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Winter 2015 | Volume 26, No. 4 | www.azmed.org | facebook.com/azmedicine

FROM OUR PRESIDENT Health Care Mandates, or How the Government is taking over Our Professional Lives… ...........................4 PUBLIC HEALTH UPDATE ADHS: West Nile Season May Be Over, But Other Diseases from Mosquitoes Approach Arizona Borders.............................................25

Trends In Healthcare Delivery & Payment FINGER ON THE PULSE Health Care’s Y2K.................................................. 10 MACRA: A Path to Value-Based Payments.......... 12 ASU (CHiR) releases new report on physicians use, evaluation and exchange of electronic medical records................................ 14

COMMUNITY UPDATE Two years in: How a first-of-its-kind clinically integrated network is changing pediatric medicine delivery and outcomes....................26

The Practice Innovation Institute: Transforming Clinical Practice in Arizona............... 16

VALLEY FEVER AWARENESS WEEK Stakeholders in Valley Fever come together................................................................28

HSAG VISTAS Government Mandates and Healthcare Delivery: Improving Care and Lowering Costs............................................... 20

MICA Same-Sex Marriage: Impact on HIPAA and Surrogate Decision Makers.....................................30

How to spur Congress to act: 7 essential elements of storytelling........................ 18

Anatomy of a Board Investigation.......................... 22

Winter 2015 | AZMedicine 3

FROM OUR

President

Health Care Mandates, or How the Government is taking over Our Professional Lives “I predict future happiness for Americans, if they can prevent the government from wasting the labors of the people under the pretense of taking care of them.” — Thomas Jefferson The Federal Government continues to impose mandates that affect the practice of medicine in the U.S. The most important of these relate to the Affordable Care Act (ACA, or Obamacare), the mandatory use of electronic medical records, and most recently, the conversion to ICD-10 coding. Another mandate that affects numerous small and large businesses, including medical practices, Nathan Laufer, MD, FACC is the raise in minimum wage eligible for a salaried employee to be exempt from overtime. Each of these major mandates that have significant effects on the viability of medical practices.

Affordable Care Act Beginning Jan. 1, 2015, the ACA imposed an employer mandate that states that employers with 50 or more full-time employees and equivalents (FTE) may be subject to a penalty if they do not offer medical coverage that provides minimum essential coverage (MEC), is affordable, and meets minimum value (MV) requirements. Employers with 50-100 full-time employees and FTEs may be qualified to delay implementation until, 2016. Employers with 100 or more full-time employees and full-time will need to comply in 2015. The employer mandate does not apply to small groups with 2-49 employees.

There are two potential employer penalties if the mandated offer is not made to full-time employees and their eligible dependents. Penalty A: If an employer does not offer any medical coverage or medical coverage that provides MEC to at least 70 percent of their full-time employees, the employer could be subject to a penalty. The annual penalty is $2,000 per year, per full-time employee. Penalty B: If an employer offers medical coverage or medical coverage that provides MEC but the full-time employee’s contribution is deemed unaffordable, for even just one employee, and/ or does not meet MV according to the employer mandate requirements, full-time employees may obtain health insurance through a public insurance Exchange and qualify for a premium credit or cost-sharing reduction. The annual penalty of $3,000 per year, per full-time employee would apply if an employee applied to a public insurance Exchange and was deemed eligible for a subsidy. The ACA also requires that employers report annually to the IRS whether they offer full-time employees and their dependents the opportunity to enroll in minimum essential coverage under an eligible employer-sponsored plan. This requirement includes providing a written statement to full-time employees. Reporting is required beginning in early 2016 for coverage provided in 2015. The first information return is due January 31, 2016. A new survey by the International Foundation of Employee Benefit Plans, 2015 Employer-Sponsored Health Care: ACA’s Impact, notes: • One-third of employers (33 percent) expect the greatest cost increase from ACA implementation to take place in 2016, as new reporting, disclosure and notification requirements take effect. • Over one-quarter (27 percent) expect the largest cost increase in 2018, when the impending excise tax on high-value plans (the “Cadillac tax”) kicks in. The nondeductible 40 percent Continued on page 6

4 AZMedicine | Winter 2015

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Continued from page 5

excise tax will be levied on plans that cost in excess of statutory thresholds (in 2018, $10,200 for self-only and $27,500 for family coverage), regardless of whether premiums are paid by employers or employees. High-deductible health plans (HDHPs) are proving a popular option among employers that are looking for a way to hold both current and future health care costs in line. As employers face the upcoming ‘Cadillac tax,’ it’s likely that HDHPs will continue to gain popularity.”1

How does ACA affect doctors? To begin with, we are likely to see an uptick in patients over the coming years. As more and more previously uninsured individuals

The passage of Obamacare happened to coincide with an anticipated brain drain in the medical profession. Sources like the U.S. Bureau of Labor Statistics have predicted significant losses in healthcare professions in the coming years, thanks to doctors, nurses, administrators, and other medical professionals reaching the age of retirement with fewer students graduating from medical programs to replace them. So pair an increase in patients with a decrease in qualified medical professionals and you can quickly see the looming problem in healthcare. Another problem for physicians is the mandatory grace period. For patients who have paid at least one month’s premium under the ACA, insurers have to provide a 3-month grace period. If that 3-month period goes by without the consumer paying all of their outstanding premiums, then the insurer is required to cancel their coverage, retroactive to the last day of the first month of the grace period. In other words, if premiums are not paid for July, the grace period would last through the end of September. If all unpaid premiums are not paid by the end of September, coverage could be cancelled effective the last day of July. So if any medical care was obtained in July, the insurer would have to pay those claims. But the insurer would not have to pay any claims submitted in August or September. This leaves physicians without payment for services rendered for those two months!

As more and more previously uninsured individuals gain access to affordable (or free) health coverage, they will start to take advantage of preventive services like check-ups, physicals, and so on. gain access to affordable (or free) health coverage, they will start to take advantage of preventive services like check-ups, physicals, and so on. Over time, this should make for a population that is healthier in general, not to mention fewer emergency medical crises that the government and taxpayers have to cover due to a lack of insurance. In the meantime, however, doctors will have to accommodate a rising number of patients that will now seek preventive medical services or schedule visits due to minor ailments that they would have simply rode out in the past. Doctors and their support personnel will have to deal with changes to medical billing related to new forms of insurance. With new options for private insurance, public options, Medicare, Medicaid, CHIP, and so on, medical offices may have to spend more time sifting through forms, billing and coding appropriately, and taking the additional steps necessary to ensure payment for services rendered. This could mean significantly more work for offices that are already understaffed or stretched to the limit. The result for patients could be greater difficulty in scheduling visits, as well as longer in-office wait times as offices get up to snuff with all the new information and processes they have to deal with. 6 AZMedicine | Winter 2015

Electronic Medical Records (EMR) The government wants to shift the health industry into the digital age and has provided reimbursement incentives and an electronic medical records deadline for those who adopt electronic medical records (EMR). However, as with all government benefits, this electronic medical records mandate comes with strings attached. For those who do not meet the electronic medical records deadline for implementation, the government has laid out a series of penalties. For physicians who either have not adopted certified EHR / EMR systems or cannot demonstrate “meaningful use” by the EMR deadline in 2015, Medicare reimbursements will be reduced by 1%. The deduction rate increases in subsequent years by 2% in 2016, 3% in 2017, and 4% in 2018. According to EMRandHipaa.com, an average AAFP (American Academy of Family Physicians) user is reimbursed 20% by

Medicare. This means that overall, a private practice with $500,000 of annual income that fails to meet the electronic medical records mandate will lose $1000 in payments in 2015, $2000 in 2016, and so on. These losses will be higher with higher percentages of Medicare patients in a practice.

The government wants to shift the health industry into the digital age and has provided reimbursement incentives and an electronic medical records deadline for those who adopt electronic medical records (EMR).

Meeting the government’s mandate and electronic medical records deadline will not be easy for everyone in the health industry, especially rural hospitals and small, independent physician practices. As part of the American Recovery and Reinvestment Act, physicians could receive up to $44,000 in Medicare incentive payments beginning in 2011 for implementing EMR systems. EMR implementation require demonstration of “meaningful use,” which is measured in stages. Stage 3 of meaningful use is shaping up to be the most challenging and detailed level yet for healthcare providers. Among the elements that warrant attention are quality reporting, clinical decision support and security risk analysis. In the face of new regulations that will make program requirements under Stage 3 of the electronic health record (EHR) meaningful use program even less achievable and more disruptive, ArMA joined the AMA and 110 other medical associations in sending letters to members of the Senate and the House, urging them to intervene. The letters point out that “the Centers for Medicare & Medicaid Services (CMS) has continued to layer requirement on top of requirement, usually without any real understanding of the way health care is delivered at the exam room level.” For the past several years, medical professionals have warned that the federal electronic medical records mandate – buried in the trillion-dollar Obama stimulus of 2009 – would do more harm than good. In theory, of course, modernizing record-collection is a good idea, which many private health care providers had already implemented. Obama’s one-size-fits-all EMR regulations have morphed into what one expert called “healthcare information technology’s version of cash-for-clunkers.” Many primary care physicians converted to “concierge care” because of the meddlesome EMR burden. Robert Wachter, author of the recently published The Digital Doctor: Hope, Hype, and Harm at the Dawn of Medicine’s Computer

Age, chronicled the damage he’s witnessed: “Physicians retiring early. Small practices bankrupted by up-front expenses or locked into ineffective systems by the prohibitive cost of switching. Hours consumed by onerous data entry unrelated to patient care. Workflow disruptions. And above all, massive intrusions on our patient relationships.” The American Medical Association (AMA), which foolishly backed Obamacare, is now balking at top-down government intrusion into their profession. Better late than never. The group launched a campaign called “Break the Red Tape” this summer to pressure D.C. to pause the new medical-record rules as an estimated 250,000 physicians face fines totaling $200 million a year for failing to comply with “meaningful use” EMR requirements. At a physician townhall recently held in Massachusetts, physicians decried the failure to achieve true “interoperability” between EMR systems despite a $30 billion federal investment through the Obama stimulus. Rep. Steve King, R-Iowa, recently introduced a bill to repeal the draconian penalties.2 The percentage of Arizona physicians using electronic medical records (EMRs) increased from approximately 45% in 2007-2009 to approximately 86% in 2013-2015. The current trend suggests that nearly all Arizona physicians will be using EMRs by 2018. The incentives and support provided by Medicare and Medicaid, combined with other influences, have succeeded in increasing EMR adoption, but important obstacles remain. Reliance on paper records continues to decrease, but utilization of EMRs as the only medical record has not increased proportionately. Instead, there has been a marked increase in the use of EMRs combined with scanned records. The reliance on scanned records appears to reflect barriers to electronic record transfers among health care organizations. The expected benefits of EMRs, such as the avoidance of duplicative tests, require the exchange of information among health care providers. However, among physicians with EMRs, less than 20% Continued on page 8

Winter 2015 | AZMedicine 7

Continued from page 7

(reminders for intervention) to 46% (e-prescribing) of the physicians share the information with others, depending on the type of information being shared. The single most important obstacle to the inter-organizational transfer of electronic health information is the shortage of Health Information Exchanges (HIEs). The Health Information Network of Arizona (HINAz) is one such HIE. Although HINAz currently serves only forty-nine participants, it continues to expand. Many discussions among HIE professionals suggest that physicians are very dissatisfied with their EMRs. Results indicate that Arizona physicians are at least somewhat positive about their EMRs, ranking them slightly above the midpoint in the 1-5 scale. The more accurate conclusion may be that physicians seek to improve individual elements of their EMRs, but recognize that EMRs offer advantages not available from scanned records or paper medical records.3

ICD-10 For starters, few outside medicine understand the complex process required for doctors to get paid by insurers for their work, but those who don’t understand are nevertheless affected by the process. To get paid, a doctor must properly log any work done, along with the reason it was done (the diagnosis), with an assigned code chosen from huge manuals containing tens of thousands of codes. Medical coding is complex and has no room for error. Pick the wrong code, and a doctor will not get paid. Pick too many wrong codes over time, and a doctor might be investigated by the government. Over the years, an entire industry has sprung up dedicated solely to medical coding. The number of codes has increased from about 15,000 to almost 70,000, and no code that appears in ICD-9 is valid in ICD-10. Decades of coding experience has carelessly tossed out the window, leaving many doctors to spend precious time figuring the new system out rather than actually treating their patients. Supporters of ICD-10 (insurance companies, bureaucrats, health IT vendors, and academics) assure us doctors that it is worth the sacrifice. They say that ICD-9 is outdated and lacks the capacity to cover the breadth of modern medicine, and it is true that almost every other country uses ICD-10, so it is time for us to “get with the program.”

Overtime Mandate The U.S. Department of Labor, under a mandate from the Obama Administration will soon require businesses to pay overtime to any 8 AZMedicine | Winter 2015

exempt salaried employee earning less than $50,440 per year, up from the previous threshold of $23,660. Employers will be forced to hire fewer employees and start them at $50,000, or put rules into place blocking junior employees from burning the midnight oil to excel. For many medical practices, it might mean having to change their exempt/salaried employees to hourly workers, further increasing practice overhead, by forcing overtime pay.

In closing The mandates I have outlined are having, and will continue to have, deleterious effects on the private practitioner, as well as the overall practice of medicine. I do think that most physicians believe in insuring their employees, without the need for the government to mandate it. It is unheard of in any other industry that professionals are mandated to provide services for up to two months with no reimbursement. Electronic records and its meaningful use attestations are transforming doctors of medicine into doctors of documentation. We now stare at our computer screens instead of into the faces of our patients. This does not make for a satisfied patient experience. Raising the minimal salaries for exempted employees will have the effect that practices will hire less employees or watch the overtime clock resulting in further inefficiencies in our practices. If these and other mandates continue, physicians will be forced to find alternative sources of medical income to supplement their professional income or ‘work at the peak of their license’ and employ more physician extenders to cover their growing practices, in order to keep their practices viable. As a last resort, physicians will seek employment in a larger health care delivery system, or quit completely. AM Nathan Laufer, MD, is the 124th ArMA President. Dr. Laufer is a cardiologist and the medical director of the Heart & Vascular Center of Arizona.

1 Stephen Miller, CEBS 5/21/2015. 2 http://townhall.com/columnists/michellemalkin/2015/10/23/ doctors-agree-obamas-electronic-medical-records-mandate-sucks-n2069809/ page/full 3 “Physicians’ Use, Exchange, and Evaluation of Electronic Medical Records,” September 2015, William G. Johnson, PhD, Professor & Founder of Center for Health Information & Research (CHiR), College of Health Solutions, Arizona State University, Sponsored by and Prepared for the Arizona Health Care Cost Containment System (AHCCCS).

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Finger on the Pulse

Health Care’s Y2K As Yogi Berra said, “It’s like déjà vu all over again.” I remember waking up early on January 1, 2000 and rushing to my computer to see what disasters awaited me. I held my breath and turned it on. When I didn’t get the

Marc Leib, MD, JD blue screen of death, I let out a small sigh of relief—so far so good. I then moved on to my next test, trying to find out whether I was still connected to the rest of the world. Yes, emails came streaming in and I could get to the Internet. I let out an even bigger sigh, knowing that we had survived the dreaded Y2K calamity that had been predicted for several years with potential consequences ranging from minor inconveniences to catastrophic malfunctions of life-sustaining 10 AZMedicine | Winter 2015

medical equipment. Anything with an internal computer or connected to something that was connected to something that was connected to something with a computer chip in it was potentially at risk, or so they said. Well, thanks to careful preparation and testing, Y2K turned out to be essentially a non-event. Sure, some people had to replace computers they purchased in the 80s and update software from DOS to Windows, but I couldn’t muster much sympathy for them given that hospital equipment continued to function, street lights didn’t suddenly turn green in both directions, bank accounts didn’t empty themselves overnight and most of the electronic world simply moved from 1999 to 2000 without so much as a whimper. This same scenario appears to have recurred a couple of months ago when the United States joined the rest of world and moved from ICD-9 to ICD-10. Sure this had the potential of bringing the US healthcare system to a standstill, not by interfering

Although there have been instances of minor dysfunctions, overall the transition appears to be much closer to Y2K than the meltdown of the federal exchange in 2013. with actual patient care or life-saving equipment, but by halting the flow of information and money between payers and providers. Instead, careful planning by millions of individuals and thousands of institutions between the time Congress first mandated the use of ICD-10 and its thrice-delayed actual implementation date has seemingly resulted in a relatively smooth transition from a coding system that described human diseases as we knew them to be in the early ’70s to one that is closer to our understanding of disease processes 45 years later. This implementation was a

far cry from the disastrous Healthcare.gov implementation in October 2013. And right up front I would suggest that much of the credit for this success goes to the hundreds of thousands of physicians who, despite their antipathy to ICD10, invested the time, effort and resources necessary to make sure they could comply with a mandate they neither requested nor desired. Although there have been instances of minor dysfunctions, overall the transition appears to be much closer to Y2K than the meltdown of the federal exchange in 2013. Early metrics indicate that this has gone relatively smoothly.

Medicare Administrative Contractors, the entities actually responsible for paying Medicare claims, are processing almost 5 million claims a day, a rate that is essentially unchanged from the months leading up to October 1st. In addition, the overall claim denial rate is statistically the same as before and denials for problems associated with ICD10 codes, as opposed to other reasons for claim denials, are equivalent to denials for problems with ICD-9 codes before the transition. Even more importantly, those claims have resulted in the continued flow of payments to physicians and hospitals providing care to Medicare beneficiaries. Similar results have been seen with most of the big payers. I would expect nothing less from Medicare. As the largest single government health insurance program in the country, they should absolutely have been prepared for the government-mandated change. Likewise, big payers and big hospital systems made sure they could exchange and process claims with ICD-10 codes and make payments in a timely manner. It has not been flawless, but when problems have been identified at the payer end, they have, for the most part, been corrected relatively quickly. When CMS has been notified of combinations of CPT and ICD-10 codes that should result in payments

but because of programming errors did not, they have generally made the corrections and reprocessed affected claims without requiring physicians and hospitals to resubmit those claims or appeal the denials. In examining the underlying reasons for many of the minor glitches and incorrect claim adjudications that have occurred over the last couple of months, it seems that a large percentage are due to mapping errors in many EHRs that do not accurately identify the correct ICD-10 codes from the information entered by physicians. This creates additional work for physicians and their coding staffs to correct information that should have been accurately provided by the EHR. That such errors would occur may not be unexpected, but it appears that some EHR vendors have been slow to update their systems and implement fixes. Physicians should hold their EHR vendors accountable and make sure the tools they were promised when they purchased their EHRs are actually available to them now that they are needed. More information about the ICD-10 implementation will certainly come to light over the next few months or years. It is likely that the planning and processes that resulted in successful transitions to ICD-10 by large health care systems will become

It is likely that the planning and processes that resulted in successful transitions to ICD-10 by large health care systems will become blueprints for future program implementations. blueprints for future program implementations. Although I expect few such stories will emerge about the efforts of small physician practices, it should not be forgotten that without those efforts, this

implementation could not have progressed as smoothly as it has. The real kudos for this success belongs to those of you who made this possible. AM Marc Leib, MD, JD, is an anesthesiologist, attorney and past president of ArMA.

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Winter 2015 | AZMedicine 11 11/16/15 11:06 AM

Dealing with Government Mandates

MACRA: A Path to Value-Based Payments The Medicare, Access and Children’s Health Insurance Program Reauthorization Act of 2015 (“MACRA”) is a comprehensive and complex law that notably, among other things, replaces the sustainable growth rate (“SGR”) method-

Paul Giancola, Esq. ology for physician payment. The law contains the most extensive changes to Medicare’s provider payment methodology since 1977 when the SGR was introduced in an effort to slow the growth of healthcare costs. Unfortunately, the SGR caused payment uncertainty for the last ten years. In view of the problems with SGR, MACRA should at least provide more predictability in provider payment. This article will focus on MACRA’s proposed transition from fee-for-service (“FFS”) payments to value-based payments. 12 AZMedicine | Winter 2015

MIPS Medicare has traditionally paid for provider services using the FFS schedule. Each assigned payment code takes into account the amount of work involved, practice overhead, and malpractice cost. However, FFS has been criticized for encouraging providers to order and/or perform more services than those that may be medically necessary, cost-effective and provide patient value. Beginning in 2019, MACRA provides two payment models that encourage quality and efficiency. The first methodology is the Merit-Based Incentive Payment System (“MIPS”), and it is closest to the existing FFS payment system. Beginning in 2015, Medicare provider payments are scheduled to increase by 0.5% annually through 2019, at which time the base fee for the FFS payments will remain at 2019 levels through 2025. In 2026, payment rates will increase by 0.25% annually. Although the FFS base rate will change little over the next ten to fifteen years, MIPS will offer providers the opportunity

to increase their payments beyond the base level through value-based performance. By 2019, MIPS will incorporate and replace the current physician performance programs: • Meaningful use of electronic health records (“MU”). • Physician Value-Based Modifier (“PVBM”). • Physician Quality Reporting System (“PQRS”). The MIPS incentive methodology will be based on a composite performance score containing both positive and negative adjustments. The maximum penalty will start at 4.0% in 2019 and increase to 9% by 2022. The maximum reward during the same period will increase from 12% to 27%. The Secretary of Health and Human Services is to develop and provide providers with a composite performance score based upon the following weighted measures: • Meaningful use of certified EHR technology (15%). Similar to and replaces the current MU requirements.

• Clinical practice improvement activities (25%). To be established by CMS. • Resource utilization (30%). To be established by CMS, but similar to and replaces PVPM. • Clinical quality (30%). Similar to and replaces PQRS. Categories include clinical care, care coordination, patient and caregiver experience, population health and prevention, and other quality measures to be determined. Based on their composite performance score, which will range from 0 – 100, providers may receive an upward, downward or no payment adjustment. MIPS is, however, budget neutral. For this reason, a scaling factor may be applied to make the total upward and downward adjustments zero balance. The Secretary may also adjust the weights for each category. This means some providers will be paid less if others are paid more. There are a few exceptions to MIPS participation. They are: first year Medicare participation, those providers participating in alternative payment models, and those

providers who are below a low volume threshold.

APMs The second and more complex methodology is called Alternative Payment Models (“APMs”) which are based on a risk-based approach to paying for medical care. APMs are to be designed to incentivize quality and value for providers with a significant Medicare population. This methodology has not been defined under MACRA, but CMS has indicated that APMs will include Medicare shared savings programs, patient-centered medical homes, accountable care organizations, and other approved APMs from the Center for Medicare and Medicaid Innovation such as those that encourage the creation of physician-focused payment models (“PFPMs”) According to CMS, most providers who participate in APMs will be subject to favorable scoring under the MIPS’ clinical practice improvement activities category. The providers who participate in the most advanced APMs will be deemed “qualifying APM participants” (“QPs”). QPs will: • Not be subject to MIPS. • Receive 5% lump sum bonus payments in years 2019-2024. • Receive a higher base fee schedule update for the years 2026 (0.75% vs. 0.25%) and beyond. At this point, CMS has provided few details on APMs.

Figure 1. Potential value-based financial rewards • APMs – and eligible APMs in particular – offer greater potential risks and rewards than MIPS. • In addition to those potential rewards, MACRA provides a bonus payment to providers committed to operating under the most advanced APMs MIPS only

MIPS adjustments

APMs

Eligible APMs

APM-specific rewards

Eligible APM-specific rewards

APM-specific rewards + MIPS adjustments

Eligible APM-specific rewards + 5% lump sum bonus

However, according to CMS, eligible APMs will be required to use certified EHR technology, will receive payment for covered professional services based on quality measures comparable to measures under the MIPS performance category, and bear financial risk. QPs must meet increasing thresholds for the percentages of the Medicare revenue they receive through eligible APMs beginning at 25% in 2019 increasing to 75% of all Medicare revenue or 75% of all-payer revenue after 2023 along with 25% of the APMS Medicare revenue must be received through eligible APMs. A QP cannot participate in MIPS, but a partial qualifying APM participant will be subject to MIPS and will receive favorable scoring under the MIPS clinical practice improvement activities performance category. CMS has provided a chart (see Figure 1).

Stay Tuned MACRA requires regulations to be implemented.

CMS recently extended the comment period on a document entitled “Request for Information Regarding Implementation of Merit-based Incentive Payment System, Promotion of Alternative Payment Models” to November 17, 2015. CMS has solicited comments from stakeholders on all of the MIPS and APM implementation issues mentioned above. CMS anticipates that proposed regulations will be issued in March 2016, with final regulations issued in October 2016. Prior experience tells us that due to the high level of complexity and the controversy involved, this is probably an overly ambitious schedule. Nevertheless, providers can start their efforts to manage cost and demonstrate value through the current valuebased programs that will be incorporated into MIPS, and by considering the economic impact of these changes on their practices.

likely generate much controversy, and it may result in providers considering whether it is economically worthwhile for them to continue to be a Medicare provider. After final regulations are issued, CMS promises to offer guidance and assistance to providers with respect to MIPS performance categories or in transitioning to the implementation of, and participation in, an APM. As MACRA rolls out, this process promises to be a rollercoaster ride. Stay tuned. AM Paul J. Giancola, JD, is a partner in the Healthcare Practice Group, Snell & Wilmer, LLP, Phoenix, Arizona.

The proposed regulations will

Winter 2015 | AZMedicine 13

Dealing with Government Mandates

ASU (CHiR) releases new report on physicians use, evaluation and exchange of electronic medical records Arizona State University (ASU) Center for Health Information & Research (CHiR) The report describes and analyzes information

William Johnson, PhD provided by more than 10,000 Arizona physicians on the effect of EMR use on their day-to-day practice of medicine and their rankings of the EMR packages that they use. A copy of the full 110 page report is available online at http://chir.asu.edu/ sites/default/files/CHIR%20 Report%20on%20EMR%20 Use%20in%20Arizona%20 2013-2015.pdf. The most important findings of the report include: • The percentage of Arizona physicians using electronic

14 AZMedicine | Winter 2015

medical records (EMRs) increased from approximately 45% in 2007-2009 to approximately 86% in 2013-2015. The current trend suggests that nearly all Arizona physicians will be using EMRs by 2018. The incentives and support provided by Medicare and Medicaid, combined with other influences, have increased EMR adoption, but important obstacles remain. • Reliance on paper records continues to decrease, but utilization of EMRs as the only medical record has hardly increased at all. Instead, there has been a marked increase in the use of EMRs combined with scanned records. The reliance on scanned records appears to reflect barriers to electronic record transfers among health care organizations. • The expected benefits of EMRs, such as the avoidance of duplicative tests, require the exchange of information among health care providers. However,

among physicians with EMRs, less than 20% (reminders for intervention) to 46% (e-prescribing) of the physicians share the information with others, depending on the type of information being shared. • The single most important obstacle to the inter-organizational transfer of electronic health information is the shortage of Health Information Exchanges (HIEs). The Health Information Network of Arizona (HINAz) is one such HIE. Although HINAz currently serves only forty-nine participants, it continues to expand. This report is the third and the last in the CHiR series to include physician rankings of EMRs by brand. EMRs were ranked on a 1-5 scale where 1=awful and 5=outstanding. Thirty-seven different EMR packages were ranked on each of five criteria. Many discussions among HIE professionals suggest that physicians are very dissatisfied with their EMRs. The results

of this report indicate that physicians are at least somewhat positive about their EMRs, ranking them slightly above the midpoint in the 1-5 scale. The more accurate conclusion may be that physicians seek to improve individual elements of their EMRs, but recognize that EMRs offer advantages not available from scanned records or paper medical records. AM This report is part of a series that began in 2007. Financial support is provided by Arizona Health Care Cost Containment System (AHCCCS). The report is made possible through the cooperation of the Arizona Medical Board and the Arizona Board of Osteopathic Examiners and, most important, by the willingness of more than 10,000 Arizona physicians to participate in surveys that accompany their license renewal applications. The Center for Health Information & Research (CHiR) is a multidisciplinary unit under the College of Health Solutions at Arizona State University. CHiR provides comprehensive health care information for Arizona and serves as a community resource and tool for academia and public health For more information about CHiR’s current initiatives as well as downloadable publications, please visit http://chir. asu.edu or email us at chir@asu.edu. We welcome comments on the report or questions: please address them to Prof. William G. Johnson: william.g.johnson@asu.edu.

Because not all solutions are black and white.

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Dealing with Government Mandates

The Practice Innovation Institute: Transforming Clinical Practice in Arizona One of our nation’s most serious and unsustainable problems is the rising cost of health care and the need to produce greater value for health dollars spent. While the skills and the knowledge of clinicians have never been

Melissa Kotrys, CEO, Arizona Health-e Connection better, the amount of waste and the lack of coordination is staggering. According to a 2012 Institute of Medicine report, there is an estimated $700 billion of health care waste annually, including: • Up to $325 billion wasted in unwarranted use; • Another $100 billion attributed to provider inefficiency; and • $50 billion in waste results from a lack of care coordination 16 AZMedicine | Winter 2015

It is with this background that the United States Department of Health and Human Services (HHS) recently announced a major national initiative aimed at improving health care quality and value across the country, and Arizona has been selected to play a significant role. The Transforming Clinical Practices Initiative (TCPI) includes awards totaling $685 million to support 39 national and regional networks aimed at assisting clinicians in improving quality and outcomes through value-based health care. As part of this national initiative, Arizona Health-e Connection, in partnership with Mercy Care Plan and Mercy Maricopa Integrated Care, has received a one-year $3.6 million grant, with a potential of $14.6 million over four years, to operate the Practice Innovation Institute that will prepare and enable 2,500 Arizona clinicians for successful participation in value-based health care. In announcing the initiative, HHS Sylvia Burwell the importance of

national Secretary stressed practice

transformation to the goal of affordable health care. “Supporting doctors and other health care professionals change the way they work is critical to improving quality and spending our health care dollars more wisely,” said Secretary Burwell. “These awards will give patients more of the information they need to make informed decisions about their care and will give clinicians access to information and support to improve care coordination and quality outcomes.” This national initiative will provide education and technical assistance for integrating quality and process improvements through both Practice Transformation Networks (PTNs) and Support and Alignment Networks (SANs).

Practice Transformation Networks (PTNs) Practice Transformation Networks (PTNs) are peer-based learning networks designed to coach, mentor and assist clinicians in developing core competencies that will prepare and enable them to participate successfully in value-based health care. This peer-based approach allows clinicians to

become actively engaged in a transformation process and promotes collaboration among a broad community of practices. The Practice Innovation Institute in Arizona is one of 29 PTNs across the country.

Support and Alignment Network (SANs) Support and Alignment Networks (SANs) provide systems for education and workforce development utilizing national and regional professional associations and public-private partnerships that are currently working in practice transformation efforts. Utilizing existing and emerging tools such as continuing medical education and core competency development, these networks will support ongoing practice transformation. There are 10 SANs across the country, including national associations such as the American Medical Association, the American College of Physicians and the American Psychiatric Association.

Practice Innovation Institute The Practice Innovation Institute will engage and prepare 2,500 Arizona clinicians for

participation in value-based alternative payment arrangements. Ideal participants will include clinicians who are either high volume Medicare providers or providers who serve a large volume of Medicaid (AHCCCS) adults and children. Clinicians involved in a Center for Medicare & Medicaid Services (CMS) innovative program such as a Medicare Shared Savings Program (MSSP) or Pioneer Accountable Care Organization (ACO) are already engaged in value-based health care and are not eligible for participation. The Institute will provide hands-on practice innovation and development assistance to help participating clinicians meet the initiative’s five phases of transformation and associated milestones, including clinical and operational results. This assistance will include:

According to a 2012 Institute of Medicine report, there is an estimated $700 billion of health care waste annually. engagement through advisory boards and community engagement in learning collaboratives.

Fives Phases of Transformation The Practice Innovation Institute will work with participating clinicians to move them through these fives phases or milestones: • Phase One: Setting aims and developing basic capabilities; • Phase Two: Reporting and using data to generate improvements;

• Phase Three: Achieving aims of lower costs, better care, and better health; • Phase Four: Getting to benchmark status; and • Phase Five: Demonstrating capability to generate better care, better health at lower cost.

Results and Rewards As these phases and milestones are met and as clinical and operational results are achieved, we believe that the Practice Innovation Institute will realize these results and rewards for

participating practices and for the community: • Efficient workflows and improved care coordination; • Better patient outcomes and enhanced patient experience; • Financial success in value-based health care participation; and • Smarter spending and healthier communities For more information about the Practice Innovation Institute, please visit www.piiaz.org or contact us at piiinfo@azhec. org or (602) 688-7200. AM Melissa Kotrys is the Chief Executive Officer for Arizona Health-e Connection (AzHeC) and the Health Information Network of Arizona. AzHeC operates the Arizona Regional Extension Center, which assists Arizona providers in achieving Meaningful Use.

• Providing dedicated coaches to help practices better manage chronic disease and offer preventive care; • Offering real-time notification alerts for clinicians caring for high-risk patients; • Improving screening and treatment of mental health and substance abuse across multiple care settings; • Centralizing data reporting and providing technical assistance with quality improvement targets and mid-course corrections; and • Promoting patient, provider and community

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Winter 2015 | AZMedicine 17

Dealing with Government Mandates

How to spur Congress to act: 7 essential elements of storytelling From the American Medical Association

The struggle with electronic health records (EHR) is real, and Congress needs to hear from physicians. But how can you pen a tale that cuts to the heart of the matter and inspires your members of Congress to take action? These seven elements of storytelling—recommended by an expert on engaging members of Congress—will help you craft the most potent version of your story. In a recent AMA Very Influential Physicians (VIP) webinar, Brad Fitch, president and CEO of the Congressional Management Foundation, delivered expert advice on how physicians can compose and position their personal EHR stories in an effort to persuade Congress to take action against meaningful use Stage 3 and further progression of the program’s troublesome regulations.

Why is storytelling important for this cause? Storytelling is a key part of the psychology of persuasion. We feel, and then we decide. In order for Congress to understand the detrimental effect meaningful use regulations have on daily practice, physicians need to deliver a perspective that will show the impact on their lives and the lives of their patients. Members of Congress deal with a lot of data, spreadsheets and graphs every day, Fitch

18 AZMedicine | Winter 2015

said. Only physicians can communicate the personal stories from the front lines and drive them to act.

The 7 elements of storytelling Your story should be brief. One page, single-spaced, is about 500 words. This length will take approximately four to six minutes to read aloud. If a story is too long, your members of Congress could lose interest, particularly with the numerous other demands for their attention, Fitch said. Condensing your story can

be difficult, but take the time to make it concise. A shorter story is more memorable and can leave a lasting impression. Fitch recommends using these seven elements of storytelling to most effectively communicate your experience: 1. “The Want” Begin with the end in mind Know what you want before you begin. Do you want your member of Congress to understand how EHRs have increased costs to your practice or impacted the delivery of care to patients? A good storyteller begins knowing what the end product should deliver emotionally. Consider various tactics and methods to achieve your goal in the story. Your goal can be to flatter, surprise, or evoke empathy or urgency. What effect do you want to have on your audience? 2. “The Opening” Set the stage and establish the stakes Your first sentence or two should make your reader want to know more. What is at stake for patients, their families or

you as the physician providing their care? As much as possible, think about the effect these regulations have on your ability to deliver quality care to your patients. Members of Congress are listening for the component that tells them, “If I don’t do X, then Y will happen.” 3. “Paint the Picture” The details and senses of your story When you experienced the moment you are writing about, what did you see, hear, touch, taste and smell? These elements will get your members of Congress involved in the story. Remember to use adjectives that enhance the power of your narrative. Make it real. Be practical, specific and graphic—don’t hold anything back! What descriptive words could make your story compelling? For example, substitute “morose” for “sad” or use the word “devastated” rather than “upset.” These are the kinds of impact words that paint the picture of your story.

4. “The Struggle” Describe the fight Identify the conflict. Real struggles in life are mental, philosophical, emotional, physical—even internal. Every story has a protagonist and an antagonist, and the interactions between them is where the conflict lies. Don’t hesitate to play the underdog. Members of Congress love to come to the aid of the underdog. They want to help David win the battle against Goliath. Play that strength. 5. “The Discovery” Always surprise the legislator What did you learn or realize in the moment of your story? Find this answer, and deliver it when it will have the most impact. Then describe how that learning impacted your life, the lives of your patients, the future of your practice and your ability to deliver quality care. You may not have a discovery, but is there a part of your story that might surprise the legislator? If you can add a twist—a moment that truly delivers the scope of your struggle—then use it. 6. “We Can Win!” Introduce the potential of success and joy Success in a story is when the hero or heroine wins the fight or struggle. Joy is when the audience can participate and take part in the celebration of victory. If you can make your members of Congress feel the

impact of success and the joy that will follow, they become a part of your cause. Think: “Senator/Representative, we have the opportunity to ….” Then describe how that victory will enhance your practice and the lives of patients and their families. 7. “The Button” Finish with a hook As you end your story, come up with a last line your members of Congress will always remember. Write it out and make it perfect. Have your ending sentence memorized when you’re speaking in person. This way, your member of Congress will rememberitfortherestoftheday. Fitch related a particularly

salient example. While delivering his story to a Congressman regarding his inability to acquire necessary medication, a veteran described a moment when his granddaughter asked him, “Poppy, why do your hands shake?” He looked at the Congressman and said, “What should I tell her?” This kind of hook will tug at the heart strings of your members of Congress and stay with them. Once your story is drafted, revised and final, deliver it to your member of Congress. Remember to take your time. A well-crafted story, no matter how small, can hold remarkable power.

How to more actively reach your members of Congress Visit breaktheredtape.org to send your story directly to Congress. You also are invited to become a member of the AMA’s “Very Influential Physicians (VIP)” program by visiting the AMA Grassroots Advocacy Web page to take part in future activities. While there, be sure to log in to view the full 7 elements of storytelling webinar. AM

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Winter 2015 | AZMedicine 19

HSAG

Vistas

Government Mandates and Healthcare Delivery: Improving Care and Lowering Costs “Government’s first duty is to protect the people, not run their lives.” — Ronald Reagan By Howard Pitluk, MD, MPH, FACS & Mary Ellen Dalton, PhD, MBA, RN

those 65 years old and older, as well as the poor, blind, disabled, and those in need of dialysis.2

Government mandates related to healthcare delivery and payment have been around since the founding of the Republic. In 1798, Congress passed “An Act for the Relief of Sick and Disabled Seamen,” which created the government-operated marine hospital service and mandated that privately employed sailors purchase healthcare insurance by levying taxes from sailors’ wages.1 Over the next 163 years, Congress continued to pass laws that enhanced the healthcare of Americans by providing services to many different groups and interests. In 1965, Lyndon Johnson, as part of his Great Society initiative, passed legislation that established the Medicare and Medicaid programs, which eventually expanded to provide healthcare coverage to

The Affordable Care Act (ACA) of 2010 provided health insurance coverage for millions of Americans and mandated the creation of the National Quality Strategy (NQS) that has as its foundation better care for individuals, better health for populations and communities, and lower cost through quality improvement. As population needs change and medicine continues to advance with new discoveries in fields that were not even imagined 20 years ago (e.g., genetic engineering and nanotechnology), government mandates that take into account the tremendous strides in evidence-based medicine must also continue to change and evolve to improve the healthcare of an aging population.

20 AZMedicine | Winter 2015

The Medicare QIO Program In 1972, Congress legislated the creation of Medicare Professional Standards Review Organizations (PSROs) to provide physician-led oversight to healthcare delivery at the local level. The role of these organizations included a focus on beneficiary protection and utilization of necessary healthcare services. In 2002, the program was renamed the Quality Improvement Organization (QIO) Program, with increasing emphasis on improving the quality of care that was mandated and paid for by the Centers for Medicare & Medicaid Services (CMS). In August 2014, in response to potential conflict-ofinterest concerns, the quality improvement and beneficiary protection case review responsibilities originally included in the mandate given to the QIOs by Congress, were split into two unique and separate contracts monitored by two distinct entities—Beneficiary and Family-Centered Care QIOs (BFCC-QIOs) and Quality

Innovation Network-QIOs (QIN-QIOs). Health Services Advisory Group (HSAG), which came into existence in 1979 as a result of early legislative mandates, currently serves as the Medicare QINQIO in Arizona, California, Florida, Ohio, and the U.S. Virgin Islands, and is the largest QIN-QIO in the nation serving nearly 25 percent of the nation’s Medicare beneficiaries. Today, CMS has aligned its QIO Program strategies and goals with the ACA’s mandated NQS in its ongoing effort to become an active purchaser of healthcare rather than a passive payer for services. Specifically, the QIO Program has been mandated through five-year contracts to improve cardiac health and reduce cardiac disparities; reduce disparities in diabetes care; improve prevention coordination using health information technology; reduce healthcare-associated infections and healthcare-acquired conditions; improve care coordination and reduce hospital readmissions; improve the quality of care in America’s nursing homes; and create value

for providers, patients, and the Medicare Trust Fund through the Physician Feedback Reporting Program. This alignment further positions CMS to set new standards that are consistently rooted in quality and value and to position the QIO Program among the largest federal programs dedicated to improving healthcare and quality at the community level.3

The Mandate of Patient Safety As the Medicare QIO for Arizona, HSAG works in support of the mandates set forth by CMS to convene providers, partners, patients, families, and caregivers at the community level to build and share knowledge, spread best practices, and integrate care through learning and action networks. These mandates are meant to protect the public and help hospitals, physicians, and other healthcare providers set new standards of care provided to patients. Furthermore, these mandates work to strengthen patient and family engagement, promote effective communication, and collaborate with communities to promote practices of healthy living that ultimately lead to better and more affordable care. Between 2011–2014, QIOs’ work nationally accounted for more than 85,000 fewer days with urinary catheters, 45,000 potential adverse drug events prevented, $1 billion in cost savings through improved transitions of care, and a 53 percent relative improvement rate in reduced central line-associated bloodstream infections. Moreover, almost

2,000 physicians have received assistance in using their electronic health records for reporting Physician Quality Reporting System (PQRS) quality measures, which positively impacted the health of more than 4 million Medicare beneficiaries.4

Improving the Health Status of Communities The Department of Health and Human Services (HHS), in conjunction with QIOs, the American College of Cardiology, and the American Heart Association, launched the Million Hearts® Initiative to prevent one million heart attacks and strokes by the year 2017. HSAG’s work supports the Million Hearts® Initiative by assisting PQRS-aligned providers to report on and implement evidence-based practices that improve the quality of care by implementing the ABCS (Aspirin therapy when appropriate, Blood pressure control, Cholesterol management, and Smoking screening and cessation). HSAG has been mandated to collaborate with these providers to identify and advance policy and systemlevel changes that promote equitable, evidence-based care for beneficiaries. In support of the ACA’s mandate for the development of programs that address, identify, and improve healthcare disparities among at-risk populations, HSAG carries out the CMS-administered Everyone with Diabetes Counts (EDC) Project. The goal of EDC nationally is to improve health outcomes for 18,000 Medicare

beneficiaries with diabetes from targeted populations through evidence-based Diabetes Self-Management Education (DMSE) classes.5 Using a community-based approach that involves community and senior health centers, faithbased organizations, and local departments of health, HSAG reaches out to beneficiaries for enrollment in DSME classes. Local healthcare providers also support HSAG in the EDC Project by referring patients to DSME classes conducted by trained HSAG instructors, hosting DSME classes in their offices, and enrolling their healthcare staff members in certified DSME community trainer courses.

Today’s Mandates While often perceived as such, government mandates in healthcare are not designed to create more hoops through which we must all jump. Rather, they are intended to promote patient safety while improving the health of populations and communities. The ACA and its mandated NQS empower the public to play an active role in its own healthcare while giving providers evidence-based guidelines that create opportunities for quality improvement. While mandates can seem burdensome, we should focus on improved community health, patient safety, and provider outcomes that are the ultimate goals of these directives. HSAG will continue to support the provider community—as well as the patients we serve—by providing the tools, resources, and information needed for

implementation of government mandates that ultimately enhance the level of patient care in America through evidence-based quality improvement interventions. AM This material was prepared by Health Services Advisory Group, the Medicare Quality Improvement Organization for Arizona, under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. The contents presented do not necessarily reflect CMS policy. Publication No. AZ-11SOW-XC-11022015-01. Howard Pitluk, MD, MPH, FACS, is Vice President, Medical Affairs & Chief Medical Officer; Mary Ellen Dalton, PhD, MBA, RN, is Chief Executive Officer. Dawn Williams, BS, Director of Communications, assisted with this article. 1 A little Perspective: Congress First Mandated Health Care in 1798. Available at: http:// www.smithsonianmag.com/ smart-news/a-little-perspectivecongress-first-mandated-health-care-in-1798-17926/?no-ist. Accessed on: October 21, 2015. 2 Becker’s Hospital Review. A Brief History on the Road to Healthcare Reform: From Truman to Obama. Available at: http://www. beckershospitalreview.com/ news-analysis/a-brief-history-onthe-road-to-healthcare-reformfrom-truman-to-obama.html%20. Accessed on: October 21, 2015. 3 Community Health Improvement. QIO News, June 2015. Available at: http://qioprogram.org/ qionews/june-2015. Accessed on October23, 2015. 4 American Health Quality Association. 10th Statement of Work Progress Infographic. Available at: http://www.ahqa.org/sites/default/files/documents/QIO%20 Program%2010%20SOW%20 Progress_Infographic%20 June%202014.pdf. Accessed on October 23, 2015. 5 Centers for Medicare & Medicaid Services Health Disparities Pulse Resource Center. Everyone with Diabetes Counts. Available at: http://www.cmspulse.org/community-initiatives/ everyone-with-diabetes-counts/ projectSpecifics.html. Accessed on October 23, 2015.

Winter 2015 | AZMedicine 21

Dealing with Government Mandates

Anatomy of a Board Investigation Patricia McSorley, Director One of the most important, but often least understood, functions of the Board is the disciplinary process. We hope that this article helps the physician community better understand how the Board’s disciplinary process works.

Core Functions The Arizona Medical Board’s mission is to “protect the public through judicious licensing, regulation and education of all allopathic physicians. In order to carry out its mission; the Board has two core functions licensing and regulation.

Regulation The regulation of Arizona’s physicians is guided by the Arizona Medical Practice Act (A.R.S. §§ 32-1401 et. seq.) and Board’s rules (A.A.C. R4-16-101 et. seq.). The regulation of physicians is dependent on a complaint driven process. Once a complaint is made that alleges a violation of the Medical Practice Act the Board notifies the physician that an investigation is being opened. 22 AZMedicine | Winter 2015

The physician is provided with a copy of the complaint and has the opportunity to make a written response to the allegations. Notice is also sent to the complainant letting them know that the Board opened an investigation. Each case is assigned to a staff investigator whose role is to obtain all of the relevant information necessary for the Board to make a decision regarding whether the allegations against the physician can be sustained. The investigators have a wide variety of tools at their disposal, including issuing a subpoena for medical records, interviewing witnesses (including the physician and complainant) and visiting the physician’s office.

Medical Consultants Play a Critical Role Our volunteer medical consultants form the backbone of the investigation process. According to statute, any case that alleges patient harm must be reviewed by a medical consultant. All of the relevant information obtained by the staff investigator is provided to the medical consultant who then is tasked with reviewing the care rendered by the

In order to carry out its mission; the Board has two core functions: licensing and regulation. physician and determining if there has been a deviation from the standard of care. Currently, the Board has a pool of 1200 volunteer medical consultants. However, the Board is in great need of additional medical consultants willing to review cases. Our consultants are critical to protecting both the public and the physician community. The Board relies on medical consultants to render an unbiased opinion of the current community medical standard. By assigning medical consultants who practice in the same area of medicine as the physician under review, the Board can assure itself that the care at issue is given the most accurate review possible. The Board needs more physicians to volunteer for this important service, especially in areas of addiction medicine,

orthopedic surgery and internal medicine. To serve as a medical consultant, a physician must hold an active Arizona medical license, have practiced for a minimum of five years, and have no disciplinary action on their license. A small stipend and continuing medical education credits are available to compensate our medical consultants for their time and expertise. However, the real impetus to volunteer is the satisfaction of contributing to the medical profession.

Due Process The Board’s disciplinary process is designed to maximize due process for the physician while protecting the public. If a medical consultant generates a report finding a deviation from the standard of care, the physician is provided with the

report along with all materials that the medical consultant reviewed so that the physician can respond to the medical consultant’s findings. The physician’s response is then sent back to the medical consultant for review and comment. This open exchange is designed to produce the fairest result. If the complaint alleges a violation of billing statute, sexual misconduct, or false advertising, the staff investigator drafts a report that is provided to the physician for response. Just like patient care cases, the physician’s response is considered when determining whether it appears that a violation of statute or rule has occurred.

Dismissal of Complaints In cases where no violations of statute have been established, the Executive Director may dismiss the complaint. Both the physician and the complainant are notified of dismissal. The complainant has a right to appeal the dismissal to the full Board.

Staff Investigation Review Committee Before the Board reviews a case, the Staff Investigational Review Committee (SIRC) reviews completed cases in order to make a non-binding disciplinary recommendation to the Board. SIRC is comprised of the Chief Medical Consultant, the Investigations Manager, and the Operations Manager. For cases where a potential violation of the

The Board’s disciplinary process is designed to maximize due process for the physician while protecting the public. Medical Practice Act has been sustained, SIRC reviews each case to ensure that there is sufficient evidence to sustain the proposed findings. The reports generated by SIRC are provided to the physician and serve as legal notice of the potential violations that the Board will consider.

Board’s Role in Adjudication of Cases For cases where discipline is recommended, the physician is provided with three options to resolve the case: enter into a consent agreement, appear before the full Board for a Formal Interview, or request a full evidentiary hearing (called a Formal Hearing) before the Office of Administrative Hearings (OAH). Typically, by this stage in the process, the physician under investigation has retained legal counsel who will provide advice on how to proceed. While a physician is not required to have an attorney representative, many physicians that appear before the Board are represented by legal counsel and are entitled to legal representation at all times. The physician is entitled to and will be provided with

all of the evidence that the Board will consider in the adjudication of the matter. For all disciplinary cases, the physician will have the opportunity to review a draft of a Consent Agreement that is based on SIRC’s recommendations. Consent Agreements are public documents utilized by the Board and its physicians to resolve a case. Once signed by the physician, the Consent Agreement will be presented to the full Board for approval. The Board has the discretion to accept, reject or modify the agreement. Once accepted by the Board, the Consent Agreement is a final action that is posted to the physician’s public profile on the Board’s website. A physician may decide to appear before the Board for a Formal Interview where he or she will be questioned by Board members about the case. If the physician chooses this route, he or she must waive the right to cross examine the Board’s medical consultant and the witnesses. If the physician disagrees with the Board’s decision, he or she may file a motion requesting that the Board reconsider its

decision, and also may appeal the ultimate outcome to the Superior Court. Alternatively, the physician may request a Formal Hearing before an Administrative Law Judge (ALJ) at OAH. Cases involving license suspension lasting longer than a year or license revocation must be heard at a Formal Hearing. At the OAH hearing, the physician may cross examine the Board’s witnesses and call their own experts and witnesses. The ALJ will then render a written report with a recommendation to the Board regarding the outcome of the case. The Board may accept, reject or modify the ALJ’s recommendation. The physician is entitled to appeal the Board’s decision arising from the Formal Hearing to the Superior Court. A helpful visual is available on our website to assist the licensed community in understanding the regulation process. It can be viewed at http://www.azmd.gov/ M i nut e sUplo a d s /pre s s / Compla int%20a nd%20 Investigation%20Process%20 Summary.pdf. We also encourage you to take some time and attend a Board meeting, either in person or via our Board’s live-stream, which is available at www.azmd.gov.

Licensing News The Board is pleased to announce that effective October 16, 2015, the Board implemented new rules Continued on page 24

Winter 2015 | AZMedicine 23

Continued from page 23

governing the initial licensing process. The new rules are a product of extensive internal review of the Boardâ&#x20AC;&#x2122;s licensing processes as well as input from stakeholders. These new rules are one of several changes the Board has made to expedite physician licensing while maintaining standards designed to protect the public. The rules can also be found at www.azmd.gov. The Board has initiated a streamlined initial application, is working closely with hospitals as they on-board new physician staff, in order to notify these physicians of the Arizona licensing

Before the Board reviews a case, the Staff Investigational Review Committee (SIRC) reviews completed cases in order to make a non-binding disciplinary recommendation. requirements as early as possible. Additionally, the Board continues to develop our online initial application process. The on-line initial application is currently in the testing phase and will soon be piloted with a small group of applicants. The Licensing Department

is dedicated to continuous improvement and welcomes any suggestions from both licensees and applicants as to how we can better serve you.

Board. There are times the Board may need to contact you and it is imperative that we have up-to-date information. For example, the Board sends email reminders regarding your renewal deadline. Please take a moment to click on the following to access your contact profile and update your contact information: https:// azdo.glsuite.us/glsuiteweb/ clients/azbom/Private/changeaddress/login.aspx). As always, thank you for the opportunity to continue to serve the physician community. AM

Lastly, we ask all physicians to maintain and update your contact information with the

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

24 AZMedicine | Winter 2015

PUBLIC HEALTH UPDATE

ADHS: West Nile Season May Be Over, But Other Diseases from Mosquitoes Approach Arizona Borders With all the media frenzy about Ebola in the past year, you might have missed the news about other emerging infectious disease threats occurring much closer to home. In December 2013, the first locally acquired cases of chikungunya in the western hemisphere occurred in the island of St. Maarten in the Caribbean. Chikungunya, an alphavirus spread by Aedes mosquitoes, causes acute febrile illness with arthralgia, arthritis, headache, and rash. Rapid disease spread in other islands quickly ensued, with locally acquired chikungunya cases popping up in Central and South American countries within the next 6 months. By October 2015, less than two years after initial detection, over 1.7 million cases had been reported among 45 countries or territories in the Americas. Although local spread of chikungunya in the United States was limited to 12 locally acquired cases in Florida last year, over 3,000 travel-associated cases

have been reported among travelers to areas experiencing outbreaks, including 22 in Arizona this year alone. In recent weeks, locally acquired chikungunya cases have been reported from Sonora, Mexico, increasing the likelihood of disease introduction in Arizona. As epidemiologists watched the rapid spread of chikungunya through the Americas with consternation, cases of another mosquito-borne disease — dengue — began occurring with alacrity among Arizona residents. In contrast to the usual 3–5 cases of dengue reported annually, 91 dengue cases were identified in Arizona last year. All cases reported travel out of the country, but many had traveled just across the border, where an outbreak in San Luis Rio Colorado, Sonora, was occurring. Although this outbreak ended in late 2014, dengue cases continue to occur in Mexico, including northern regions where Arizona residents frequently travel.

Although all dengue and chikungunya cases among Arizona residents have been associated with travel to endemic areas (outside the United States), each new infected traveler returning to Arizona represents a risk for local disease transmission. Patients are infectious to mosquitoes in the first week of illness, and all suspect cases should be encouraged to avoid mosquitoes by staying indoors or using insect repellant. The Aedes aegypti mosquitoes that carry both viruses are present in Arizona, with high densities in Maricopa County and confirmed presence in much of the southern part of the state. Chikungunya and dengue can be challenging to differentiate based on clinical symptoms. Both diseases can cause fever, headache, and muscle pain; however, patients with chikungunya are more likely to report joint pain, whereas dengue cases might be more likely to report more general muscle/bone pain.

When testing for either dengue or chikungunya, serum is the preferred specimen. If collected in the first three days of illness, PCR should be performed; if collected during days 4–7 of illness, both PCR and IgM serologic tests are valuable; if collected after day 7, IgM serology is preferred. Testing for chikungunya and dengue can be performed at several commercial laboratories, as well as the Arizona State Public Health Laboratory. To report a suspect case, or learn more about these diseases, please contact your local health department or the state health department at 602-364-3676. AM

Additional resources: azhealth.gov/mosquito cdc.gov/chikungunya cdc.gov/dengue

Winter 2015 | AZMedicine 25

COMMUNITY UPDATE

Two years in: How a first-of-its-kind clinically integrated network is changing pediatric medicine delivery and outcomes In 2013, Phoenix Children’s debuted Phoenix Children’s Care Network (PCCN), the nation’s first pediatric clinically integrated organization (CIO). The creation of PCCN provided a strategic opportunity to create a collaborative

Scott Schraff, MD and cohesive system of care that allowed our organization to improve quality, manage costs and move beyond a hospital-centric model. PCCN, a strategic hospital and physician alignment, offers patients access to more than 800 providers, representing half of all general pediatricians across metro Phoenix, as well as 80 percent of pediatric subspecialists and all of Phoenix Children’s Hospital’s sites of service. PCCN is comprised predominantly of communitybased physicians representing

26 AZMedicine | Winter 2015

close to 90 independent pediatric practices. In designing the infrastructure of PCCN, we envisioned a collaborative and integrated delivery system. The organization’s purpose is to align high-value, costeffective care that begins in the Valley’s independent pediatric practices and extends to independent and Phoenix Children’s Hospital-based specialists. The PCCN methodology is based on moving from the traditional fee-for-service model to value-based contracting. The switch to a value proposition framework eliminates the current inefficient medical delivery system and instead focuses on collaborative care that promotes quality outcomes. Network partner reimbursement rates are tied directly to documented evidence of superior care and cost-efficiencies. PCCN relies upon integration and alignment across the network. It requires uniform standards for care delivery, including evidence-based, standardized clinical protocols. In addition to physician

collaboration, the Network’s reporting mechanisms, communication platforms and data aggregation all work in conjunction to create a cohesive system of care. To accomplish these goals, PCCN physicians have established 14 primary care and 34 specialty care measures by which our performance will be assessed. It’s these initial measures that are the foundation of our efforts to improve quality outcomes, eliminate

a pediatric-dedicated CIO must be structured to address the specific operational and financial challenges facing pediatric

PCCN is comprised predominantly of communitybased physicians representing close to 90 independent pediatric practices. clinical redundancies and avoidable patient encounters and, ultimately, lower the cost of care. As we begin the third year of PCCN, there have been some vital lessons:

• Over the last two years, we’ve learned

care. One of the challenges of establishing a pediatric CIO is that there are no established quality measures for pediatrics as there are in adult medicine. Adult ACOs have a list of 33 measures developed by the Centers for Medicare & Medicaid Services. Faced

Our members have set high care standards by establishing the care metrics that will be used to improve care and cut costs. quality metrics include the following: • Asthma management • Immunizations Childhood Age 2 • Immunizations Childhood Age 6

with the need for quality measures, PCCN providers – not payers – worked diligently to identify and ratify 13 primary care and 34 specialty measures. Primarily based on data gathered from claims information, the measures are pediatricfocused and provide the baseline for PCCN’s quality improvement efforts.

• Operational benefits of the CIO include a deeper and more robust communication platform for partners to collaborate and achieve benchmarked quality results.

• Providers want to deliver the best care. Our members have set high care standards by establishing the care metrics that will be used to improve care and cut costs. Our primary care

• Immunizations Childhood Age 13 • Influenza Vaccine Seasonal

fee-for-service model. The formula is based on an incentive framework: compensation depends on valuation of effective and quality outcomes, not on procedures and volume.

• The investment in information technology (IT) infrastructure is significant yet essential. Our holistic

IT systems enable effective care coordination, measure quality achievement, and improve communication across the care continuum. As the complexities of the health care marketplace continue to push change and strategic direction, efforts such as PCCN provide a winning formula for ensuring the finest health care for pediatric patients. AM Scott Schraff, MD, is a fellowshiptrained pediatric otolaryngologist with Arizona Otolaryngology Consultants, vice chair of the Phoenix Children’s Care Network Board of Directors and member of the Phoenix Children’s Hospital Medical Staff. He is also associate professor of Otolaryngology at the University of Arizona College of Medicine – Phoenix and adjunct assistant professor at Mayo Clinic.

• Pharyngitis Acute Pediatric • Well Child Visits First 15 Months • Well Visits Ages 3-6 Years • Well Visits Ages 7-18 Years • Diabetes A1c – Monitoring Only • Weight Assessment – Monitoring Only • Chlamydia Screening – Monitoring Only • HPV Immunization – Monitoring Only

• The effectiveness of our CIO model depends on a value-based contracting proposition in contrast to the traditional Winter 2015 | AZMedicine 27

VALLEY FEVER AWARENESS WEEK

Stakeholders in Valley Fever come together

The Arizona Medical Association (ArMA) was pleased to partner with the University of Arizona (UA) Valley Fever Center for Excellence (VFCE) in holding a stakeholder meeting on November 17 as part of the Valley Fever Awareness Week proceedings. The stakeholder meeting offered an opportunity for members of the clinician community to gather, learn and collaborate. An ArMA House of Delegates resolution passed this year established ArMA’s position of supporting Valley Fever awareness, education, and funding, and called for ArMA to convene a statement of support with other clinician representative and health community organizations. The meeting was wellattended by representatives from six Congressional offices, members of the community

28 AZMedicine | Winter 2015

and our health partners at organizations including the Arizona Hospital and Healthcare Association (AzHHA), Arizona Osteopathic Medical Association (AOMA), Arizona Academy of Family Physi-

Mr. Daniel Leis provided an unfortunately not-atypical story of patient experience and perspective. He described how his stepson, who lives in Poland, came and worked in Arizona construction

The stakeholder meeting offered an opportunity for members of the clinician community to gather, learn and collaborate. cians (AzAFP), and Arizona Chapter, American College of Physicians (AzACP). The agenda began with an introductory overview of the current Valley Fever data in Arizona by Ken Komatsu, MPH, State Epidemiologist, Arizona Department of Health Services (ADHS).

for three months and then struggled through a series of misdiagnoses and improper treatment before finally accessing the right resources to pursue a Valley Fever diagnosis and treatment. This patient experience is mirrored in many places across the country.

Dr. Tom Chiller, Deputy Chief, Mycotic Diseases Branch at the Centers for Disease Control and Prevention (CDC) presented a concise and dynamic national perspective on the State of Valley Fever. He noted that the formation and work of the Congressional Task Force on Valley Fever has provided impetus for the CDC to take an interest in the disease. Occurrences of the disease and the presence of the fungus in soil have emerged as far away as eastern Washington state. Presentations from industry representatives working on diagnostics and treatment aspects of Valley Fever provided an exclusive view of some exciting developments. In the words of Tom Carpenter, DVM, PhD, President and CEO of Nielsen Biosciences, “While Valley Fever is nationally considered an orphan

disease, in this region it is prevalent, and small business has an important role in tackling aspects of the disease related to diagnosis and treatment.” Nielsen has a skin test that will be complementary to blood diagnostics and treatment. Todd Snowden, Director of Business Development at DxNA, described a genetic Valley Fever test to detect the fungus in respiratory specimens which is currently in clinical trials with clearance for market entry expected in April 2016. Kathryn Sykes, PhD, VP of Research for HealthTell, reviewed the biotech company’s work in developing a snapshot of an individual’s Valley Fever immune status using a single drop of blood. Sean Bauman, PhD, of IMMY, described Valley Fever screening as the “Wild Wild West” as there is no consensus. IMMY has a Later Flow Assay test currently in clinical trials with 2016 market entry expected. David Larwood, MS, JD, MBA, of Valley Fever Solutions presented his company’s progress and future plans to make nikkomycin Z, a potential cure for Valley Fever, clinically available. The companies present described the National Institutes of Health (NIH) as generally interested in developments related to Valley Fever, including grant support.

The community action discussion reviewed the pyramid of Valley Fever developments [see Figure 1]; while the top tier envisions a valley fever vaccination, the bottom tier urges us to do better now—educate and create complete awareness among all Arizona physicians and clinicians. As described by Dr. Kerilyn Bollmann, “You wake up, brush your teeth, and think about TB and cocci.” The first step is available to all clinicians for free right now. Learn about Valley Fever and take advantage of the FREE Valley Fever online CME offered by the VFCE at www. vfce.arizona.edu/clinicians/ FreeOnineCME.aspx. ArMA thanks our meeting organizers, John Galgiani, MD, Director, University of Arizona Valley Fever Center for Excellence, and Peter Kelly, MD, epidemiologist, ADHS,

Figure 1. Valley Fever developments

for their invaluable leadership and coordination in bringing together the individuals who contributed to the agenda. We thank Michael Grossman, MD, Special Assistant to the Dean, UA College of Medicine –Phoenix, for hosting the meeting and moderating the discussion. Dr. Grossman served as Chair of the ArMA Committee on Public Health for many years.

The meeting was generously supported by The University of Arizona College of Medicine – Phoenix, who hosted the meeting on their campus, and industry sponsors DxNA, HealthTell, IMMY, and Nielsen Biosciences. AM

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www.catalinarecruiters.com It’s about matching lifestyles, personalities and practice philosophies. Winter 2015 | AZMedicine 29

MICA

Same-Sex Marriage: Impact on HIPAA and Surrogate Decision Makers In October 2014, same-sex marriage became legal in Arizona. This means same-sex spouses should be accorded the same legal rights as oppositesex spouses. Generally when an adult patient is unable to make or communicate health

Paul Giancola, Esq. care treatment decisions, the health care provider, in addition to making a reasonable effort to follow a health care directive, shall make a reasonable effort to communicate with a surrogate. Absent a designated agent pursuant to a health care power of attorney or a court appointed guardian, state statutes provide an order of priority for the health care provider to make reasonable efforts to contact individuals related to the patient to serve (if willing) as the surrogate for health care decisions.

30 AZMedicine | Winter 2015

The patient’s spouse, if not legally separated, is always first in priority. In view of the change in the law on samesex marriage, “spouse” now includes same-sex spouses. If a same-sex couple is not married, the statutory order of priority will apply as usual – spouse, children and parent with the partner viewed as either a domestic partner or a close friend of the patient. The Office of Civil Rights (“OCR”) published new guidance “HIPAA and Same-Sex Marriage: Understanding Spouse, Family Member, and Marriage in the Privacy Rule” (the “Guidance”) (US Department of Health and Human Services, September 2014) regarding certain HIPAA provisions impacted by the Supreme Court ruling in United States v. Windsor, in which the Court found section 3 of the Defense of Marriage Act – which defined marriage and spouse to exclude same-sex partners – unconstitutional. In light of this ruling by the Court, OCR states that for purposes of HIPAA the term “spouse” must be interpreted to include individuals who are in a “legally valid same-sex

In view of the change in the law on same-sex marriage, “spouse” now includes same-sex spouses. marriage sanctioned by a state, territory, or foreign jurisdiction”; the term marriage includes both same-sex and opposite-sex marriages; and that the term “family members” includes dependents of both marriages. These terms apply whether or not the legally married couple lives or receives services in a state that recognizes same-sex marriages. The Guidance discusses two key HIPAA provisions affected by this definition. • Section 164.510(b) permits disclosure and notification of patient information to family members under certain circumstances. The Guidance states that “[l] egally married same-sex spouses, regardless of where they live, are family members of the purposes of applying this provision.”

• Section 164.502(a) (5) (i) prohibits a health plan from using or disclosing genetic information for underwriting purposes. The Guidance states that genetic tests related to or genetic disease of family members includes an individual’s same-sex spouse. AM Paul J. Giancola, JD, is a partner in the Healthcare Practice Group, Snell & Wilmer, LLP, Phoenix, Arizona.

US Department of Health and Human Services (September 2014). HIPAA and Same-Sex Marriage: Understanding Spouse, Family Member and Marriage in the Privacy Rule. Office for Civil Rights. Retrieved from http:// www.hhs.gov/ocr/privacy/hipaa/ understanding/special/samesexmarriage/. (September 2014)

Supervising Editor Marc Leib, JD, 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 Nathan Laufer, MD

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2015-2016 Board of Directors Robert M. Aaronson, MD At-Large Director Gretchen B. Alexander, MD President-Elect, Executive Committee Miriam K. Anand, MD At-Large Member, Executive Committee Suresh C. Anand, MD Maricopa Director

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Rebecca Fega, MD Resident Physician Director Gary R. Figge, MD AMA Delegate Howard B. Fleishon, MD Maricopa Director

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

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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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