REP April 2022 by BOC design Inc

vol.30 no.4 • April 2022

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HardEarned Lessons Amidst the pandemic’s challenges, physicians gain insights.

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We know it’s been a challenging year, and it matters that we made it through together. That’s what trusted partnerships are all about. Our experienced sales and service teams are always here to help ensure your success, providing diagnostic products that deliver the highest quality results. Because for you, for us, and for your customers, every result matters. POINT-OF-CARE READER

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APRIL 2022 • VOLUME 30 • ISSUE 4

HardEarned Lessons Amidst the pandemic’s challenges, physicians gain insights.

PUBLISHER’S LETTER

TRENDS

Honoring a Legend............................... 2

Primary Care Takes Center Stage Primary care physicians are the key to providing value-based care and population health.......................................... 36

PHYSICIAN OFFICE LAB Taking it Home A look at the emerging home testing market........................................ 4

ROAD WARRIORS PODCAST ‘This is a Great Business’ Quidel’s Mike Abney on medical distribution, leadership, and mentoring the next generation of sales reps................ 10

IDN OPPORTUNITIES Hospital @ Home More and more providers are turning to acute care in the home. But how effective, and safe, is the new model?.......... 12

IDN NEWS IDNs in the News................................... 20

BOOK REVIEW Are We Making Money Yet?

Rising Health Insurance Costs New report finds that working families shoulder increasing share of health insurance costs................................... 41

Breaking The Rules of Healthcare: Selecting The Best Technology Several modern technologies could positively and powerfully transform patient care. So why aren’t physicians using them as much as they could?............ 42

NEWS Primary Care News.............................. 45

TRENDS Next-Gen Blood Tests Theranos made a hasty exit, but blood-based diagnostics for cancer detection are beginning to settle in............ 46

HEALTH NEWS Health News and Notes................... 52

MARKETING MINUTE Lessons healthcare manufacturers can learn from other industries about medical device reprocessing.............................................. 54

HIDA Bipartisan PREVENT Pandemics Act Will Advance Preparedness................. 56

LEADERSHIP How to Have Tough Conversations with Confidence.................................................. 58

NEWS Industry News........................................... 60

Book Review: Profit Guide for the Small Distributor.............................. 32

Subscribe/renew @ www.repertoiremag.com : click subscribe repertoire magazine (ISSN 1520-7587) is published monthly by Share Moving Media, 1735 N. Brown Rd. Ste. 140, Lawrenceville, GA 30043-8153. Copyright 2022 by Share Moving Media. All rights reserved. Subscriptions: $49.00 per year for individuals; issues are sent free of charge to dealer representatives. If you would like to subscribe or notify us of address changes, please contact us at the above numbers or address. POSTMASTER: Send address changes to Repertoire, 1735 N. Brown Rd. Ste. 140, Lawrenceville, GA 30043-8153. Please note: The acceptance of advertising or products mentioned by contributing authors does not constitute endorsement by the publisher. Publisher cannot accept responsibility for the correctness of an opinion expressed by contributing authors. Periodicals Postage Paid at Lawrenceville, GA and at additional mailing offices.

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April 2022

PUBLISHER’S LETTER

Honoring a Legend Where does one start when honoring a

legend? Richard Riley was a legend in our industry, yes. He was also a legend of Jacksonville Beach where he served on the Life Saving Corps for more than 50 years and twice as president. He was a legend at St. Paul’s Catholic Church where he was born, baptized, married, and remembered by over 500 people during his funeral in March. Most imScott Adams portant, he was a legend to his family, from his son Doug Riley and brother-in-law Doug Barrow, to his son-in-law and oldest grandson. I cannot remember a more impressive service about anyone I’ve ever known. Trying to fit who Richard was in this Publisher’s Letter isn’t possible, so I will instead tell you a few stories about this amazing human being. At the age of 16 while working at a restaurant in Jacksonville called Stricklands, Richard worked with a young man who was deaf. Richard took it upon himself to learn sign language so he could talk with him, ensuring he wouldn’t feel left out. As a founding member of PSS, Richard impacted thousands of lives. When we announced his passing in the Dail-eNews, I received no less than a 100 Thank You notes and countless stories about Richard. One that struck me was a young woman working at PSS corporate. Richard found out her car was in the shop, so he drove her to work for the next week. When it came time to pick up her car, he paid for the repairs. Richard had his entire family at Ruth Chris for a dinner a few months back. The day before the dinner his grandson, who seemingly was a chip off the old block, said, “Papa I’d rather just have McDonalds.”

As the servers brought out the spread, one meal was missing. Richard set him up and a beautiful happy meal box was placed on the table. Fortunately, it had a Ruth Chris steak in it. He also loved pranks. Three weeks ago, Richard called me out of the blue because I told a story about him on a podcast. I got a few of the facts wrong and he wanted to bust my chops. He had me laughing for the next 30 minutes. I’m forever grateful for that phone call. It had been over a year since I had last spoken to him. Richard Riley – husband, father, brotherin-law, grandfather, mentor, volunteer, lifeguard, businessman, friend, prankster, and legend. I will never think about Richard and not smile or laugh. He made everyone better. In honor of this legend, I would like to leave you with this life lesson: Don’t let years go by while not talking to the people you love and respect. As thankful as I am for that call, I wish I would have talked to him every week. There was never a call, meeting, or interaction with Richard that I didn’t gain something from. Dedicated to the industry, R. Scott Adams

Repertoire is published monthly by Share Moving Media 1735 N. Brown Rd., Suite 140, Lawrenceville, GA 30043 Phone: (800) 536-5312, FAX: (770) 709-5432; e-mail: info@sharemovingmedia.com; www.sharemovingmedia.com

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Thanks for your partnership To our distribution partners across the country, our sincerest thanks. You have been instrumental in helping Quidel provide access to crucial diagnostic tools, improving human health for millions in need. Together we faced unforeseen obstacles, from supply chain disruptions to emerging variants, all while never losing sight of our customer’s needs during the urgency of COVID-19 test distribution. Our shared efforts have empowered individuals to take charge of their health and removed barriers to testing access for communities across the country. For this and so much more, the entire Quidel Team thanks you. We look forward to continuing to work alongside you, instilling health conﬁdence in millions.

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PHYSICIAN OFFICE LAB

Taking it Home A look at the emerging home testing market.

With the emergence of the COVID-19 pandemic, most of us have spent more time at home in the past two years

than in previous years. Sheltering-at-home mandates, companies offering employees the flexibility to work from home and good common sense have changed our behavior in many ways, especially in what home means to us. More time at home has changed life in many ways: home sales are up substantially as well as home improvement projects, probably reflective of our desire to improve the environment where we are spending so much time. Testing and healthcare visit patterns have undergone significant change as well. Virtual visits have grown rapidly, pop-up testing facilities offering either on-site testing or on-site sample collection for testing in a clinical lab have emerged as a significant trend. Unsurprisingly, testing at home either under a physician prescription or by patient direction has become a dominant factor particularly for SARS CoV-2 antigen (COVID-19) detection. Under EUA, there were 17 COVID-19 antigen detection kits available for home use at press time. The U.S. federal government has implemented a program to provide four home use COVID-19 antigen tests per house4

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By Jim Poggi

hold. At least 500 million tests are planned for distribution under this program and the first wave of tests has already become available. In addition, the Health Resources and Services Administration (HRSA) of the Department of Health and Human services is providing HRSAsupported healthcare centers and Medicare certified rural health clinics with no cost COVID-19 antigen test kits for patient distribution.

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PHYSICIAN OFFICE LAB Though the proposed OSHA mandate of “test or vaccinate” stalled out in the courts, some employers are initiating home testing for employees as an element of their workplace safety and health program. Home use tests are popping up everywhere and they are new. Or are they? In this column I plan to look at the emergence of home testing, its current state and to speculate a bit on how it’s likely to evolve over time.

reported into the patient record sporadically through patient: care giver interaction. In the early going, EMR was not available to capture this data. It seemed that new tests would follow this pattern.

will continue to grow and provide a surprising array of new tests and deployment of testing technology unheard of just a few years ago.

Home under change: smart phone, EMR, cloud data storage and digital results

Availability of home testing for COVID-19 has posed a dilemma regarding data: How do we report the result, assure its accuracy and transport it into the patient record? IT to the rescue; there are several smartphone applications that record the test process, document the result photographically, time stamp when it was created, report it to the requester and those they give permission to see it (employers and care givers) and even post in into EMR. Fundamentally, this changes everything. Benefits include assurance that test results can be automatically reported, can be assured to be accurate and that results can be presented to the patient and care giver for proper patient care. These are all arguably good things. Yet, they do come with costs, concerns and questions. What about data privacy and cybersecurity? What about standardizing results of a specific test among different methods? Can they be equivalent? If not, how can they be compared for meaningful data across patients and technologies? What kind of damage can result from a large-scale data breech?

Changes in technology, even before COVID-19 hit, began to change this

For many years, home testing involved a narrow range of tests, mostly available through the patient’s pharmacy. Home glucose testing and urinalysis dominated the market until the development of CLIA-waived lateral flow tests for pregnancy, which created the next wave of test expansion. Home then: land line, paper patient records and visually read tests For many years, home testing involved a narrow range of tests, mostly available through the patient’s pharmacy. Home glucose testing and urinalysis dominated the market until the development of CLIA-waived lateral flow tests for pregnancy, which created the next wave of test expansion. Pregnancy, fertility testing and urinary tract infection tests have become commonplace in the past 30 years. Fast forward and home drug tests for marijuana, amphetamines and several other drugs have entered the market and are widely available. Other than glucose tests that deliver quantitative results, the majority of these assays had a few things in common: they were CLIA waived, used lateral flow technology, qualitative (presence or absence) and used urine as a sample. Results were visually read and only 6

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pattern. Continuous glucose monitoring systems use a combination of patient sensors coupled with smart phone applications to replace frequent daily finger stick testing with continuous transdermal monitoring of patient’s glucose without a blood sample. In parallel, the deployment of EMR technology provided a pathway to capture off site testing data for later management and reporting. Smart phone applications and cameras, along with cloud storage of data, meant that data could be collected, documented by photo, transmitted, and stored in EMR or elsewhere with relative ease. Data that previously would be available to only the user and perhaps their care giver could now become part of the patient record. These technologies set the stage for the revolution we are just beginning to experience surrounding COVID-19, and which I predict

Home becoming a connected testing site

Home becoming a dominant testing site? Once again, COVID-19 proves that the pressure created by change drives progress. Home testing under EUA for COVID-19 antigen has become the gateway to challenge WHAT we can and should test for at home. At the same time, as saliva samples have proven to be acceptable for COVID antigen tests, they’ve expanded the

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PHYSICIAN OFFICE LAB

non-invasive sample types available and lead to the question of what else can we properly test using saliva. Forward thinking university and commercial research facilities have now demonstrated that molecular assays can be performed at home using a simple, relatively inexpensive analytical platform coupled with the cell phone to create a RT-LAMP assay for COVID-19. This is not a commercial reality at present, but points to at least one future direction: previously expensive and sophisticated technology CAN be down scaled to provide results at home or other non-laboratory settings.

The home/POL connection Among the questions that remain to be answered are not only the complex issues related to data collection, management, security and 8

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Availability of home testing for COVID-19 has posed a dilemma regarding data: How do we report the result, assure its accuracy and transport it into the patient record? ownership, but also how home testing will impact testing in centralized sites, such as hospitals, private reference labs and the POL. Which tests will be available and cleared for use at home? What sort of proficiency tests will be needed? Will home testing be only for the worried well? Will it be accepted by the mainstream clinical community which has been slow to embrace change? Will results from the same test type from disparate technologies be sufficiently similar to co-exist? Once EUA is terminated, will the 510(k) process inhibit or accelerate deployment of testing

outside the typical lab environment? There is tremendous promise in the future for more and better testing to be available when and where needed to initiate or modify a patient treatment program. Nonetheless, there are several issues to be resolved for the pathway to the future of testing to be clear. One thing is certain: we are not going back to the days where the patient was only the recipient of patient testing. Patients are now squarely involved in determining the future state of lab testing. Your voice counts in the direction of future testing. Be informed; be heard.

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Internalclinical clinicaldata dataheld heldon onfile file2.2.ID IDNOW™ NOW™RSV RSVProduct ProductInsert Insert 1.1. Internal TheID IDNOW NOWTMTMCOVID-19 COVID-19product producthas hasnot notbeen beenFDA FDAcleared clearedoror approved. been authorized FDA under an Emergency Authorization (EUA) for use by authorized laboratories and patient settings. Thehas testbeen has been authorized only the detection of nucleic acid from The approved. It It hashas been authorized byby thethe FDA under an Emergency UseUse Authorization (EUA) for use by authorized laboratories and patient care care settings. The test authorized only for thefor detection of nucleic acid from SARS-CoV-2,not notfor forany anyother otherviruses virusesororpathogens, pathogens,and and only authorized the duration declaration that circumstances exist justifying authorization of emergency use in vitro diagnostic for detection and/or diagnosis of COVID-19 Section 564(b)(1) the21Act, 21 U.S.C. SARS-CoV-2, is is only authorized forfor the duration of of thethe declaration that circumstances exist justifying thethe authorization of emergency use of inof vitro diagnostic teststests for detection and/or diagnosis of COVID-19 underunder Section 564(b)(1) of the of Act, U.S.C. 360bbb-3(b)(1),unless unlessthe theauthorization authorizationisisterminated terminatedoror revoked sooner. 2022. rights reserved. trademarks referenced trademarks of their respective owners. photos displayed areillustrative for illustrative purposes Any person depicted inphotos such photos is a model. COL-10047 §§360bbb-3(b)(1), revoked sooner. ©© 2022. AllAll rights reserved. AllAll trademarks referenced areare trademarks of their respective owners. AnyAny photos displayed are for purposes only.only. Any person depicted in such is a model. COL-10047 02/2202/22

ROAD WARRIORS PODCAST

‘This is a Great Business’ Quidel’s Mike Abney on medical distribution, leadership, and mentoring the next generation of sales reps. By Pete Mercer

In a recent episode of Repertoire’s podcast Road Warriors and Their

Breaking into the industry

Untold Stories, Mike Abney spoke with Repertoire publisher Scott Adams about his career, the mentors he’s worked with over the years, and the state of the healthcare industry. Abney is the Senior Vice President of North America Sales & Distribution for Quidel, where he’s worked since 2015. Abney is also a recipient of the 2021 John F. Sasen Leadership Award from HIDA. The John F. Sasen Leadership Award recognizes exceptional individuals who demonstrate the qualities of leadership, commitment, and service that made John Sasen an icon in the industry.

Abney started out at PSS World Medical, Inc., in 1989, helping the company move into its first big Jacksonville warehouse. He intended to work for a bank but was encouraged by Pat Kelly to come and join PSS, starting out in the warehouse. In the ’90s, Abney ran operations with

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PSS before being promoted to VP of Supplier Management. He joined Quidel in 2015. In fact, he has used the way he broke into the industry as a way to encourage the next generation to consider a career in medical sales and distribution. Abney said, “I have finally hit the age where a lot of people I’ve worked with over the years, their kids are actually coming into the industry. My son and several of his best friends started in the business in the last couple of years. I’m seeing a lot of that, and I think that says a lot right there that people would go to their own kids and say, ‘This is a great business.’” He encourages the younger generations to jump in wherever they can. “I’ve told many people over the last five years, just get in on the sales side somewhere. Start anywhere you can. If you’re more inclined to be on the ops side do that. But there’s still a very clear path to success on the sales side. I think if you get in where you can, take care of customers and work hard, great things are going to happen for you.”

Working with distinguished leaders Along the way, Abney has had the opportunity to work with distinguished leaders in the industry like Pat Kelly, Richard Riley, Bill Riddel, Doug Barrow, Doug Bryant, and the namesake of the HIDA leadership award, John Sasen. Abney said, “In my time shadowing him, I never saw anybody that was able to get along with everyone and be liked by everyone as much as John. I knew that was unattainable. But if I could get half of the people in the industry to work with me the way he does everyone, I can still have a pretty darn good career. He

was one of those people that loved to negotiate and debate, but he was just one of the nicest people that you could ever meet.” Sasen operated with the mindset of “win-win,” which is used in negotiations to ensure that each party comes out with a positive result. According to Abney, John’s ability to build friendships with people on the other side of these negotiations was unique. “When I started working with John, I thought that ‘win-win’ was me losing. He taught me and many others that worked with him that there are plenty of ways that everybody can come out happy at the end, and he was the master of that. He could work with anyone and build an immediate bond and friendship with that person and still get the job done.”

tributors, some even very large. And those companies are mostly part of McKesson or Henry Schein, all the larger distributors today. Moving to the manufacturing side, I can tell you it’s easier to deal with seven to ten organizations than hundreds.” Because these relationships are with larger companies, it puts greater pressure on the relationships themselves. “It’s allowed for huge technology advances in supply chain, which has led to better fill rates and consistent service for customers. Doctors used to expect delivery in four to five days. Now, they expect to get something they’ve ordered the very next day.” Even with these differences, having the bigger companies be a larger part of the picture has allowed for more positive changes. There’s better

“ I think if you get in where you can, take care of customers and work hard, great things are going to happen for you.” For Abney, winning the John F. Sasen Leadership Award was “probably the best thing that’s happened to me.” Working with Sasen over the years and learning how to better negotiate for his company and the other party has been a huge point of inspiration in Abney’s life.

Changes in the industry In the years since Abney joined the medical sales and distribution business, the industry has gone through several radical transformations. As new innovations and technologies are introduced, the industry has had to adapt and develop new processes for each change. Abney said, “In 1989, even into the ’90s, there were hundreds of independent dis-

forms and methods of communication, information materials, and an industry group that’s gotten better at influencing people in the right way to help everyone perform better. Despite all the challenges presented by the pandemic, the industry was forced to change and adapt to keep supplies moving. Abney found that the pandemic has even helped the industry grow, saying, “Even in the last two years, we lost the meeting in-person every three to six months format, which we had gotten used to. And somehow, we’ve become more efficient. The challenges that the pandemic presented really challenged the cohesiveness that we were used to, and it has somehow made us better.” www.repertoiremag.com

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April 2022

IDN OPPORTUNITIES

Hospital @ Home More and more providers are turning to acute care in the home. But how effective, and safe, is the new model? By Graham Garrison

When Bruce Leff, MD, is in his office space at Johns Hopkins seeing an older adult who is acutely ill, he thinks very

hard on whether hospital admission is the best choice. “I know I can take care of the heart failure, or the pneumonia, or anything else,” he said, “but will they end up worse for wear, just by virtue of having been in the hospital?”

It’s a question hospitals and health systems have been grappling with for decades, including Johns Hopkins. And it’s one that came front and center during the pandemic as providers, strained by volume and workforce shortages shifted to new models of care. Researchers started to think about the ability to provide acute hospital-level care in the home, instead of the bricks and mortar hospital in the mid-90s. Questions they asked themselves included: Who should be treated in Hospital At Home? What conditions? How do you choose the right patients?

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“You want patients who absolutely meet threshold requirements for an inpatient hospital stay, but they’re not so sick that they need an ICU or have a high risk of deteriorating during the hospital stay, so we developed those kinds of criteria,” said Dr. Leff, professor of medicine and the director of the Center for Transformative Geriatric Research at the Johns Hopkins University School of Medicine. Johns Hopkins conducted early studies on whether patients would actually sign up for this kind of care, and it seemed that they would. Anecdotally, researchers knew that many

older adults refuse to go to the hospital if they can avoid it. “There’s a very robust literature to suggest that the hospital is not always the most hospitable environment for older adults,” Dr. Leff said. Older adults can develop confusional states in the hospital, like deliria. It can cause long-term cognitive outcomes. “They develop more functional impairments, because it’s hard for them to get out of bed, and then they end up in a nursing home. They fall out of bed, they get nosocomial infections, all of that.” Researchers at Johns Hopkins did some early clinical trials of Hospital At Home, and reported that patients did well with clinical, economic and positive patient experience outcomes. Back then, there was no fee for service payment for Hospital At Home. Johns Hopkins tried unsuccessfully to get a payment waiver from CMS to pay for Hospital At Home in fee-for-service Medicare in the mid-late 90s, but was unsuccessful. So, they pursued larger studies with Medicare Advantage plans and the VA. Within 2014, a Center for Medicare and Medicaid Innovation demonstration of Hospital At Home was conducted at Mount Sinai in New York. “Again and again, it proved out all the basic hypotheses

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IDN OPPORTUNITIES we had about Hospital At Home,” Dr. Leff said. People opted in at high rates, there was better patient and caregiver experiences, clinical outcomes were excellent, costs were lower, and in many cases better than what they would be at the hospital. Over the last few years, several commercial entities have entered into the Hospital At Home space. Dr. Leff thinks that has helped accelerate adoption quite a bit. “I think it’s fair to say that it is the most studied health service delivery innovation over decades. Depending on how you count, in the U.S. and the international literature, a lot has been done on this … and the theme and the results are very consistent across all those studies.”

is leveraging the latest innovations and technology to help health care systems that are facing significant challenges to increase their capacity to make sure patients get the care they need,” said CMS Administrator Seema Verma at the time. “With new areas across the country experiencing significant challenges to the capacity of their health care systems, our job is to make sure that CMS regulations are not standing in the way of patient care for COVID-19 and beyond.” The program was developed to support models of at-home hospital care throughout the country that have seen prior success in several leading hospital institutions and networks, and reported in academic journals, including a major study

“ You want patients who absolutely meet threshold requirements for an inpatient hospital stay, but they’re not so sick that they need an ICU or have a high risk of deteriorating during the hospital stay, so we developed those kinds of criteria.” Hospital At Home amid the pandemic COVID has only accelerated its adoption. In March 2020, CMS announced the Hospitals Without Walls program, which provided broad regulatory flexibility that allowed hospitals to provide services in locations beyond their existing walls. In November 2020, CMS expanded on it by launching the Acute Hospital Care At Home program, providing eligible hospitals with “unprecedented” regulatory flexibilities to treat eligible patients in their homes. “We’re at a new level of crisis response with COVID-19 and CMS 14

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funded by a Healthcare Innovation Award from the Center for Medicare and Medicaid Innovation (CMMI). “The development of this program was informed by extensive consultation with both academic and private sector industry leaders to ensure appropriate safeguards are in place to protect patients, and at no point will patient safety be compromised,” CMS said in a release. “CMS believes that treatment for more than 60 different acute conditions, such as asthma, congestive heart failure, pneumonia and chronic obstructive pulmonary disease (COPD) care, can be treated appropriately and safely in home

settings with proper monitoring and treatment protocols.” Participating hospitals are required to have appropriate screening protocols before care at home begins to assess both medical and non-medical factors, including working utilities, assessment of physical barriers and screenings for domestic violence concerns. Beneficiaries will only be admitted from emergency departments and inpatient hospital beds, and an in-person physician evaluation is required prior to starting care at home. A registered nurse will evaluate each patient once daily either in person or remotely, and two in-person visits will occur daily by either registered nurses or mobile integrated health paramedics, based on the patient’s nursing plan and hospital policies. CMS said it anticipates patients may value the ability to spend time with family and caregivers at home without the visitation restrictions that exist in traditional hospital settings. Additionally, patients and their families not diagnosed with COVID19 may prefer to receive care in their homes if local hospitals are seeing a larger number of patients with COVID-19. “It is the patient’s choice to receive these services in the home or the traditional hospital setting and patients who do not wish to receive them in the home will not be required to.”

Factors to consider Mark Larson, principal, Sg2, has been studying the Hospital At Home model closely for several years. The programs he’s observed mainly treat medical conditions including congestive heart failure, COPD, and other non-surgical type diagnoses that can be treated safely in the home environment.

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IDN OPPORTUNITIES “You also have to think about, would the patient be able to have Hospital At Home in their home environment? Is there support there from a family member or a spouse? Because the home environment needs to be safe. So there’s the clinical side of it and then there’s the socioeconomic side of it – making sure the right support in the household exists.” Typically, Hospital At Home programs are in larger geographical areas, urban or suburban areas. There aren’t many programs in rural areas, due to the logistics of delivering care in such a remote location, Larson said. It’s more time-consuming and not as efficient. “The numbers piece definitely comes into play.” Larson said overall, clinical outcomes from Hospital At Home programs have been pretty good. “We’ve seen lower length of stays in some of the early pilots. We’ve also seen lower readmission rates, as well as lower skilled nursing utilization.” If you have the same providers, you have the same nurses delivering care post-discharge, thus the chances of having issues with care

“ You don’t start with a big program. Obviously you start the program slow, and you build upon your success. Showing good results demonstrates that this is a good avenue for the provider.” transitions are lower. “Really it’s the same care team taking care of the patient during the acute care episode and post-acute care.” Patients seem to like the program. Patient satisfaction scores for organizations like Mount Sinai in New York and others have been pretty high, Larson said. It’s no wonder – hospitals represent a changed environment for the patient. Alarms may go off in the middle of the night, nurses and doctors are coming in and out of the room at all hours of the day. “It can be very disruptive, especially for the elderly population.”

Questions providers must ask Still, the Hospital At Home model is not for everyone, Larson cautions. “You have to be a pretty good-sized hospital or health system, and you have to have adequate volume in

your marketplace, just as an entry point,” he said. Larson offered the following as pieces that providers must consider: CAPABILITY Do you have the capabilities to deliver Hospital At Home? “Of course providers are really good at delivering care in the hospital,” Larson said. “They’re used to doing that. They’ve been doing it for years, serving their community well. But when you go out into the Hospital At Home environment, it’s a whole different ballgame.” First and foremost, you need to have foundational home care nursing services. That’s key, because nurses are a core element to your service, Larson said. “The organizations who have elevated and delivered Hospital At Home and rapidly been able to

Safety first How safe are the Hospital At Home programs being implemented across the country? Even in the preremote patient monitoring, there were many Hospital At Home studies conducted, and safety was well-demonstrated in those studies, said Dr. Leff. “And now, with the advent of the technology over the last 10 years, you can do much more monitoring at home than you could do previously.” Dr. Leff said. Choosing the right patients for the program is one critical component. The providers all have a way of selecting patients in a systematic way, and they’re

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choosing patients that match what their programs can do, “so safety really works out,” Dr. Leff said. “People do well, and they’re getting multiple visits per day from various providers in the program.” “I think the other thing to think about is that people have the notion that just because in the hospital, they’re being ‘monitored,’ but that that is not always entirely accurate.” Most providers are using remote patient monitoring now, “so the programs can keep tabs on vital signs whenever they want or continuously.”

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1. Moulik Moulik PK, PK, Mtonga Mtonga R, Gill R, Gill GV. GV. Amputation Amputation andand mortality mortality in new-onset in new-onset diabetic diabetic footfoot ulcers ulcers stratified stratified by etiology. by etiology. Diabetes Diabetes Care. Care. 2003;26(2):491-494. 2003;26(2):491-494. Kamaratos 2. Kamaratos AV, Tzirogiannis AV, Tzirogiannis KN, KN, Iraklianou Iraklianou SA, Panoutsopoulos Panoutsopoulos GI, Kanellos GI, Kanellos IE, Melidonis IE, Melidonis AI.stratified Manuka AI.stratified Manuka honey-impregnated honey-impregnated dressings dressings in the in the treatment treatment of neuropathic of neuropathic diabetic diabetic footfoot ulcers. ulcers. Int Wound Int Wound J. 2012;9:1-7. J. 2012;9:1-7. Moulik 1. Moulik PK, PK, Mtonga Mtonga R, Gill R, Gill GV. GV. Amputation Amputation andSA, and mortality mortality in new-onset in new-onset diabetic diabetic foot foot ulcers ulcers by etiology. by etiology. Diabetes Diabetes Care. Care. 2003;26(2):491-494. 2003;26(2):491-494. FifeKamaratos 3. Fife CE, CE, Carter Carter MJ, Tzirogiannis MJ, Walker Walker D,KN, Thomson D,KN, Thomson B, Eckert B, Eckert KA. KA. Diabetic Diabetic foot ulcer off-loading: off-loading: TheThe gap between between evidence evidence andand practice: practice: Data Data from from the the U.S. U.S. Wound Wound Registry. Registry. Advances Advances infoot Skin infoot Skin and and Wound Care. Kamaratos 2. AV, Tzirogiannis AV, Iraklianou Iraklianou SA, SA, Panoutsopoulos Panoutsopoulos GI,foot Kanellos GI,ulcer Kanellos IE, Melidonis IE, Melidonis AI. gap Manuka AI. Manuka honey-impregnated honey-impregnated dressings dressings in the in the treatment treatment of neuropathic of neuropathic diabetic diabetic ulcers. ulcers. IntWound Wound IntCare. Wound J.2014;27(7):310-316. 2012;9:1-7. J.2014;27(7):310-316. 2012;9:1-7. Armstrong 4. Armstrong DG, DG, Nguyen Nguyen HC, Lavery LA, B, LA, van van Schie Schie CH,KA. CH, Boulton Boulton AJ, foot Harkless AJ, Harkless LB. Off-loading LB. Off-loading the the diabetic diabetic foot foot wound: wound: a randomized a randomized clinical clinical trial. trial. Diabetes Diabetes Care. Care. 2001;24(6):1019-1022. 2001;24(6):1019-1022. Fife 3. Fife CE, CE, Carter Carter MJ, MJ, Walker Walker D,HC, Thomson D,Lavery Thomson Eckert B, Eckert KA. Diabetic Diabetic foot ulcer ulcer off-loading: off-loading: TheThe gap gap between between evidence evidence andand practice: practice: DataData from from the the U.S. U.S. Wound Wound Registry. Registry. Advances Advances in Skin in Skin andand Wound Wound Care. Care. 2014;27(7):310-316. 2014;27(7):310-316. Armstrong 4. Armstrong DG,DG, Nguyen Nguyen HC,HC, Lavery Lavery LA, LA, van van Schie Schie CH,CH, Boulton Boulton AJ, Harkless AJ, Harkless LB. Off-loading LB. Off-loading the the diabetic diabetic footfoot wound: wound: a randomized a randomized clinical clinical trial.trial. Diabetes Diabetes Care. Care. 2001;24(6):1019-1022. 2001;24(6):1019-1022.

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IDN OPPORTUNITIES scale it up have had a really strong home nursing care program.” Second, providers must have physicians and nurse practitioners that can support the program. Typically, there are two different models, Larson said. In one model, providers actually go physically to the home as physicians and nurse practitioners when the patient needs it. There is also the virtual model, which is more scalable. When the home care nurse is providing hospital care in the home, they may call the physician or the nurse practitioner and have a visit with them on the status of the patient, the same as a rounding physician would do in a hospital. “You really need to have the physicians and nurse practitioners on board,” Larson said.

own technology, to be able to say, OK, there’s an admission. We need this, this, and this going into the home. Here’s the timing, here’s the schedule. We need the nurses on site right away, all these things need to be orchestrated. And without that logistical capability, it becomes very challenging.” COST Providers need to be able to look at services and understand whether or not they have the ability to provide care more cost effectively in the home. “Cost is certainly the biggest piece,” Larson said. “From a financial perspective the biggest opportunity is when you don’t look at just the acute care visit, but you’re looking across the episode of care. In other

“ I think it’s fair to say that it is the most studied health service delivery innovation over decades. Depending on how you count, in the U.S. and the international literature, a lot has been done on this … and the theme and the results are very consistent across all those studies.” For either model, providers must demonstrate the safety and value of the program to a patient, to the hospitalists in the hospital and the emergency department physicians and leadership as well. “You don’t start with a big program,” Larson said. “Obviously you start the program slow, and you build upon your success.” Showing good results demonstrates that this is a good avenue for the provider. “This is not a small undertaking,” Larson said. “Providers need to become very strong administratively and logistically. As some health systems deliver more care in the home, they will need to become very logistically strong, whether through a partner or developing their 18

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words, the hospital piece is important, the acute care piece, but there’s also that 30-day post-discharge piece, where there might be skilled nursing care or other care post-discharge, or potentially a readmission.” Organizations that have been successful often contract with Medicare Advantage payers, and they’ll go at-risk on that the full 30-day episode. “The numbers we’ve seen are you can save close to $1,000 per patient if you look at that entire episode,” Larson said. “If you only look at the acute care piece, the savings isn’t as significant – it can be $200 to $400 in savings. So I think that’s a key financial piece.”

Another important piece is that often when you’re negotiating with payers with Hospital At Home, they’re looking for a discount off of what they typically would pay you for acute care in the hospital. “So you have to factor that discount into it, and obviously negotiate that with the payers when you’re developing a program,” Larson said. “And that’s a big deal. Contracting for Hospital At Home is a big portion of the hard work that has to be done.” CAPACITY Does the hospital or health system have capacity constraints? Larson said a lot of the academics, tertiary quaternary providers gravitated to Hospital At Home because they were at capacity during COVID, and some even before COVID. They saw Hospital At Home as an opportunity to potentially decant patients from the acute care environment and have them receive care in the home. “Hospital at Home patients are typically lower acuity, and lower payment. The contribution margin for these patients is also much lower than the typical average population served,” Larson said. “So if you have a patient that goes into the Hospital At Home, receives care in the home, you’re potentially swapping a lower contribution margin patient out to Hospital At Home with the opportunity to bring a higher contribution margin patient in that needs higher acuity care.” Larson said there are two points to this strategy to consider. First, you’re serving a population that you’re more set up to manage – higher acuity care – especially in a larger tertiary care center. Second, you’re able to bring higher contribution margin patients into that environment. “For hospitals that are thinking they might

have to build a new tower, maybe this is an opportunity to reduce the number of future beds built.”

The future of medicine Larson predicts that every market is going to play out a little bit differently, but as far as care being delivered in the home, “we’re already seeing a pretty significant shift.” The organizations that have the higher need are going to move faster. “So when you think about it, where is the shift occurring?” Larson

asks. “It’s maybe less capital investment, brick and mortar investment, but more investment in operations, logistics, and care that providers can deliver in the home. I think something else you need to consider is, can you recruit and retain nurses who are willing to provide care in the home? That’s not for every nurse. Some nurses are much more comfortable going into hospitals and ambulatory sites to deliver care.” What’s ultimately driving the shift is the technology to enable

more remote monitoring, and consumers, who would prefer to receive care outside the traditional four walls of a hospital. “We really do expect more entrepreneurial companies to deliver things like home diagnostics and making it much more seamless to the process,” Larson said. “Right now it’s still a little clunky, but it’s going to get there. It’s going to be more about making it convenient for the consumer and more cost effective for the health system as well, hopefully in the future.”

Owens & Minor to acquire home equipment provider Owens & Minor, Inc. and Apria, Inc. announced in January that the companies have entered into a definitive agreement pursuant to which Owens & Minor will acquire Apria for $37.50 in cash per share of common stock, representing an equity value of approximately $1.45 billion. “I’m very excited about the acquisition of Apria, which will strengthen our total company value proposition. The combination of two complementary businesses in Byram Healthcare and Apria will enable us to better serve the entire patient journey – through the hospital and into the home – ultimately furthering our mission of Empowering Our Customers to Advance Healthcare,” said Edward A. Pesicka, President & Chief Executive Officer of Owens & Minor. “In addition, this transaction diversifies our total company revenue stream by expanding our presence in the higher-growth home healthcare market.” Pesicka added, “We are impressed by what Apria has built for its customers, and I look forward to welcoming Dan Starck and the Apria team to Owens & Minor upon close.” “I am energized and enthusiastic to join Owens & Minor,” said Dan Starck, Chief Executive Officer of Apria. “Both companies share cultures fueled by a commitment to customers, patients, teammates and the communities we serve. We look forward to joining together and delivering the highest quality healthcare solutions to our customers.” In a press release, Owens & Minor provided the following strategic rationale for the acquisition: ʯ “Strengthens total company value proposition, enables us to better serve the entire patient journey and positions Owens & Minor as a leader in the

ʯ ʯ

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home healthcare market. The transaction builds upon Owens & Minor’s strong capabilities in product manufacturing and healthcare services.” “Accelerates growth and diversifies revenue base by expanding our presence in the higher-growth home healthcare market.” “Accretive to revenue, adjusted EBITDA, adjusted earnings per share, and enhances our free cash flow generation, enabling Owens & Minor to rapidly deleverage while continuing to invest across the business.” “Expands our Patient Direct platform with access to over 90 percent of insured healthcare customers in the U.S.” “Broadens our Patient Direct product portfolio by combining our strength in diabetes, ostomy, incontinence, and wound care, with Apria’s product portfolio strength in home respiratory, obstructive sleep apnea, and negative pressure wound therapy. These product portfolios are complementary and do not overlap as many of these products are needed to treat the same and multiple chronic and acute conditions.” “Increases the attractiveness to Payors, Providers, and Patients due to the broader product portfolio, combined with our scale, geographic footprint, and delivery model.” “Creates a platform for future growth within this highly fragmented and growing space, with an approximate $50 billion total addressable market.” “Enables the acceleration of support for our hospital customers seeking to expand into home healthcare delivery.”

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IDN NEWS

IDNs in the News

1 West: Intermountain Healthcare launches new COVID navigation for ‘long haulers’ Intermountain Healthcare is launching a major new medical resource for Utahns who’re considered “long haulers” – people who have tested positive for coronavirus who continue to experience chronic symptoms months after their recovery from the virus. Intermountain doctors outlined the new Intermountain Healthcare Long COVID Navigation Program and how it will serve as a resource for Utahns at a press briefing. The program is designed to help triage resources and care for COVID patients in Utah who have experienced ongoing COVID symptoms for 12 weeks or longer. Based on a patient’s condition, symptoms, and acuity, they’ll be referred to a specialist who can follow up and address their ongoing medical issues. “As far as we know, this is one of the first kinds of COVID patient navigation programs in the nation,” 20

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said Dixie Harris, MD, a critical care physician at Intermountain Healthcare, who treats patients with COVID. “This is not a standalone clinic, but a multi-disciplinary approach and resource for patients across the state of Utah who are experiencing Long COVID.” Some studies and surveys with patients show that between 30–50% of people infected with COVID continue to have bothersome symptoms for months, even though the virus is no longer in their bodies.

2 Midwest: Organ transplants reached record levels at Cleveland Clinic in 2021 Cleveland Clinic performed 1,039 transplants in 2021, including heart, kidney, liver, intestine and lung transplants. That is up 18% from the number of transplants performed at Cleveland Clinic in 2020. Cleveland Clinic’s global transplant programs reached several milestones in 2021, including:

Cleveland Clinic’s liver and intestine transplant programs in Ohio were the largest in the United States, according to data from the Organ Procurement and Transplantation Network (OPTN). Cleveland Clinic’s liver transplant program in Ohio completed 210 liver transplants, which is the highest number in the history of the program.

Cleveland Clinic’s main campus completed 58 living-donor kidney transplants and 33 living-donor liver transplants.

4 South: Atrium Health debuts first new hospital in the Charlotte area in more than 30 years

3 North: Philadelphia hospital tops list of America’s Best Large Employers 2022 Forbes announced that Children’s Hospital of Philadelphia secured the top spot on its list of America’s Best Large Employers 2022. “Children’s Hospital of Philadelphia, also known as CHOP, has stood up a variety of programs to help employees navigate the uncertainty, including offering more flexibility in scheduling and split shifts, bringing back retired nurses and offering subsidized childcare through the YMCA,” Forbes said. “It also created a public health department with a hotline and town halls to help

address employee questions around testing, vaccination and issues like returning to work and school for their families.” Despite two years of challenges, including staffing shortages, supply chain issues and reductions in many outpatient and elective procedures, employees at several large hospitals expressed pride and purpose in their work and how their employers were handling the pandemic. Joining CHOP in the top 10 are Memorial Sloan Kettering Cancer Center (No. 4), Mayo Clinic (No. 7), University of Texas Southwestern Medical Center (No. 9) and MD Anderson Cancer Center (No. 10).

Atrium Health Union West opened for the first time in February 2022, making it the health system’s first newly built hospital in the Charlotte area in more than 30 years. The hospital will serve the western part of Union County, North Carolina, including the towns of Matthews, Mint Hill, Stallings, Indian Trail, Weddington and surrounding communities in the eastern part of Mecklenburg County. Atrium Health saw the necessity for this hospital as the area’s population increased over the last decade. With the closest Atrium Health hospitals located in Monroe and Charlotte – often making for an inconvenient drive for those seeking care – providing health care close to home became an important need to serve local patients. In January 2020, ground was broken on the approximately 150,000 square foot facility. It is opening with 40 licensed beds, a 24/7 emergency department with a helipad, three operating rooms and a maternity care unit with c-section capability. The construction of Atrium Health Union West is a large part of the Atrium Health growth plan which includes more than $1 billion in capital expenditures Atrium Health committed to invest back in 2018 to better position the system to serve the community. Last fall, new facilities opened included the Palmetto Tower at Atrium Health Pineville, and Birkdale Medical Plaza in Huntersville. Recently, a new emergency department in the Mountain Island Lake community opened its doors. Later this year, a new Atrium Health Carolinas Rehabilitation Center will be opened. www.repertoiremag.com

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By Mark Thill

Hard-Earned Lessons Amidst the pandemic’s challenges, physicians gain insights.

Throughout the pandemic, healthcare providers, like

everyone else, have faced interpersonal, emotional and financial challenges. In the process they have gained insights and growth. Ron Holder, senior vice president of the Medical Group Management Association, says that even as late as this February, some patients still were avoiding as much physical contact with others – including doctors – as possible. Meanwhile, others were eager to get back to see their doctor in the office, a fact that has presented its own set of challenges. “It’s a little bit like what happened when the healthcare exchanges first started,” says Holder, who served as vice president of operations and Central Texas cardiovascular service line administrator for Baylor Scott & White Health prior to joining MGMA. “When that happened, significant patient populations who had lacked healthcare coverage for years suddenly wanted to address everything they had been unable to have addressed previously. The patients in those initial ‘suddenly covered’ visits were more complex on average than the average primary care patient. “With some patients, that is what is happening now,” he says. Due to COVID-19, they were deferring care, some by their own choice, others by necessity (e.g., discontinuation of elective procedures by medical practices or hospitals). www.repertoiremag.com

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Hard-Earned Lessons

Many practices find themselves in a situation where they can only do so much during one visit, Holder says. “They are triaging for the most important issues and asking patients to schedule appointments for the additional ones. “That means that the schedule can’t just be eight or nine one-hour appointments per day, because that would drive the appointment backlog way out into the future,” he says. Lack of access could lead to increased urgent care or emergency room visits and present financial challenges for practices in risk-based or capitated contracts. “These impacts won’t necessarily be lasting in perpetuity. Once the backlog of care starts getting worked through, we will begin to approach pre-COVID levels of care and expectations.”

Some physicians and practice owners have found that the pandemic has given them a chance to isolate and eliminate non-productive activities and attitudes, and replace them with patient-centric and staff-centric ones. The emotional toll Lingering challenges have exacted an emotional toll on practices. But many of these pressures didn’t start with COVID-19. “Learning how to do documentation in electronic health records that weren’t necessarily built for managing a patient in an outpatient setting, managing patient message/work queues, and responding to requests from insurance companies for information to approve denied or delayed claims all represent additional work,” says Holder. “Add in value-based contracts with their inherent assumption of risk to the physician’s practices, learning telehealth, and staff shortages. On top of that, pile on COVID with its anxiety and depression, rollercoaster of uncertainty, risk of infection, fluctuating patient volumes, and the political battles around the science of medicine.” Clinical and non-clinical support staff may be working longer or more unpredictable hours. In practices in which some people lost their jobs early in the pandemic, 24

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others fear they may be next. “That in and of itself is a stressor,” says Holder. Another challenge facing practices is a rise in disruptive patients. A recent MGMA poll showed that 71% of practices saw their levels of disruptive patients increase in 2021, he says. And if one member of the care team is feeling stress, everyone on the team feels it. “A burned-out physician will spread anxiety and stress to the staff and vice versa. The irony is that having a team that is supportive of each other is one of the best ways to combat burnout.”

Increased stress, tension Internist E. Linda Villarreal opened her adult medicine practice in 1989 in Edinburg, Texas, in the southern part of the state. Dr. Villarreal, who is president of the Texas Medical Association, became employed by WellMed Medical Management in 2018. She has “definitely” seen increased levels of stress and tension among colleagues – not just doctors, but midlevel practitioners and ancillary personnel. Being covered from head to foot in PPE was itself a source of depression and anxiety, she says. “I didn’t realize the impact it had on me until one year later, when we were able to remove gowns and shields.” Trained to take care of patients no matter what, physicians have traditionally put their emotions on the back burner, she says. But during the pandemic, it was difficult if not impossible to relax, reflect and recharge. Dr. Villarreal says she saw depression among colleagues who had exhausted their savings and cashed in their 401(k)s as patient volumes dropped at the height of the pandemic. This on top of growing federal requirements in modern medicine. “Medical assistants are feeling the pressure too, because they are doing twice what they did 20 years ago,” she says.

Grey Tsunami “Absolutely there’s burnout among staff, because more is being asked of fewer people,” says Edward Fry, M.D., FACC, chair of the Ascension Health Cardiovascular Service Line in Indianapolis and vice president of the American College of Cardiology. At the height of the pandemic, following a day’s work, many had to catch up with children at home who had been remote learning, or tend to elderly parents, he points out. Meanwhile, nursing ratios in the hospital were stretched. Supply chain snags and the complexity of

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Hard-Earned Lessons

today’s patients in the outpatient and inpatient settings added to the tension. Among physicians, the rate of retirement had been accelerating prior to COVID-19, simply because of aging of the workforce, says Dr. Fry. “We’re still seeing some effects from the Great Recession of 2008, as many people who had been planning to retire were unable or unwilling to do so, but are ready now. It’s the Grey Tsunami, and it’s occurring along with the challenges of medical practice today, including the pandemic.”

Telemedicine is here to stay One pandemic lesson learned by providers and patients has been the value of telemedicine, according to those with whom Repertoire spoke. “Telemedicine is here to stay,” says Dr. Villarreal. “It’s the best thing to happen to patients, and it’s an additional tool for physicians to use. “In the early months of the pandemic, when we were all isolated, we would call patients on the phone, and the grandkids would help grandma get on a Zoom call. We were able to find out what was going on with them, make sure they were taking their medicine. We stayed in touch with our patients. And we continue to offer that option today.” Telemedicine can be especially helpful for those who are bedridden or for whom transportation is difficult, she adds. Donald Hoscheit, M.D., chief medical officer of Duly Health and Care, a Chicago-area multispecialty medical group with more than 900 primary care and specialty care physicians in over 150 locations, believes the pandemic has definitely influenced how patients access care. “Our demand for telehealth visits exploded with the onset of COVID,” he says. “Last year [i.e., 2021], Duly physicians completed more than 250,000 telehealth visits – dramatically up from about 2,500 in the 18-month period prior to the pandemic. [The rapid increase] opened our eyes to the benefits of digital health. Payer reimbursement of digital visits will allow us to expand further. “Patients’ perspectives of telehealth have changed too,” he says. “Senior patients have adapted quite well on a number of levels. It has brought them great and easy access, especially those elderly patients who don’t drive. No question these impacts will be lasting.” Says Dr. Fry, “We have been surprised that many patients whom you would expect to be resistant or not tech-savvy have really engaged with telemedicine. Now it’s a resource to complement traditional care.” 26

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That said, as the pandemic wanes, Fry and colleagues have found that many of their patients are eager to return to face-to-face visits. That may reflect the age of many cardiology patients, as well as the fact that many come from rural Indiana, with poor or non-existent access to broadband. MGMA’s Holder believes that patients’ interest in telehealth won’t go away. On the upside, telehealth reduces the need for bricks and mortar in expensive areas to serve patients, he says. “But when – likely not ‘if ’ – payment for telehealth services is reduced to levels lower than in-person care, practices will have to ... alter their cost structure for those visits or end up deciding not to do it. [But] if the practice does not offer it, they will lose some business to someone who has figured out how to do telehealth more cost-effectively.”

“ Enduring a pandemic has strengthened the concept of a healthcare team, working together, selflessly and heroically in every twist and turn thrown at us, caring for our communities under every circumstance.” Poorly managed, telehealth can rub patients the wrong way, he adds. Even those who love telehealth bristle when, after waiting weeks for a telehealth appointment, the provider says this is an ‘in-person visit issue’ only. “Practices have to have methods in place to make sure that the practice is treating the patients in the best method possible, and not just best clinically. A practice that uses two appointment slots – one virtual and one inperson – to address a single problem is creating its own patient access problems as well as damaging patient satisfaction and engagement.”

Infection control Another sure thing that will last beyond the pandemic is a heightened sense of infection prevention on the part of practices and patients, says Dr. Villarreal. “Patients will feel safe going to a practice that promotes infection prevention,”

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“ Practices should use COVID as a springboard to look for easier ways to accomplish tasks, to create a team culture that drives beyond employee engagement to employee loyalty, to rightsize physical space needs, to move appropriate functions out of expensive real estate to more economical options, and engage with patients between in-person or virtual visits.” she says. But maintaining protocols will demand time and money. Curbside screening and check-in take time, and they may call for rearranging job descriptions, adding staff or lowering the number of patients seen per day, she says. Solo practices or those with two or three doctors may simply be unable to afford the changes. Says Dr. Hoscheit, “We have always been steadfast in adhering to infection control protocols. With COVID, however, more direct attention has been paid to managing non-essential visitors, that is, those care companions who are integral to the patient’s care. “Before the pandemic, care companions often accompanied patients on their visit to the doctor. In pediatrics, it was not at all unusual for parents to have children ... along for the visit of a sibling. To stop the spread of COVID, providers everywhere implemented strict policies, including mask wearing and physical distancing, and, when peaks were at their worst, restricting visitors entirely. For example, in our ambulatory surgery centers, we have asked patients’ drivers to wait outside the facility and be reachable by phone instead of spending time in the waiting room while procedures are performed. “We have worked tirelessly to lessen exposure for patients, family and staff by providing PPE, greater environmental spacing and symptom screening. Most challenging is not so much pivoting on new protocols as it is fostering compliance.” Ron Holder believes the most challenging infectionprevention-related changes for small practices are those that require facility changes, such as finding new space or renovating existing space. That said, practices can “find space” without renovation or bricks and mortar by: ʯ Conducting telehealth from outside the clinic, either in new but inexpensive space, remotely, or in space owned by the practice that wasn’t in clinical use. 28

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ʯ ʯ ʯ

Borrowing the “We will text you when your table is ready” concept from restaurants. (For larger practices with multiple locations), setting up a “COVID-positive” or “COVID-suspected” clinic and a separate “non-COVID” clinic. Offering separate entrances and staging areas to keep the COVID and non-COVID populations separate.

And when this is over? Some physicians and practice owners have found that the pandemic has given them a chance to isolate and eliminate non-productive activities and attitudes, and replace them with patient-centric and staff-centric ones. “We have learned a lot of good things,” says Dr. Villarreal. “The underlying issue is maintaining, protecting and preserving the patient-physician relationship. We have learned that we can do that in more than one way, including telemedicine.” The experience has indeed had a transformative effect,” says Dr. Hoscheit. “Duly has implemented a Nurse Call Center where patients can reach us 24 hours a day, seven days a week with questions, concerns, requests for refills or certain test results. This helps patients address basic needs easily and efficiently and takes some of the workload off physicians. Additionally, we are developing a Care Ally program in which trained staff assist those who come for care and help navigate the visit, scheduling and testing. This makes for a more efficient visit for both the patient and our team. “Enduring a pandemic has strengthened the concept of a healthcare team, working together, selflessly and heroically in every twist and turn thrown at us, caring for our communities under every circumstance.”

A focus on high-value care Says Dr. Fry, the many months of pandemic-induced isolation, in which patients sought and received less care

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Hard-Earned Lessons

than they would have under normal circumstances, has reinvigorated the value discussion among providers, payers and patients. “We are asking ourselves, ‘What is highvalue care?’” he says. “It’s a healthy process, because it brings us back to the importance of joint decision-making about care,” involving patients and providers. Will these lessons last? “Early in the pandemic, there was a lot of energy around the idea of care transformation. In some ways, that was an antidote to the burnout and stress that people were feeling.” But as providers face the economic reality of surviving quarter to quarter, it’s difficult to maintain that long-term view, he says. “Still, a return to normal would be a failure. We need to take a little time to breathe, then come back and execute on the lessons we’ve learned.” “Some practices have, can, and will use their experiences with COVID-19 to drive care transformation,” says

Holder. “Practices should use COVID as a springboard to look for easier ways to accomplish tasks, to create a team culture that drives beyond employee engagement to employee loyalty, to right-size physical space needs, to move appropriate functions out of expensive real estate to more economical options, and engage with patients between in-person or virtual visits.” Practices must also work on combating burnout, perhaps through formal training programs. “Some are investing in different staffing strategies or tech solutions to minimize ... work that doesn’t necessarily require clinical judgment. Some are looking for ways to use artificial intelligence to aid in decision-making and/or automate functions that don’t necessarily require staff time to allow all levels of staff to spend a greater percentage of the day working at the maximum of their licensure.”

Four opportunities for practices Frontline healthcare workers have been pushed to the brink of exhaustion by the COVID-19 pandemic, says Donald Hoscheit, M.D., chief medical officer, Duly Health and Care, a Chicago-area multispecialty medical group with more than 900 primary care and specialty care physicians in over 150 locations. He described the practice’s multipronged response to Repertoire.

Listen more empathetically and encourage feedback. A comprehensive, equitable and sustainable approach requires that we listen. As we continue to identify ways to prevent and address burnout, we must work with physicians, team members and key leaders to ensure that decisions are informed by perspectives that represent everyone we serve. Provide resources to support balance. Physicians and team members can best serve their patients when they are able to prioritize and address their own mental, emotional and

physical health. Duly offers subscriptions to apps including Calm (meditation, sleep, and relaxation) and Noom (personal health and wellness) to help team members disconnect and find focus outside of work. They also have a free, confidential program that partners physicians with a mental health coach to help address a range of professional needs, work-life balance and self-care. Break from old models and build new ones. Duly has implemented a triage line to reduce pressure on on-call physicians. It’s also important

to commit to a culture where people feel valued for their dedication to patient care. Duly recently raised minimum wage to $15 per hour for team members and are incentivizing value-based care. Put safety first. Everyone deserves a workplace that fosters a healthy environment. Duly moved in 2021 to require COVID-19 vaccinations for all physicians and team members. Decision-making will continue to be grounded in the belief that they have a duty to take all steps to ensure that healthcare workers, patients and communities are safely cared for.

To beat burnout, we must proactively foster a culture where all healthcare workers can flourish – physically, financially and emotionally.

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Are We Making Money Yet? Book Review: Profit Guide for the Small Distributor As a sales rep, you run your territory as your own business. But it’s part of something larger. The decisions you

make in the field – the number of calls you make, the sales you close, and yes, the prices or terms you negotiate – have an impact on the company at large.

A book by Albert D. Bates, “Profit Guide for the Small Distributor” (©2021, D.M. Kreg Publishing), looks at factors affecting the profitability of small distributors. Although intended for owners, it offers plenty for field reps to think about. Bates is principal in the Boulder, Colorado-based Distribution Performance Project, a research group dedicated to distribution issues.

Return on assets The most basic questions for any business owner are: Where do we stand? Are we profitable today? Are 32

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we likely to be more profitable in five years – or less? Bates believes the answers lie in figuring out the company’s return on assets (ROA), that is, profit before taxes divided by total assets (e.g., cash on hand, accounts receivable, inventory and fixed assets). He believes that in terms of ROA, distribution companies can be divided into three categories: ʯ Disasters (below 5% ROA). ʯ Soldiers (an ROA between 5% and 10% – where about 70% of distributors lie). ʯ Winners (10% ROA or higher).

For the Disasters and Soldiers, inadequate profits are bad enough. But there’s more. “Firms that don’t produce strong profits can’t be sold in the future for anything other than fire-sale prices,” he says. “At retirement time there is no residual value to the business.” The good news is, anyone can be a Winner by putting programs and practices in place that ensure profits today and tomorrow, he says. Nor must those changes be drastic. Slow and steady is better. “Winners inevitably produce two, three or even four times the profit of the Soldiers, even on the same sales volume.”

It doesn’t take too long to get off plan. When this happens, a lot of owners just forget the plan. Critical Profit Variables Bates believes that of all the things they can worry about, distributors should stay focused on five “Critical Profit Variables” – net sales, gross margin, total expenses, accounts receivable and inventory. They’re all related, as adjusting one inevitably affects the others. But in the author’s opinion, keeping a sharp eye on just three – net sales, gross margin and total expenses – can keep the company moving in the right direction. While important, accounts receivable and inventory have a much more modest impact on profit than the other three, he says. The critical variables are: ʯ Net sales: Total revenue generated by the firm. Even a very small sales increase will generate higher profit.

Gross margin: The dollars of gross profit produced by sales, expressed either in dollars or as a percentage, that is, gross margin dollars divided by net sales. (Of the two – dollars or percentage – the latter is more precise.)

Total expenses: Payroll represents about twothirds of the typical distributor’s expenses. “This means that controlling – not necessarily lowering – payroll is essential,” he says. In other words, reducing head count is less effective than improving the productivity of people already onboard.

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Accounts receivable: Bates says it’s a myth that this number should always be lowered.

Inventory: Although the value of merchandise in the facility is important, even more important is ensuring that the inventory there is fresh and salable.

What about sales? Sales don’t have to increase rapidly in order for the small distributor to increase profit appreciably. Rather, distributors should think in terms of something close to inflation rate plus 3%. So, when inflation is averaging 2%, a worthy goal would be 5% growth every year. “As long as sales are growing by 5% [in this example], the non-payroll expenses will more or less take care of themselves,” says Bates. “The challenge arises in matching up the growth in sales with the growth in payroll expenses.” He refers to that as “real sales gain,” that is, the percentage by which the growth in sales exceeds that of payroll expenses.

time to recruit with the rigor of large firms,” he says. On top of that, sales training in small firms may be haphazard or even nonexistent. “Too much to do in too many ways.” Owners of small distributors wrestle with another, less tangible, factor: They may resist firing a salesperson who’s been with the company for years but whose sales are falling short (compared to the territory’s potential, as determined by the owner or sales manager). But again, firing people is often less effective than improving the productivity of the reps on the team.

Price cutting Assuming the distributor has made the correct hiring decisions, owners need to stay in touch with what’s happening in the field. Price cutting is an example. “Cutting price becomes the fallback option when customers register any concern about anything,” he says. “Over time customers become acutely aware that the price cutting option is always on the table. The

Firms that don’t produce strong profits can’t be sold in the future for anything other than fire-sale prices. Distributors have two options to maintain or increase real sales gain: 1) change order economics, such as lines per order, fill rate, or average order line value, or 2) “control” the sales force. (Bates’ term, not ours.) Controlling the sales force begins with successful recruiting and hiring, both of which are real challenges for small companies. “[They] seldom [have] the 34

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one-time cut becomes the ‘any time and all-the-time’ cut.” In what he calls the “normal commission plan,” the rep’s commission rate stays at the same percentage of gross margin dollars regardless of whether sales – in terms of dollars – rise or fall. In a sliding plan, however, the commission rate falls along with the company’s profit margin. In that case,

the rep stands to lose a chunk of compensation if sales drop, but the company maintains a decent level of profitability. Not great news for the rep, but tolerable for the company.

Planning People resist planning, including small-business owners. There are too many other things they’d rather be doing. Yet it is an essential part of the job for the owner, and it will have an impact on reps in the field. One approach to planning is the “what-if ” method, in which the owner considers a series of changes which they think are genuinely attainable, then figure out their impact on profit. But Bates believes this approach is limited. “With that approach, managers simply diddle around until they get a plan they kind of like. That plan may or may not result in the improvement in profit that is required.” He prefers a more rigorous approach, which he calls “profitfirst” planning, in which the owner sets company profit goals and then works backward to establish targets for sales gross margin and expenses. “Only about one company out of every 50 that considers the concept of profit-first planning ends up using it,” he says. “That small group has one common characteristic: They all generate a lot more profit than the other 49.” Planning is only as good as follow-through, he adds, referencing the oft-cited Mike Tyson quote, “Everybody has a plan until they get punched in the mouth.” “It doesn’t take too long to get off plan. When this happens, a lot of owners just forget the plan. Resist that temptation. It is actually a good time to dig into things and see what is happening financially.”

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TRENDS

Primary Care Takes Center Stage Primary care physicians are the key to providing value-based care and population health.

As we transition to a world of risk/value-based healthcare and overall population health, the role of the

primary care physician needs to take center stage. The role of the primary care physician should not be subservient to all the other specialties. In fact, the role of the primary care physician should be more like the conductor of the orchestra. Conductors need not know how to play each instrument, but they know enough to bring them all together to make beautiful music. Likewise, the primary care physician can help orchestrate the care from the other providers to bring forth a better health status for the patient.

Also, just like the conductor, the primary care physician needs to have a holistic approach in that they are responsible for the entire ensemble or the overall health of the patient. The important role of the primary care physician: ʯ The primary care physician can and should be a trusted patient advisor and advocate. Sadly, not all primary care physicians play the role as patient advisor and advocate. In some cases, the 36

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By Tom Campanella

primary care physician acts as more of an entry point for the patient to receive access to specialists and subspecialists. As a non-clinician, while I may not be an expert, I do know that I am made up of more than organs and body parts. I need a physician advocate who can look at me

from a holistic perspective. I also know as a non-clinician, I need someone in my corner to guide me through the often-confusing maze we call healthcare.

As a trusted patient advisor and advocate, the primary care physician can play a key role in engaging patients in their own health. Poor lifestyles and a lack of patient compliance will negate to different degrees the best and most expensive healthcare services provided. Primary care physicians play a key role in transitioning our healthcare system to be value-based. As noted in an article in Health Affairs, “Primary care clinicians are uniquely trained to diagnose and treat the vast majority of medical ailments and chronic diseases, to reduce over-treatment, and to care for the whole patient. Primary care’s value in cutting costs, preventing disease, improving patient satisfaction, and enabling individualized care based on shared decision making has been well established.” As we are evolving to reimbursement methodologies that are more riskbased and rely on patient compliance, the role of the primary care physician needs to be enhanced. The key to profitability for providers in a risk/valuebased world will be keeping

patients healthy, which is the focus of the primary care physician.

The primary care physician plays an important role in positively impacting population health and social determinants. The primary care physician can and should be linking patients with needed community services to remove gaps of care. As the conductor, the primary care physician needs to have a holistic approach in that they are responsible for the entire ensemble or the overall health of the patient. In this holistic role, the primary care physician links clinical, behavioral/mental health and chronic disease management in a team-based approach to better serve their patients.

The need for timely and appropriate data A key ingredient to unleashing the real power of the primary care physician is timely and appropriate data. The primary care physician cannot be a real advocate of the patient without the necessary data from the other caregivers. The primary care physician is also in the best position to play a key role in managing risk and the provision of value-based care throughout the continuum but, again, they need timely data from all caregivers. Too often (as we all know as consumers of healthcare services) our primary care physician does not have access to timely and appropriate patient data. Electronic Medical Record (EMR) connectivity is critical

to unleashing the real power of the multiple roles of the primary care physician. The EMR, ideally, also needs to have critical social determinants factors identified that are integral to the patient’s health status. We need to strengthen interoperability of the EMR through enhanced data management and collaboration with provider, payers, and community partners.

Not enough docs We do not have enough primary care physicians to meet today’s needs, let alone our future needs. We will need many more primary care physicians, given their increased role in our new risk/value-based world, who are focused on improving the health status of our population. Approximately 30% of physicians are in primary care which stands in stark contrast to other highincome countries, where the ratio of primary care providers to specialists is generally 70:30. I am an advocate of increasing the number of NP and PA programs, but it should not be a substitute for the needed growth in numbers of primary care physicians. I am also a believer in the increased use of technology, including telehealth, to allow us to better leverage our primary care resources in an economical manner. But this does not mean we reduce primary care to sound bite answers, with little or no personal interaction. Ultimately, the value of the primary care physician-patient relationship is based on trust. If we identify the expansion of NPs/PAs programs and the growth of virtual office visits as the answer to this physician shortage, then we are downgrading the potential value that primary care physicians can bring to the table www.repertoiremag.com

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April 2022

TRENDS Healthcare payers can help Ultimately, the combination of lower pay and the large amount of student debt along with a less than satisfying role in caring for their patient, has resulted in fewer medical students selecting primary care as their area of practice. Healthcare payers’ passivity was a major factor in creating the “sick care” system that exists today, which devalues primary care. I define “passive” as sitting on the sidelines and observing escalating healthcare costs and inconsistent quality and accepting it as a norm rather than proactively addressing the root causes. This passivity also created an environment that placed the primary care physician in a second-class role in the healthcare continuum, especially with regard to their level of pay vs. specialists.

Health insurance companies also played “follow the leader” in cloning Medicare RBRVS fee schedule as their own base for determining payment levels for the physicians and the related services. This again was done to the detriment of the primary care physician.

Active Purchasers As a result of escalating healthcare costs Passive Purchasers of healthcare services are now transitioning to Active Purchasers who are demanding better value for their healthcare dollar. Medicare Advantage Plans, Medicaid Managed Care, Self-insured employers, enlightened health insurance companies, and consumers who are more financially engaged with their healthcare purchasing decisions (Health Savings Accounts, etc.) are all examples of Active Purchasers or potential active purchasers.

If we recognize the value of the enhanced role of primary care physicians and their teams, then we need to support these efforts by paying for their services in a more holistic fashion. The reliance on a fee-for-service payment methodology (“the more you do the more you make”) primarily benefited specialists and was the growth engine for hospitals and all to the detriment of primary care physicians. The primary care physician was further penalized when Medicare developed the Resource Based Relative Value Scale (RBRVS) as a basis for calculating reimbursement for physicians. This coding system does not adequately account for the work performed by primary care physicians in that it rewards procedural work over cognitive work. 38

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Each of these Active Purchasers can play a key role in moving the primary care physician to “center stage.” These Active Purchasers finance healthcare and a healthcare system is shaped by “what you pay and how you pay for it.” Payers, as well as innovative organizations, are also collaborating or creating physician practice management service organizations. These organizations provide administrative infrastructure and support services to independent primary care practices transitioning to value-based care models. Payers, such as United’s Optum, are also buying primary care practices or hiring primary care physicians directly.

Innovators such as Privia Health hire and collaborate with primary care physicians and practices to better serve patients, self-insured employers, health systems and payers. Organizations such as Agilon Health have partnered with independent primary care physician groups such as Central Ohio Primary Care to allow the practice to embrace risk/value-based payment methodologies such as capitation. Enlightened consultant and brokers are partnering with self-insured employers and third-party administrators in developing value-based benefit designs as well as incorporating Direct Primary Care and other vehicles to further the search for value. These disruptive organizations are also sending a message to traditional insurance companies who do not value the role of the primary care physician in the value equation.

Transitioning to payment methodologies that incent If we recognize the value of the enhanced role of primary care physicians and their teams, then we need to support these efforts by paying for their services in a more holistic fashion. In the ideal world this would be in some form of per member capitation, and as it relates to health systems, global capitation. In 2016, the Urban Institute published a thoughtful study that focused on primary care capitation. That report stated the following: “The theoretical virtue of primary care capitation is that it permits primary care physicians themselves to decide what mix of activities best serves each patient, rather than rely on third-party payers to approve payment codes and payment levels to influence how clinicians spend their time.”

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TRENDS “Primary care capitation places decision-making in the hands of health professionals who may be in a better position than distant insurers to act in patients’ best interests. In addition, in direct contrast to fee schedules, primary care capitation in effect establishes spending limits for the patients a physician is responsible for, thereby creating financial incentives in favor of activities that reduce spending.” As further stated in the Urban Institute report, “A hybrid of primary care capitation and fee schedule payment, as well as incremental payments such as Shared Savings and Pay for Performance are all compatible – and in some contexts, probably desirable.” The Center for Medicare & Medicaid Innovation Center (CMI) plays a key role in transitioning payment systems, including for primary care physicians, to be value-based. If appropriate, CMI hopes that private payers will clone these payment systems to both enhance their effectiveness as well as to cut down the administrative burden of providers of care. Finally, the consumers also have a role in moving primary care physicians to center stage. The more consumers value the role of the primary care physician and partner with them in achieving better health and quality of life, the greater the likelihood that primary care physicians would be moved to center stage. Consumers also need to demand that their specialists provide their primary care physician with all information related to their visits.

The more consumers value the role of the primary care physician and partner with them in achieving better health and quality of life, the greater the likelihood that primary care physicians would be moved to center stage. Enhancing their role The enhancement of the role of the primary care physician along with increased income (and less financial educational debt) will attract more medical students to this needed specialty. Another advantage for medical students selecting primary care as their area of specialty is the increased career options (or career doors) that will be available to them in this risk/ value-based world ahead. I am a strong believer in the Direct Primary Care (DPC) model since it plays a key role in both patient health as well as addressing employee health

and related productivity which positively impacts employers’ profitability. Even though I am an advocate of increasing the role of primary care physicians, I am not under-valuing the role of specialists and subspecialty physicians. I am not suggesting that a primary care physician has the expertise of these specialists, nor would any primary care physician make such an assertion. Patient care should be a team approach, and the primary care physician does play a necessary and increasingly important role in our new world of healthcare. Primary care physicians, the future is yours.

Tom Campanella is the Healthcare Executive in Residence at Baldwin Wallace University. Backed by more than 35 years of experience in the industry – particularly the health insurance, physician and hospital sectors – he’s focused on strategic advising and community outreach. For more information, visit Tom on LinkedIn at: linkedin.com/in/ thomascampanella or Baldwin Wallace University at www.bw.edu. 40

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TRENDS

Rising Health Insurance Costs New report finds that working families shoulder increasing share of health insurance costs. By Pete Mercer A report from Commonwealth Fund has found that in 37 states, worker’s health insurance premiums and deduct-

ibles take up to 10% or more of their median income. State Trends in Employer Premiums and Deductible, 2010-2020 found that median incomes have not kept pace with rising health insurance costs and deductibles, which are fueled by high health care and drug prices.

Sara Collins, lead author of the study and Commonwealth Fund Vice President for Health Care Coverage, Access, and Tracking, said in a media release, “Employer health insurance is taking a big bite out of many working family’s incomes, leaving them with less money to spend on housing and food, and saddling millions with medical debt.”

as their incomes fail to keep pace with rising health care prices.” The authors also suggest additional reforms to improve health insurance for U.S. workers. Policymakers should address the high health care prices that are driving up employer premiums and deductibles, as well as informing workers with employer coverage about their options to enroll in subsidized marketplace plans.

What the report found The State Trends report found that premium contributions and deductibles totaled 11.6% of median income in 2020, a 9.1% increase from 2010, and middle-income households faced average deductibles that left them underinsured to high out-ofpocket costs. Additionally, workers in lower-wage companies contribute more to family premiums than workers in higher-wage firms do. David Blumenthal, M.D., Commonwealth Fund President, said, “Middle-class workers in a majority of states spend 10% or more of their family budgets on health insurance premiums and deductibles. That’s a burden that many families are finding increasingly difficult to shoulder,

Consequences of high insurance premiums Aside from the increased costs for premiums and deductibles, these trends pose a greater threat to the

health of those affected. The report says that while only about 6% of U.S. working-age adults reported losing their health insurance during the pandemic, the financial burden of commercial insurance is causing many American workers to avoid necessary medical treatment altogether. Blumenthal said, “There are also health implications: people who are worried about costs are less likely to get the health care they need. Solving this problem will require policy actions to extend affordable health insurance coverage to all Americans. But we also need to get at the root, which are the high costs that make health care so expensive for everyone.”

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April 2022

TRENDS

In the 21st century, all but one U.S. industry has used information technology (IT)

to cut costs, increase access to products and services, and improve quality. Healthcare is the lone exception. For decades, medical costs have risen faster than inflation – with spending now above $4 trillion annually. For patients, accessing medical care is both time consuming and burdensome. Meanwhile, U.S. healthcare lags other wealthy nations in nearly all measures of quality, including life expectancy and childhood mortality. Modern technologies could help solve these problems. So, why haven’t they? 42

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One answer involves the technology, itself. Take the electronic health record (EHR), which has become a symbol of what’s wrong with tech in medicine. Though EHRs can improve collaboration among doctors, give patients fuller access to their medical data and reduce clinical errors, they rarely do. Instead, these systems are cumbersome and clunky, and they sit (literally) between doctors and patients. Year after year, the Medical Economics survey of “things ruining medicine for physicians” rates EHR usability at or near the top of the list. But form and function aren’t the only barriers to widespread tech adoption in healthcare. Also standing in the way is an unwritten rule that governs the relationship between doctors and technology – a rule that has held firm for centuries.

This article, part of a series called Breaking The Rules Of Healthcare, explains this rule and offers a viable solution.

Rule No. 3: The best technology preserves the status of the doctor The expression “lay hands on the sick and they will recover” dates back to biblical times when the hands of healers were believed to have curative powers. In the millennia that followed, physicians embraced the tradition of laying hands on patients. By the 18th century, doctors took great pride in their ability to assess a patient’s temperature using only their hands. This skill took years of training to master, helped distinguish doctors as experts and boosted the prestige of the entire profession. Around that same time, Daniel Fahrenheit invented a new device called the thermometer, which could measure body temperature within one-tenth of a degree. What happened next was a seminal moment in medical history. Rather than welcoming Fahrenheit’s technological wonder with open arms, doctors dismissed it as clunky, cumbersome and painfully slow to calibrate. Indeed, the first-gen version was all those things. But those design flaws don’t explain why physicians ignored – and outright denied – the thermometer’s potential to help patients. In reality, doctors saw the device as a threat to their professional status and relative importance. If just anyone could accurately determine a patient’s temperature without years of hands-on training, then physicians would lose a big part of what makes them special. To preserve their status, doctors spent the next 130 years fighting to keep the thermometer out of the exam room.

Wanted: Technology that elevates the doctor’s status

Good for patients, bad for physicians?

In the centuries since, doctors have given preference to technologies that boost their reputation. Consider the industry-wide obsession with operative robots. These multimillion-dollar machines look like space-aged command centers with doctors (and only doctors) sitting in the captain’s chair, directing the movements of several large robotic arms.

In sharp contrast to surgical robotics, there are several modern technologies that could positively and powerfully transform patient care. Yet, most generate lukewarm to negative reactions from physicians. Here are two examples.

It’s easy to see the appeal: These machines are incredibly cool and the surgeons who use them are seen as rock stars on the cutting edge. Medical journals overflow with descriptions of new and interesting applications for these technologies. It’s therefore no surprise that the surgical robotics markets is projected to grow by 42% annually over the next decade.

Telemedicine Prior to the pandemic, only 1 in 10 patients had experienced a virtual visit with a doctor. That changed at the onset of Covid-19, when physician offices were forced to close. Suddenly, telehealth accounted for 70% of all visits and – to the surprise of doctors and patients alike – the experience was resoundingly positive. Physicians resolved patient problems faster and more effectively than before. Patients, meanwhile, enjoyed the added convenience and most (75%) expressed high satisfaction with virtual care.

If just anyone could accurately determine a patient’s temperature without years of hands-on training, then physicians would lose a big part of what makes them special. Here’s the problem: Independent research from 39 clinical studies has determined that robot-assisted surgeries have only modest clinical advantages over other approaches. They have so far failed to extend life expectancy or significantly reduce surgical complications. Looking objectively at the impact this technology has on patients, the operative robot is a dud. But for the reputation of physicians using it, the machine is a megahit.

Yet, in the months that followed, telemedicine usage receded to almost pre-pandemic levels, accounting for just over 10% of patient visits today (not including virtual mental health). The problem isn’t the technology. It’s what the technology represents. Telehealth constitutes a threat to the physician’s office, a place where the doctor’s prestige is on full display. Physicians take great pride in seeing their names on the front door, embossed in bold letters. Even the www.repertoiremag.com

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TRENDS “waiting room” communicates the importance of the doctor’s time. Telemedicine strips these status symbols from the doctorpatient experience. And so, even though virtual care offers patients greater convenience with no evidence of quality issues, doctors undervalue and underuse it. Unlike what we’ve seen with surgical robotics, you won’t find journal articles in which clinicians attempt to push the boundaries of telehealth. AI and data analytics Computing speeds continue to double every couple of years. It’s a phenomenon known as Moore’s Law, and it means that tools like artificial intelligence (AI) and data analytics are becoming smarter and more capable of transforming healthcare delivery. Already, AI has been shown to interpret certain X-ray studies (mammograms and pneumonia) more accurately than skilled radiologists. In the future, computers with machinelearning capabilities have the potential to make diagnostic readings both better and faster than humans. Meanwhile, data analytics (which inform evidence-based algorithms) have the power to dramatically improve physician performance. When doctors consistently follow science-based guidelines, they achieve far better clinical outcomes than on their own. With these tools, physicians have the opportunity to lower mortality rates from heart attacks, stroke and cancer by double digits. But, as with the thermometers of centuries before, you won’t

find physicians clamoring for these tools, either. Instead, you’ll hear doctors from every specialty denounce the use of computerized checklists and algorithmic solutions as “cookbook medicine,” just some recipe to be followed. They argue that data analytics and AI will make every doctor average, ignoring the fact that the “new average” would be vastly better than today’s. No matter how better the results, technologies that tell doctors what to do are seen as a threat to the profession. Invariably, physicians reject them.

Selecting the best tech with forced transparency Transparency is the best first step toward breaking the outdated rule of technology in healthcare. Here’s how it might look. In partnership with a highly respected agency like the National Institutes of Health (NIH), scientists

would analyze the scientific merits of various healthcare technologies. The list might include the surgical robot, along with telemedicine, AI, proton-beam accelerators, wearable heart monitors, PET scanners and chatbots for self-diagnosis, among others. Researchers would review published data, analyze each technology and publish a cost-benefit rating, similar to what you’d find in Consumers Reports. Though this exploratory body wouldn’t have regulatory power – the way the FDA has authority over drug approvals – it would nonetheless serve an important function. This process would provide an unbiased evaluation of the most promising tools for patients. To improve healthcare in the areas of cost, access and quality, we must measure technologies by their impact on the health of patients, not their impact on the status of medical professionals.

Dr. Robert Pearl is the former CEO of The Permanente Medical Group, the nation’s largest physician group. He’s a Forbes contributor, bestselling author, Stanford University professor, and host of two healthcare podcasts. Pearl’s newest book, “Uncaring: How the Culture of Medicine Kills Doctors & Patients,” is available now. All profits from the book go to Doctors Without Borders. For more information or to sign up for his newsletter, visit robertpearlmd.com. 44

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NEWS

Primary Care News Funding to support primary care residents in rural and underserved communities The U.S. Department of Health and Human Services (HHS), through the Health Resources and Services Administration (HRSA), announced the availability of $19.2 million in American Rescue Plan funding to support and expand community-based primary care residency programs. Awardees will use this funding to train residents to provide quality care to diverse populations and communities, particularly in underserved and rural areas. The Teaching Health Center Graduate Medical Education (THCGME) program supports training in community-based care settings. These training sites offer primary care and dental residents experience working with diverse, high-need patient communities in areas that often lack sufficient primary care physicians and dentists, according to a release. After completing residencies, the majority of THCGME program graduates will continue to practice in underserved or rural settings and two-thirds continue to practice primary care – nearly double the average of all medical and dental graduates.

“Training physician and dental residents in community settings is helping us to build a stronger primary care workforce that better supports the communities served,” said HRSA Administrator Carole Johnson. “The American Rescue Plan funding announced will help us to grow the number of primary care residents training and practicing in underserved communities, a critical step toward

expanding access to high-quality health care and advancing health equity.” This THCGME funding opportunity will increase the program’s reach and support the equivalent of approximately 120 full-time resident positions. Teaching Health Center primary care residency programs offer training in skills needed to care for populations such as members of tribal communities, residents of rural areas, and people who are medically underserved.

Walmart, Health at Scale launch customized provider recommendations for plan participants Health at Scale announced a collaboration with Walmart to provide personalized provider recommendations to Walmart associates and their families who work in locations where Health at Scale is offered and are enrolled in the company’s health plan. This technology will be incorporated into Walmart’s health plan administrator’s search engine and virtual care referrals for associates in select geographies, making it easier for plan participants to find providers that match to their unique health needs and care history, according to a release. Through this initiative, Walmart and Health at Scale will establish a more personalized healthcare experience that focuses on the needs of each individual in the moment and leverages industry-leading machine intelligence to identify providers who have successfully treated patients with similar characteristics and care needs. “Finding the right provider is one of the most important health decisions a patient makes. It is also one of the hardest. What we really need to optimize is the patientprovider match,” said Health at Scale CEO Zeeshan Syed. “We’re delighted to work with Walmart as the leader in employer health and benefits innovation and provide Walmart associates and their families in certain locations with smart, hyper-personalized provider matches that reflect a deep understanding and respect for their individual health needs.” Health at Scale said its Precision Navigation™ goes beyond non-personalized process-based star ratings, reputation rankings, and volume-based metrics and instead uses AI and machine learning to model variations in provider outcomes across thousands of health factors. The service covers 25 different specialties as well as 34 procedures and imaging. www.repertoiremag.com

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April 2022

TRENDS

Next-Gen Blood Tests Theranos made a hasty exit, but blood-based diagnostics for cancer detection are beginning to settle in. By Mark Thill

How’s this for a worthy goal: To quickly, conveniently

and inexpensively conduct dozens of tests with one drop of blood! At home! We all know the rest of the story. Well, Theranos may have fallen victim to haste and deceit, but blood-based diagnostics for cancer detection through genomic profiling is no empty promise. Questions remain about its impact on outcomes and cost, and it’s way too early to say if it will enter the physician’s office, or be used for routine screening, or yield results at the point of care. But some experts believe these things may someday be possible. Genomic profiling is a laboratory method used to learn about the genes in a person or in a specific cell type, including cancer biomarkers. (Genes are pieces of DNA that hold the codes for making proteins – the instructions that make the body run.) The genes in our cells – about 30,000 of them in total – make up the genome. Changes to genes called mutations can make a person more likely to get cancer. 46

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April 2022

TRENDS Biomarkers (sometimes called tumor markers) are genes, proteins and other substances that can provide information about cancer. Each person’s cancer has a unique pattern of biomarkers. The promise of genomic profiling is to spot cancer biomarkers early, target the cancer with specific therapeutics matched to those biomarkers, and gauge the progress of treatment. That is the essence of what is called precision, or personalized, medicine. For example, people with cancer that has genetic changes in the EGFR (epidermal growth factor receptor) gene may be treated successfully with EGFR inhibitors.

patient is too sick for such a procedure. In such cases, a noninvasive approach, which can identify circulating tumor DNA, or ctDNA, in blood, is an appealing alternative. Circulating tumor DNA is extracellular DNA from cancer cells that have undergone cell death. The Food and Drug Administration approved the first liquid biopsy test – the cobas® EGFR Mutation Test v2 (Roche Molecular Systems Inc.) – in June 2016. The test uses plasma specimens for the detection of epidermal growth factor receptor (EGFR) gene mutations in ctDNA of patients with non-small-cell lung cancer. The test identifies patients

‘ The pace of biomedical engineering and discovery is fast. But we’re at the ground floor. None of us know what the real performance of these tests will be.’ Tissue or blood biopsy? “Next generation sequencing” of a tumor – a technology that can sequence an entire human genome within a single day – is the gold standard for molecular profiling, according to the American Society of Clinical Oncology. (To “sequence” DNA means to determine the order of the four chemical building blocks, or bases, of the DNA molecule – adenine, thymine, cytosine and guanine. The sequence tells scientists the kind of genetic information that is carried in a particular DNA segment.) As applied in traditional tissue biopsies, next-generation sequencing allows the clinician to compare tumor DNA with normal tissue DNA. But not all patients can get a tissue biopsy, either because the tumor is inaccessible or lacks adequate tissue, or the 48

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who may be candidates for treatment with erlotinib (Tarceva®A) and osimeritinib (Tagrisso®), targeted therapies that attack cancer cells with EGFR mutations. “In my opinion, tissue biopsies and liquid will be complementary,” Daniel Hayes, M.D., FASCO, FACP, Stuart B. Padnos Professor of Breast Cancer Research, University of Michigan Rogel Cancer Center, told Repertoire. A tissue biopsy yields more cells, which improves accuracy, he says. “But the downside is, it demands a biopsy. If it’s on your skin, that’s one thing; but if it’s in your liver or lung, that’s a very big deal. The other problem is, you only get results of the tissue that is biopsied. We’ve known that within a breast – even within the same tissue – cancer can be heterogeneous,

meaning some cells are cancerous, some are not. “Finally it’s difficult to do serial tissue biopsies, because, by definition, there’s nothing to biopsy in a person who is free of disease. So they are not helpful for monitoring the progress of treatment.” Liquid biopsies, on the other hand, are convenient to administer, facilitate serial monitoring, and offer a snapshot of the patient’s entire tumor burden, he says. Sandip Patel, M.D., associate professor, University of San Diego Moores Cancer Center, says that today, some biopsies can only be performed reliably with tissue. Liquid biopsy offers advantages in instances where detection of biomarkers isn’t feasible based on the distribution of disease, e.g., in bone or the brain. Both tissue and plasma biopsy methods continue to progress, he adds. “There’s a rising tide for both boats. I foresee complementary usage of both.”

Where do we go from here? Since that first FDA approval in 2016, researchers continue to develop applications for liquid biopsy. FoundationOne Liquid CDx from Cambridge, Massachusetts-based Foundation Medicine is said to be capable of analyzing over 300 genes from two tubes of blood, plus MSI and blood tumor mutational burden (bTMB), both of which are genomic signatures that can help predict whether a patient might respond to immunotherapy. In addition, the company’s genomic profiling test was FDA-approved to identify prostate cancer patients likely to respond to Lynparza® (olaparib) or Rubraca® (rucaparib). In January 2022, researchers at the University of Sussex in the United Kingdom reported identifying distinctive biomarkers in patient blood

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TRENDS samples that may signal the presence of glioblastoma, the most common high-grade primary brain tumor in adults. The team identified biomarkers within extracellular vesicles, which are small particles secreted by all cells carrying different information, such as proteins or DNA. Meanwhile, South San Francisco, California-based Freenome and Redwood City, California-based Guardant Health are undertaking clinical studies on the effectiveness of liquid biopsies in detecting earlystage colorectal cancer.

Early cancer detection The National Cancer Institute is supporting an initiative to advance the development and validation of liquid biopsy technologies that can detect early-stage cancers, distinguish cancer from benign conditions, and identify fast- and slow-growing cancers. Such tests could screen for early-stage cancer in high-risk individuals, such as those with hereditary cancer syndromes. Meanwhile, The University of Texas MD Anderson Cancer Center reported in January that a blood test using a four-protein marker panel, combined with a risk model based on an individual’s history, more accurately determined who is likely to benefit from lung cancer screening than current U.S. recommendations. “We recognize that a small percentage of people who are eligible for lung cancer screening through an annual low-dose CT scan are actually getting screening,” Sam Hanash, M.D., Ph.D., leader of the McCombs Institute for the early Detection and Treatment of Cancer, was quoted as saying. “Moreover, CT screening is not readily available in most countries. So, our goal, for many years, has been to develop a simple blood 50

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test that can be used first to determine need for screening and make screening for lung cancer that much more effective.” In February, Menlo Park, California-based GRAIL announced an agreement with Point32Health, the combined organization of Harvard Pilgrim Health Care and Tufts Health Plan, to collaborate on a two-phased pilot of Galleri®, GRAIL’s multicancer early detection blood test. GRAIL has reported that in a clinical study, the Galleri test detected more than 50 types of cancer, over 45 of which lack recommended screening tests today, with a false-positive rate of less than 1%. When cancer is detected, Galleri can determine the cancer signal origin with high accuracy, according to the company.

treatment response for patients with certain cancer types, but they are not sensitive enough to detect small changes in tumor size and they tend to be costly, according to Mark Roschewski, M.D., of NCI’s Center for Cancer Research. As a potential alternative, Dr. Roschewski and colleagues have tested the ability of a liquid biopsy test to track treatment responses in patients with lymphoma. They showed that changes in ctDNA correlated with positive responses to chemotherapy. Furthermore, they were able to use ctDNA patterns to detect when some patients’ disease was coming back—months before it was possible to do so via CT scan. NCI researchers have also correlated changes in ctDNA levels with

Liquid biopsies are convenient to administer, facilitate serial monitoring, and offer a snapshot of the patient’s entire tumor burden.

Monitoring cancer treatment response Another potential application for blood-based diagnostics is monitoring progress – or lack thereof – of cancer treatment. Because they are noninvasive and easily repeated, ctDNA-based liquid biopsies may be useful for monitoring patients’ responses to therapy both during treatment and after it is completed, says NCI. Clinicians are hopeful that tracking a patient’s response to treatment may allow adjustments to be made in real time. In other words, the treatment could be stopped or adjusted if the test indicates it is not working. Imaging techniques such as CT scans are currently used to track

patients’ responses to immunotherapy treatment – a type of therapy that uses substances to stimulate or suppress the immune system to help the body fight cancer, infection, and other diseases. They found that they could detect these changes within two weeks of the start of treatment. Having an early indicator of the treatment’s efficacy could be helpful because only a small proportion of patients typically respond to immunotherapy treatment. Last year, GRAIL announced collaborations with biopharmaceutical companies Amgen, AstraZeneca and Bristol Myers Squibb to evaluate the company’s technology for the detection of minimal residual disease, or MRD (referring to cancer

cells remaining after treatment that can’t be detected by other scans or tests). Currently, many MRD tests for solid tumors require tissue samples and development of patient-specific assays. GRAIL says its methylation platform could enable a bloodbased MRD detection assay for solid tumors that perform comparably to tissue-based assays, while reducing complexity and processing times. Another firm, Italy-based Menarini Silicon Biosystems, reports that its CELLSEARCH® Circulating Tumor Cell Kit provides in vitro diagnostic applications that are FDA-cleared for predicting overall and progression-free survival in metastatic breast, prostate, and colorectal cancers. Evaluation of circulating tumor cells at any time during the course of disease allows assessment of patient prognosis and predictions of progression-free survival and overall survival.

Questions Early-detection tests have potential, and some day may be incorporated into clinical guidelines, according to the American Society of Clinical Oncology. In fact, a bill (The Medicare Multi-Cancer Early Detection Screening Coverage Act of 2021) was introduced into the U.S. Senate in May 2021 that would provide Medicare coverage and payment for multicancer early detection screening tests that are approved by the Food and Drug Administration. But questions remain: How often should these tests be performed? Who will pay for them? Can the cost be justified by the number of lives saved? Would such testing lead to overdiagnosis, leading to more tests and even treatment of cancers that might pose little threat to the patient?

Dr. Patel believes routine screening for cancer with blood-based diagnostics is a possibility. “Two years ago, mRNA vaccines were science fiction. Now millions of people accept it as fact. The pace of biomedical engineering and discovery is fast. But we’re at the ground floor. None of us know what the real performance of these tests will be.” As for rapid turnaround of blood-based biopsies, Dr. Hayes foresees bioengineers working on it, but he questions its clinical utility. A great deal more clinical research will be necessary to demonstrate that the benefits of screening with so-called Multi-Cancer Early Detection (MCED) assays outweigh the harms, he says. “Screening is catching everyone’s attention, and intuitively it is perceived to be good no matter what. But early detection,

which has been proven to be beneficial in some cancers – breast, cervical, lung, colon, and probably prostate – is not necessarily better for all cancers, and the benefits in regard to mortality reduction need to be rigorously demonstrated. The odds of hurting people by overdiagnosing them are almost the same as helping them. So the stakes are very high.” Even more promising than screening is the progress being made to match biomarkers with drugs specifically designed to treat the patient’s cancer, he says. He looks forward to cancers being treated based on their molecular profile rather than their origin (e.g., lung, prostate, breast). “We may find opportunities to treat people based on their molecular findings, which is different from what we ever imagined.” www.repertoiremag.com

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April 2022

HEALTH NEWS

Health News and Notes

Study: “Tranquil” virtual reality experience lowers stress in frontline healthcare workers Researchers found that brief sessions of virtual reality stimulation helped frontline healthcare workers reduce stress in the short term. According to the journal PLOS ONE, researchers from Ohio University Heritage College of Osteopathic Medicine, OhioHealth Healthcare Organization and Ohio University piloted a three-minute Tranquil Cinematic-VR simulation of a nature scene to lower subjective stress among frontline healthcare workers in COVID-19 treatment units. They chose to film a nature scene “because of the extensive empirical literature documenting the benefits of nature exposure and health,” according to the research article, and 102 individuals participated in the study. Among the study participants, 82.4% participants provided direct 52

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patient care. Post-simulation, researchers observed a significant reduction in subjective stress scores from pre- to post-simulation, and only four participants met the cutoff for high stress after the simulation. Post-simulations scores did not differ by provider type, age range, gender, or prior experience with virtual reality.

Music is good for the heart As part of a collaboration with music streaming service Pandora, the American Heart Association had a station takeover of Pandora’s Dance Cardio Radio during February in recognition of American Heart Month. Three Modes featuring specially curated tracks by Pandora were available for the month of February: Reclaim Your Heart: Surviving and Thriving, featuring the anthems of the 2022 Go Red for Women Real Women Class, national volunteers for the American Heart

Association, each with a unique heart or brain health journey; Reclaim Your Day, featuring celebrated Black artists in recognition of Black History Month; Reclaim Your Beat, featuring music you can dance to, groove to, and keep the beat, 100 to 120 bpm, for Hands-Only CPR. “Curating a personal playlist can help reclaim rhythm, whether it’s cardio, meditative, or a soundtrack for resting,” the AHS said in a release. Additionally, the AHS recommended five other ways to create heart healthy habits: ʯ Mellow out and reduce stress: “Stress can lead to depression or anxiety, as well as unhealthy habits like overeating, physical inactivity, smoking and risk factors for heart disease and stroke like high blood pressure.”

Move to the music: “Create a playlist that will get listeners moving and grooving. Staying active is one of the best ways to keep body and mind healthy. Not only can it help everyone feel, think, sleep and live better, it also improves overall quality of life. Physical activity is linked to lower risk of diseases, stronger bones and muscles, improved mental health and cognitive function and lower risk of depression.”

Feed your soul, rock your recipes: “The meaning of “family” may have changed, but family meals still make an impact. Regular meals at home with family can help reduce stress, boost selfesteem and make the whole family feel connected.”

Stay on beat with your blood pressure: “High blood pressure is a leading cause and controllable risk factor for heart disease and stroke and can contribute to worse outcomes for people who contract COVID-19. Close to half of American adults have high blood pressure. Of those, about 75% don’t have it controlled and many don’t even know they have it. The best way to know your blood pressure numbers is to have it measured at least once per year by a health care professional. If your blood pressure is normal and you are at least 20 years of age, regularly monitor it at home with a validated monitor and discuss the numbers with a doctor. “

Keep the Beat! Learn Hands-Only CPR: “Each year, more than 350,000 EMS-assessed out-of-hospital cardiac arrests occur in the United States and about 70% of out-of-hospital cardiac arrests happen in homes. When a person has a cardiac arrest, survival depends on immediately receiving CPR from someone nearby. CPR, especially if performed immediately, can double or triple a cardiac arrest victim’s chance of survival. Help your community reclaim their rhythm by learning the two simple steps of Hands-Only CPR: Call 911, then press hard and fast in the center of the chest. Visit heart.org/handsonlycpr to watch the Hands-Only CPR instructional video and share it with the important people in your life.”

FDA cleared first smartphone app that delivers extra doses of insulin The FDA has approved the first application for iPhone and Android devices that is capable of providing insulin doses to patients with diabetes. Tandem Diabetes Care, an insulin delivery and diabetes technology company, said in a media release that its app will allow diabetic users to administer a dose of insulin through their smartphone. The app connects to Tandem’s t:slim X2 insulin pump, and is used for bolus insulin dosing, preventing glucose spikes after meals. “This FDA clearance further validates our commitment to innovation and the diabetes community by providing one of the most requested feature enhancements,” John Sheridan, president and CEO

of Tandem Diabetes Care said. “With the improvements in diabetes management provided by Tandem’s Control-IQ technology, giving a meal bolus is now the most common reason a person interacts with their pump, and the ability to do so using a smartphone app offers a convenient and discrete solution. The FDA-cleared feature will be available to U.S. t:slim X2 insulin pump customers for free through a software update. Tandem plans to roll out the feature throughout the spring in a series of limited launch groups and through an expanded launch during the summer. Doctors: Pandemic delayed screenings leading to advanced colorectal cancer cases The Orlando Sentinel recently interviewed doctors who say there is evidence of an increase in colorectal cancer after pandemic delayed screenings. Researchers from the Fred Hutchinson Cancer Research Center in Seattle estimate as of April 2021 there was a 50% decrease in colonoscopies, and that number was as high as 90% earlier in the pandemic. Likely as a result of delayed diagnoses over the last two years, Orlando Health and AdventHealth doctors say they see more patients showing up with advanced colorectal cancer that is harder to treat, and they worry that missed screenings will increase cancer deaths for years to come, the Sentinel reported. “Cancer is often curable if it’s caught at an early stage,” said Orlando Health Cancer Institute medical oncologist Dr. Sreeram Maddipatla. “I think this is going to have a domino effect for the next few years because we missed out on this crucial two-year period where we would have diagnosed more cancers.” www.repertoiremag.com

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April 2022

MARKETING MINUTE

Lessons healthcare manufacturers can learn from other industries about medical device reprocessing. Medical device reprocessing is not a new concept, but the popularity of recycling is increasing as companies both

in and out of healthcare become more eco-conscious. Innovative businesses that use device reprocessing include BMW, Ritz Carlton, and Rolex. In this article, we will look at best practices healthcare manufacturers can learn about medical device reprocessing from these three businesses.

Types of medical device reprocessing

Medical device reprocessing is the industrial process medical equipment undergoes so that facilities can use them again. Reprocessing has two different meanings in healthcare depending on whether you are working with a reusable device or a single-use device.

Reusable Device Reprocessing is the strict cleaning and treatment practices technicians use to sterilize medical equipment and prepare it for future use.

Single-Use Device Reprocessing is the recycling of used devices to create parts for new equipment.

Johnson & Johnson is leading the way in medical device reprocessing. They offer reprocessing services for both their machines and equipment from other manufacturers. Medical device reprocessing for single-use devices saved an estimated $8.6 million. They also kept around 281,000 pounds of regulated medical waste out of landfills. Here are some other examples of item reprocessing, based on practices by BMW, Ritz Carlton, and Rolex.

BMW implements a circular economy BMW recently unveiled its new plans for creating a more sustainable future. Their targets include: ʯ Lowering CO2 emissions ʯ Consistent implementation of circular economy Circular economy refers to planning products by following a circular pattern. The circle includes the planning, designing, production, and end of life of the product. They want to increase the number of secondary materials they use in manufacturing to as high as 50% through reprocessing. They have also partnered with recycling organizations to help them keep plastics out of landfills. 54

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They also created RE: BMW CIRCULAR LAB. This communication and experience platform helps educate and spread awareness about the benefits of a circular economy. They post regular news updates and host workshops where consumers can be part of the solution.

Ritz Carlton furnishes hotels with recycled materials The Ritz-Carlton revolutionized the hospitality industry with strategies that reduce waste through innovative recycling practices. They have dozens of processes in place that help their hotels run more sustainably. Here is a look at some of Ritz-Carlton’s recycling practices. ʯ Kept 3,900 tons of debris out of landfills by recycling more than 80% of hotel construction ʯ Furnished their rooms with products made from recycled leather ʯ Developed suits from recycled plastic bottles for some departmental uniforms ʯ Printed information on post-consumer waste recycled paper ʯ Built meeting room tables from recycled aluminum

Rolex remakes watches from recycled products Rolex watches represent more than just a timepiece that lasts a lifetime. They are also an organization founded in the belief that we should devote our lives towards making the world a better place – which they support through their Rolex Awards for innovative pioneers. They also support environmental efforts through their reprocessing practices. The company created a sustainable product life cycle that reprocesses materials from their watches at the end of the product’s lifespan. The company accepts old watches from consumers who no longer want it or can no longer use it. In their facilities, the staff retrieves any usable part of the watch, such as its Bezel, bracelet, and mechanical components. These parts are refurbished for use in lowerend models. In addition, the staff will meltdown other metal parts to reform new watches.

5 key strategies Here are five takeaways for healthcare companies from the previous examples about reprocessing. No. 1. Plan the full lifecycle of your devices. You can create a circular economy in healthcare by looking beyond how to create products. Instead, build a plan that follows the device through your healthcare supply chain and to the end of its life, including a sustainable disposal method.

No. 2. Educate consumers about sustainable practices. Sustainable living is a global issue and requires worldwide participation. You can help spread awareness by educating healthcare professionals about more sustainable practices, including reprocessing in their facilities. One way of encouraging eco-friendly practices is by hosting events that give healthcare workers and distributors a close-up view of the medical device recycling process and a chance to ask any questions. In addition, these events are a way to build trust with your distributors and clients. No. 3. Refurbish used products. Healthcare manufacturers can refurbish both one-use and reusable items to decrease their waste. However, recycling one-use items still requires adherence to a Nationally Recognized Testing Laboratory’s (NRTL) code to ensure the equipment is safe and fully working before you sell it as a new product. When studying the regulations for reprocessing medical devices, you should pay special attention to instruments you cannot refurbish due to health risks. No. 4. Create new products. Sometimes you can’t refurbish a product because it is beyond repair or unsafe to do so. Unfortunately, this is the case for many one-use plastic products. Instead, you can use those products to create new parts or donate them to a manufacturer that produces non-medical equipment with recycled parts. No. 5. Offer recycling services. Rolex and Johnson & Johnson both showed how their facilities also offered recycling services. These services increase the chances of your customers recycling their devices because they don’t have to search for a facility that accepts used medical equipment. In addition, in both businesses, they took products from other manufacturers, which benefits them as they receive additional recyclable materials. It also helps the earth by reducing landfill waste.

Help improve the environment starting with your business You can be a voice for the environment by supporting worldwide organizational efforts to reduce waste through reprocessing. Your manufacturing company can begin implementing some of the strategies you learned today and educate your clients about proper medical device disposal through your online content. Contact us to learn about our content services and how we can help you spread the word about the benefits of medical device reprocessing: https://sharemovingmedia. com/contact-us. www.repertoiremag.com

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April 2022

HIDA

Bipartisan PREVENT Pandemics Act Will Advance Preparedness The Health Industry Distributors Association (HIDA) continues to work with Congress to support a pandemic

preparedness strategy that builds domestic reserves, diversifies production, and is distributor managed to ensure a resilient healthcare supply chain. The recent introduction of bipartisan legislation in the United States Senate gives us reason for optimism that Congress may be able to pass legislation by the end of the year that applies many of the lessons our members have acquired during the COVID-19 pandemic.

Senators Patty Murray (D-WA) and Richard Burr (R-NC), the Chairwoman and Ranking Member of the Senate Health, Education, Labor, and Pensions (HELP) Committee, have introduced the Prepare for and Respond to Existing Viruses, Emerging New Threats (PREVENT) Pandemics Act. The PREVENT Pandemics Act is focused on strengthening the nation’s public health and medical preparedness and response systems in the wake of the COVID-19 pandemic. There is much to be commended in the PREVENT Pandemics Act: ʯ Bipartisan Legislation: HIDA applauds Senator Murray and Senator Burr for their leadership on pandemic preparedness. Bipartisan solutions are required to respond to the COVID-19 pandemic. HIDA has worked closely on the drafting of preparedness legislation, and worked closely with Senators Murray and Burr to incorporate policy recommendations that are based on our years of collaboration with federal partners on preparedness and the medical supply chain.

Public-Private Partnerships: The PREVENT Pandemics Act recognizes the vital role of publicprivate partnerships in managing medical supplies during a pandemic. The bill incorporates authorizing the Department of Health and Human Services to contract with medical products distributors to manage a surge capacity of pandemic supplies. This would create a bigger cushion of needed supplies, and allows for critical time to ramp up manufacturing production.

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Extended Contract Duration: To invest in capacity, manufacturers need certainty that there will be long term market demand for certain medical supplies. The By Mary Beth Spencer, HIDA Federal government should Director of make long term commitGovernment Affairs ments to manufacturing partners, which will ensure surge capacity in the event of a public health emergency. The PREVENT Pandemics Act takes a step in the right direction by requiring contract commitments of at least two years. HIDA believes five-year contracts would give manufacturers a stronger incentive to invest in capacity. HIDA has welcomed the introduction of the PREVENT Pandemics Act, and has continued to share our input with Congress on these issues. Medical products distributors have unique subject matter expertise on this topic. There are more than 500 healthcare distribution centers in over 46 states, with established, direct relationships with end users of medical supplies. HIDA members deliver medical products and supplies, manage logistics, and offer customer services to virtually every healthcare provider. In 2020, they reliably delivered 51 billion units of PPE “the last mile” to providers. As Congress continues to deliberate on these critical issues, HIDA is proud to remain a voice for our industry in Washington and beyond.

The 2022 PWH® Leadership Summit lineup will Open to women and men include Leadership Insights (TED-style Talks) at all leadership levels. addressing pressing issues in leadership today, motivating keynote speakers, engaging panel discussions and breakout sessions that will cover a host of topics. Leadership Insights

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Aster Angagaw Board of Directors, Owens & Minor

Stephanie Muir Chief Technology Officer, Midmark

Elizabeth Hilla Moderator SVP, HIDA

Joe Grispo Sr. VP of Sales, CSO, B.Braun

Joe Machicote Chief Diversity Officer, Premier

Joe Walsh Founder, Supply Chain Sherpas

Amanda Chawla VP Supply Chain, Stanford

Tina Murphy Chief Commercial Officer, GHX

David Gillan Chief of Client Retention & Strategy, Sodexo

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LEADERSHIP

How to Have Tough Conversations with Confidence By Lisa Earle McLeod

Do you ever find yourself putting off challenging conversations at work?

Sometimes, just thinking about a potentially difficult conversation has the power to fill us with anxiety. And that wave of dread often causes us to kick the can down the road, and avoid a conversation that really needs to happen. But here’s the thing: Conflict avoiders always wind up with more conflict. Putting off a challenging conversation pacifies the worry of the moment but exacerbates the overall angst over time.

People who cannot voice concerns are eternally fraught with worry; People who are unwilling to push back will feel constantly disempowered. It gnaws at you all the time. It doesn’t have to be this way. Being able to navigate challenging conversations is a hallmark of exceptional formal and informal leaders. Leaning in when you’re tempted to pull back takes practice. Roberta Matuson’s new book, “Can We Talk?”, offers a number of key tips:

No. 1: Start small If you struggle with difficult conversations and want to get better, focus on small wins first. This will boost your confidence. Getting comfortable with low-stakes conversations could be speaking up when your restaurant order is incorrect, offering another point of view in a brainstorming meeting, or simply saying “no thank you” to plans you don’t want join (instead of making up a white lie). Matuson suggests, “Start small, build your strength, and get a few wins under your belt.” These small wins will emotionally prepare you for more difficult conversations later. Over time, you will become less wary of temporary discomfort and more empowered to speak the truth.

No. 2: Don’t blindside the other person If the conversation you need to have will have lasting implications (beyond a moment or two of discomfort for you), it’s important to prepare the other party for the conversation. The conversation should not come as a surprise. 58

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Why Why Choose Choose Dale? Dale? Security Security You You Can Can Count Count on on

Matuson notes, “In this day and age, they could be sitting at their dining room table with the kids running around. They could be driving. They could be sitting beside a colleague at happy hour. You don’t know.” Ask the person you’d like to speak with if there’s a time the two of you could speak privately. This gives them the opportunity to come to the conversation with a level head, free of distractions.

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No. 3: Use notes I remember many years ago, the U.S. President at the time was continually criticized for bringing notes to meetings with other foreign leaders. I didn’t understand the criticism. To me, it felt totally normal. Why wouldn’t you come prepared for high-stakes conversations? I’d rather have a President who brought notes than a President who tried to remember everything only to forget important details. There is no shame in using notes. If you are preparing for a potentially difficult conversation, Matuson advises being transparent, saying something like,“This is an important conversation. I’ve been giving this a lot of thought and I’ve written down some notes.” When you come prepared, you don’t need to worry about perfect memorization of the speech you rehearsed in the shower. Instead, you can authentically lean into the conversation. Difficult conversations are a part of any impactful, purpose-driven career. Being able to navigate these conversations with kindness, truth, and authenticity is a learned skill. The more you do it, the better you become (and the less anxiety you will feel).

Lisa Earle McLeod is a leading authority on sales leadership and the author of four provocative books including the bestseller, “Selling with Noble Purpose”. Companies like Apple, Kimberly-Clark and Pfizer hire her to help them create passionate, purpose-driven sales organization. Her NSP is to help leaders drive revenue and do work that makes them proud.

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Dale, Hold-n-Place, ACE Connector, and IV-ARMOR are registered trademarks of Dale Medical Products, Inc. ©2022 Dale Products, Inc. All rights reserved. AD-111 Dale, Hold-n-Place, ACE Connector, andMedical IV-ARMOR are registered trademarks of Dale Medical Products, Inc. REV A ©2022 Dale Medical Products, Inc. All rights reserved. AD-111 REV A

NEWS

Industry News Concordance Healthcare Solutions Announces Sales Team Expansion with New Business Development Roles Concordance Healthcare Solutions LLC, announced the continued expansion of its sales team. “I am extremely excited to announce two new additions to our sales team,” said Mark Henderson, Sr. Executive Vice President Sales and Marketing at Concordance. “These new team members bring the experience, industry knowledge and leadership

skills that will help us achieve our goal of geographic expansion and support our purpose of Positively Impacting Lives™. I look forward to their help in developing and implementing the strategies and solutions that will deliver increased value for our customers by working cross functionally with marketing and sales.”

Sara Reschke – Director, Business Development – Southeast Zone. Sara is new to the organization and brings 17 years of healthcare industry experience. Shawn Francis – Director, Business Development – West Zone. Shawn is new to the organization and brings 28 years of healthcare supply chain and distribution experience.

PRODUCTS TO WATCH

DETECTO’s Portable Digital Stretcher Scales DETECTO manufactures two stretcher scale models for ED, Dialysis, LongTerm Care, and Nursing Homes, available in models 8500 with remote indicator and 8550 with columnmounted indicator. The stretcher scales feature a spacious, low-profile platform that accommodates all common stretcher types, two integral wheels and guide handles for mobility, and steel construction for optimal durability. These high-capacity digital scales provide precision weighing for patients in stretchers, gurneys, or wheelchairs. The scales feature 800 lb/360 kg capacity, optional Wi-Fi for EMR/EHR, two-way built-in ramps for accessibility from both sides, spacious 60 in x 32.5 in/152 cm x 83 cm platform, clinical-grade accuracy to 0.2 lb/0.1 kg, battery or AC power, and up to 99 tares (optional) to store stretcher weights for efficient patient weighing.

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The single-pass weighing feature saves time by allowing you to enter the stretcher or wheelchair tare weight using the numeric keypad on the indicator. You may also use the convenient pushbutton tare

feature to remove the stretcher or wheelchair weight if you don’t know the weight already. Learn more at: https://detecto.com/ product/product-category/stretcher-scales.

Better BP is Better Care ®

Set the stage for better care and set yourself apart with this Midmark approach. We designed the only fully integrated point of care ecosystem to help promote a more consistently accurate blood pressure measurement by targeting 3 key areas using 3 unique products.

1. Proper Patient Positioning The Midmark® 626 with Patient Support Rails+ is designed to promote AMA-recommended patient positioning for blood pressure capture.1 The barrier-free low chair height allows most patients to place their feet flat on the floor while the accessory rails support the arm at heart height.

2. Accurate, Consistent BP Capture IQvitals® Zone™ with the SPRINT BP Protocol introduces automation at the point of care that can help ensure a higher level of standardization, minimizing human variables while maximizing consistency and data accuracy.

3. EMR Connectivity Seamless connectivity from the IQvitals Zone device to the EMR saves time and reduces the likelihood of data transcription errors. Midmark Zone technology transfers data to the EMR using a secure Bluetooth® Low Energy connection at the point of care.

Midmark 626 Barrier-Free® Examination chair with Patient Support Rails+ accessory and IQvitals Zone Vitals Signs Monitor shown.

Proper Patient Positioning

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EMR Connectivity

= Better BP Contact your Midmark Representative to start the conversation. See all 3 at midmark.com/betterBPcare 1 https://www.ama-assn.org/system/files/2020-11/ in-office-bp-measurement-infographic.pdf Bluetooth is a registered trademark of Bluetooth SIG, Inc. © 2022 Midmark Corporation, Miamisburg, Ohio USA

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At Sri Trang infection prevention is our calling. Ventyv® is the premier brand of Sri Trang USA, Inc. Sri Trang is a proven glove producer protecting the world against infection since 1991. We look forward to protecting you and your patients.

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REP April 2022

Articles inside

Industry News

Bipartisan PREVENT Pandemics Act Will Advance Preparedness

Health News and Notes

Confidence

Theranos made a hasty exit, but blood-based diagnostics for cancer detection are beginning to settle in

reprocessing

Primary Care News

Several modern technologies could positively and powerfully transform patient care. So why aren’t physicians using them as much as they could?

for the Small Distributor

shoulder increasing share of health insurance costs

A look at the emerging home testing market

More and more providers are turning to acute care in the home. But how effective, and safe, is the new model?

Primary care physicians are the key to providing value-based care and population health

Honoring a Legend

IDNs in the News

Quidel’s Mike Abney on medical distribution, leadership, and mentoring the next generation of sales reps