Summer 2015 AzMedicine

Roberts court upholds Obamacare again | An Update from the Arizona Medical Board Summer 2015

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Summer 2015 | Volume 26, No. 2 | www.azmed.org | facebook.com/azmedicine

FROM OUR PRESIDENT Uniting the House of Medicine ............................... 4 ArMA 2015 Annual Meeting ..................................... 8 EDITORIAL Roberts court upholds Obamacare again ............ 24 MACRA: The Good, the Controversial, and the Uncertain .................................................. 26 An Update from the Arizona Medical Board .......................................... 28 From enacting a law to meeting the HIE needs of Arizona providers ....................... 30 HSAG VISTAS Health Policy: Creating Value for Patients and Providers ..................................... 32

AHCCCS Physician Solutions to the Prescription Drug Misuse and Abuse Epidemic ........................ 34 MICA Quality of Care Analysis in the Medical Practice .......................................... 36 COMMENTARY Arizona Providers, You Have Reporting Requirements ....................................... 38

2015 LEGISLATIVE REPORT MISSION ACCOMPLISHED:

ArMA’s Advocacy in a Historically Short, yet Action-Packed Legislative Session ...........13

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FROM OUR

President

Uniting the House of Medicine “If am not for myself, then who will be for me?

And if am only for myself, then what am I?

choice. So much so that many don’t recommend the medical profession to the next generation.

“And if not now, when?”

Medical education funding has not kept up with the demand for qualified primary care and specialty care training. It is estimated that the US will face a shortfall of more than 130,000 physicians in 10 years, equally divided between primary care and specialties.

–Hillel, Ethics of the Fathers, 1:14 I am originally from Montreal, Canada and have been in practice in Phoenix over 30 years. My wife, Judy, a kindergarten teacher, has been an inspiration to me and my moral compass. I do believe that everything we need to know in life, we learned in kindergarten!

I am a medical graduate from McGill University in Montreal, as is Bob Orford, one of our past presidents.

Having come from Canada, I have a somewhat different perspective on the U.S. health care debate and of the turmoil we are undergoing. I see the beginnings of the Canadian Nathan Laufer, MD health care problems and more developing in the U.S. as the health care dollar continues to shrink and the Health Care Reform starts to take hold.

In the words of Dr. William Osler, “Medicine is a science of uncertainty and an art of probability.” This statement continues to hold true today, not only with the practice of medicine, but also with the business of healthcare! We are living in uncertain times and yet have to make medical and business decisions without having all the facts at hand.

Current challenges to physicians include the following:

1. The physician shortage.

Physicians are retiring or changing careers at a younger age, and those that remain are increasingly dissatisfied with their career

4 AZMedicine | Summer 2015

2. The administrative load and competing regulatory programs are increasing.

One of the greatest frustrations to physicians is the time and expense they must devote to administrative and regulatory requirements, taking their time away from patient care. Some of these administrative burdens include PQRS and Meaningful Use documentation, HIPAA security risk analysis, and ICD 10 implementation.

3. The Medicare physician payment system is changing.

Congress has repealed the sustainable growth rate (SGR) formula which would have resulted in a 21 percent pay cut, scheduled to take effect April 1. However, this is a mixed blessing!

The “Medicare Access and CHIP Reauthorization Act of 2015 (MACRA),” was signed into law by the President on April 16, 2015. MACRA permanently repeals the flawed SGR formula and stabilizes Medicare payments for physicians. There will be a 0.5% yearly increase in the Medicare fee schedule until 2018, but then it will be frozen until 2024.

MACRA will shift Medicare compensation from fee-for-service to pay-for-performance. CMS intends to require that 30% of Medicare payments are made through alternative payment modes by 2016, and 50% by 2018, in order to improve the efficiency of care.

MACRA replaces Medicare’s multiple quality reporting programs with a new single Merit Based Incentive Payment System, also called the “MIPS” program. MIPS is a consolidation of three payfor-performance programs already underway plus a new one.

Assessments will be based on four categories of metrics: 1. quality – similar to the PQRS; 2. resource use (or efficiency); 3. meaningful use of electronic health records, and 4. clinical practice improvement activities.

The poorest performing doctors will see their payments cut by up to up to nine (nine!) percent. The new incentive structure would be budget neutral. For every doctor that makes more from the MIPS metrics, there will be one who makes less. A true zero sum game, if you will.

Private insurers are also increasingly adopting value-based payment models and risk sharing. This is projected to increase to 75% of covered lives by 2017.

4. More physicians are employed by hospitals than ever before.

To serve the ACA models of care, hospitals are rapidly acquiring primary and specialty practices and new grads.

The solo practitioner continues to disappear. Thirty-nine percent of physicians younger than 45 years of age have never worked in private practice. But joining a hospital system is not a panacea for physicians.

Some physicians are returning to private practice because their compensation from hospitals became less attractive after the expiration of their initial contract. The hospitals switch to

Physicians are retiring or changing careers at a younger age, and those that remain are increasingly dissatisfied with their career choice. performance-based pay, which can end up being lower than their initial salary. Further, physicians are asked to see more patients in less time while reporting to a hospital administrator and following hospital-imposed guidelines.

As large hospital networks acquire more and more physicians, they direct patients to their physicians. If you are outside of their network, the hospital systems will hire people to compete with you and take the losses up-front, in order to increase their patient base.

The solo practitioner continues to disappear.

Thirty-nine percent of physicians younger than 45 years of age have never worked in private practice.

The pressures on independent physicians are such that more physicians are likely to seek to join a hospital in the coming years.

5. There continues to be efforts to expand non-physicians’ scope of practice.

Numerous groups continue to try and encroach on the physician practice of medicine. Here I would like to note ArMA’s unflagging work in countering these efforts in Arizona, accomplished just in the last year.

• ArMA has successfully stopped psychologist prescribing legislation, and stopped all scope of practice expansion efforts by chiropractors and naturopaths.

• ArMA has worked to curb unsafe expansion in scope of practice (VBAC, breech, and multiples) by lay-midwives.

• ArMA was part of the Coalition that stopped administration of vaccines to children 6 - 17 years old by pharmacists without a physician’s order.

ArMA will need to stay vigilant at the state legislature, to block new attempts at expansion of scope of practice by non-physicians, in order to protect the public from untrained providers.

6. Government and payers are meddling in the doctor patient relationship.

I believe in the sanctity of the doctor-patient relationship. However, chart audits and prior authorizations are some of the ways payers are inserting themselves into the physician-patient relationship and into medical decision making.

In addition, more payers are tightening their provider networks in an attempt to rein in costs. This move toward narrow networks means many physicians are being evaluated for costs and quality, and patients may be forced to switch physicians because their physicians are dropped from networks.

Continued on page 6

Summer 2015 | AZMedicine 5

Continued from page 5

Arizona became the first state in the nation to pass into law an informed consent provision that guarantees women seeking abortions be told by their physician, that it may be possible to reverse the effects of the abortion pill with progesterone. This law is based on six patients treated by a family doctor in San Diego. It’s junk science, and it is suspended as it awaits a challenge in the courts.

ArMA is making a difference.

I have, for over three decades, been a firm believer in the institution of organized medicine and the good that we can accomplish with unified action. ArMA has steadily grown to be the most significant, recognized, health care voice at the Arizona State Capitol and with regulatory agencies. Its successes are too numerous to list here, but I urge you to review our Annual Legislative Report included with this publication.

Looking forward during my presidential term.

My goals for ArMA during my term as president include the following: 1. Have ArMA become a liaison with the department of insurance to help oversee health plan violations, which include dropping physicians from networks and delay in payments for clean claims.

As I have outlined, there will be many changes to American medicine in the coming years. We must always remember that, as physicians, we are still the best, and sometimes the only advocates that patients have. Patients and their families are turning to us to help them navigate the complexities of their health plans, Medicare, and hospital systems.

It is crucial for us all to understand the changes coming and hopefully help guide and lead some of these changes. Despite any future reorganization, we must continue to provide the most honest, ethical, and superb care that the public expects of us.

Healthcare reform won’t be easy, but I cling to the notion that the new generation of doctors and patients will figure it out.

I still recommend medicine to any young person who asks my opinion.

2. Be vigilant regarding potential antitrust activities of large hospital and health plan networks.

3. Increase ArMA membership by demonstrating relevance to employed as well as private practice physicians.

4. Work with specialties and county societies to help them be more united in the House of Medicine in Arizona.

5. Work with the medical board to streamline complaints and improve efficiencies.

6. Continue the physician leadership program that was pioneered by our Immediate Past President Jeff Mueller, M.D. Insurance companies and hospitals have powerful political lobbies.

Yet, without physicians they cannot function very well. These entities have managed to divide us by specialty and by groups within each specialty. This has to stop!

At this critical time we must have a united House of Medicine.

We still have power in numbers, if we can overcome specialty and group differences and unite in some fashion under one tent.

It is surprising to me that the laws of supply and demand don’t seem to apply to the healthcare field. This is due to government intervention and to a lack of unity within the physician community.

6 AZMedicine | Summer 2015

I also remain cautiously optimistic about the future. Healthcare reform won’t be easy, but I cling to the notion that the new generation of doctors and patients will figure it out. I still recommend medicine to any young person who asks my opinion.

The life of a practicing physician can still be incredibly rewarding.

As Hippocrates said, “Wherever the art of Medicine is loved, there is also a love of Humanity.”

Physicians continue to be unique in that our services will always be needed. We are still one of the most highly respected and trusted professions in the country. No matter how the healthcare debate evolves, and no matter what actions we may take to preserve our profession, we must never jeopardize our patients’ trust in us. 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. Dr. Laufer delivered his inaugural speech, from which this column is derived, to the ArMA House of Delegates on Friday, May 29, 2015.

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2015 LEFT: President Nathan Laufer, MD, and Immediate Past President, Jeff Mueller, MD

BELOW: Lilya Kraynov, MSII, Ross Goldberg, MD, and Erika Lodgek, MSII

ABOVE: The House of Delegates Annual Meeting opened May 29, 2015

CONGRATULATIONS OF THE 2015 A DAVID 0. LANDRITH HUMANITARIAN AWAR D David O. Landrith, Ina ugural recipien

t

RIGHT: Raymond Woosley, MD, PhD, recipient of the Distinguished Service Award

ARMA DISTINGUISHED SERVICE AWARD Raymond Woosley, M D, PhD EDWARD SATTENSPIEL

, MD, AWARD William Thrift, MD

WALLACE A. REED, M D

AWARD Daniel Von Hoff, MD

NATIONAL SERVICE AW ARD William Bohnert, MD, FACS

RIGHT: Ross Goldberg, MD, Karen Restifo, MD, and Awad Mohamed, MSII

ABOVE: Dr. Javier Cardenas, recipient of the Sportsman Award

8 AZMedicine | Summer 2015

LEFT: (Back) Dr. Valerie Brodsky, Dr. Adam Brodsky, Omar Tarabichi, Lauren Cole, MSIII, Chic Older, Jeannie Older, Dr. Barry Krumholz (Front) Ms. Julee Landau, Dr. Robert Shahan, Dr. Nathan Laufer, Judy Laufer, Dr. Carolyn Pettit

Annual Meeting

S TO THE RECIPIENT S ARMA AWARDS!

ABOVE: Dr. Bill Thrift, recipient of the Sattenspiel Award

ABOVE: Walk the Talk Award recipients Michael T. Liburdi, JD, and R. Screven Farmer, MD

LEFT: Dr. Mitchell Humphreys and Leanne Andreasen accepted the Ruhe Award on behalf of Mayo Clinic Arizona SCPD

C.H. WILLIAM RUHE,

MD AWARD Mayo Clinic in Arizona Mayo School of Continu ous Professional Developme nt

ARMA/ADHS PUBLIC HEALTH SERVICE AWARD Will Humble, MPH LEFT: Dr. William Bohnert, recipient of the National Service Award

“WALK THE TALK” AW ARD R. Screven Farmer, MD Michael T. Liburdi, JD SPORTSMAN AWARD Javier Cárdenas, MD

LEFT: Dr. Charlie Daschbach, winner of the Annual Meeting Grand Prize drawing

ABOVE: Dr. Cara Christ, current Director of ADHS, co-presented the Public Health Service Award to Will Humble, past Director of ADHS, with Dr. Nathan Laufer

Summer 2015 | AZMedicine 9

Encouraging Physician Leadership in Arizona

Chic Older, EVP, ArMA; Judy Rich, CEO, Tucson Medical Center, AzHHA Board Chair; Dr. Jeff Mueller, ArMA President; and Greg Vigdor, CEO, AzHHA.

Dr. Jeff Mueller introduces the CEO panelists; Rich Boals, CEO of BCBSAZ, Dr. Curtis Page, CEO of Commonwealth PC ACO, Judy Rich, CEO of Tucson Medical Center, and Linda Hunt, CEO of Dignity Health Arizona.

The Arizona Medical Association (ArMA) was proud to hold our first Physician Leadership Conference, “Balancing the Hippocratic Oath and the Business of Health Care,” on March 21, 2015. We welcomed 89 attendees to the conference, held at Mayo Clinic in Phoenix.

The conference concept developed by ArMA President Jeffrey Mueller, MD, and ArMA past Presidents Marc Leib, MD, JD, and Jacque Chadwick, MD, was designed for ArMA physician members to encourage and ensure strong, sustainable physician leadership in Arizona.

Combes, MD, Senior VP of American Hospital Association (AHA), and Stan Stead, MD, MBA, VP for Professional Affairs, American Society of Anesthesiologists (ASA). A panel discussion between regional chief executive officers included Richard Boals of Blue Cross Blue Shield of Arizona (BCBSAZ), The 2015 Physician Leadership Linda Hunt of Dignity Health, Conference was a valuable learning Curtis Page, MD, of experience and I plan to attend Commonwealth Primary Care again in 2016. The speakers ACO, and Judy Rich of addressed the key issues we face Tucson Medical Center. as physician leaders, and it was a wonderful networking opportunity with colleagues from around Arizona.

The speaker Q & A and panel discussions were marked — Keith A. Frey, MD, MBA, by active audience participaChief Physician Executive, Arizona tion, fielding questions from Service Area & President, Dignity several dozen attendees.

Health Medical Group in Arizona All surveyed respondents Conference speakers feaaffirmed that the conference tured thought-leaders in physician leadership was worth the time spent, in particular citing Peter Angood, MD, CEO for American Assothe quality of the speakers’ presentations ciation for Physician Leadership (AAPL), John

10 AZMedicine | Summer 2015

and expressing that they felt more empowered to participate in the process of transition in health care.

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.

Regardless of a physician’s career stage (medical school, residency, early, mid- or late career), specialty, or path (clinical, research, and/or administrative), a physician leader fosters an environment of continuous learning. Attending ArMA’s 2015 leadership conference “Balancing the Hippocratic Oath and the Business of Health Care” provided a much needed opportunity to engage thought leaders in this arena. These types of opportunities are integral in bringing together physicians to discuss our leadership role within the ever-changing landscape of medicine.

— Sara Salek, MD, Chief Medical Officer, AHCCCS

Key health care leaders from across Arizona attended the conference, including: Dr. Harry Alberti, CMO, Thompson Peak Hospital, HonorHealth; Dr. Manny Arreguin, Chief of Staff, El Rio OB/GYN Associates and Tucson Medical Center; Dr. Bruce Bethancourt, CMO, Dignity Health Medical Group; Dr. James Burke, Senior VP and Chief Physician Executive, HonorHealth; Jay Conyers, PhD, Executive Director, Maricopa County Medical Society; Ed Donahue, MD, CMO, St. Joseph’s Hospital and Medical Center; Dr. Stuart Flynn, Dean, University of Arizona College of Medicine – Phoenix; Dr. Keith Frey, Chief Physician Executive, Dignity Health Arizona; Dr. Robert Fromm, Senior VP and CMO, Maricopa Integrated Health System; Steve Nash,

The 2015 ArMA Physician Leadership Conference was held at the Mayo Clinic Waugh Education Center.

Executive Director of Tucson Osteopathic Medical Foundation; and Greg Vigdor, President and CEO, Arizona Hospital and Healthcare Association (AzHHA).

The ArMA Physician Leadership Conference is a fantastic resource for Arizona physicians to better understand the challenges of leading a practice or taking on a high-level administrative role at a local hospital. Far too few physicians currently serve as a senior decision maker for hospitals, with fewer than 250 claiming the CEO or President role at the nearly 7,000 hospitals nationwide. ArMA’s leadership conference will assuredly provide valuable training for physicians wishing to help lead their colleagues in this ever-changing healthcare landscape.

— Jay Conyers, PhD, Executive Director, Maricopa County Medical Society

SAVE THE DATE!

2016 CONFERENCE | MARCH 19, 2016 Mayo Clinic Hospital, Phoenix, AZ

Endorsed by Arizona Hospital and Healthcare Association (AzHHA)

Summer 2015 | AZMedicine 11

Because not all solutions are black and white.

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INTRODUCTION

Committee of Reference: an effort by the naturopaths to be allowed to prescribe Schedule II drugs and an effort by the Arizona Pharmacy Association to allow pharmacists to immunize children ages 6-17 without a physician’s prescription. During session, ArMA soundly defeated SB 1040 in the Senate Health & Human Services Committee, a bill by the chiropractors to add prescribing rights to their scope of practice while bypassing the state’s sunrise process.

The shortest regular session in modern state history – a mere 81 days – is the way many will remember the first session of Governor Doug Ducey’s administration; but ArMA will also take pride in stating that, as far as results are concerned, it was another outstanding one for Arizona’s physicians and their patients. ArMA was hugely successful in this session in terms of advancing much-needed legislation and staving off bills that would hurt physicians and patients. While in global terms the Republican-controlled Legislature cannot be considered “pro-health care,” from a policy standpoint, no serious efforts were made to undo the AHCCCS expansion proposal enacted in 2013 (there is, however, at the time of this writing, an Arizona Supreme Court case pending that could jeopardize it).

And, in the wee hours of Sine Die dawn, ArMA stood tall in stopping an ill-conceived Senate Resolution that would have taken a position of opposition by the Legislature as a whole, against future consideration of the Interstate Physician Licensure Compact – an important model act that’s been introduced in seventeen states during this past year and already enacted in six of them.

On the positive side of the ledger, we helped shepherd through the process two vital bills to help eliminate the licensing backlog and restore proper function at the Arizona Medical Board (AMB). As part of those AMB reforms, physicians will no longer have to undergo fingerprinting and background checks when they renew their licenses.

ArMA was also thrilled that two physician members, Gary Figge, M.D., and Lois Krahn, M.D., were appointed by Governor Ducey to the AMB and unanimously confirmed by the AZ Senate in the final days of the session.

By the time the session skidded to a stop shortly before dawn on April 3, the 81st day, the Legislature had considered the following tally of bills, memorials and resolutions: • • • •

1163 bills introduced 344 bills passed 89 memorials & resolutions introduced 36 memorials & resolutions passed

Of the 344 bills that reached Governor Ducey, 320 were signed and, unless specifically noted otherwise, they will all go into effect July 3, 2015. Governor Ducey only used his veto pen on 20 bills, a modest number by modern standards. During this session, ArMA followed 118 bills (not including the 13 budget bills) which had the potential of positively or negatively affecting physician practices.

ArMA also successfully advanced legislation to insulate physicians from harassment through licensing board complaints for merely performing independent medical exams (IMEs) in workers’ comp cases. We worked closely with other medical groups to make improvements in the laws that govern prescriber compliance with the state’s controlled substances prescription monitoring program (CSPMP). And we aided in the passage of a bill to help better protect from liability physicians groups who perform peer review activities.

Our success would simply not be possible without the support, invaluable insights and feedback from those ArMA members who stepped forward to support our legislative efforts and have a meaningful impact on their profession.

We sincerely thank the 48 physicians who took time from their busy schedules to serve as Doctors of the Day (DoD) at the State Capitol. ArMA’s DoD program continues year-after-year to be meaningful and exciting to the legislators and their staff as well as the physician volunteers.

Rest assured we will continue to advance this hallmark program on your behalf as effectively as possible.

As usual, scope of practice issues were front and center again – both leading up to and during this legislative session.

ArMA was successful in stopping all of them, including two overreaching proposals that were put forward during the “sunrise” process last December before the legislative

2

BUDGET

AHCCCS announced that the provider rate cuts had been cancelled. The leadership and resourcefulness of the Governor’s staff and AHCCCS leadership led to identification of unused funds and eliminated any AHCCCS budget cuts for the next two years.

We all knew going into this session that it would be a tough one on the budget side, considering that Arizona’s recovery has been a weak one and the state faced a significant budget shortfall. What we didn’t expect was such harmony and coordinated activity between the Governor’s Office and the Senate and House GOP leadership.

Another interesting piece of the health-related budget bill was a provision that tries to copycat states like Indiana, which recently received a waiver from CMS to allow cost-sharing mechanisms in the state’s Medicaid program in return for agreeing to expand the program. The budget bill provision directs AHCCCS to seek approval from CMS for new cost-sharing mechanisms which differ slightly for the expansion population and the traditional Medicaid population. It ties in with SB1092 (see below), sponsored by Sen. Nancy Barto. ArMA is participating in a business-based coalition to provide input to the Ducey administration on realistic CMS waiver ideas.

In an effective power move led by Senate President Andy Biggs, the GOP leadership team at the Arizona Legislature rammed a budget through between weeks eight and nine that carried by just enough votes to land it on Governor Doug Ducey’s desk the Monday following a grueling, mandatory work-weekend. The process began with the introduction of 13 identical budget bills in both chambers.

Things moved relatively quickly and after a lot of arm twisting by the Leadership and the Governor, the Legislature pulled a rare “all-nighter” on Friday, March 6th and approved the austere $9.1 billion budget.

In numerous floor speeches, Republicans boasted that the budget was fiscally responsible, balanced and set the state on a path to be fiscally balanced by FY18. However, this GOPbacked budget may be obliterated if the Legislature loses its appeal in the Cave Creek K-12 funding lawsuit later this year.

Moderate Republican lawmakers tried to bargain for reduced cuts, but in the end only managed to secure some slight reductions, along with a series of minor policy adjustments in the budget proposal. The proposed $104 million cut to state universities, the largest sticking point for many lawmakers, was only reduced to $99 million. Likewise, the holdouts were unable to lessen the five percent cut to provider rates under the Arizona Health Care Cost Containment System (AHCCCS) program, a cut that AHCCCS Director Tom Betlach (who briefed ArMA’s Board in April) was to decide how best to mete out. Republican Rep. Heather Carter, along with almost everyone in the Democrat caucuses (led by Rep. Eric Meyer, M.D., and Sen. Katie Hobbs) stood firm and were among those who voted “no” on the health-related budget cuts, to no avail. ArMA made it clear to all that these cuts will put availability of physicians in jeopardy as payment for care may now be below cost.

Lastly, although ArMA and others continue to work to develop legislative awareness of the importance of GME funding, there was no opportunity, given the bad fiscal climate, to restore that funding and there likely will not be until the state’s economy is considerably stronger.

LEGISLATIVE TALLY SHEET The rest of our report will deal with the specific bills that ArMA monitored, supported or opposed. These bills, coupled with the budget and larger policy issues reviewed above, comprise the most significant of the 118 bills that ArMA followed during this legislative session. The key bills below are divided into the issue categories used by ArMA’s Committee on Legislative and Governmental Affairs to establish ArMA’s advocacy positions. Those categories are: Regulatory Boards/Regulations, Insurance, Tort Reform/Liability, Public Health/Public Policy and Healthcare Institution Issues.

Initially, the cut was delayed to take effect October 1. During the public comment period, ArMA and others shared our strong concerns about the cuts, and we now know these were given serious consideration by the Governor, AHCCCS leadership, and the Legislature. On June 5,

3

REGULATORY BOARDS/ REGULATIONS

n SB1149: ARIZONA MEDICAL BOARD; FINGERPRINTING; DISCLOSURE n HB2521: ARIZONA MEDICAL BOARD; FINGERPRINTING; DISCLOSURE

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 category, ArMA followed 35 bills during this session. The most significant of these measures are discussed below.

Governor Ducey wasted little time in putting his signature on SB1149, only the second bill to reach him in the session. These identical bills, simultaneously introduced by Senate Health Vice Chair Kelli Ward (a D.O.) and House Health Chair Heather Carter to expedite passage, were a big priority for ArMA because they were crucial to clearing the physician licensing backlog at the AMB which had affected many practices’ ability to bring on new physician hires and stymied the license renewals of current AZ doctors. As enacted, SB1149 does three things: (1) rectifies the interpretation problems with the fingerprinting and criminal background check requirements signed into law last session; (2) retroactively removes the requirement for fingerprinting of physicians at the time of license renewal (the fingerprinting requirement will only apply to new license applicants); and, (3) requires the AMB to refund fees collected from physicians for background checks during their license renewals. ArMA’s position on both versions of the bill was Active Support.

n SB1032: AHCCCS CONTRACTORS; PRESCRIPTION MONITORING

Sen. Kelli Ward sponsored this bill which requires AHCCCS contractors to intervene if an AHCCCS member has 10 or more prescriptions for controlled substances within a 3-month period and also requires them to monitor prescriptions that are being filled by members and intervene with both the prescriber and the member when excessive amounts of controlled substances are used.

AHCCCS contractors are further required to direct cases involving excessive controlled substance use to the system medical director for review. On March 23rd, the bill was signed into law by Governor Ducey. ArMA’s position on the bill was General Non-Support. n SB1040: CHIROPRACTIC; LIMITED PHARMACOLOGY CERTIFICATION; REQS

Sponsored by Senate Health Chair Nancy Barto, this scope of practice expansion bill would have authorized the Board of Chiropractic Examiners to certify chiropractors to prescribe prescription-strength dosages of ibuprofen, naproxen, methocarbomol and cyclobenzaphrine upon documentation of successful completion of an unspecified number of hours (later amended to 75 hours) of study in pharmacology at an accredited chiropractic college; documentation of successful completion of a rotation that included an unspecified number of hours (later amended to 300 hours) under the supervision of a licensed M.D. or D.O.; and documentation of having passed a Board-approved pharmacology examination. ArMA vigorously opposed this bill, as did Arizona Osteopathic Medical Association (AOMA) and other provider groups, both because it bypassed the state’s sunrise process and because it would endanger public health and safety. We succeeded in stopping the bill in the Senate Health and Human Services Committee at a showdown hearing on February 4th and the bill never resurfaced.

ArMA’s position on the bill was Active Non-Support.

n SB1257: MEDICAL LICENSURE; STATE PROGRAMS; PROHIBITION

Another bill by Sen. Ward, SB1257 would have forbidden the AMB and Arizona Board of Osteopathic Examiners from requiring a licensee to pass any periodic licensing examination to demonstrate professional competency unless specifically authorized by statute, and from requiring a “specialty certification” or “maintenance of a specialty certification” (both defined) as a condition of licensure. Any state agency, board or commission would have been prohibited from requiring a specialty certification or maintenance of a specialty certification for licensed physicians as a condition of participation in any program that accepts state monies. This bill passed the Senate but when it reached the House, it became the vehicle to move the behavioral health program from Arizona Department of Health Services (ADHS) to AHCCCS (see below under the Public Health/Public Policy category). ArMA’s position on the original content of this bill was Active Study.

4

n SB1258: MEDICAL BOARD; AFFILIATION VERIFICATION; RULEMAKING

The Compact is a model bill being advanced by the FSMB as a voluntary, optional pathway for physicians to gain multistate licenses and avoid the cost and hassle of applying state-by-state. Senator Ward saw it as a threat to state sovereignty, but fortunately most House members saw the issue far differently and they rejected the Resolution by a 16-40 floor vote. ArMA believes the Compact should be introduced and favorably considered in the coming legislative session. ArMA’s position was General Non-Support.

Sponsored by Senator Ward, this bill, which calls for expedited rulemaking, requires the Executive Director of the AMB to submit to the medical consultant only those medical complaints that involve a standard of care issue and that require medical training and expertise to determine whether a violation has occurred. If a license applicant is employed by a hospital or medical group or organization, the AMB is required to accept the verification or affiliations or employment from the applicant’s employer. Further, the Board is required to issue a Request For Information for the sole purpose of seeking information about the availability in the commercial marketplace of materials or services to outsource any or all of the credentialing or verification process relating to licensure; but the bill does not require the Board to outsource any or all of the credentialing or verification process relating to licensure. The bill passed and was signed by the Governor.

ArMA’s position on this bill was Active Study.

INSURANCE ArMA followed 21 bills this session in the Insurance category.

Of those, the eight described here are the most important ones: n SB1092: AHCCCS; ANNUAL WAIVER SUBMITTALS n HB2075: AHCCCS; ANNUAL WAIVER SUBMITTALS

Pursuant to this bill brought forward by Sen. Barto (and

by Rep. Warren Petersen), by March 30 of each year, the AHCCCS Director is required to apply to CMS for waivers or amendments to the current section 1115 waiver to allow Arizona to institute a work requirement for all “able-bodied” “adults” (both defined) receiving AHCCCS services; place a lifetime limit of five years of benefits on able-bodied adults except in specified conditions; and develop and impose meaningful cost-sharing requirements to deter the nonemergency use of emergency departments and the use of ambulance services for nonemergency transportation or when it is not medically necessary. By April 1 of each year, the Director is required to submit a letter confirming the submission of the waiver requests to the Governor and the Legislature. SB1092 was signed by the Governor. ArMA’s position was General Non-Support.

n SB1370: CONTROLLED SUBSTANCES PRESCRIPTION MONITORING PROGRAM

ArMA worked closely with sponsor Sen. John Kavanagh on this bill to make improvements to prescriber compliance with the controlled substance prescription monitoring program (CSPMP). ArMA supported this bill after working out acceptable language through a productive stakeholders’ process with the senator. As enacted, the bill encourages physician compliance with the CSPMP rather than imposing another burdensome government mandate on them. The bill was signed by Governor Ducey on March 23rd. ArMA’s position on the final bill was General Support.

n SB1189: HEALTH INSURANCE; INTERSTATE PURCHASE n SCR1003: INTERSTATE MEDICAL LICENSURE COMPACT

Sponsored by Senator Ward, SB1189 was yet another GOP attempt at allowing foreign insurers that issue policies and hold a certificate of authority in another state to issue health insurance in Arizona. AZ residents would be permitted to purchase such a policy, if the insurer registers with and provides specified information to the Department of Insurance (DOI). Any policy issued under this authorization would have to meet the benefit requirements of other policies issued in the state where the insurer holds

Sponsored by Senator Ward, this Senate Concurrent Resolution called for the members of the Legislature to oppose any participation in the Federation of State Medical Boards’ (FSMB’s) Interstate Physician Licensure Compact. Interestingly, this SCR was a preemptive strike against the Compact, which has yet to be introduced at our Legislature although it has been well-received in many other states (introduced in 17 states, enacted in 6 so far).

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a certificate of authority. Circumstances under which the DOI may revoke an insurer’s registration were specified.

The bill passed the Senate on party lines, but it died in the House where it was used as a vehicle for another unrelated issue. ArMA’s position was Active Study.

to prepare a report that compares the prescription rate of “psychotropic medication” (defined) prescribed to foster children who receive services from AHCCCS with the prescription rate of psychotropic medications prescribed to non-foster children who receive AHCCCS services.

Information that must be included in the report was specified. The report was to be submitted to the chairpersons of the House Children and Family Affairs Committee and the Senate Health and Human Services Committee, or their successor committees. While SB1297 cleared the Senate easily, it died in committee in the House. ArMA’s position on the bill was General Non-Support.

n SB1241: AHCCCS; CONTRACTORS; PROVIDERS

This bill by Sen. Barto would have prohibited the AHCCCS Director from mandating or prescribing the nature of the relationship between AHCCCS contractors and AHCCCS providers and their agents, and from making contracting or payment decisions based on specified factors. It arose out of a dispute with an AHCCCS contractor in Tucson that had eliminated its workforce and instead went to all independent contracted workers, in a cost-savings move. But AHCCCS said this wasn’t allowed under CMS rules. The bill ultimately stalled and was used as a vehicle for an unrelated subject. ArMA’s position on the initial language was Active Study.

n HB2373: AHCCCS; ORTHOTICS

Pursuant to this bill by Rep. Kate Brophy-McGee of Phoenix, the list of medically necessary health and medical services that AHCCCS contractors are required to provide is expanded to include orthotics ordered by a physician or primary care practitioner if specified conditions are met, including that the orthotic is less expensive than all other treatment options. The AHCCCS Administration is required to submit an application to the Centers for Medicare and Medicaid Services for approval of orthotic services. Governor Ducey approved the bill on April 10th.

ArMA’s position on the bill was General Support.

n SB1288: PRESCRIPTION DRUG COVERAGE; MEDICATION SYNCHRONIZATION

Sen. Kimberly Yee sponsored this bill for the pharmacy association to require health insurance contracts issued or renewed on or after January 1, 2016, that provide coverage for prescription drugs to prorate the cost sharing rate for a covered prescription drug that is dispensed by a network pharmacy for less than the standard refill amount if specified conditions are met. The health insurer must allow a pharmacy to override a denial code related to an early refill if the drug is being dispensed as part of a “medication synchronization” (defined) program, and is required to pay a full pharmacy dispensing fee for each prescription drug dispensed and cannot prorate a dispensing fee. This bill, which the Governor signed on April 1st, was worked out through a stakeholder’s process with Senator Yee. ArMA’s position on the bill was Active Study.

n HB2417: DIRECT PAYMENTS; DEDUCTIBLES n SB1284: DIRECT PAYMENTS; PROVIDERS; FACILITIES; DEDUCTIBLE

A compromise hammered out between Senator Barto and the health insurers (after battling over SB1284), HB2417 mandates that when a health insurance enrollee pays the direct pay price to an out-of-network health care provider or facility for a lawful health care service that is covered under the enrollee’s health care plan, the health insurer must apply the amount paid by the enrollee first to his/her in-network deductible, with any remaining monies being applied to his/her out-of-network deductible, if applicable. The amount applied to the in-network deductible is to be either (1) the amount paid directly by the enrollee, or (2) the insurer’s highest in-network contracted rate in Arizona for the service or services, whichever is lower.

If an enrollee is enrolled in a high deductible plan that

n SB1297: PSYCHOTROPIC DRUGS; FOSTER CHILDREN; REPORT

Under this bill by Sen. Debbie Lesko of Peoria, by August 31 of every odd numbered year, the Department of Health Services, the Department of Child Safety and the AHCCCS Administration would have been required

6

qualifies the enrollee for a health savings account (HSA), the insurer is not liable if the enrollee submits a claim that jeopardizes the enrollee’s status as an individual eligible for favorable tax treatment of the HSA. The bill does not create any private right or cause of action for or on behalf of any person against the health insurer. There is a delayed effective date of January 1, 2017, and the bill only applies to policies, contracts or plans that are issued or renewed beginning on that date. ArMA’s position on the bill was General Non-Support.

including specifying that sharing information about quality assurance activities as permitted by this legislation does not waive or otherwise impair the confidentiality of the information, and that otherwise discoverable information does not become confidential based solely on its submission to or consideration by a health care entity conducting confidential quality assurance activities. This bill, which the Governor has signed, also contains a legislative intent section. ArMA’s position on the bill was General Support.

PUBLIC HEALTH/PUBLIC POLICY

TORT REFORM/LIABILITY

During this session there were 41 bills in the Public Health/Public Policy category that ArMA followed. Of those, the following are the most important:

Under the category of Tort Reform/Liability, ArMA followed two bills, both of which are discussed here. n SB1290: INDEPENDENT MEDICAL EXAMS; BOARD COMPLAINTS

n SB1257: BEHAVIORAL HEALTH; TRANSFER; AHCCCS

Via a striker amendment in House Appropriations, this bill effectuates the repeal of the Division of Behavioral Health at ADHS and transfers its powers and duties for various mental and behavioral health services to the AHCCCS Administration, except for those relating to the state hospital, in order to conform to Laws 2015, Chapter 19 (part of the FY2015-16 budget). AHCCCS is required to act through the Regional Behavioral Health Authorities (RHBAs) to establish and operate various existing behavioral health programs. Statute governing contracts with RBHAs for behavioral health services is repealed and replaced. The ADHS Director, instead of the Deputy Director of the Division, has charge of the state hospital and related responsibilities and duties. ADHS is required to adopt rules relating to the state hospital, including standards for providing services and admission and transfer of patients. ADHS is required to present a budget request for the state hospital and to submit an annual report on the state hospital to the Governor and the Legislature. The bill also repeals the Serious Mental Illness Services Fund and transfers all unexpended and unencumbered monies remaining in the Fund to the general fund on the effective date of this legislation. By November 15, 2015, the AHCCCS Administration and ADHS are required to submit a joint report for review by the Joint Legislative Budget Committee and the Governor’s Office of Strategic Planning and

This is an important bill which ArMA successfully lobbied through the process, with help from Copper Point Mutual and other workers’ comp insurers. ArMA members Carol Peairs, M.D., and Mike Powers, M.D., provided invaluable first-hand testimonials to legislators as the bill advanced, explaining how harmful it can be to a physician to be subject to a groundless complaint for unprofessional conduct merely based on a disagreement with the findings and opinions expressed by the physician in an independent medical examination (IME) in a workers’ comp case. As a result of this bill, IME-related complaints will no longer be acted on by the AMB, Osteopathic Board or Podiatric Board.

ArMA’s position on the bill as enacted was Active Support. n HB2556: HEALTH CARE QUALITY ASSURANCE

Resurrected via a striker amendment, this helpful “peer review” bill sponsored by House Health Committee Vice Chair Rep. Regina Cobb of Kingman helps better protect health care providers, hospitals and outpatient surgical centers that conduct “quality assurance activities” (defined), and clarifies that health care entities are authorized to share “quality assurance information” (defined) with appropriate state licensing or certifying agencies and with licensed health care providers who are the subject of quality assurance activities. Regulations on the confidentiality of quality assurance information are modified,

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Budgeting that details the transfer of resources between the two departments. The bill, signed by Governor Ducey on April 6th, has a delayed effective date of July 1, 2016.

ArMA’s position was General Support.

abortion if the woman changes her mind but that time is of the essence, and that information on and assistance with reversing the effects of a medication abortion is available on the ADHS website. The information that must be included on the ADHS website is expanded to include information on the potential ability of qualified medical professionals to reverse a medication abortion, including information directing women where to obtain further information and assistance in locating a medical professional who can aid in the reversal of a medication abortion. Also, under the bill as enacted, any qualified health insurance policy, contract or plan offered through any health care exchange operating in Arizona, is prohibited from providing coverage for abortions, and abortion coverage is no longer permitted to be offered as a separate optional rider for which an additional premium is charged. The list of exceptions from this prohibition is expanded to include coverage for an abortion when the pregnancy is the result of rape or incest, in addition to an abortion that is necessary to save the life of the woman or avert substantial and irreversible impairment of a major bodily function of the woman. On initial licensure and any subsequent renewal, an abortion clinic is required to submit to ADHS all documentation required by statute, including verification that the clinic’s physicians have admitting privileges at a health care institution. The list of ADHS information that is not available to the public is expanded to include personally identifiable information of a physician that is received and any records kept regarding the physician’s admitting privileges to an abortion clinic.

ArMA’s position on the bill was No Action – Monitor. A lawsuit stopping implementation of the legislation was filed in June, and state attorneys have agreed to not enforce the law until mid-September, pending the U.S. District Court decision. At the time of this printing, ArMA has joined as amicus the American Medical Association (AMA) and the American Congress of Obstetricians and Gynecologists (ACOG) in support of legal action to stop implementation of the requirements set forth in SB 1318.

n SB1194: MEDICALLY UNDERSERVED AREAS n HB2495: MEDICALLY UNDERSERVED AREAS

Under this bill (initially introduced by Rep. Carter as HB2495 which faltered and was brought back by Sen. Gail Griffin as SB1194), the Primary Care Provider Loan Repayment Program (Program) and the Rural Private Primary Care Provider Loan Repayment Program (Rural Program) are expanded so that they may be used to pay off portions of education loans taken out by pharmacists, “advance practice providers” (defined as a physician assistant or registered nurse practitioner) and “behavioral health providers” (defined) who meet other Program or Rural Program qualifications, including service for at least two years in rural areas, high-need health professional-shortage areas or medically underserved areas. The bill also increases the maximum amount of loans for each provider that may be repaid with Program monies. ADHS is permitted to implement the Program independent of federal grants based on the needs of Arizona, and to use monies to develop programs such as employer recruitment assistance to increase participation in the Program. It also repeals the Behavioral Health Practitioners Loan Repayment Program. ArMA’s position on the bill as enacted was General Support. n SB1318: ABORTION; HEALTH CARE EXCHANGE; LICENSURE

Clearly one of the most controversial and second-guessed bills of the session, this abortion-related bill introduced by Senator Barto was one that ArMA attempted without success to influence behind the scenes. It is a classic example of our Republican-controlled Legislature not letting the facts get in the way of making yet another anti-abortion political statement. Unfortunately, the “bad medicine” it calls for may have repercussions that extend beyond the abortion issue, namely: the list of information that a physician must inform a woman of at least 24 hours before performing an abortion is expanded to include a notice that it may be possible to reverse the effects of a medication

n SB1404: HEALTH CARE DIRECTIVES, CONFLICTS

Sponsored by Senator Yee, this bill helps clarify the handling of advance health care directives by patients. It states that if there is a conflict between a provision of a valid

8

health care directive or the decision of a patient’s agent pursuant to a valid health care power of attorney and a health care provider’s order, the health care directive or decision of the patient’s agent is presumed to represent the wishes of the patient. This bill was signed by the Governor on April 1st. ArMA’s position was General Support.

of the Legislature and Governor, had the U.S. Supreme Court not upheld the insurance subsidies under the ACA in its June 25th ruling. ArMA’s position was No Action – Monitor. n HB2645: LAB TESTING WITHOUT PHYSICIAN ORDER

Sponsored by Rep. Carter, this bill was “wired” from start to finish, thanks to high-powered lobbying by lab juggernaut Theranos and backing by Speaker Gowan and Governor Ducey. As enacted, it states that a person may to obtain any lab test from a licensed clinical lab on a direct access basis without a health care provider’s request or written authorization, provided that the lab offers that test to the public on a direct access basis (prior AZ law allowed direct access for only about 50 tests). For tests not conducted at the request or authorization of a physician, the test results must be reported to the person who was the subject of the test and must state in bold type that it is the person’s responsibility to arrange with the person’s health care provider for consultation and interpretation of the test results. ArMA worked hard on the bill behind the scenes to secure language stating that a health care provider’s duty of care to a patient does not include any responsibility to review or act on lab test results that the provider did not request or authorize. A clinical lab cannot submit a claim for reimbursement from a third party payor for any lab test conducted without a health care provider’s request or written authorization. The bill does not require that a lab test be covered by a health insurance plan or AHCCCS plan.

ADHS is required to adopt rules to address the changes in direct access lab testing. ArMA’s position was General Non-Support.

n HB2604: EPINEPHRINE AUTO-INJECTORS

This bill by Rep. Cobb cleared the House without difficulty but failed to get a hearing in the Senate. It would have authorized health care practitioners to prescribe epinephrine auto-injectors in the name of an “authorized entity” (defined as any entity or organization other than a school at which allergens capable of causing anaphylaxis may be present). Authorized entities would have been permitted to acquire and stock a supply of epinephrine auto-injectors and designate employees or agents who are trained to be responsible for the injectors. Trained employees or agents would have been authorized to provide or administer an epinephrine auto-injector to any individual s/he believes in good faith is experiencing anaphylaxis.

Training requirements were specified in the bill. ArMA’s position was General Support. n HB2643: SOVEREIGN AUTHORITY; AFFORDABLE CARE ACT

Under this politically-charged and confusingly-drafted bill, signed on April 10th by Governor Ducey, the state and all political subdivisions will now be prohibited from using any personnel or financial resources to enforce, administer or cooperate with the Affordable Care Act by funding or implementing a state-based health care exchange or marketplace, limiting the availability of selffunded health insurance programs, funding or aiding in the prosecution of any entity for a violation of the Act, or funding or administering any program or provision of the Act other than those involved with AHCCCS, health insurance navigators and other specified programs. There are some exceptions, including that the state and all political subdivisions are permitted to use personnel or financial resources to provide employee health insurance benefits, and those benefits may be in compliance with all provisions of the Act. This one certainly telegraphs the punch

HEALTH CARE INSTITUTION ISSUES In the Health Care Institution Issues category, ArMA followed five bills this session, two of which are discussed below. n SB1166: HEALTH CARE INSURANCE; UTILIZATION REVIEW

Under this bill sponsored by Sen. David Farnsworth of Mesa, a health care insurer who utilizes the services of an outside utilization review agent is responsible for the

9

administration of all patient claims processed by the utilization review agent on behalf of the health care insurer.

ArMA’s position on the bill as enacted was Active Study.

As we approach the off-season there is work to be done, as always, to prepare for the known (those practice scope expansions and “bad medicine” bills we tend to see almost annually) as well as the unknown. We will redouble our efforts to educate lawmakers and staff on the importance of sound public policy decisions in the realm of health care, and the need for them to be supportive of the needs of both physicians and patients. We cannot lower our guard for a moment because we live in a time of great uncertainty with regard to the future of health care – all it takes is a quick glance at the monumental cases pending before the U.S. Supreme Court and the Arizona Supreme Court to confirm that fact.

n SB1283: OUTPATIENT TREATMENT CENTERS; COLOCATION

Introduced by Sen. Barto, this bill states that one or more outpatient treatment centers which provide medical, nursing and health-related services are authorized to colocate with one or more licensees that provide behavioral health services or with one or more licensed counseling facilities and are authorized to share common areas and non-treatment personnel. Requirements for co-location applications and use of treatment areas are specified. ADHS is “required” rather than “allowed” to adopt licensing provisions that facilitate the co-location and integration of outpatient treatment centers that provide medical, nursing and health-related services with behavioral health services.

The bill contains an emergency clause, allowing it to become effective as of April 1st. ArMA’s position on the bill as enacted was Active Study.

As we have said before, it is vital for all physicians to acknowledge and embrace the need to support the legislators (and, perpetually, the candidates) who fight for ArMA’s causes. We would especially like to thank Representative Heather Carter, House Health Committee Chair; Representative Eric Meyer, M.D., House Minority Leader; Senator Kelli Ward, D.O., Vice Chair of Senate Health & Human Services; Senator Katie Hobbs, Senate Minority Leader; and rising stars Representative Regina Cobb, Vice Chair of House Health; and Representative Jill Norgaard, for their willingness to stand strongly for us on the proactive and defensive issues we fought so hard for this year.

CONCLUSION By any measure, ArMA accomplished its advocacy mission extremely well this legislative session, a notable feat considering that we were sadly forced to turn to an outside lobbyist after losing our beloved David Landrith. Fortunately, ArMA chose wisely, securing the services of Steve Barclay, a top-flight professional lawyer-lobbyist with over 31 years of health care lobbying experience and expertise.

Steve served us extremely well and we look forward to having him continue on as ArMA’s champion.

As is frequently the case, our efforts throughout this session were oriented towards playing defense — stopping bad bills from advancing and protecting ground we have already gained — which we did with great success in nearly all instances. However, we were also successful in moving our own health care legislation forward to the finish line, which is difficult even under the best of circumstances (and these were clearly not). Those wins are especially gratifying.

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Thank you Your membership ensures that we continue to successfully advocate on behalf of you and your patients.

DUEL SURVIVAL EDITORIAL

Roberts court upholds Obamacare again On June 25th, the U.S. Supreme Court rejected the challenge to the Affordable Care Act (ACA) in King v.

Burwell in a 6-3 decision written by Chief Justice John Roberts. The challenge, based

Michael F. Hamant, MD on an ambiguous four word phrase referring to exchanges “established by the State” in the 900+ page law, would have eliminated the subsidies provided to qualifying Americans in those states which had not established their own insurance exchange and instead relied on the Federal exchange.

Had the challenge succeeded, more than six million Americans would have lost their subsidies, making their insurance unaffordable. As Chief Justice Roberts wrote 24 AZMedicine | Summer 2015

“Congress passed the Affordable Care Act to improve health insurance exchanges, not destroy them.”

Since the intent of the law is “Quality, affordable health care for all Americans” it seemed improbable to the majority opinion that Congress intended to limit subsidies to only those states that established their own insurance exchange. At no point in the debate during passage of the ACA in 2010, was it ever mentioned by anyone, opponents included, that the subsidies were limited to state exchange participants.

So essentially, the Supreme Court agreed to rule on a typo!

However, the consequence of ruling in favor of the challenge would have been to eliminate the subsidy in 34 states where the Federal government runs the exchange, including of course, Arizona.

The charade of the challenge was not apparent to Justice Scalia whose dissenting opinion was inconsistent with even his own previous opinion.

In the 2012 challenge to the

ACA, he stated the Federal subsidies were crucial to the function of the exchange and the overall effectiveness of the ACA (and that the Medicaid expansion was not).

The early success of the ACA has exceeded expectations.

The number of uninsured has dropped four percentage points since 2013. The drop is significantly greater in those states that accepted Medicaid expansion as did Arizona.

Around 15 million Americans have gained coverage under the ACA (remember, at least 6 million would have lost coverage if the King challenge had succeeded).

In states that fully implemented the Medicaid expansion, the uninsured rate has fallen from 16 to 8 percent. It has taken Massachusetts almost 10 years with guaranteed coverage to obtain a 5 percent uninsured rate.

The biggest fears raised by the

opponents to the ACA were: • Premium increases would doom the ACA; however, the actual rise of 2 percent has been lower than expected.

• Job growth would be destroyed by the ACA; instead, actual job growth has averaged 240,000 per month since the ACA began, which is the greatest growth since the 1990s.

• Healthcare spending and the deficit would explode; instead, the actual rate of spending has declined as well as the deficit. The non-partisan Congressional Budget Office has ruled that repeal of the ACA would increase, not decrease, the Federal deficit.

Although the partisan divide over the ACA might not be over for a generation, many observers believe that the Republicans actually breathed a sigh of relief when the ACA

2016 would be able to repeal the law with 20 million or more citizens covered by it.

The Roberts decision preserves the integrity of the ACA. It is unlikely that even a Republican President and Congress in 2016 would be able to repeal the law with 20 million or more citizens covered by it.

was again upheld by the Roberts Court. There was no consensus in the Republican Congress on what to do about the 6 million who would have lost coverage. While cries of “repeal and replace” have been heard for years, no real “replace” has ever been articulated. The Republican Congress no longer needs to supply the legislation the various wings of the party could not possibly have agreed upon.

President Obama boasted that the law is “here to stay.”

In fact, many predict that many more red states with Republican governors, like Arizona, will now move to accept Medicaid expansion.

The ACA is of course far from perfect. It is not even intended to provide universal coverage. It perpetuates the private health insurance industry and its huge profits.

The ACA makes no attempt to reduce the burdensome overhead costs that our system places on providers.

The U.S. still spends per capita twice as much on

healthcare as any other developed country with far worse outcomes. The ACA has certainly boosted the profit margins of both the insurance and pharmaceutical industries (by providing millions of new customers). Medicaid expansion has certainly helped hospitals, particularly rural hospitals, survive these tough economic times.

In my opinion, the most cost effective and efficient way to provide universal coverage to all Americans would be an expanded and improved Medicare for all. We should be spending our resources on patient care, disease prevention, and universal coverage, not pharmaceutical and insurance company profit and provider overhead.

The consensus is that the country has moved toward a more progressive direction nationally regarding social issues (for instance gay marriage). It is unknown if this trend will give impetus to a renewed push for universal coverage through the public option, Medicaid expansion, or even Medicare for all. The SCOTUS decision in King v.

Burwell entrenches the ACA further and does not make any of that more likely, and possibly even less likely. AM Michael Hamant, MD, is a family physician practicing in Tucson.

He is ArMA’s Vice President and the supervising editor of this edition.

The Roberts decision preserves the integrity of the ACA. It is unlikely that even a Republican President and Congress in

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DUEL SURVIVAL

MACRA: The Good, the Controversial, and the Uncertain The Medicare, Access and CHIP Reauthorization Act of 2015 (“MACRA”), and its repeal of the sustainable growth rate (“SGR”) formula

Paul J. Giancola, JD for physician payment is one of the rare bills to pass Congress and be signed by the President with broad bipartisan support.

Much has been written about this lengthy and complex law.

The purpose of this article is to highlight some of the more significant provisions of the law, but without the complex level of detail contained in the law.

The Good • The repeal of the SGR formula (which was up to a -21.2% payment cut effective April 1, 2015), and providing that Medicare physician payments will increase by 0.5% annually through 2019, at which time 26 AZMedicine | Summer 2015

the fee-for-service payments will remain at 2019 levels through 2025. Beginning in 2019, however, there will be two payment incentive tracks. One for physicians who participate in an Alternate Payment Models (“APM”) and one for those who remain fee-for-service, and participate in a Meritbased Incentive Payment System (“MIPS”), which will contain both positive and negative adjustments for meeting the selected standards. APM is based on a patient-centered risk bearing medical home model.

MIPS is based on selected performance categories.

• Extends funding for the Children’s Health Program (“CHIP”) for two years, which affects eight million children and pregnant women whose income fall slightly above Medicaid eligibility levels and cannot afford private health insurance.

• Provides that mandatory funding for community health centers under the Affordable Care Act is extended through 2017.

• Medicare, Medicaid, and Affordable Care Act quality

standards and measures (such as PQRS) shall not be construed to establish the standard of care or duty of care owed to a patient in any medical liability case.

• Extends various Medicare Part B outpatient therapy cap exceptions, and certain other Medicare and Medicaid policies that were set to expire.

• Meaningful use measures will count for 25% in MIPS, and the law sets a goal to achieve widespread electronic exchange of health information between certified EHR technology systems by the end of 2018.

• Amends the civil monetary penalty (“CMP”) law to allow payments to physicians to reduce or limit services unless the services were “medically necessary.”

• Directs the Secretary of HHS to issue a report to Congress recommending safe harbors from fraud and abuse to provide available options to permit gainsharing arrangements between physicians and hospitals to improve quality and efficiency.

• The GAO is to conduct studies and report to Congress on the use of telehealth and remote patient monitoring technology under the federal programs.

The Controversial To pay for the increase in payments to physicians and the extension of some benefits MACRA (costing approximately $214 billion and adding $141 billion to that deficit over 10 years) provides for, among other things, several beneficiary and provider offsets, including: • Restricting Medigap plans from offering “first-dollar” coverage for inpatient hospital payment rate adjustments for new beneficiaries beginning in 2020.

• Restructuring and extending Medicaid disproportionate share hospital payments.

• Imposition of a levy against payments owed to Medicare providers with tax delinquencies.

• Reductions in the prospective payment system (“PPS”) updates in 2018 for certain post-acute care

correct such errors, and pay attention to such education, could eventually be subject to false claims actions.

Beginning in 2019, however, there will be two payment incentive tracks. APM is based on a patient-centered risk bearing medical home model. MIPS is based on selected performance categories. providers such as skilled nursing facilities, home health, hospices, long-term care hospital and inpatient rehabilitation hospitals.

• Expands physicianidentified claims data to be released by CMS on an annual basis.

• Higher income Medicare beneficiaries will pay higher premiums beginning 2018.

reduce or limit medically necessary care.

• To reduce improper Medicare payments, MACRA requires Medicare contractors to establish and have in place an “Improper Payment Outreach and Education Program” offering Medicare providers

a list of the most frequent and expensive payment errors, instructions on how to avoid such errors, and their own utilization and payment data, including the number of services and submitted charges and payments for such services. Providers who do not access this information,

• The CMS policy that required the transition of all 10-day and 90-day global surgical packages to 0-day global periods has been preserved for over 4,000 surgical codes.

Instead, beginning in 2017, the Secretary of HHS is to begin collecting data using a process established

by Rulemaking, with the accuracy of the claims data to be determined by the Inspector General. Once the process for collecting data is established, the Secretary Continued on page 37

The Uncertain Fee-for-service remains the primary payment system for Medicare part B services. However, as previously promised by CMS, pay-for-performance is transitioning as the preferred future payment scheme.

• Gainsharing is a potent hospital-physician alignment tool. Congress will be considering, after receiving recommendations from HHS, developing safe harbors to encourage effective gainsharing. These safe harbors should address ownership and other compensation arrangements while ensuring that such arrangements do not result in inducements to

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DUEL SURVIVAL

An Update from the Arizona Medical Board

By Patricia McSorley, Director

I. E-Licensing

while allowing licensing staff to devote their time to processing documentation actually received by the Agency.

The Arizona Medical Board (Agency) is looking forward to implementing changes that will positively impact the licensing process. The Licensing Department is emerging from a period of intense review of its policies and processes.

It is now positioned to move forward on multiple fronts to modernize and streamline the process. The Agency is confident that by employing a whole host of improvements the result will be a shrinkage of time it currently takes to license a physician.

In the 2015 legislative session SB 1258 passed and was signed into law. SB 1258 grants the Agency an opportunity to engage in rulemaking related to licensing and credentialing on an expedited basis. This law coincides with Governor Ducey’s mandate in Executive Order 2015-01 to all agencies to “enact rules that reduce or ameliorate a regulatory burden while achieving the same regulatory objective.”

In the next few months the Agency plans to introduce an online initial application process – E-Licensing. E-licensing will allow the applicant to submit an application on line, render payment and log into the system to check the status of the application. E-licensing Is designed to allow an applicant to have web based 24-hour access to monitor and check their application status. This should allow the applicant real-time knowledge of any application deficiency

The Agency is now in the process of completing a rulemaking package to modernize the licensing process. The goal is removal of non-value added requirements. Some of the proposals included in this rule package address alternatives for certification requirements and original documentation. Similarly, the proposed package plans address a more practical approach to required documentation including reporting of specific malpractice information to allowances

28 AZMedicine | Summer 2015

II. Legislative & Rule Making Update

In the next few months the Agency plans to introduce an online initial application process – E-Licensing. for exceptions in the event applicants are functionally unable to produce various documents.

The Agency views the updating of the rules as a key instrument in improving its processes. Once the Agency receives the go-ahead, the public and all stakeholders will have an opportunity to provide commentary.

III. Ongoing Efficiency Review The Agency has also been working closely with the Government Transformation Office (GTO) to examine its internal processes and identify more efficient practices using the LEAN management tool.

The Licensing Department has commenced a pilot program employing process changes.

These include a process for providing application deficiency letters more quickly to

applicants so they are able to remedy these deficiencies more quickly.

In addition, the Agency has distributed fingerprint cards to key facilities such as the post graduate programs and to credentialing agencies. In 2014 the Arizona Legislature amended A.R.S. §32-1422 to require finger-printing for initial applicants. The licensing staff encourages applicants to submit their fingerprint cards for processing at the same time the application is submitted.

The Agency remains open to suggestions and continually engages in dialogue with stakeholders on process improvements. Please send ideas to pmcsorley@azmd.gov. AM

DUEL SURVIVAL

From enacting a law to meeting the HIE needs of Arizona providers Since its inception in 2007, Arizona Health-e Connection (AzHeC) has had a core mission to collaborate and coordinate public policy initiatives to advance health information technology (HIT) and health

Enabling statewide HIE and providing patient choice and privacy House Bill 2620 (now Arizona Revised Statutes (ARS) 36-3801, et seq.) included these essential features: • The law defines health information organizations (HIOs) and permits providers and clinical laboratories to securely share health information through an HIO, so long as HIPAA privacy requirements are met.

Melissa Kotrys, CEO, Arizona Health-e Connection information exchange (HIE).

This meant a collaborative effort in 2011 to lead community support for passage of House Bill 2620 which helped enable statewide HIE in Arizona. The passage of House Bill 2620 began the process of meeting the requirements of the law and providing a valuable statewide HIE platform (today simply called The Network) to provide more complete patient information and enable better care coordination and transitions of care for Arizona providers and their patients.

30 AZMedicine | Summer 2015

• The law allows any patient or consumer to “opt out” of participating in an HIO, restricts how HIOs may use health information and requires HIOs to have policies in place to protect the privacy and security of the health information that they handle.

• The law defines the notification and “opt out” process that participating providers must have in place for their patients.

Statewide HIE for Arizona providers Two community HIEs were combined in 2010 to form Arizona’s statewide HIE,

Health Information Network of Arizona (HINAz). HINAz had strong support from Arizona health care stakeholders, including hospitals, health plans and a statewide reference laboratory, to implement a statewide HIE platform.

Beginning in 2012, HINAz was able to offer HIE options for Arizona providers that included view-only access to patient information, bidirectional exchange for sending and receiving patient information and the provision of clinical data for health plans for care management purposes.

In early 2014 AzHeC and HINAz combined operations, and at that point, AzHeC looked at changes in the market and what would be required to meet the emerging needs of Arizona providers in the future. It was clear that change was needed quickly.

So, in less than a year, AzHeC went from a thorough vendor selection and contract negotiation process to the development of a new funding model and a major data migration, culminating in the launch of new and expanded services. This past April the

new services and technology platform went live, a remarkable turn-around made possible by the active involvement of the AzHeC and Network Boards of Directors and The Network’s Participants, as well as a lot of hard work by the AzHeC staff.

A Design with Providers in Mind What drove this rapid turnaround was a recognition from the start that a successful statewide HIE meant meeting the practical information and workflow needs of providers – a design with providers in mind. The design of the new statewide HIE was based on meeting a few basic needs of providers: • Practical, actionable information that integrates into the workflow of a practice An immediate and tangible benefit of Network participation is the ability to send and receive direct, secure messages among Network participants. Not only does this enable private and secure communication with other participants, this

direct messaging function enables another key benefit: the receipt of real-time alerts and notifications.

Providers are able to provide a list of patients to The Network, typically high-risk patients, and The Network can send an alert when a patient is admitted, transferred or discharged from a hospital and provide a notification when a patient has an out-of-range clinical or lab result. These real-time alerts and notifications integrate easily into workflow, enabling earlier interventions and, in some cases, even enhancing reimbursement when patients are seen within a short window after a hospital discharge.

• Services and assistance in meeting Meaningful Use Stage 2 There are several objectives and measures of Meaningful Use Stage 2 that can be more easily met through the services of The Network.

Care summaries can be sent electronically for transitions

of care and referrals. In addition, the Network’s public health reporting service allows Network participants to submit state and federally required public health information from their certified electronic health record (EHR).

The types of reporting available include immunizations, syndromic surveillance, reportable labs, and reportable diseases.

These services all enable and assist with meeting Meaningful Use Stage 2.

connectivity. There are no separate interface fees or other add-on fees, just one single participation fee.

• Provider participation and integration costs as low as possible In creating the funding model to support The Network, there was agreement among staff and Board members to keep provider participation costs as low as possible. As a result, the new funding model places 95% of the operational funding responsibility on hospitals and health plans,

• Direct secure email • Public health reporting • Connection to eHealth Exchange (national network) The potential of the new Network platform and services is difficult to overstate. While Arizona enjoys robust and growing HIE that is connecting providers, hospitals, health care systems and payers across the state, The Network is the community asset and network of networks that enables better care coordination, improved transitions of care and more

In early 2014 AzHeC and HINAz combined operations, and at that point, AzHeC looked at changes in the market and what would be required to meet the emerging needs of Arizona providers in the future.

• Bundled services for participating providers In the funding model for the new services and technology of The Network, providers receive a bundled set of services for a single participation fee.

This includes bidirectional exchange, unlimited provider/payer portal access, unlimited Direct secure email accounts and unlimited alerts and notifications.

In addition, this single fee also includes eHealth Exchange connectivity and public health reporting

with just 5% of the funding responsibility borne by providers. What this means for providers is an annual provider participation fee of $250, with volume discounts for groups of providers.

A Summary of Key Services The key services of the new Network technology platform include: • Bidirectional exchange • Alerts and notifications

informed care decisions. If you would like more information on the new Network services and technology platform or if you would like to discuss joining The Network, please contact a Network representative at (602) 688-7200 or thenetwork@azhec.org. 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.

• Provider and payer portals Summer 2015 | AZMedicine 31

HSAG

Vistas

Health Policy: Creating Value for Patients and Providers “The bottom line: healthcare reform is about the patient, not about the physician” —Abraham Verghese

By Howard Pitluk, MD, MPH, FACS & Mary Ellen Dalton, PhD, MBA, RN The Affordable Care Act (ACA) of 2010 did much more than provide insurance coverage for millions of Americans who had previously been uninsured or underinsured. A major component of this landmark legislation was the creation of a National Quality Strategy (NQS) that had as a primary objective a redesign of Medicare’s feefor-service payment structure. Medicare adapted the NQS’ three cornerstone domains of better care for individuals, better health for populations and communities, and lower cost through quality improvement to inform its own evidence-based quality strategy with the express goal of becoming an active purchaser of quality healthcare instead of a passive payer for medical services.

A major component of the ACA was mandating that all providers gradually adopt an electronic health record (EHR). Using the efficiencies found in EHRs, the physician’s role in the provision of healthcare has expanded. In addition to the traditional responsibility for individual care, today’s physician practice model embraces the concept of population health with the purpose of involving providers, stakeholders, patients, and communities in creating a connected and interactive healthcare system rooted in evidencebased best practices. This approach promotes, maintains, and restores health not only through treating disease and injury, but also by incorporating the latest advances in technology while staying current in healthcare and reimbursement policies. Fortunately, physicians do not have to go it alone. Professional organizations, specialty societies, and governmental programs like the Medicare Quality Innovation Network-Quality Improvement Organization (QIN-QIO) stand ready to offer assistance at no cost in order for the practice of medicine to achieve the lofty policy goals set forth in the NQS.

32 AZMedicine | Summer 2015

Policy and Quality Improvement An increasingly aging and chronically ill population has necessitated the shift toward a population health model of care in the United States. Standards rooted in evidence-based medicine, such as diabetes and cholesterol management and cardiovascular treatment and prevention protocols, are tied to an electronic reporting system through the EHR that allows physicians to monitor the care they are giving and payers to gauge the quality of that care.

These evidence-based standards, created by physicians for physicians, inform the federal healthcare payment policy, which is evolving into a pay-for-performance (P4P) model grounded in the practice of good medicine. This payment policy has fostered accountability through the public reporting of data and has led to

A major component of the ACA was mandating that all providers gradually adopt an electronic health record (EHR). a more transparent and open system of healthcare delivery than in any previous time. The intent of these healthcare policies is positive, although their provisions are often perceived as burdensome to physicians who must make adjustments to their practice patterns in order to achieve the incentive payments to which they are entitled. The Medicare QIN-QIO Program can help physicians and other healthcare providers by working with them to meet these regulatory requirements and establish a practice work flow that creates value for the patient, the provider, and ultimately the Medicare Trust Fund.

History of the QIO Program In 1972—seven years after Medicare and Medicaid were signed into law, Congress legislated that entities known as Medicare Professional Standards Review Organizations be created with

physician oversight of quality of care locally. Over time, these organizations assumed new, legislated roles focused on protecting Medicare beneficiaries from underutilization of necessary healthcare services and premature discharges from the hospital. In 2002, the program was renamed the Quality Improvement Organization (QIO) Program in recognition of the increasing emphasis on the quality of care being mandated and paid for by the Centers for Medicare & Medicaid Services (CMS) and expanded into other settings that included nursing homes, home health agencies, and physician offices. In August of 2014, the QIO Program was split into two separate entities: one dealing with beneficiary protection (Beneficiary and Family-Centered Care QIOs) and the other focused on quality initiatives (QIN-QIOs). Today, the two Medicare QIO programs, directed by CMS, are the largest federal programs dedicated to improving healthcare quality at the federal, state, and local levels.1

fundamental changes. However, physicians need not tackle these changes alone. By breaking down silos and understanding the inherent interconnectedness of the healthcare system, physicians will be better equipped to face the challenges of 21st century medical practice. Using the extensive support network available through HSAG for knowledge sharing, improving communication, and creating collaboration, providers can improve individual care, create healthy communities, and lower costs for generations to come. AM

Payment and Quality Improvement

Howard Pitluk, MD, MPH, FACS, 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, and Keith Chartier, MPH, Communications Project Manager, at Health Services Advisory Group, assisted with this article.

As the Medicare QIN-QIO in Arizona, California, Florida, Ohio, and the U.S. Virgin Islands, Health Services Advisory Group (HSAG) has extensive partnerships across its states and territory with providers, stakeholders, organizations, and government to improve the health of all it serves—with particular emphasis on the most vulnerable populations. HSAG’s mission is closely aligned with the NQS and focused on programs and processes that are most effective in promoting evidence-based strategies that create value.2 For example, HSAG’s current work supports physicians and providers with incentive programs like Hospital Value-Based Purchasing and the Physician Quality Reporting System (PQRS).

In addition, HSAG’s work aligns with programs that facilitate reimbursement by helping hospitals, nursing homes, home health agencies, and physician offices reach benchmarks that increase payment and preclude penalties. These programs, mandated through public policy legislation, are shifting the practice of medicine to a value-based reimbursement model that rewards high-quality care as demonstrated through improved outcomes. Between 2011 and 2014, QIOs nationally helped the healthcare community prevent more than 95,000 Medicare beneficiaries from being admitted to the hospital and 27,000 from being readmitted, resulting in nearly $1 billion in cost savings to the Medicare program.3 As a result, hospitals and Accountable Care Organizations were able to take advantage of the shared savings and incentives associated with these payment models, creating a “win-win-win” for hospitals, providers, and most of all patients. Moreover, similar value-based purchasing models are now part of CMS payment policy implementation for individual physician’s offices, with EHR reporting of quality measures leading to value-based incentive payments.

1 VHQC. Advances in Quality: QIO Program Progress Report, July 2011.

Available at: https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/QualityImprovementOrgs/downloads/ QIO_ProgressReport_July2011.pdf. Accessed on: May 15, 2015.

2 James J. Health Policy Brief: Pay-for-Performance. Health Affairs, October 11, 2012. Available at: http://www.healthaffairs.org/healthpolicybriefs/brief. php?brief_id=78. Accessed on: April 16, 2015.

3 American Health Quality Association. QIO Program 10S0W Progress Fact Sheet. Available at: http://www.ahqa.org/quality-improvement-organizations/ how-qios-improving-health-care. Accessed on: April 30, 2015.

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-052215-01

Technology, payment methodologies, and public policy, essential components of the modern healthcare system, are undergoing Summer 2015 | AZMedicine 33

AHCCCS

Physician Solutions to the Prescription Drug Misuse and Abuse Epidemic

By Sara Salek, MD, Chief Medical Officer, AHCCCS As the physician community, we serve a critical role in reducing the toll of prescription drug misuse and abuse. We have a difficult task of weighing the risks vs. benefits of treatment with controlled medications with our patients, ultimately determining what will provide our patients with the most benefit while minimizing risk of misuse and abuse. The following two strategies are aimed at assisting us in making safe and informed clinical decisions:

“Prescription opiates have become a gateway drug.”

—CDC Director Thomas Frieden, MD Utilizing best practice guidelines The following are two best practice guidelines developed by the Arizona Department of Health Services (ADHS) in collaboration with multiple stakeholders: Prescribing Opioids for Acute and Chronic Pain http://www.azdhs.gov/clinicians/documents/clinical-guidelinesrecommendations/prescribing-guidelines/141121-opiod.pdf Emergency Department Controlled Substances Prescribing Guidelines http://azdhs.gov/phs/owch/pdf/injuryprevention/az-emergencyprescribing-guidelines.pdf Although not all-inclusive, they provide guidance to physicians managing acute and chronic pain as well as those working within the Emergency Department setting. There are many other practice guidelines available depending on your field of practice.

34 AZMedicine | Summer 2015

Utilizing The Controlled Substances Prescription Monitoring Program (CSPMP) The CSPMP provides a central repository of all prescriptions dispensed for Schedule II, III, and IV controlled substances in Arizona. Before prescribing a controlled medication to a patient, it is recommended that the CSPMP be checked in order to make an informed decision about the risks vs. benefits of treatment. As a reminder, A.R.S. § 36-2606 requires each medical practitioner who is licensed under Title 32 and who possesses a DEA license to register with the CSPMP. There is no fee to the practitioner for this registration. Register and access the CSPMP at https://pharmacypmp.az.gov/. AM

The ArMA Committee on Public Health was charged by resolution 10-14, “Comprehensive Action for Drug Poisoning Epidemic” to survey and continuously monitor the CME market place for high quality CME regarding the use and management of controlled substances. The ArMA Committee on Public Health has reviewed and identified the four courses below to recommend as CME resources for ArMA physicians. These courses are not intended to be an exclusive list, but rather resources that have been vetted by members of the Committee.

Prescription Drug Misuse and Abuse http://www.vlh.com/ AZPrescribing/ Arizona Department of Health Services, Arizona School of Medicine, Arizona School of Public Health, and 2 hours CME, Free Treating Chronic Pain http://www.coperems.org/ University of Washington School of Medicine 206-685-3184

Chronic Pain Syndromes: Current Concepts and Treatment Strategies (#98700) CME Resource, www.NetCE.com 1-800-232-4238 15 hours CME, Cost = $39.00 Extended-Release and Long-Acting Opioid Analgesics Informed Continuing Medical Education 1-800-237-6999 3 hours CME, Cost = $50.00

4 hours CME, Free

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Quality of Care Analysis in the Medical Practice There are many definitions of quality of care, but the Institute of Medicine (IOM) has proposed one that captures the features of many other definitions and has received wide acceptance. “The degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge.” The IOM has identified seven specific aims of high quality care: SAFE – avoiding injuries to patients from the care that is supposed to help them.

EFFECTIVE – providing services based on scientific knowledge to all who could benefit and refraining from providing services to those not likely to benefit (avoiding underuse and overuse).

PATIENT-CENTERED – providing care that is respectful of and responsive to individual patient preferences, needs, and values and ensuring that patient values guide all clinical decisions.

TIMELY – reducing waits and sometimes harmful delays for both those who receive and those who give care.

EFFICIENT – avoiding waste, in particular waste of equipment, supplies, ideas, and energy.

EQUITABLE – providing care that does not vary in quality because of personal characteristics, such as gender, ethnicity, geographic location, and socioeconomic status.

How does a physician medical practice establish a QA Committee and ensure peer review protection? The applicable Arizona quality assurance statutes are under ARS 36-2401 to 36-2404. This statute was recently amended to mirror hospital review statutes, ARS 36-445 et seq. The amended statute, effective July 3, 2015, specifically includes group medical practices as a healthcare entity that may, but is not required to, perform quality assurance activities. Medical group QA activities will remain confidential and protected from discovery in medical malpractice cases, provided that the QA process adopted and followed by the medical group 36 AZMedicine | Summer 2015

Medical group QA activities will remain confidential and protected from discovery in medical malpractice cases, provided that the QA process adopted and followed by the medical group includes written standards and criteria. includes written standards and criteria. The intent of the statute is to encourage more healthcare entities to conduct and share quality assurance information without fear of waiver of privilege. The amended statute also: • Allows a healthcare entity to share quality assurance information with appropriate state licensing or certifying agencies and with licensed healthcare clinicians who are the subject of quality assurance activities.

• Allows a healthcare entity to share quality assurance information with other healthcare entities only for the purpose of conducting quality assurance activities.

• States that a healthcare entity or person that receives information and that participates in quality assurance activities is not subject to liability for civil damages or any legal action in consequence of such action except for injunctive relief provided for in A.R.S. 36-445.02.

• Allows healthcare entities to jointly conduct quality assurance activities.

• Does not preclude liability arising from treatment of a patient, from negligent credentialing decisions, or from an allegation that the QA activities were inadequately or negligently conducted.

• Does not preclude discovery of information that is otherwise discoverable, such as a patient’s medical records.

To successfully use the privilege and assert that QA performed by the medical group remains confidential and protected from discovery in civil litigation, it is important for the group to carefully structure and follow its written QA policy. Although the statute does not specify the written standards and criteria for the process, a QA policy typically contains the following elements: • A statement that the purpose of the policy is to assure that there is a QA process to investigate the quality of healthcare by a review of professional practices and behavior to improve clinical and organizational performance.

• The matters addressed are confidential pursuant to ARS 36-2401 et seq.

• Definitions of the quality assurance process and how case review is conducted.

• The components of the program such as: • Composition of the QA Committee.

• Circumstances triggering QA review which include

quality of care and behavioral issues.

• Procedure for QA review, including coding determinations and corrective action.

• Preparation of QA minutes to maintain confidentiality.

• A methodology to assure consistency and effectiveness and, • Annual program evaluation.

If a medical group adopts a QA written process and consistently follows it, it is likely its process and its QA documents will withstand any legal challenges to maintaining the privilege of confidentiality from discovery in civil litigation and protection from liability while serving to improve patient care. AM

MACRA Continued from page 27

of HHS may withhold portions of payments to incentivize the reporting of information. After the information is collected, the Secretary will reassess the values for services with a global period every four years.

Summary Although the annual SGR battle is over, MACRA has a number of provisions that need to be addressed in Rulemaking, and how the APM and MIPS bonuses work in practice may result in new challenges and disappointments. As the population ages, there will continue to be cost pressures, and continued efforts to improve quality. The return of inflation alone could pose a significant problem for physicians locked into small annual fee-for-services increases. If all goes well, HHS will continue its dialogue with providers as the law is implemented, and Congress, in contrast to the Affordable Care Act implementation, will be willing to address in a bipartisan manner any unforeseen challenges or glitches in the law. AM Paul J. Giancola, JD, is a partner in the Healthcare Practice Group, Snell & Wilmer, LLP, Phoenix, Arizona.

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COMMENTARY

Arizona Providers, You Have Reporting Requirements

By Lisa Villarroel, MD, MPH What do diagnoses of syphilis, pesticide exposures and melanoma have in common? Under Arizona Administrative Code Title 9, providers must report them to public health.

Providers have their own reporting requirements, separate from those of laboratories. Public health agencies depend on reports from providers to identify outbreaks, environmental threats, cancer trends, and to protect the overall health of Arizonans.

Arizona County Health Departments Apache County - 928-337-4364 Cochise County - 520-432-9400 Coconino County - 928-679-7272 Gila County - 928-402-8811 Graham County - 928-428-1962 Greenlee County - 928-865-2601 La Paz County - 928-669-1100 Maricopa County - 602-506-6767 Mohave County - 928-753-0714 Navajo County - 928-524-4750 Pima County - 520-724-7770 Pinal County - 520-866-7325 Santa Cruz County - 520-375-7900 Yavapai County - 928-771-3134 Yuma County - 928-317-4450

1. Communicable diseases These are diagnoses made every day – the complete list is available at azdhs.gov/phs/oids/pdf/rptlist.pdf. The classic public health diseases such as HIV, meningitis and pertussis are reportable, but so are hepatitis, cocci and Salmonella. Some diagnoses require only a provider suspicion (see telephone icons on list).

When provider-suspected measles cases were not reported earlier this year, it caused a delay in outbreak management.

2. Environmental threats These diagnoses include pesticide-related illnesses and elevated blood lead levels. Both conditions can trigger environmental investigations, as did one recently that ultimately identified imported spices as the source of lead.

3. Cancer From colon cancer to melanoma – providers must report cancers diagnosed in the outpatient setting. Lack of provider reports impacts public health statistics: melanoma rates in Arizona appeared to be decreasing!... but the drop was actually due to a decrease in provider reports. Again, laboratories have different reporting requirements; providers have their own duty to report outpatient cancer cases.

Legal requirements aside, provider reporting affects public health outcomes and the ultimate health of Arizona. Which in the end, is the mission of both public health and clinical providers.

Disease reporting forms can be found at the following locations: Communicable Diseases: www.azdhs.gov/phs/oids/pdf/forms/cdr_form.pdf Pesticide Illnesses: www.azdhs.gov/phs/oeh/children/pesticides/reporting.htm; Elevated Blood Lead levels: www.azdhs.gov/phs/oeh/children/lead/reporting.htm; Cancer: http://www.azdhs.gov/phs/phstats/cancer-registry/ case-reporting.htm

38 AZMedicine | Summer 2015

Supervising Editor Michael F. Hamant, MD

AzMedicine Advisory Council Robert W. Bina Marshall B. Block, MD Jacqueline Chadwick, MD Ronnie Dowling, MD Michael F. Hamant, MD M. Zuhdi Jasser, MD Phil Keen, MD Marc Leib, JD, MD J. Michael Powers, MD Mary E. Rimsza, 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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Daniel M. Lieberman, MD Maricopa Director Robert J. Marotz, DO Rural Director Timothy M. Marshall, MD Pima Director Jeffrey T. Mueller, MD Immediate Past President, Executive Committee Robert R. Orford, MD At Large Director Traci Pritchard, MD Secretary Allison Rosenthal, DO At-Large Director Thomas C. Rothe, MD Outgoing Past President, Executive Committee Susan M. Whitely, MD Treasurer, Executive Committee

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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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