasons for this change, and some of the consequences to our profession and patients are as follows: Healthcare in the U.S. today is big business, with total expenditures in 2014 reaching $3 trillion2. Of this figure, it is interesting to note that physician compensation accounts for only 10%3, while administrative costs have been estimated at 30%, with one out of every four healthcare workers being engaged in administrative work as opposed to direct patient care4. Our healthcare system 4 AZMedicine | Summer 2016
is increasingly complex, fragmented and, at times, ineffective. The direct costs of administrative complexity and failure of care coordination were estimated to be between $132 and $434 billion in 20115. This inefficiency is occurring in spite of unprecedented levels of consolidation among insurers, hospital systems and large group practices in recent years6. Over these same years the largest healthcare insurers and hospital groups saw record profits and stock prices7. Possibly not coincidentally, those years also saw record amounts spent on legislative representation of corporate interests in healthcare8. Who is not doing so well in the new world of Big Healthcare? Our patients, for one. At least twenty-seven percent of personal bankruptcy cases in the U.S. are related to medical bills9. Health outcomes in the U.S. notoriously lag those of our peers in the developed world in benchmarks such as life expectancy and infant mortality rates. And recent work suggests that medical error may be the third most common cause of death in the United States with an estimated 250,000 deaths per year10. Physicians are also suffering in this system. As we become subject to a corporate construct where our work is seen as a product intended to drive a revenue stream, rather than a calling, we find ourselves conflicted between a corporate culture that tends to value affability, efficiency and expediency and our own medical culture in which thoughtful diligence in the service of our patient is the highest value. Regulatory requirements for quality metrics and preventive health add additional tasks to the physician’s already full plate. A recent study estimated that a primary care physician would spend 21.7 hours per day to provide all recommended acute, chronic, and preventive care for a panel of 2,500 patients11. The typical medical practice spends $83,000 per physician per year on administrative costs12 and the typical physician spends about 16% of his or her workweek engaged in non patient care-related paperwork, with more time spent on paperwork by physicians using entirely electronic health records13. Continued on Page 6
These working conditions are unsustainable, and they are significantly impacting physician engagement and wellness. Burnout rates for our profession range from 30%-65% with higher rates for emergency medicine, general internal medicine, and female physicians14. 58% of physicians would not recommend medicine as a career for their children15 and 15-30% of medical students and residents are found on screening to have symptoms of depression16. As our professional engagement falters, access to medical care is being affected. Physicians are ”working fewer hours, seeing fewer patients and limiting access to their practices...The research estimates that if these patterns continue, 44,250 full-time-equivalent physicians will be lost from the work force in the next four years17.” In spite of all, we should maintain hope. It is my opinion that we have a great deal to be thankful for. Physicians still, by and large, enjoy a level of financial security that many U.S. workers do not. Our work is intellectually stimulating, and when we are given time to do it well, there is no better reward than the appreciation of our patients and their families. We must work hard to preserve those positive features. Our profession involves unique stressors in the forms of delayed gratification, chronic sleep deprivation, limited control over our daily workflow, and ever-increasing cognitive workloads. There must be some degree of balance so that our profession can continue to attract qualified young people who want to be engaged in full-time patient care, as opposed to administrative work. We must become more comfortable about working within organized medicine to ensure that our professional organizations work effectively to set limits and advocate for our profession, for in doing so, we are ultimately advocating for our patients and the quality of the medical care that they receive. In order to accomplish this successfully, we must work to improve physician engagement not only in our profession but with each other, and with the efforts of organized medicine. With this overarching goal in mind I propose objectives for ArMA in the following areas: 1. Legislative representation: Our overseers are writing healthcare policy which advantages them in the business arena, to the detriment of both patients and physicians. In order to respond effectively, organized medicine must move from a defensive to a proactive legislative stance. We must be participating in writing healthcare policy, not just reacting to legislation we don’t like. An opportunity in this area has arisen from ArMA’s work over the last year to create a liaison with the state department of insurance which could advocate for physicians attempting to deal with health plan violations. It has become apparent from those efforts that a statutory approach would be most effective. I have asked that for 2016-2017, a goal of our legislative
department be to seek introduction of a bill in the next session which would create an office within the insurance department dedicated to addressing physician complaints and concerns. Currently, and perhaps surprisingly, no such function exists. This needs to be rectified. An additional area of potential opportunity for proactive legislation would be in the area of Maintenance of Certification. No one can deny that lifelong learning is a critical aspect of responsible medical practice. However, the current iteration of the MOC system is deeply compromised by concerns about lack of evidence of efficacy, financial impropriety and the administrative burdens of required data collection and QI activities. Several states have recently passed legislation
Our work is intellectually stimulating, and when we are given time to do it well, there is no better reward than the appreciation of our patients and their families. preventing MOC status to be required for licensure or medical credentialing. In my opinion, consideration should be given to ArMA supporting such legislation in Arizona. A secondary objective for the year would be enhanced physician engagement in ArMA’s legislative work. I have begun talks with Chic Older, EVP, and with Pele Fisher, our VP of Policy and Political Affairs about strategies that ArMA could use to facilitate member communication with legislators and participation in advocacy efforts. In the coming year we hope to achieve some small but useful changes that will facilitate such engagement. 2. Finances: In order for an organization to be effective, it must be financially sound. ArMA must continue to work toward establishing an operating reserve comparable to the reserves that other state medical societies maintain. Such reserves allow organizations to respond effectively to unanticipated losses in revenue or significant advocacy challenges. In support of this goal, I have requested that the 2016-2017 budget reflect an increased net margin over that which has been previously instituted and observed. Continued on Page 6
Summer 2016 | AZMedicine 5
Continued from page 5
An additional goal in this area is the long-discussed sale of the ArMA building. Our building was designed for us in 1969 by Bennie Gonzales, a distinguished architect who was a native Phoenician and was responsible for the design of many delightful structures across Arizona including the Heard Museum, the Gloria Dei Lutheran Church in Paradise Valley and most of the City of Scottsdale’s civic buildings. Our building is a wonderful example of Gonazales’ unique contemporary Southwest style and it has served us well; however, as it ages, its maintenance costs significantly impact our bottom line. A financial analysis carried out last year shows that it would be more fiscally prudent for ArMA to rent comparable space and put the proceeds from the sale of the building into operating reserves. Therefore, the Executive Committee has requested that ArMA make a firm commitment to accomplishing the listing of the building for sale, this year. Once the building is sold, proceeds from the sale will be used to create a separate operating reserve fund. 3. Consolidation and coordination of efforts within the house of medicine: In order to effectively advocate for our profession, we must learn to speak as one voice. We are, at times, working
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In order to effectively advocate for our profession, we must learn to speak as one voice. to oppose forces which have effectively used consolidation to acquire increasing degrees of power over the future of healthcare. We must look to consolidate ArMA’s efforts with those of other organizations in the medical community. In support of this goal, I intend to continue the highly successful expansion of quarterly meetings with our state’s medical specialty societies which Dr. Laufer initiated last year. Additionally, continued exploration of partnership opportunities with other medical societies will be actively pursued. 4. Membership: Enhanced engagement of our membership is critical. The continued fiscal health of ArMA depends on sufficient revenue from membership dues to support our mission; opportunities for membership growth exist among female physicians and primary care physicians. Also importantly, through effective engagement of our members, we can address burnout by helping to support improved professional self-efficacy. Opportunities for social and educational programs that support mastery of our increasingly difficult practice environment are key in providing that support. With this in mind, I am focused on member programming for the coming year to include the following: a. Continued expansion of the successful physician leadership conference introduced by Dr. Mueller in 2014. This program has been a popular forum for our members to meet with one another and with leaders in the healthcare industry to freely exchange thoughts and ideas about the future of healthcare. I pledge to do whatever is necessary to ensure its continued success. b. Accomplishment of a membership needs assessment, in order to gain actionable insight into the concerns of practicing physicians in Arizona. By knowing what concerns our members and potential members the most, ArMA will create targeted programming in order to stay responsive to member needs. c. Institution of a more effective means by which House of Delegates resolutions are considered by the Board for active implementation. Each year, great suggestions are made by our membership through the resolution process for advocacy work by ArMA. Seeing these resolutions through wherever possible, to meaningful action on the part of ArMA, will enhance member engagement and organizational efficacy.
d. Smaller and more informal meetings to provide socialization and practical guidance to our members on matters of interest to practicing physicians such as contract negotiation and effective practice management in the face of MACRA. Only through talking to each other can we unite and become effective. ArMA must continue to look for ways to provide Arizona physicians with those opportunities. None of this can occur without significant effort on the part of all involved. I would like to thank my supportive husband and our wonderful children George, Anna and John who have tolerated many late nights, mediocre dinners and opportunities to babysit each other as I engaged in ArMA work over the last several years. I would also like thank our hardworking ArMA staff, the Board of Directors and the House of Delegates for their active participation and guidance. Thanks are also due to past presidents Orford, Thrift, Rothe, Mueller and Laufer and also my department chair at MIHS, Dr. Carol Olson, for their invaluable mentorship over the last several years. Last, but not least, thanks to all of you for the opportunity to serve you in the coming year. Please feel free to contact me at gretchen@ ipls.com with comments, questions or suggestions. 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.
6. “Top ten health industry issues of 2016: Consolidation.” PwC Health Research Institute. http://www.pwc.com/us/en/health-industries/top-health-industryissues/consolidation.html 7. La Monica, P. “Thanks, Obamacare! Health insurer stocks soar.” CNN Money. January 21, 2015. http://money.cnn.com/2015/01/21/investing/ unitedhealth-earnings-obamacare/. 8. “Lobbying/Industry: Pharmaceuticals/Health Products, 2015.” Center for Responsive Politics. https://www.opensecrets.org/lobby/indusclient. php?id=H04&year=2015. 9. Mathur, Aparna. “Medical Bills and Bankruptcy Filings.” American Enterprise Institute. July 2006. http://web.archive.org/web/20120723055727/http://www. aei.org/files/2006/07/19/20060719_MedicalBillsAndBankruptcy.pdf 10. Makary MA. “Medical error—the third leading cause of death in the US.” BMJ 2016;353:i2139. 11. Altschuler, Margolius, Bodenheimer, Grumbach. “Estimating a Reasonable Patient Panel Size for Primary Care Physicians With Team-Based Task Delegation.” Ann Fam Med: September/October 2012 vol. 10 no. 5 396-400. 12. D. Morra, S. Nicholson, W. Levinson et al., “U.S. Physician Practices Spend Nearly Four Times as Much Money Interacting with Health Plans and Payers Than Do Their Canadian Counterparts,” Health Affairs Web First, Aug. 3, 2011. 13. “Administrative work consumes one-sixth of U.S. physicians’ time and erodes their morale, researchers say.” Physicians for a National Health Program. October 23, 2014. http://www.pnhp.org/news/2014/october/ administrative-work-consumes-one-sixth-of-us-physicians%E2%80%99time-and-erodes-their-mor 14. Linzer M1, Levine R, Meltzer D, Poplau S, Warde C, West CP. “10 bold steps to prevent burnout in general internal medicine.” J Gen Intern Med. 2014 Jan;29(1):18-20. doi: 10.1007/s11606-013-2597-8. 15, 17. “A Survey of America’s Physicians: Practice Patterns and Perspectives.” The Physician’s Foundation. September 2012. 16. Andrew, L. “Physician Suicide.” Medscape. June 1, 2016. http://emedicine. medscape.com/article/806779-overview.
References 1. Cruess SR, Cruess RL. “Professionalism and Medicine’s Social Contract with Society.” AMA Journal of Ethics, April 2004, Vol 6, No 4. 2. “National Health Expenditures 2014 Highlights.” https://www. cms.gov/researchstatistics-data-and-systems/ statistics-trends-and-reports/ nationalhealthexpenddata/ downloads/highlights.pdf 3. Rampell, C. “Doctors’ Salaries and the Cost of Health Care.” The New York Times. November 14, 2008. http://economix. blogs.nytimes.com/2008/11/14/ do-doctors-salaries-drive-uphealth-care-costs/ 4. Pfeffer, Jeffery. “The Reason Health Care Is So Expensive: Insurance Companies.” Bloomberg.com. April 2016. 5. Berwick, Hackbarth. “Eliminating Waste in U.S. Health Care.” JAMA 2012;307(14):1513-1516.
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2016
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Annual Meeting
CONGRATULATIONS TO THE RECIPIENTS OF THE 2016 ARMA AWARDS! President’s Distinguished Service Award JUDY LAUFER
ArMA Public Health Service Award REP. HEATHER CARTER
ArMA Distinguished Service Award M. WALT DAVIS CAROL WAGNER
National Service Award DOUGLAS FAIGEL, MD KEITH LINDOR, MD
ArMA Sportsman Award ANIKAR CHHABRA, MD
Edward Sattenspiel, MD Award RONNIE DOWLING, MD
David O. Landrith Humanitarian Award KARLA BIRKHOLZ, MD
C.H. William Ruhe, MD Award MAYO CLINIC Mayo School of Continuous Professional Development Arizona9 Summer 2016 | AZMedicine
A New Era in Health Policy
The Life Cycle of a Resolution: Resolution 04-16 The Arizona Medical Association (ArMA) Annual Meeting marks the inauguration of a new president, elections of officers, and voting on policy and business matters by the House of Delegates (HOD), the voting body of ArMA. Resolutions may be proposed by any county society, or by any ArMA member or ArMA
constituency. Resolutions passed by the HOD set ArMA policy, positions and action items. Resolutions calling for federal government action or national policy changes are submitted to the American Medical Association (AMA) for consideration in that House of Delegates. Resolution 04-16, “Transfer of Jurisdiction Over Required
Clinical Skills Examinations to U.S. Medical Schools” was submitted by the Medical Student Section of the University of Arizona Colleges of Medicine in Tucson and Phoenix. All resolutions are made available through online forums for members to log in and submit comments, and votes for or against individual resolutions. When the comment period has closed, the comments are pulled from the forums and compiled for the reference committee. The reference committee carefully reviews the resolutions and member feedback, and documents its recommendations to adopt, change, or reject the resolutions. Those recommendations are then used to create the agenda of resolutions for the HOD. The reference committee reviewed Resolution 04-16 and the accompanying comments of members, and determined to remove the first Resolved from the original submission. The reference committee then submitted the updated Resolution 04-16 to the HOD agenda with the recommendation to pass the resolution, which the HOD did, in the following form:
10 AZMedicine | Summer 2016
“04-16 Transfer of Jurisdiction Over Required Clinical Skills Examinations to U.S. Medical Schools RESOLVED, That the Arizona Delegation to the American Medical Association (AMA) ask the AMA to work with the Federation of State Medical Boards and state medical licensing boards to advocate for the elimination of the United States Medical Licensing Examination (USMLE) Step 2 Clinical Skills (CS) exam as a requirement for Liaison Committee on Medical Education-accredited graduates who have passed a school-administered, clinical skills examination; and be it further RESOLVED, That the Arizona Delegation to the American Medical Association (AMA) ask the AMA to amend D-295.998 by insertion (bold) and deletion (strikethrough) as follows: Required Clinical Skills Assessment During Medical School D-295.998 Our AMA will advocate that encourage its representatives to the Liaison Committee on Medical Education (LCME) to ask the LCME, to 1) determine and
disseminate to medical schools a description of what constitutes appropriate compliance with the accreditation standard that schools should “ develop a system of assessment” to assure that students have acquired and can demonstrate core clinical skills, and 2) require that medical students attending LCME-accredited institutions pass a school-administered clinical skills examination to graduate from medical school.”
Medical Student Perspective
The Arizona delegation to the AMA is comprised of elected delegates who are members of both ArMA and the AMA. It is the delegation’s responsibility to advocate for the passage of any ArMA resolutions submitted to the AMA Annual Meeting of the House of Delegates (HOD).
Some future issues I can see coming of very direct relevance to medical students are potentially tweaking Step 1, funding for medical education - especially residency positions (GME), and ensuring resident work hours and lifestyle are honestly reported and improved upon. I think as students we often also get to take a long view, so we are super interested in improving all areas of medicine and public health. I’m very excited by many of the creative and forward thinking policy proposals being discussed and brought to the broader community by medical students.
The Arizona delegation submitted Resolution 04-16 to the AMA Annual (A-16) HOD, where it became AMA Resolution 317 and was assigned to a reference committee that reviewed and consolidated it with three other similar resolutions. The final resulting resolution was voted upon and passed to become AMA policy position. The final language will be available through the AMA in July. We asked two members of the Medical Student Section University of Arizona College of Medicine Tucson, to share their thoughts on the policymaking process and following their resolution’s progress through the state and national levels (see inset to right). AM
Danny Hintze, MD Candidate, Class of 2019, University of Arizona College of Medicine (on attending both the ArMA and AMA Annual Meetings) It was my first ArMA and AMA meeting, so the biggest things for me were just seeing the process and how things worked! As a medical student, the biggest issue right now is the End Step 2 CS movement and I was very interested to see how that would be received. In many ways medical students are a vulnerable population within the medical community, and this issue really hits at that in many ways. It has been wonderful to have such strong support by ArMA leadership, both at the state and national level. I also feel that the ArMA leadership and HOD are very focused on helping to ensure quality and accountability in our medical education, which is good to see.
Jared Brock, MD Candidate, Class of 2018, University of Arizona College of Medicine (on attending the ArMA Annual Meeting) The issues that affect medical students such as myself were my natural focus, so the resolution towards getting rid or replacing the USMLE Step 2 CS was a priority. In Tucson, sometimes we are isolated from the rest of the state so the ArMA meeting was a great way to hear what was on everyone else’s minds. To a very large extent, I felt supported by ArMA leadership on these issues. The only comment I would have concerned the USMLE Step 2 CS resolution. While they were wonderfully supportive of taking national action and referring it to the AMA, the crux of the resolution was local action with the State Medical Board and changing their requirements for certification and licensing in Arizona; this was an area and Resolved that was unfortunately struck in committee. That being said, I am sure that during this next year we will be able to start working with the Arizona Medical Board to address these concerns and will reintroduce the local clause of the resolution next year. I have found that many [physicians] do not understand the amount of stress and burnout that already happens to future physicians while still in school, namely because of the paramount importance of the USMLE step 1 test literally and definitively determining your career and specialty options by the end of your second year of med school. The financial landscape has significantly changed. Tuition can be up to $50,000+ a year in Arizona, plus living expenses and school supplies on top of that. Loan rates are also at an all-time high. After interest, I calculate I will have to pay back a total of about $400,000 in student loans. Combined with the rising career threat of APRNs, big healthcare and insurance oligopolies, and corresponding loss of autonomy, these factors weigh heavily on all medical students’ minds, but often we feel the older generations are either unaware or downplay these challenges in the radically changing landscape of modern medicine. I understand that once formal schooling is completed, one does not give it much thought, but we cannot forget where we came from and cannot ignore the direction medical education is going. We owe this diligence and this safeguard to the future physicians of Arizona.
Summer 2016 | AZMedicine 11
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A R I ZO N A MED I C AL A SSO CI ATI O N
2016 Legislative Report
INTRODUCTION From an advocacy perspective, the best measure of a state medical association’s effectiveness is how well it handles political adversity in general, and specifically, how effectively it responds to threats against and opportunities to enhance the practice of medicine. Using that litmus test, the 2016 legislative session was one in which Arizona Medical Association (ArMA) resoundingly demonstrated that it is a highly effective advocate for Arizona physicians. The ArMA policy team and your voice at the Capitol worked hard to promote and educate about bills that would advance and enhance medical practice. While it is an honor to promote this kind of legislation, what we often find is that we are called upon to protect patient and physician interests by defeating legislation that would threaten patient safety or limit a physician’s ability to practice medicine. ArMA did so most notably this year by successfully thwarting an extremely serious medical threat to expand the scope of practice for advanced practice registered nurses (APRN), an effort led by national and state nurses’ groups. Continued on next page
Summer 2016 | AZMedicine 13
Beyond the labor-intensive victory over APRN legislation,
During the course of the 117 days this year, the Legislature
legislation which we fully expect to see again in a future
worked through the following tally of bills, memorials and
session, our legislative session was marked by a number
resolutions:
of other meaningful wins, including a very hard-fought
• 1247 bills introduced
effort by an ArMA-led health care coalition making Arizona
• 388 bills passed
the 13th state to adopt the Interstate Medical Licensing Compact, and the restoration of KidsCare, the state’s CHIP program providing Medicaid coverage for children. This and other legislative activity played out over the course of nine months. It began with a four-month pre-session ramp up
• 374 bills signed • 14 bills vetoed • 114 memorials & resolutions introduced • 36 memorials & resolutions passed
period that included the so-called “sunrise process” for the
During this session, not counting budget bills, we monitored
APRN practice scope expansion proposal and other less-
over 120 bills that we believed had the potential to affect
controversial proposals.
physician practices.
In the 2016 legislative session, which was not nearly as brief
Simply put, none of the many legislative successes we
as last year’s 81 days, legislators took 117 days to finish work,
achieved this year would have happened without the
But the session was marked by much less partisan bicker-
unfailing support of ArMA’s leadership and our engaged
ing. Why? Mostly because of a modest budget surplus for
members. We faced an “all hands on deck” environment for a
the state, something we hadn’t seen for quite some time.
prolonged period this session, and the outpouring of contri-
The ability to restore some of the money to programs that suffered previous cuts helped to assuage many lawmakers’ concerns. And ultimately, they all realized that they could not get out on the reelection campaign trail as long as they remained at the Capitol. So on May 7, at 5:45 am, they adjourned the legislative session sine die.
butions of time and talent from so many ArMA members was remarkable and impactful. Support came from all parts of the state and from all physician disciplines. Our allied groups in medicine, from Arizona Osteopathic Medical Association (AOMA), to the anesthesiologists, to the surgeons, to the family practice doctors and pediatricians, to the obstetricians and gynecologists, to the emergency doctors, to the
During the session ArMA successfully worked with the
psychiatrists, and the ophthalmologists, all stepped up to
Governor’s Office to enact significant changes to the laws
assist in what was truly a physician-led team effort.
that govern prescriber compliance with the Controlled
We offer a special thanks to Carol Wagner, who for the 25th
Substances Prescription Monitoring Program (CSPMP),
straight year led our stellar Doctor of the Day program at the
including a future requirement that prescribers check that
Legislature, and all the physicians who took time from their busy
database before prescribing opioids and benzodiazepines
schedules to serve as Doctor of the Day. And we wish Carol,
in most instances. The Governor’s office spearheaded an
who has just retired from ArMA after so many years of faithful
effort to streamline all health regulatory boards, and while
and inspired service, a well-deserved “Happy Retirement!” We
it did not make it into enacted bill form this year, ArMA is
will miss her, and will carry on Carol’s work and continue our
pleased to be a part of the Administration’s efforts to ensure
Doctor of the Day program next session and beyond.
changes do not diminish the functionality of the Arizona Medical Board. We also worked closely with Health Chairs Representative Heather Carter and Senator Nancy Barto, as well as other committee members, on a number of meaningful pieces of legislation, including bills dealing with anatomical gifts, biological products, mental health care, opioid antagonists, and a host of other health care issues.
BUDGET We knew going into the session that the fiscal picture for the state had improved considerably since 2015, with increasing revenues leading to projections of at least a short-term surplus in the state’s coffers. This led to many calls from both outside constituencies, as well as from Democrat and Republican lawmakers, for restoration of many of the previous budget cuts. Governor Ducey and Legislative Leadership, however, stressed the need for continued
14
ArMA 2016 Legislative Report
prudence on the spending side, arguing that the surplus
revive the issue once again. After hours of delay, debate,
was a temporary phenomenon and tougher fiscal times lie
and numerous procedural motions and moves, the House
ahead. They signaled that any spending restorations would
with bipartisan support voted to amend SB 1457, adding
need to be one-time in nature and not permanent.
language to lift the KidsCare freeze. Ultimately, the bill as
Despite many rounds of closed-door talks between the Ducey team and House and Senate Leadership, it took most of the session before a budget emerged, causing the session to bog down at times before the final push occurred in May. After several weeks of suspense, the Legislature approved a roughly $9.6 billion budget shortly after midnight on the morning of Wednesday, May 4.
amended passed 38-21, sending the issue back over to the Senate and resuscitating it from the dead, one more time. The following day in the Senate, a group of five Republicans joined forces with eleven Democrats to force a final floor vote on SB 1457, despite the opposition of Senate Leadership. It passed on a 16-12 vote and when it arrived on Governor Ducey’s desk, he immediately signed the bill into law. Now that KidsCare coverage has been restored, approximately
Governor Ducey signed the entire budget package into
30,000 - 40,000 children in Arizona are expected to enroll.
law on Tuesday, May 10. According to the Joint Legislative
Applications for KidsCare will be accepted beginning July
Budget Committee, the budget is expected to leave the
26, 2016 for coverage that will begin September 1, 2016.
state with $66 million in the bank by the end of next fiscal year and a $1.5 million structural balance.
After session, most lawmakers breathed a big sigh of relief when voters narrowly approved Proposition 123 in a special
There were several key issues ArMA was focused on during
election held on May 17, authorizing the use of $3.5 billion in
budget work: ensuring that needed legislation was included
funds held in the State Land Trust to fill the gaps in K-12 fund-
to reverse the never-enacted Arizona Health Care Cost
ing over the next ten years, thereby resolving the budget
Containment System (AHCCCS) rate cut from last year,
dilemma arising out of the Cave Creek K-12 funding lawsuit.
restoration of coverage for podiatry services for AHCCCS,
The $9.6 billion state budget that was passed had assumed
and restoration of KidsCare. The final budget bills included
passage of Prop 123. Had it failed, the entire budget would
necessary language to offset AHCCCS rate cuts and to
have fallen apart.
restore podiatry services for AHCCCS patients. KidsCare is Arizona’s State Children’s Health Insurance
LEGISLATIVE TALLY SHEET
Program (CHIP). Before it was temporarily frozen, KidsCare
The remainder of the report will deal with the specific bills
provided high quality, affordable, and cost-effective health
that ArMA monitored, supported or opposed. These bills,
care to low income children from working families. KidsCare
coupled with the budget and larger policy issues reviewed
covers children in families with incomes from 138 percent to
above, comprise the most significant of the more than 120
200 percent of the federal poverty level, or $27,000 - $40,000
bills that ArMA followed during this legislative session. The
for a family of three. Arizona has had a temporary enrollment
key bills below are divided into the issue categories used
freeze on KidsCare for the past five years and was the only
by ArMA’s Committee on Legislative and Governmental
state in the country without functioning CHIP coverage. Ari-
Affairs to establish ArMA’s advocacy positions. Those cat-
zona has the third highest percentage of uninsured children
egories are: Regulatory Boards/Regulations, Insurance, Tort
in the US — around 160,000 kids.
Reform/Liability, Public Health/Public Policy and Healthcare
There was a huge push to include KidsCare in the budget,
Institution Issues.
but in the end it was not included as part of the budget. The amendment to restore the program was offered but lacked sufficient Republican votes to be adopted. This would have been the end of the effort to restore KidsCare for the session.
REGULATORY BOARDS/REGULATIONS
This section deals with occupational licensing, scope of practice and the imposition of state authority that directly or indirectly affects the practice of medicine. Under this
However, a day after the budget package was passed, on
category, ArMA followed over 40 bills during this session, by
May 5, one final huge push was made at the Legislature to
far the most of any of the categories. The most significant of
give KidsCare new life. ArMA worked relentlessly with Chil-
these measures are discussed below.
dren’s Action Alliance and the Cover Kids Coalition to help Continued on page 16
ArMA 2016 Legislative Report
15
SB 1096: MEDICAL RADIOLOGIC TECHNOLOGY
child’s identified primary care physician within 48 hours, and
This enacted bill was filed by Sen. Nancy Barto for the Medical
failure to report is unprofessional conduct. It establishes a
Radiologic Technology Board of Examiners, and it makes vari-
list of methods a pharmacist must use to make a reasonable
ous changes affecting licensees. The minimum standards of
effort to identify the person’s primary care physician. This
education and training for licensees adopted by the Radiation
bill and the changes that were implemented is a solid work-
Regulatory Agency and approved by the Board must include
ing example of how professions can collaborate in the best
the types of applications of ionizing radiation for practical
interests of patients.
technologists in bone densitometry, radiation therapy technologists, mammographic technologists, nuclear medicine technologists, bone densitometry technologists, computed tomography technologists, radiologist assistants, physician assistants and any new radiologic modality technologists.
As a result of late-breaking developments surrounding the change in Food and Drug Administration (FDA) labeling on mifepristone, this bill was amended at the end of session to repeal previously-enacted SB 1324 (see the description of that bill under the Public Health/Public Policy section). SB
The minimum numbers of continuing education hours
1112 now says that if a woman has taken mifepristone as part
required for licensees are established. Training and educa-
of a two-drug regimen to terminate her pregnancy, has not
tion requirements for certification as a mammographic
yet taken the second drug and consults an abortion clinic
technologist are modified. The Board is authorized to
to question her decision to terminate her pregnancy, or
investigate, on its own motion, any evidence that appears
seeks information regarding the health of her fetus or the
to show the existence of any of the causes or grounds for
efficacy of mifepristone alone to terminate the pregnancy,
disciplinary action. Additionally, the statutory life of the
the abortion clinic staff are required to inform the woman
Radiation Regulatory Agency, the Radiation Regulatory
that the use of mifepristone alone to end a pregnancy is not
Hearing Board and the Medical Radiologic Technology
always effective and that she should immediately consult a
Board of Examiners is extended two years to July 1, 2018,
physician if she would like more information. It additionally
retroactive to July 1, 2016. By December 1, 2016, the Board
requires the Arizona Department of Health Services (ADHS)
and the Radiation Regulatory Agency are required to issue
website to include information explaining the efficacy of
a joint report to the legislative committees of reference
mifepristone taken alone, without a follow-up drug as part of
regarding progress on the implementation of the Auditor
a two-drug regimen, to terminate a pregnancy and advising
General’s recommendations.
a woman to immediately contact a physician if the woman
SB 1096 was amended to exempt PAs from certification by the Medical Radiologic Technology Board of Examiners (MRTBE). ArMA is currently working with the PA Board and will continue advocating to ensure that educational and clinical standards are reviewed and adopted that ensure PAs performing ionizing radiation are educationally prepared and clinically competent in order to ensure patient safety. SB 1112: PHARMACISTS; SCOPE OF PRACTICE
Another enacted bill from Sen. Barto, SB 1112 came about as a compromise after a sunrise application and stakeholder meetings during the months preceding session between representatives for pharmacists and physicians. It allows pharmacists to administer influenza vaccines to a child at least three years of age, to give booster doses for the primary adolescent series as recommended by the CDC, and to administer immunizations or vaccines recommended by the CDC to a child at least 13 years of age. The pharmacist must report the vaccine administration to the
Medicine | Summer 2016Report 1616AZArMA 2016 Legislative
has taken only mifepristone and questions her decision to terminate her pregnancy or seeks information regarding the health of her fetus. SB 1112 removes the requirement that a woman be told both of the following for purposes of establishing voluntary and informed consent to an abortion: that it may be possible to reverse the effects of a medication abortion but time is of the essence; and information on and assistance with reversing the effects of a medication abortion is available on the ADHS website. SB 1283: CONTROLLED SUBSTANCES PRESCRIPTION MONITORING PROGRAM
ArMA worked very closely with Sen. John Kavanagh and Governor Ducey’s team to implement workable changes to the bill regarding mandated use of the Controlled Substances Prescription Monitoring Program (CSPMP), and do so under a realistic timetable. This was a platform issue for the Governor heading into this session, to help address the problems our state has been facing with opioid abuse.
ArMA worked hard with stakeholders to amend the bill in
SB 1443: HEALTH PROFESSION REGULATORY BOARDS
order to address physician concerns with the legislation
Senator Barto sponsored this bill to make further changes to
which incorporated: including clinical discretion into the
the laws governing several professional regulatory boards,
mandate; tailoring the mandate so it is not overly broad; the
including the Arizona Medical Board and Arizona Board
timeline for technology improvements and the mandate;
of Osteopathic Examiners in Medicine and Surgery. The
and ensuring that functionality concerns with the system
bill specified that a member of a board would have been
itself are addressed.
ineligible for reappointment to that board once the person
SB 1283 says that beginning the later of October 1, 2017, or 60 days after the statewide health information exchange has integrated the CSPMP data into the exchange, before prescribing an opioid analgesic or benzodiazepine controlled substance listed in schedule II-IV for a patient, a medical practitioner is required to obtain a patient utilization report regarding the patient for the preceding 12 months from the Program’s central database tracking system at the beginning of each new course of treatment, and at least quarterly while that prescription remains a part of the treatment. There are exceptions for patients receiving hospice care, palliative care for a serious or chronic illness, care for cancer, a cancerrelated illness or condition or dialysis treatment. The bill does not include situations where a medical practitioner will administer the controlled substance, or when the patient is receiving the controlled substance during the course of inpatient or residential treatment in a hospital, nursing care facility, assisted living facility, correctional facility or mental health facility. There is an exception for prescriptions for no more than a 10-day period for an invasive procedure or one that results in acute pain to the patient, and an exception for no more than a five-day prescription when the practitioner has reviewed the Program’s database for that patient within the last 30 days and the system shows that no other prescriber has prescribed a controlled substance in the preceding 30-day period. Lastly, there is an exception for when a practitioner is prescribing the controlled substance for no more than a 10-day period for a patient who has suffered an acute injury or a medical or dental disease process (other than back pain) that is diagnosed in an emergency department setting and that results in acute pain to the patient. The Board of Pharmacy is required to contract with a third party to conduct an analysis of the Program and complete a report on specified information by January 1, 2017. By October 1, 2016, and quarterly for the following four years, the Board must do additional reports. ArMA will be providing all members with resources to assist in navigating the requirements of this legislation.
had been appointed for two full terms. A person would have been allowed to be reappointed to a board once the person had not been on the board for a time period of at least one full term. Health profession regulatory boards would have been required to audio or video record all open meetings of the board and to maintain the recordings for three years. Each board would have been required to publish nondisciplinary actions taken against licensees online. The bill passed the Legislature handily but was later vetoed by Governor Ducey. In his veto message, the Governor stated that he does not believe the best way to address needed reform for regulatory boards is small, isolated changes which do not address the root of the problem. He also expressed a desire for future legislation that aggressively addresses reforms of boards and commissions. SB 1473: REGISTERED NURSES; ADVANCE PRACTICE
This one was truly a “battle royal,” pitting doctors against nurses in a showdown over an aggressive APRN scope of practice expansion proposal effort, led by the Arizona Nurses Association (AzNA) and forcefully driven by the Arizona Association of Nurse Anesthetists (AZANA). Those groups collectively filed a major “sunrise” application back in September 2015 seeking four things:
one, to end the
requirement of “collaboration” by nurse practitioners (NPs) and certified nurse midwives (CNMs); two, to allow certified registered nurse anesthetists (CRNAs) to both prescribe/ dispense drugs (including opioids) and to eliminate the MD/ DO/DDS/DPM “direction and presence” requirement in their scope of practice statute; three, to give unlimited prescribing privileges to Clinical Nurse Specialists (CNS); and fourth, to change the process for all APRNs from certification to full licensure. After emerging from the sunrise hearing in December on a 5-4 vote, the nurses’ groups went forward with a major legislative and PR effort, in the form of SB 1473 sponsored by Senate Health Chair, Sen. Nancy Barto. ArMA and its Continued on page 18
2016 | AZReport Medicine1717 ArMA Summer 2016 Legislative
allied medical groups organized a coalition of opponents,
HB 2035: COSMETOLOGY; OMNIBUS
assembled a top-notch lobbying and PR team, and recruited
This enacted bill was sponsored by House Speaker David
an esteemed cadre of physician and patient spokespersons
Gowan, and it makes various changes relating to the Board of
to tell the story of why these proposals were not compat-
Cosmetology. Specifically of interest to ArMA, the bill estab-
ible with good patient care, and to the contrary, could put
lishes a six-member Cosmetic Lasers Study Committee to
patients at risk., That led to an epic showdown on Febru-
study the regulatory framework and monitoring process for
ary 10, when the two sides and their respective champions
the use of cosmetic lasers and report by December 31, 2016.
battled it out in a five-hour hearing before Sen. Barto’s
As initially introduced, the bill would have removed the direct
Health and Human Services Committee.
physician supervision requirement for the use of cosmetic
Our diverse and professional team provided thoughtful, comprehensive medical testimony demonstrating why this bill was not safe for patient care. When the dust finally settled, the bill was held from a vote by Sen. Barto, who admitted on the record that she lacked the requisite four yes
lasers, but thanks to relentless pressure from physicians, that change was deleted from the bill on the House floor. We will continue to work to make sure physician concerns regarding patient safety are heard as part of the committee process.
votes to get it out of committee. Despite a number of efforts
HB 2225: RADIOLOGIC TECHNOLOGY; OUT-OF-STATE LICENSED PRACTITIONERS
to resurrect SB 1473 by offering a variety of watered-down
Sponsored by Rep. Lawrence, HB 2225 authorizes a certified
(but still dangerous) amended versions, our solid contingent
radiologic technologist to use ionizing radiation on human
of no votes on the committee did not waver and the clock
beings for diagnostic purposes only while operating in each
began to run out.
particular case at the direction of a “licensed practitioner”
On March 11 there was a major turning point in this fight – ArMA was able to formalize an agreement with the AzNA and its component groups. We agreed to let the nurses run a striker bill with language for a clearer definition
(defined elsewhere in statute) who is licensed in any other state, territory or district of the U.S., in addition to a practitioner licensed in Arizona.
of “collaboration” required of nurse practitioners and
HB 2501: HEALTH REGULATORY BOARDS; TRANSFER; DHS
Certified Nurse Midwives, but the striker did not include
Governor Ducey announced early in the session his desire to
any other parts of their bill. That meant the contentious
begin a process of health regulatory board streamlining and
CRNA components, the clinical nurse specialist scope
modernization, and HB 2501 was the vehicle chosen to move
expansion, and the move to go from certification to licen-
forward in this effort. Rep. Carter, as Health Chair, stepped
sure for all APRNs were all now dead for this session. ArMA
forward to sponsor this bill and give the boards and profes-
agreed to take a neutral position on the new striker bill and
sionals impacted a fair opportunity to have input in this
to participate in stakeholder meeting after session regard-
process. She and Governor Ducey’s health advisor, Christina
ing the current CRNA statutes and the implications of
Corieri, stayed true to that commitment by holding regular
existing requirements in the context of healthcare delivery
stakeholder meetings as the session went on. ArMA was an
in Arizona. No commitments were made as far as legisla-
active participant in these meetings. The bill called for mov-
tion in future sessions. Ultimately, the nurses’ groups
ing specified regulatory boards to office space at ADHS, a
decided to drop even that striker bill for the session. We
study relating to moving the groups to ADHS, an Auditor
don’t think this ends the issue, by any stretch of the imagi-
General study to evaluate the structure and operations of
nation, and we are fully expecting to see the legislation
the health boards and recommendations regarding board
resurface again soon.
processes that can be streamlined to benefit licensees and
Legislative victories, while sweet, are by nature not long-
be more uniform among the boards while protecting public
lived. Nevertheless, considering the quality of the nurses’ position and the momentum they had going into the session, it was one of the biggest legislative wins for ArMA in a very long time.
Medicine | Summer 2016Report 1818AZArMA 2016 Legislative
health and safety. HB 2501 passed the House rather easily but then got bogged down in the Senate due to opposition, and ultimately the Ducey Administration decided to abandon the effort for 2016. This subject is likely to be revisited in 2017, and ArMA plans to be actively engaged again.
HB 2502: MEDICAL LICENSURE COMPACT
by dramatically decreasing licensing time, and lets the
ArMA led a coalition of Arizona’s health and business orga-
world’s most talented physicians know that Arizona is open
nization in support of HB 2502, sponsored by Rep. Heather
for business.”
Carter. This bill allows Arizona to safely and effectively license physicians at the speed of business. It creates a new
INSURANCE
pathway to expedite the licensing of physicians seeking to
It was a remarkably light year in terms of insurance-related
practice medicine in multiple states, enhance license por-
legislation. ArMA followed less than 20 bills this session in
tability and improve access, efficiency and quality of care
the Insurance category, most of which did not advance. The
for patients. The Compact will preserve Arizona’s ability
two described here are the more important ones:
to maintain control over medical licensure, discipline, and patient protection.
SB 1363: INSURANCE COVERAGE; TELEMEDICINE
An ArMA-backed bill by telemedicine champion Sen. Gail
HB 2502’s enactment of the Interstate Medical Licensure
Griffin, SB 1363 makes further improvements to Arizona’s
Compact makes Arizona the 13th state to do so, allowing a
insurance parity law from 2013. This bill requires policies or
streamlined process for physicians to become licensed in
contracts executed or renewed on or after January 1, 2018 to
multiple states if they so choose. Like the other compacts
provide coverage for health care services for trauma, burn,
do, this one gives authority to an Interstate Commission
cardiology, infectious diseases, mental health disorders,
and establishes Commission powers and duties to imple-
neurologic diseases, dermatology and pulmonology that
ment the Compact.
are provided through “telemedicine” if the service would
In addition, beginning July 1, 2017, the bill allows the
be covered were it provided through in-person consultation
Arizona Medical Board (AMB) and the Arizona Board of Osteopathic Examiners in Medicine and Surgery (DO Board) to issue a temporary license to allow a physician who is not an Arizona licensee to practice in Arizona for a total of up to 250 consecutive days if the physician holds an active and unrestricted license to practice medicine
and if the service is provided to a subscriber receiving the service anywhere in Arizona, instead of only in a rural region of Arizona (as current law states). The bill was signed by Governor Ducey on May 17th and has a delayed effective date of January 1, 2018.
in a U.S. state or territory, has never had a license sus-
HB 2306: HEALTHCARE PROVIDERS; FAMILY MEMBERS; COVERAGE
pended or revoked, is not the subject of an unresolved
Sponsored by Rep. Cobb, HB 2306 requires all health and
complaint, has applied for an Arizona license, and has
disability insurance contracts and policies issued, delivered
paid any applicable fees. The temporary license cannot
or renewed on or after July 1, 2017 in Arizona to provide
be renewed or extended.
coverage for lawful health care services provided by a health
The AMB and DO Board are prohibited from requiring an
care provider to a subscriber regardless of the familial
applicant for licensure to hold or maintain a “specialty certi-
relationship of the provider to the subscriber if that service
fication” as a condition of licensure in Arizona. Additionally,
would be covered were it provided to a person who is not
employers are prohibited from requiring a physician to seek
related to the health care provider.
licensure through the Compact as a condition of initial or continued employment. The Boards are required to create
HB 2264: INSURANCE; PRESCRIPTION EYE DROPS; REFILLS
a proposal for the expedited licensure of a physician who is
A helpful bill for patients (especially older ones), HB 2264 as
licensed in at least one other state, whose license is in good
enacted resulted from compromise discussions between
standing and who chooses not to be licensed through the
patient advocates and health insurers, including Blue Cross
Compact, and are required to submit a report to the Legisla-
Blue Shield of Arizona (BCBSAZ). It addresses the problem
ture by December 1, 2017.
of patients who run out of prescription eye drops early (often
Governor Ducey signed HB 2502 into law on May 11, stating
due to inadvertent spillage) by calling for early refills. Begin-
that “[t]he Interstate Medical Licensure Compact increases
ning January 1, 2018, health insurance policies that provide
Arizona’s ability to attract top quality doctors to the state
Continued on page 20
2016 | AZReport Medicine1919 ArMA Summer 2016 Legislative
coverage for prescription eye drops to treat glaucoma or
the following court day. Some exceptions are stated. Except
ocular hypertension are prohibited from denying coverage
during times when the principal has been found to be inca-
for a refill of a prescription for those eye drops if the sub-
pable, the principal under a mental health care power of
scriber requests the refill within specified time periods, the
attorney may disqualify an agent or revoke all or any portion
prescription eye drops are a covered benefit, the prescribing
of the power of attorney.
provider indicates on the original prescription that additional quantities are needed, and the refill requested does
SB 1324: ABORTION CLINICS; MEDICATION ABORTIONS
not exceed the number of additional quantities prescribed.
This highly controversial bill was another example of politics
TORT REFORM/LIABILITY
abortion-focused policy above sound medical science.
There were no bills enacted under the category of Tort
Thankfully, as a result of some very timely FDA action, this bill
Reform/Liability, ArMA followed a handful of bills, but none
was quietly done away with. SB 1324, filed by Sen. Kimberly
of them advanced.
Yee, mandated that ADHS rules relating to the medication
interfering with the safe practice of medicine, of placing
abortion procedure require that any medication, drug or PUBLIC HEALTH/PUBLIC POLICY
During this session there were over 40 bills in the Public Health/Public Policy category that ArMA followed. Of those, the following are the most important ones: HB 2061: MEDICAL MARIJUANA; PREGNANCY; SIGNAGE
Sponsored by Rep. Towsend, HB 2061 mandates the ADHS to adopt rules that require each medical marijuana dispensary to display signs warning pregnant women about the potential dangers to fetuses caused by smoking or ingesting marijuana during pregnancy or to infants while breastfeeding and the risk of being reported to the Department of Child Safety (DCS) during pregnancy or at the birth of the child by mandated reporters. The rules also require each certifying physician to attest that the physician has provided information to each qualifying female patient that warns about the same dangers and risks.
other substance used to induce or cause a medication abortion be administered in compliance with the mifepristone label protocol approved by the FDA as of December 31, 2015. This meant following an outdated and medically discredited label and prescribing a three times higher dose of a medication than is currently being prescribed/recommended by evidence-based medicine. ArMA, the Arizona Chapter of the American Congress of Obstetricians and Gynecologists (ACOG), and other medical groups had been on record saying mandating use of the old FDA label was bad medical science and placed physicians in a dilemma of either following the law or following their medical oath. Nevertheless, the bill was signed by Governor Ducey on March 30. However, the FDA thereafter updated the mifepristone label bringing its recommended usage in line with the medical best practices that have been used by physicians for years. As a result, SB 1324 was later repealed through
SB 1169: MENTAL HEALTH POWER OF ATTORNEY
an amendment to SB 1112 (discussed under the Regulatory
Following a productive stakeholders’ process on this bill
Boards/Regulations section above).
and SB 1442, Sen. Nancy Barto introduced this legislation to make several changes to the laws on the mental health care power of attorney. Under SB 1169, the physician that determines that a person lacks the ability to give informed consent may be a specialist in neurology, in addition to psychiatry or a psychologist. If a patient admitted to or being treated in an outpatient psychiatric facility under the authority of an agent pursuant to a mental health care power of attorney manifests the desire to disqualify an agent or revoke the power of attorney and requests in writing to be discharged from the facility, the facility is required to either discharge the patient within 48 hours or to initiate proceedings for court ordered evaluation or treatment on
Medicine | Summer 2016Report 2020AZArMA 2016 Legislative
SB 1442: MENTAL HEALTH SERVICES; INFO DISCLOSURE
The second of two mental health focused bills by Sen. Barto, SB 1442 modifies the requirements for a health care provider or entity to disclose confidential health care records to allow the disclosure to relatives, close personal friends or any other person identified by the patient as otherwise authorized or required by state or federal law. If the patient is present or otherwise available and has the capacity to make health care decisions, the health care entity is permitted to disclose the information if the patient agrees verbally or in writing, the patient is given an opportunity to object and does not object, or the entity reasonably infers from the circumstances that the patient does not object. If the
patient is not present or the opportunity to agree or object to the disclosure cannot practicably be provided, the entity may disclose the information if the entity determines that the disclosure is in the best interests of the patient. Factors a provider or entity must consider in determining whether the release of information is in the best interest of the patient are specified in the bill. Information disclosed under these provisions can only include information that is directly relevant to the person’s involvement with the patient’s health care or payment related to the patient’s health care. A health care entity is required to keep a record of the name and contact information of any person to whom any patient information
HB 2307: ANATOMICAL GIFTS; PROCUREMENT ORGANIZATIONS; LICENSURE
Sponsored by Rep. Cobb, HB 2307 sets up a new regulatory scheme under ADHS for licensing anatomical gift procurement organizations. Requirements for documentation and record-keeping are set forth, and ADHS is given the right to take various enforcement actions against a licensee in violation of statutory requirements and related rules it adopts. ADHS is required to recognize organizations accredited by a nationally recognized accrediting agency, and accredited organizations are exempt from certain statutory requirements. Hospital-affiliated entities are also
is released.
exempted from this law.
SB 1445: HEALTH CARE SERVICES; PATIENT EDUCATION
HB 2310: BIOLOGICAL PRODUCTS; PRESCRIPTION ORDERS
SB 1445 sponsored by Sen. Barto, forbids the state, state agencies, political subdivisions and private entities contracted with a health profession regulatory board from “punishing” (as defined) a health professional, directly or indirectly, for making a patient aware of or educating or advising a patient about lawful health care services for which there is a reasonable basis, including the “off-label use” (as defined) of health care services or health care-related research or data. Unless an entity has a sincerely held religious or moral belief, the entity is prohibited from restricting a health professional who is an employee of or affiliated or contracted with the entity for making a patient aware of or
Another bill Sponsored by Rep. Cobb, HB 2310 addresses the cutting edge topic of interchangeable biological products. A pharmacist is only permitted to substitute for a prescribed biological product if a list of specified conditions is met, including that the FDA has determined the substituted product to be an “interchangeable biological product” (as defined) and that the prescribing physician does not designate that substitution is prohibited. Documentation of the substitution and electronic notification to the prescribing physician is required.
educating or advising a patient about lawful health care
HB 2355: OPIOID ANTAGONISTS; PRESCRIPTION; DISPENSING; ADMINISTRATION
services, including the off-label use of health care services
One of the great “sleeper” bills this session – one that
or health care-related research or data.
undoubtedly will save the lives of Arizonans – is Rep. Carter’s HB 2355. Under this landmark bill, a licensed physician, nurse
HB 2265: EPINEPHRINE AUTO-INJECTORS
practitioner or other health professional who has prescrib-
Rep. Regina Cobb had success this time around (her effort
ing authority and is acting within the scope of practice is
last session stalled out), in terms of passing a law to allow
authorized to prescribe or dispense naloxone hydrochloride
health care practitioners to prescribe epinephrine auto-
or any other opioid antagonist that is approved by the FDA
injectors in the name of an “authorized entity” (defined
to a person who is at risk of experiencing an opioid-related
as any entity or organization other than a school at which
overdose or a family member or community organization
allergens capable of causing anaphylaxis may be present).
that may be in a position to assist that person.
Authorized entities are permitted to acquire and stock a supply of epinephrine auto-injectors and to designate employees or agents who are trained to be responsible for the injectors. Trained employees or agents are authorized to provide or administer an epinephrine auto-injector to any individual they believe in good faith is experiencing anaphylaxis.
Without a prescription, pharmacists will be authorized to dispense, according to Board of Pharmacy protocols, naloxone hydrochloride or any other approved opioid antagonist to a person who is at risk of experiencing an opioid-related overdose or to a family member or community member who is in a position to assist that person. Continued on page 22
2016 | AZReport Medicine2121 ArMA Summer 2016 Legislative
Physicians, pharmacists and persons who take these
Our front line ArMA team of Pele Fisher (VP of Policy & Politi-
actions with reasonable care and in good faith are
cal Affairs) and Steve Barclay (our lawyer/lobbyist) proved
immune from specified liability, except in cases of wanton
to be an extremely effective and resilient duo. They accom-
or willful neglect.
plished victories which many thought not possible. The involvement of many ArMA members, in a way that allowed
HB 2599: AHCCCS; PROVIDER PARTICIPATION; EXCLUSIONS
Rep. Justin Olson filed this enacted bill to require AHCCCS to exclude from participation in the program any individual or entity that meets any basis for mandatory exclusion described in federal law. The AHCCCS Administration, in its sole discretion, is permitted to exclude from participation any individual or entity that has met any basis for permissive exclusion described in federal law or committed a list of prohibited acts.
us to have the direct physician voice when it was needed most, was a critical reason for that success. The information and support provided by the American Medical Association (AMA) Scope of Practice Partnership and the American Society of Anesthesia (ASA) on the APRN legislation allowed us to proceed with information and expertise otherwise unavailable. The AMA support allowed us to institute the inauguration of our grass-roots and electronic response that will now be an integral part of our advocacy program. Gratifying as they may be, we understand only too well the
HEALTH CARE INSTITUTION ISSUES
fleeting nature of the legislative victories we have achieved.
In the Health Care Institution Issues category, ArMA followed
Each new legislative session starts with a fresh slate, and we
a dozen bills this session, one of which is discussed below.
are faced with new threats and opportunities.
SB 1327: HOSPITALS; DIETICIANS; PRESCRIPTIONS; DIET ORDERS
We enter this “off-season” with much to attend to – a whole
A bill sponsored by Sen. Barto at the request of Arizona
as planning our defensive and offensive strategies for the
Hospital and Healthcare Association (AzHHA), SB 1327
2017 session (which will be here in less than six months).
permits a licensed hospital to allow a “registered dietitian”
New (or resurrected) threats will emerge – proposals to
or other “qualified nutrition professional” (both defined) to
expand practice scopes being just one example – and we
order diets, enteral feeding, nutritional supplementation
must continually take time to educate our lawmakers and
or parenteral nutrition if authorized by medical staff pursu-
staff about emerging health care policy issues. One thing all
ant to federal law and if the hospital’s written policies and
ArMA members can count on:
procedures allow it and the hospital has written policies and
guard; we will always stand ready to defend the practice of
procedures that address the hospital’s response to adverse
sound medicine.
events, if any, that arise as a result of orders issued by a registered dietitian or other qualified nutrition professional. For the purpose of Board of Pharmacy regulations, the definition of “prescription order” is expanded to include “enteral feeding,” “nutritional supplementation” and “parenteral nutrition” (all defined) that is initiated by a registered dietitian or other qualified nutrition professional in a hospital.
CONCLUSION
new crop of legislative candidates to get to know, as well
we will never lower our
In closing, we wish to acknowledge and sincerely thank those legislators who have been absolute stalwarts in terms of protecting the interests of quality health care for all Arizonans. Our special thanks goes out to the following health care heroes: Representative Heather Carter, House Health Committee Chair; Representative Eric Meyer, House Minority Leader; Senator Katie Hobbs, Senate Minority Leader; Representative Regina Cobb, Vice Chair of House Health; Senator Debbie Lesko; Senator David Bradley;
Once again, ArMA got the job done through its legislative
Representative Kate Brophy-McGee, and Representative
advocacy, securing victories on key pieces of legislation in
Randall Friese, for their willingness to stand strongly for us
the face of significant adversity. And ArMA did so by hold-
on the proactive and defensive issues we fought so hard
ing the line against ideas that would be contrary to the best
for this year.
interests of both patients and physicians. We showed to all that it is the physician who is still watching out for the patient and who is the head of the medical care team.
Medicine | Summer 2016Report 2222AZArMA 2016 Legislative
n
A New Era in Health Policy
Profiles in Policy Leadership
Senator Debbie Lesko (LD 21)
Making a Difference in the Arizona Senate I am very pleased to serve on the Senate Health and Human Services committee, where vital issues that affect everyone are discussed and voted on. This is my 8th year serving in the Arizona Legislature and my 2nd year on the Health Committee. I also serve as the Chairman of the Senate Finance committee where we vote on tax and public pension policy; Vice Chairman of the State Debt & Budget Reform committee; and serve as a member of the Appropriations committee and Water & Energy Committee. I absolutely love my job and learn something new every day. This year I learned a lot about Medical Licensure Compacts and the advanced practice registered nurses’ desire to expand their scope of practice. These were very controversial issues
and each side hired highpowered lobbyists to state their case. After hearing from both sides on the issue, I sided with the physician community and was a key committee vote. I voted in favor of HB2502, the Medical Licensure Compact, and opposed the nurse scope of practice expansion legislation. This year, I also sponsored legislation that requires privatization of the backlog of child safety investigations and worked to ensure that the State budget included required progress benchmarks be met before appropriating more funds to the agency. Serving on the Joint Legislative Budget Committee, I was outraged to learn in September 2015 that even though the legislature had appropriated $29 million to decrease the number of child safety backlogged cases, the number of backlogged cases had actually increased. In response, I worked with Republican and Democratic legislators, the Department of Child Services Director and the governor’s office on Representative John Allen’s and my legislation. I am pleased to report that the Department of Child Safety has reduced its number of Continued on Page 24
Rep. Heather Carter (LD 15)
Politics and policy: What’s the difference and why do both matter? When people ask me why I ran for office, I always talk about the personal passion for working on important public policy for the state of Arizona. I want to help shape the future of our great state by putting forth policy that advances Arizona and makes our state the best place to live, learn, work and retire. However, as an elected official, I would not have the privilege of serving without running for office. Running for office brings politics into the equation of advancing public policy. To be effective, it is important to work both sides of an issue: the political and public policy sides. While many people prefer to focus on the policy side, to be effective, you must participate in the political process.
Why is it important to focus on politics? This year, there is tremendous attention paid to the national political landscape. However, now is the time to pay particular attention to what is happening at the state level. As state legislators, we have tremendous influence on healthcare, both within the two health committees and as legislative body as a whole. Many of the important healthcare votes are bipartisan, and often times, the most important legislation passes by a mere one or two votes. Your state government oversees important issues like licensing, reimbursement rates, insurance coverage, scope of practice and more. If you are not involved and engaged in both the policy AND political process, you will not have the opportunity to help shape your professional future and healthcare in Arizona. What can you do? There are three simple things you can do right now to get more engaged in the political process. Register to vote. You can go online and register to vote at ServiceArizona.com. You would be amazed at how many people are not registered to vote. Often times, I hear the Continued on Page 24
Summer 2016 | AZMedicine 23
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Rep. Carter
Continued from Page 23
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The value of more complete reason people not want to inactivepatient cases and open reports information anddothe register to vote is because they from over 15,000 in January importance of securely want to avoid jury duty. This to 8,500 in June of this year. is a weak excuse. If you have a Although it is still too many, sharing information among driver’s license, you are already we are now on the right path. the ‘list’ for jury duty (and Using skilled providers to help physical and onbehavioral it is a civic responsibility to agency caseworkers is a winhealth providers be serve oncan a jury!). Another reawin proposal. The director son I hear is that people do not believes the backlog cases will readily seen in a their look think voteat ‘matters.’ It be eliminated by year’s end. does and I will talk more about the highest My most patients significant work with this that in a moment. year was on pension reform. needs andVotecosts. in the primary election. After a year’s work with the firefighters, police, cities, and governor’s we negotiated growth in office Network participasignificant reform,community including tion, and adding Proposition 124, which will behavioral health providers sustain theof firefighter to the list those withand no police pension system and save participation fees will spur taxpayers over $1.5 Billion. even stronger growth. Since launching its new technology Please feel free to contact me platform in April of 2015, anytime at Dlesko@azleg.gov The Network has grown from or 602-926-5413. AM 33 participants to more than 100 participants by the second
l-out inteHeC with rated vioral BHA) , to crisis ehavwide. crisis d to and later
parunity rong 24 AZMedicine | Summer 2016
Many of our legislative districts are deemed ‘non-competitive’ quarter of 2016, and many of districts, meaning the voter the newest participants are registration percentages behavioral health organizafavor one have political partyjoined over tions that recently another. So in a district where The Network. Republican or Democrats have As advantage, with otherthe initiatives the decision throughout our on who represents you history, will be AzHeC relied on broad made during the primary eleccommunity outreach tion. If you are not votingand in engagement develop the primary, youtodo not have ana
statewide strategy. Muchwho of opportunity to determine the represent information over will yougathered at the legislaa period of several ture or in other offices. months During helped to inform and (2014), design the last primary election the plan and its decided implementamany races were by a tion. number In the of end, notInonly small votes. my was there broadI community primary election, was the top support statewide vote earner,for and one the next seat in integrated the Arizonahealth House information was decided exchange for votes! physical and by just over 30 behavioral health information, Reach out and to know there was also get a consensus your elected officials. Thisone is in the community that critical. At some point, you system would provide the best will want to contact your care and the best outcomeslegfor islator and voice your opinion Arizona patients. AM on legislation. As with any Melissa Kotrys iswhen the Chief relationship, you know Executive Officer for Arizona Health-e the person before you make a Connection (AzHeC) and the Health request, haveof more Informationyou Network Arizona.influAzHeC operates the suggest you ence. I strongly Arizona Regional Extension Center, reach out during this election which assists Arizona providers in achieving Meaningful Use. cycle to simply introduce yourself to the candidates running “Mental disorders and comorbidiin1 your legislative district. You ty,” Goodell, S, Druss BG, Walker, could an emailProject explaining ER,send The Synthesis 21), do Robert the (Policy work Brief thatNo.you or you Woods Johnson Foundation, could invite the candidate to February 2011. coffee or to your office for a
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more in-depth conversation. If the meeting goes well, you may even feel compelled to donate to that person’s campaign. Last but not least. Social media is an important way to communicate in today’s political process. While posting to Twitter, for example, does not replace getting to know your elected representatives personally, it has become a quick way to express your opinion to a large audience. I recommend you immediately start to build a social media presence, including creating a Twitter profile, and begin to follow BOTH your elected officials and your professional organizations such as ArMA. This is a quick and easy way to participate in the process by simply posting quick reminders and information to build your social media following. You should also “re-tweet” posts from your professional associations. This will help establish your footprint in the digital world, which will help you be an effective advocate when the Arizona Legislature is back in session. In summary, the Arizona Legislature has tremendous influence on your medical career and it is vitally important that you take an active role in shaping public policy in healthcare for Arizona. To do this important work, you must also remember the political side to the process. As citizen legislators, we need to hear from clinicians like yourself to help us make the best decisions for the citizens of Arizona. AM
Spring 2016 | AZMedicine 25
Get involved! Social Media Advocacy 101
A New Era in Health Policy
Your legislators are on social media. Are you? It’s 2016 and social media is here to stay. The number of individuals using social networking sites such as Facebook, Twitter, LinkedIn, and YouTube is growing at an astounding rate. Facebook has
Sophie O’Keefe-Zelman, Director, OH Strategic 1.65 active monthly users, and Twitter sees approximately 500 million Tweets per day. Given the numbers, social media mobilization has become an integral part of any successful advocacy effort. It’s an effective way to engage and coalesce association members and opinion leaders from across the state around a single subject. Social media offers opportunities for rapid knowledge exchange, dissemination and response among many people. It can direct communication at a particular user,
and it can turn up the volume on a particular topic by sheer numbers of engagement. Tweets, retweets, posts, likes, and shares have added another layer of communication and influence to public policy debates. At ArMA, we’ve been working hard to harness the potential of social media with our members during critical debates. We believe our social advocacy - and especially yours – during this year’s legislative session made a big difference in the outcomes of SB1473 and Kidscare. Moving forward we see it as a valuable communication and influencer tool and hope to see more and more of our members and the physician community engage. Targeting legislators and opinion leaders with a consistent message from constituents and subject matter experts can make a big difference in the outcome of a vote or position statement. The ArMA team is thankful for our members, who have created a growing presence for Arizona physicians across social media with (to date)
809 followers on Twitter and 520 likes on Facebook. As we head into the next legislative cycle your voice will be more important than ever. Even with our social media success least year we know there is still a lot for all of us to learn so here’s a quick 101. If you don’t have a Twitter or a Facebook account we encourage you to get one, and if you need help – just ask! ArMA thanks you for your due diligence and engagement with social media. This will be an increasingly important advocacy tool and we appreciate your time and willingness to engage and share pertinent information with your networks. AM Sophie O’Keefe-Zelman is a Director at OH Strategic Communications where she manages communications, community relations, and public relations campaigns for non-profits, associations, and corporate clients.
You can support ArMA’s initiatives across social media by: • Retweeting or sharing ArMA information regularly. • Retweeting or sharing ArMA information with a third party endorsement from yourself. • When you post, identify yourself by name and role as validation. People trust physicians and other medical professionals! • Retweeting or sharing with ArMA hashtags to help a topic trend. • Even if you don’t agree with a conflicting post, always respect others’ opinions. • Make sure your content addresses the issue and not a person. • Add value to the conversation with your personal experience and expertise. • Use your post to encourage others to take action, either by retweeting, reposting or by contacting their elected official. • Encourage your associates to join social media and follow ArMA accounts for the latest updates and action items. • Recognizing that content posted by you represents you and not the association or another individual.
Summer 2016 | AZMedicine 25
PHYSICIAN LEADERSHIP CONFERENCE
Encouraging Physician Leaders in Arizona The Arizona Medical Association (ArMA)
Jacque Chadwick, MD also serving on the pro-
convened the second annual Physician Leadership
gram committee. The conference is designed
Conference, “The Opportunity of Value-Based
to grow and support effective physician leader-
Payment,” on March 19, 2016. We welcomed
ship in Arizona in the face of a rapidly changing
90 attendees to the conference, held at Mayo
health care environment. Health care’s growing
Clinic in Phoenix, Arizona.
complexity requires more advanced leadership
The conference was developed by ArMA Immediate Past President Jeff Mueller, MD, with ArMA past Presidents Marc Leib, MD, JD, and
skills in order to successfully operate one’s medical practice. Physicians must also engage in leadership beyond the bedside and exam room, and directly participate in hospital, health system, government and insurer decision-making roles and opportunities.
The conference speakers were experts in valuebased payment systems including Stan Stead, MD, MBA, CEO of Stead Health Group, Vishu Jhaveri, MD, MSA, Senior Vice President and Chief Medical Officer for Blue Cross Blue Shield of Arizona, and Tom Betlach, MPA, Director, Arizona Health Care Cost Containment System (AHCCCS). A panel discussion between regional CEOs and CMOs included William Ellert, MD, CMO of Abrazo Community Health Network; Keith Frey, MD, MBA, Chief Physician Executive of Dignity Health Arizona & President, Dignity Health Medical Group in Arizona; Linda Hunt, President and CEO of Dignity Health Arizona; and Robert Trenschel, DO, MPH, President and CEO, Yuma Regional Medical Center.
Surveyed respondents affirmed that the conference was worth the time spent, in particular citing the timely topic, the quality of the speakers’ presentations and expressing that they were now more empowered to participate in the process of
The speaker Q & A and panel discussions were marked by active audience participation and included critical questions from many attendees.
payment transitions. Respondents to the conference survey overwhelmingly felt it was important for ArMA to continue offering this opportunity and suggested a number of excellent topics for consideration. The Conference was endorsed by the Arizona Hospital and Healthcare Association.
COMING SOON
PHYSICIAN LEADERSHIP CONFERENCE
2 0 17 STAY TUNED FOR UPDATES
A New Era in Health Policy
The politics of physician credentialing A lot has been said about politics; some of it complimentary, but most of it accurate. — Eric Idle We are living in a bizarre political environment. As co-chair of the Arizona Medical Group Management Association’s (AzMGMA) Legislative Committee I can’t help but make a political statement: Less government is better government because well intended laws have unintended consequences
Chip Hardesty that often do more harm than good. I don’t need to iterate examples of politicians in Washington telling doctors in Arizona how to practice medicine. You know them all too well. One of the well-intended objectives of the Affordable Care Act was to reform the healthcare insurance system. 28 AZMedicine | Summer 2016
I have only seen the big insurance companies getting bigger and more dysfunctional. One glaring example is the slow and tedious process of credentialing doctors in Arizona. Now, before you decide that this article has turned dull and tiresome because I’ve turned from politics to a boring clerical function, let me explain. It frequently takes more than nine months to credential new physicians with the health plans and load them into their systems so they can be paid for seeing patients. For example, A pediatrician who was fully credentialed and practicing was required to start from scratch when she changed practices. In another case, a clean application was submitted for one of our radiologists in September of 2015 and she still has not been loaded into the Tricare system. Finally, last July a new partner out of training joined a surgical practice in Phoenix. Her application was started in April. In October, United
Healthcare responded to endless calls that she was effective September 21st however, we were instructed NOT to send claims until we received their letter of approval. This letter did not arrive until January 2016, along with a request for time to load her into their systems. You may not be personally affected by this if you’ve practiced in the same place for many years but new doctors joining your practice may not be able to be paid for the work they perform for nine months or longer. Babies are conceived and born in less time. I’m not talking about little, under capitalized companies (those no longer exist). I’m talking about multibillion dollar companies with very sophisticated capabilities with offshore labor that could easily complete this task within 90 days. This practice of sandbagging the applications should be illegal because it restricts access to care for patients and actively prevents physicians from making a living in Arizona. When the Chief Medical Officer from a large insurance
company told me that delays are due to a huge liability risk for them, I had to call Bravo Sierra. My research was unable to find documentation of any major insurance carrier ever being fined or successfully sued for poor credentialing practices. We’re talking about physicians who have been source verified and granted a license to practice medicine from the Arizona Medical Board, including finger printing, which is used for state and federal criminal background checks by the Arizona Department of Public safety in conjunction with the FBI. They have been source verified by their liability carrier and allowed to purchase an insurance policy. They have been assigned an NPI number by Medicare and enrolled in the PECOS program. They have been granted a DEA license to prescribe narcotics by the federal government. They have been granted privileges and admitted to the medical staff of local hospitals. How much more vetting could possibly be needed? Companies that are so skilled at denying claims cannot be so inept at handling these basic
clerical functions. The only reason that I can see is that it is to their financial benefit. They have learned that, out of desperation, doctors are unable to wait them out and will begin seeing patients once they are approved by Medicare and some of the faster plans. Your practice administrators have had enough. They are taking action and need your support. These actions include: Working closely with the Arizona Medical Association (ArMA) to empower the Arizona Department of Insurance to have more muscle in the health insurance company policies that directly impact patient care. Raising awareness of the problem through articles such as this, presentations at monthly AzMGMA meetings, and a petition drive at www.change. org/p/cindy-leonard-credentialing-contracting-impedespatients-access-to-physicians
This last point gives me heartburn. I stated at the opening of this article that I believe that less government is better government. Unfortunately, it may truly take an act of Congress to force the insurance industry to do the right thing and allow doctors to see patients and be paid for their services in a timely manner. What a concept. Please sign our petition. www.change. org/p/cindy-leonard-credentialing-contracting-impedespatients-access-to-physicians
Because differences matter.
TM
AM Mr. Hardesty is Chief Operating Officer at a radiology group in Arizona. He currently serves as co-chair of the Arizona Medical Group Management Association (AzMGMA) Legislative Committee.
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Engaging with the insurance carriers through their representatives, their trade group, their C-suite, and their boards. Working with the Governor, the Legislature, and the Department of Insurance to ensure that existing laws are being enforced and that new laws and regulations are being drafted to address the problem.
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Summer 2016 | AZMedicine 29
Supervising Editor Jacqueline Chadwick, MD
AzMedicine Advisory Council Marshall B. Block, MD Jacqueline Chadwick, 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 Gretchen B. Alexander, MD
Executive Vice President Chic Older chicolder@azmed.org
Managing Editor Sharla J. Hooper, MA Associate VP, Communications sharla@azmed.org
2016-2017 Board of Directors
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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
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
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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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