REP Post Acute Feb 19 by BOC design Inc

vol.27 no.2 â&#x20AC;˘ February 2019

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Home Care Changes Ahead Feds try to steer home care toward technology, value-based care

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FEBRUARY 2019 • VOLUME 27 • ISSUE 2

PUBLISHER’S LETTER Slowing Down...................................................................6

PHYSICIAN OFFICE LAB PAMA One Year Later.............................................................8

EXCELLENCE IN SALES: FOLLOW UP

Heart Disease: An Uphill Climb

Brad Jacob: Navigating a Complex Marketplace....................................................... 12

IDN OPPORTUNITIES

POST-ACUTE

Home Care Changes Ahead Feds try to steer home care toward technology, value-based care

Contracting Executive Profile Jonathan Kepley, Director of Strategic Sourcing Wake Forest Baptist Medical Center Winston-Salem, North Carolina......................................... 14

repertoire magazine (ISSN 1520-7587) is published monthly by Share Moving Media, 1735 N. Brown Rd. Ste. 140, Lawrenceville, GA 30043-8153. Copyright 2019 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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February 2019

FEBRUARY 2019 • VOLUME 27 • ISSUE 2

QUICK BYTES

HIDA GOVERNMENT AFFAIRS UPDATE Distributors Can Play Key Role for Community Emergency Preparedness.......... 28

MACRA UPDATE

Technology news

WINDSHIELD TIME

Physician Practices Question MACRA Reporting is cumbersome, and clinical benefits and financial rewards are lacking, they say............... 38

LEADERSHIP Indulging Your Creative Spirit Why watching movies can help make you a better businessperson............................. 46

HIDA INSIGHTS Rising Costs, Revenue Pressures Shape Physician Practice Priorities................ 48

HEALTHY REPS Health news and notes........................................... 50

REP CORNER

44 4

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Walk a Mile

Empathy trumps apathy, says Will Cambardella..... 52

INDUSTRY NEWS News........................................................................................... 56

You Keep Us Going Some things are essential to win the day. For us, it’s distributors like you who sustain and fuel our success. And we want to thank you. Thank you for providing the high-quality products critical to healthcare professionals’ needs. Because of you, B. Braun is a leading healthcare provider.

B. BRAUN AND YOU

Sales representatives in your area are ready to discuss how to further improve your customer experience.

PUBLISHER’S LETTER

Slowing Down Time is a funny thing, and a limited commodity, that we all cherish. Or do we? As I write

this month’s Publisher’s Letter, I realize how fast the years, months, and days fly by, and how infrequently we stop to smell the roses. For example, last month between Christmas and New Years, I was shopping in a CVS store, and low and behold what did I see? Valentine’s Day decorations, cards, and candy. As a consumer, it aggravates me to hear Christmas music before Thanksgiving, and to see Valentine’s Day junk before the New Year. We are a society of the “Next Thing.” What if we all slowed down for a minute and dedicated some time to being in front of our customers? I realize we can’t do this every visit, and customers probably wouldn’t allow it, but I believe we could make an effort to do this every other month, or at least once a quarter. How much would it set you apart from your competitor if you got into a cadence bimonthly or quarterly where you spent an extra 10-15 minutes with your accounts to talk about what’s important to them? Maybe the conversation is about their kids, parents, or their career goals. I’m not even suggesting this window of time be used as a business conversation. Think of it more as a relationship building mission. I actually need to stop and do the same thing! Life is flying by, so let’s try and enjoy some of it by building relationships that last a career and making people feel special.

Scott Adams

By the way, Happy Valentine’s Day! BARF! Dedicated to the industry, R. Scott Adams PS: Don’t forget to Check out this month’s “Road Warriors and Their Untold Stories” featuring Ty Ford and Eddie Dienes. These podcasts are found at Repertoiremag.com

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; www.sharemovingmedia.com

editorial staff editor

Mark Thill lthill@sharemovingmedia.com managing editor

Graham Garrison ggarrison@sharemovingmedia.com editor-in-chief, Dail-eNews

Alan Cherry acherry@sharemovingmedia.com art director

Brent Cashman bcashman@sharemovingmedia.com

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vice president of sales

Jessica McKeever jmckeever@sharemovingmedia.com (800) 536.5312 x5271 director of business development

Alicia O’Donnell aodonnell@sharemovingmedia.com (800) 536.5312 x5261 sales executive

Lizette Anthonijs Lizette@sharemovingmedia.com (800) 536.5312 x5266

publisher

Scott Adams sadams@ sharemovingmedia.com (800) 536.5312 x5256 founder

Brian Taylor

Subscriptions

www.repertoiremag.com/ subscribe.asp or (800) 536-5312 x5259

2019 editorial board Richard Bigham: IMCO Eddie Dienes: McKesson Medical-Surgical

btaylor@ sharemovingmedia.com

Joan Eliasek: McKesson Medical-Surgical

circulation

Doug Harper: NDC Homecare

Ty Ford: Henry Schein

Laura Gantert

Mark Kline: NDC

lgantert@ sharemovingmedia.com

Bob Ortiz: Medline Keith Boivin: IMCO Home Care

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PHYSICIAN OFFICE LAB

PAMA One Year Later By Jim Poggi PAMA: One year later: Do you feel lucky?

Not since CLIA â&#x20AC;&#x2122;88 has a single piece of legislation stirred so much controversy and anxiety in the healthcare and lab communities as PAMA. Under PAMA, the Centers for Medicare and Medicaid Services (CMS) was under congressional mandate to align Medicare lab test reimbursement with private pay, which was acknowledged to be about 20 percent lower overall. As a result, in 2018, year one of PAMA, 996 CPT codes (about 88 percent of all the lab CPT codes) experienced a reduction to meet this mandate. Reductions to most CPT codes are expected in each of the first three years of implementation of PAMA and are capped at 10 percent annually. 2019 is year two, and nearly 1,000 CPT codes are expected to be reduced by up to 10 percent again. Reimbursement data is being collected by labs in 2019 and the next changes to CLFS rates based on these findings is expected to take place in 2021.

has created concern in government and healthcare circles alike for some time. An Office of the Inspector General Report published in 2017 described the scope of the lab test cost problem as Congress saw it: in 2016, Medicare spent $6.8 billion on lab tests under Medicare Part B (outpatient services) and Medicare lab payment rates were known to exceed private payment rates. This analysis underscored the objective to align Medicare lab payment rates with private insurance rates. The first-year goal of PAMA was to lower Medicare CLFS payments by about $100 million. CMS later estimated 2018 reductions at $390 million and industry estimates come in at about twice that figure. Since the OIG estimates Medicare lab spending at only 2 percent of the Medicare/Medicaid healthcare budget, one cannot help but wonder if CMS is squeezing the wrong end of the balloon to lower the costs of Medicare while assuring access to healthcare under Medicare.

Where are we now? How did we get here? Overall, Medicare costs have been rising faster than expected, and the ballooning cost of Medicare is a substantial element to the overall federal budget. As such, it

February 2019

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In addition to reductions in CLFS payment rates, PAMA made other changes. PAMA created one national fee schedule to replace the prior 57 local carrier fee schedules. It also eliminated the discounts applied to tests frequently

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PHYSICIAN OFFICE LAB ordered together in panels (Automated Test Panel reimbursement schedule), such as Comprehensive and Basic Metabolic panels. The panels continue to exist and be paid at “panel” rate, but the tests within the panels are no longer discounted if ordered separately. The Sustainable Growth Rate formula, while never actually implemented, was eliminated from Medicare regulations also. Overall, PAMA has created the most fundamental changes to CLFS reimbursement under Medicare since 1984. Reaction in the market regarding PAMA has been predictably mixed. The lab and healthcare communities are united in arguing that PAMA cuts too deep, may reduce access to lab tests especially in rural areas and did not equitably align new payment rates because only a fraction of labs performing Medicare tests submitted

A General Accounting Office publication in November 2018 called for the most sweeping changes to data collection and the methodology of setting future CLFS rates. Arguably, its recommendations are even more aggressive in cutting CLFS reimbursement than the current structure. The GAO’s summary observation is that rather than lowering the costs to Medicare due to PAMA’s new CLFS rates, CMS may experience significantly higher costs due to two factors. First, the new PAMA rates were set against the prior maximum Medicare payment rates per CPT rather than actual Medicare payment rates. Second, they argue that eliminating the bundled payment rate for test panels could lead to widespread implementation of these tests in unbundled fashion, which could cost Medicare “as much as $10.3 billion from 2018 to 2020”. Their recommendations involve requiring CMS to make data collection more complete (add data from more laboratories), re-set CLFS payment rates and rate reductions based on actual Medicare payment rates, and finally to re-establish the bundled test panel reimbursement system. Given that current estimates of cost reduction to Medicare under CLFS significantly exceed initial estimates, the GAO recommendations are at substantial conflict with the healthcare and laboratory community viewpoint and the initial extent of PAMA cost reductions. Only an analysis of actual costs under the first year of PAMA will lead to the clarity needed to understand just how deep the PAMA cuts impacted the Medicare CLFS budget. The impact of these cuts on the large number of labs that care givers and patients count on to provide needed services is also unclear at this point. Will PAMA cut Medicare costs without impacting healthcare delivery and access to lab tests for Medicare beneficiaries? Will the cuts substantially exceed initial estimates and objectives? Will PAMA lead to widespread use of “unbundled” tests and increase costs to the system? Will it unbalance competition among laboratories and favor only the largest, most high scale labs? All eyes in the lab community are on these questions. Uncertainty and anxiety will continue until we have the data needed to truly understand the impact of PAMA. To (mis)quote a line from a famous 1971 movie: “Do you feel lucky? Well, do you?”

Overall, Medicare costs have been rising faster than expected, and the ballooning cost of Medicare is a substantial element to the overall federal budget. As such, it has created concern in government and healthcare circles alike for some time. private payer data. Only 5 percent of POLs and 44 percent of the independent reference labs’ data is represented by the median private insurance lab rates used to set the current CLFS rates. On the other hand, in reporting on comments it received and changes planned for 2019, CMS in its November 23, 2018 final and interim rule publication in the Federal register defended its data collection methodology, with the exception of agreeing to add lab tests provided under Medicare Part C (Medicare Advantage Plans) and broadening the range of hospital outreach laboratories eligible to report data to the calculation base for the 2019 data collection period. CMS indicated that they would “consider” lowering the CLFS revenue for a lab to be eligible to report data from the current level of $12,500 to $6,250, but did not commit to do so. From a purely statistical viewpoint, it is unlikely the addition of the new data will materially impact the median CLFS reimbursement level going forward.

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EXCELLENCE IN SALES: FOLLOW UP

Brad Jacob:

Navigating a Complex Marketplace Editor’s note: Every year since 2000, Repertoire has recognized recipients of the Repertoire/HIDA Excellence in Sales Award. In this issue, we follow up with one of those recipients.

In 2000, when Brad Jacob (of what was then called

McKessonHBOC) was named the first recipient of the Repertoire/HIDA Excellence in Sales Award, he described the California physician market of the early 1980s – when he began his sales career – as “a little more predictable and simpler” than the market of 2000. Now, 19 years later, he says that “less predictable and less simple” has become “sophisticated and complex.” Jacob is account manager for McKesson Medical-Surgical, serving the San Jose market. He began his medical sales career in 1983, with Bischoff Surgical Supply. Like most of the rest of the country, the Northern California market has consolidated significantly, he says. “I have seen many independents either close down, work for Kaiser, or sell out to other large regional IDNs.” But even 19 years ago, he was preparing for the transformation. “When this started happening in the early 2000s, I changed who I called on,” he says. “Instead of marketing to the person in charge of ordering, I would market to owners, decision makers, and/or divisional ownership offices. I wanted to establish a relationship and market to those who could influence change. I also started to call on other markets, like surgery centers.” Despite the complexity and sophistication of today’s customers,

“honest, transparent relationships are still valued today, once they are established,” he says. Account managers may find it difficult to win the business of a large physician practice or health system, but once they have done so, they have an excellent opportunity to retain it by acting ethically, fairly and efficiently. Jacob says he believes he is a better consultative rep than he was back in 2000. And thanks to technology, he is more efficient too. “Embracing technology that makes sense and is applicable has increased accuracy, capacity and throughput,” he says. “As I look back on my years in this job, sentimental warm memories dominate my thoughts. This job has not only provided a career, but has introduced me to individuals – not only clinicians, but non-clinicians as well – who are true friends. Many of these relationships will continue to be enjoyed in my retirement years.” The job can be demanding, but Jacob wouldn’t change a thing. “My family and I will be forever grateful to DeWight Titus [owner of F. D. Titus & Son, who acquired Bischoff, and later sold his company to General Medical, now McKesson Medical-Surgical] and McKesson, because they not only allowed, but encouraged and rewarded, the entrepreneurial spirit that so many other employers didn’t and still don’t today.”

“This job has not only provided a career, but has introduced me to individuals who are true friends.”

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IDN OPPORTUNITIES

Contracting Executive Profile Born and raised in Lexington,

North Carolina, about 20 miles south of Winston-Salem, Jonathan Kepley joined Wake Forest in 1995 in the general storeroom. He was promoted to coordinator of the receiving dock, then buyer and purchasing agent, contract administrator and contract administration manager. He assumed his current role – director of strategic sourcing – in 2015, and is responsible

Jonathan Kepley

Director of Strategic Sourcing Wake Forest Baptist Medical Center Winston-Salem, North Carolina for contract administration, purchasing, value analysis and the health system’s materials management information systems group. His experiences have given him a broad perspective of supply chain, from the point at which supplies are requested all the way through invoice payment.

About Wake Forest Baptist Medical Center Wake Forest Baptist Medical Center is an academic medical center in Winston-Salem, North Carolina,

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with an integrated health care network that serves the residents of 24 counties in northwest North Carolina and southwest Virginia. The Medical Center’s primary divisions are Wake Forest Baptist Health, a regional clinical system that includes Brenner Children’s Hospital, four community hospitals, a critical access hospital in a joint venture with Hugh Chatham Memorial Hospital, more than 300 primary and specialty care clinics, approximately 2,100 physicians and 1,535 acute care beds; and Wake Forest School of Medicine. Repertoire: What is the most challenging and/or rewarding supply-chain-related project in which you have been involved in the past 12-18 months? Jonathan Kepley: Over the last 18 months, I led a medical/surgical products distribution vendor conversion from a 20+-year incumbent, and a GPO conversion from a 10+year incumbent, and integrated two regional medical centers into the Wake Forest Baptist network. In addition, I served as lead for a project to remove $30 million of non-labor expenses from the health system. To reach that goal, we examined all costs associated with supplies, equipment, service contracts, purchased services and implants (especially spinal, orthopedic and cardiac rhythm management). Over the years, I’ve developed close working relationships with the chairs of our clinical service lines, so they were very engaged throughout the process. It should be noted we weren’t asking our surgeons to change vendors, but rather, to leverage those vendors we already had. We also evaluated our revenue cycle, human resources and IT agreements. We worked with all departments, including some we traditionally have not worked with. As a result, we have developed working relationships throughout the system, and have opened many doors.

portfolio, GPO affiliation, med/surg distributor, pharmaceutical distributor and ERP system. Repertoire: In what way(s) have you improved the way you approach your job or profession in the last five to 10 years? Kepley: Technology plays a much bigger role in our purchasing decisions than it did even five years ago. Data companies and GPOs can gather and analyze all kinds of information, including price and utilization benchmarks. Having that information at our fingertips makes such a difference when negotiating contracts or making operational decisions. Repertoire: In your opinion, what will be some of the challenges or opportunities facing the next

Technology plays a much bigger role in our purchasing decisions than it did even five years ago. Data companies and GPOs can gather and analyze all kinds of information, including price and utilization benchmarks. Having that information at our fingertips makes such a difference when negotiating contracts or making operational decisions.

Repertoire: Please describe a project on which you look forward to working in the next year. Kepley: We acquired High Point Regional Health this past summer, and are examining its entire contract

generation of supply chain professionals? What should they be doing now to prepare to successfully meet those challenges and opportunities? Kepley: The next generation is obviously a lot more tech-savvy than we were, but they may need some help with their interpersonal skills. They communicate very well digitally, but at some point, they will have to master face-to-face conversations with executives and physicians. They’ll also have to give lots of presentations to work groups and committees. But that aside, I find their ability to analyze data and look at projects from a new and different perspective to be very positive.

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February 2019

RESPIRATORY

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Heart Disease: An Uphill Climb Editor’s note: Refer your clinical customers to the Million Hearts website at www.millionhearts.hhs.gov

espite decades-long improvement, heart disease and stroke remain leading causes of morbidity, mortality, and healthcare costs in the United States. One year ago, the Centers for Disease Control and Prevention and the Centers for Medicare & Medicaid Services launched Million Hearts® 2022, a national initiative to prevent a million heart attacks, strokes, and other acute cardiovascular events during 2017–2021. A predecessor program – Million Hearts® – aimed to prevent 1 million heart attacks and strokes in the United States over the course of five years, 2012 to 2016. During the first two years of that initiative, about 115,000 cardiovascular events were prevented, relative to the expected number of events. And although final numbers had not been reported at press time, Million Hearts estimates that up to half a million events may have been prevented from 2012 through 2016.

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Million Hearts 2022 focuses on a small set of priorities selected for their impact on heart disease, stroke, and related conditions: • 2 0 percent reduction in sodium intake • 2 0 percent reduction in tobacco use • 2 0 percent reduction in physical inactivity • 8 0 percent performance on the ABCS Clinical Quality Measures (i.e., (i.e., Aspirin when appropriate, Blood pressure control, Cholesterol management, and Smoking cessation). • 7 0 percent participation in cardiac rehab among eligible patients. Every 40 seconds, an adult dies from a heart attack, stroke, or other adverse outcome of cardiovascular disease (CVD), reports the CDC. These deaths account for about one third of all deaths in the United States, or more than 800,000 deaths each year. About one in five of these deaths

The economic toll of CVD is high. More than $316 billion each year in the United States, with CVD treatment accounting for about one of every seven dollars spent on healthcare in this country.

is a person younger than 65. Heart disease and stroke can also lead to other serious illnesses, disabilities, and lower quality of life. The economic toll of CVD is high. More than $316 billion each year in the United States, with CVD treatment accounting for about one of every seven dollars spent on healthcare in this country. And while cardiovascular deaths have been declining for the past 40 years, the reduction in these deaths has slowed since 2011, indicating the need for focused, sustained action by public and private partners to improve our nation’s cardiovascular health, says the CDC. Managing blood

Heart disease: Where you live matters Aspirin use, blood pressure and cholesterol control, cardiac rehab and heart-healthy behaviors are effective healthcare strategies to combat heart disease. Nevertheless, adherence is inconsistent throughout the country, resulting in geographic variation in cardiovascular disease (CVD) outcomes, reports the Centers for Disease Control and Prevention. In 2016, state-level mortality was higher in the southeastern United States, which aligns with the findings from previous studies. Rates for emergency-department visits and hospitalizations were higher in the Southeast and elsewhere, including many Midwestern states. State-level variation in 2016 occurred in heartdisease-related rates of: • Emergency department visits (a low of 56 per 100,000 in Connecticut, to 275 per 100,000 in Kentucky). • Hospitalizations (from 484 per 100,000 in

Wyoming, to 1,670 per 100,000 in Washington, D.C.) •M ortality (from 111 per 100,000 in Vermont, to 267 per 100,000 in Mississippi). Each state would need to realize an approximate 6 percent decrease in its expected event totals during 2017–2021 to collectively prevent 1 million events at the national level. For that to occur, the participants in Million Hearts® 2022 believe an 80 percent or greater performance on the ABCS (i.e., aspirin use, blood pressure control, cholesterol control and cessation of smoking) and at least a 20 percent reduction in physical inactivity, tobacco use, and sodium consumption are necessary. Source: Centers for Disease Control and Prevention, https://www.cdc.gov/ mmwr/volumes/67/wr/mm6735a3.htm?s_ cid=mm6735a3_w

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February 2019

Heart Disease pressure and cholesterol levels is more important than ever. Cardiac rehabilitation programs, increased physical activity and healthy eating habits are other priorities. In 2016, heart disease caused: • 2 .2 million hospitalizations (850.9 per 100,000 population). • $ 32.7 billion in costs. • 4 15,480 deaths (157.4 per 100,000).

The CDC reports that acute myocardial infarctions and strokes accounted for approximately half (47 percent) of hospitalizations (rates = 204.5 and 199.1 per 100,000, respectively) and approximately two thirds (61 percent) of deaths (42.2 and 53.7 per 100,000, respectively). Other cardiovascular events, which include those related to heart failure, contributed to 46 percent of hospitalizations and 38 percent of deaths (rates = 394.6 and 59.8 per 100,000, respectively).

Heart disease testing: What’s new?

– By Jim Poggi

(Editor’s note: In case you missed lab expert Jim Poggi’s January column on cardiac marker testing, here’s an excerpt that’s worth remembering during Heart Month.) With the rapid proliferation of new tests, particularly molecular-based assays, in microbiology, infectious disease and respiratory testing categories, what’s new and what’s on the horizon for heart disease testing? There are a TON of lipid fractionation and lipid phenotyping tests out there. Most of them are performed in specialty lipid testing reference labs and not applicable in our market yet. They try to identify, quantify and risk stratify less-well-understood lipids. Some examples include apo A-1, apoB-100, LDL subclasses and other even more esoteric markers. There are a few new tests and test combinations that I THINK may become pertinent to us sooner rather than later. All are making their appearance in the acute care market first: • Although high-sensitivity Troponin I is becoming available on an increasing number of chemistry system platforms we sell, it is clearly an acute-care marker and unlikely to become a mainstream factor in primary care. • A new multi-test risk-assessment tool (high sensitivity Troponin I, glucose and glomerular filtration rate) is finding its way into the acute-care market to stratify

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risk of acute coronary syndrome. Due to the number and type of tests in this panel, I doubt it will make a meaningful impact on testing in primary care. • S mall dense LDL testing is entering the hospital and reference lab market as a newer risk stratification marker. Of all the new tests, it is my impression that this one is most likely to come into our market next. Depending on whether studies in process will demonstrate whether it is a better way to assess risk of a future heart attack, it could well become part of the routine lipid panel down the road. While molecular has rapidly advanced in several other testing areas, it has yet to become a factor in heart disease testing. I predict that as things change, it is most likely to find its way in risk prediction and preventive medicine. So far, tests in this area are still in the early research stages. Bottom line: February may be heart month, but heart disease is a year-round leading cause of death, and our customers deserve our best efforts to provide them with the right test mix to diagnose and manage this serious disease. So, stop reading and get selling cardiac tests!

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Blackshear, Joseph L., MD, “Appendage Obliteration to Reduce Stroke in Cardiac Surgical Patients With Atrial Fibrillation” <http://www.annalsthoracicsurgery.org/article/0003-4975(95)00887-X/pdf>, The Annals of Thoracic Surgery, 1996;61:755-759

http://www.heart.org/en/health-topics/atrial-fibrillation/what-is-atrial-fibrillation-afib-or-af

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC101077/

MC15639

Heart Disease The cost of heart disease, 2016 By gender Men (total) Women (total)

Hospitalization/mortality rates 1.18 million 1.06 million

Hospitalization cost ($) $18.6 billion $14.1 billion

Men by age 18-44 years 45-64 years 65-74 years 75 years and over

Hospitalization/mortality rates 73,000 426,000 286,100 395,000

Hospitalization cost ($) $1.3 billion $7.4 billion $4.8 billion $5.1 billion

Women by age 18-44 years 45-64 years 65-74 years 75 years and over

Hospitalization/mortality rates 46,900 258,700 231,100 520,500

Hospitalization cost ($) $0.8 billion $4.1 billion $3.3 billion $5.9 billion

Race/ethnicity Hospitalization/mortality rates White, non-Hispanic 320,200 Black, non-Hispanic 52,200 Hispanic 25,400 Other, non-Hispanic 12,600 Asian/Pacific Islander 10,600 Alaskan native 2,000

Hospitalization cost ($) NA NA NA NA NA NA

Sources: Agency for Healthcare Research and Quality’s Healthcare Cost and Utilization Project (HCUP) National Inpatient Sample (NIS); National Center for Health Statistics’ National Vital Statistics System Mortality Data. (https://www.cdc.gov/mmwr/volumes/67/wr/mm6735a3.htm?s_cid=mm6735a3_w)

Special attention needed Addressing heart disease is important for all Americans, but four groups require special attention, as heart disease and stroke events among them are increasing: • Blacks/African-Americans with hypertension. • 35-to-64-year-olds. • People who have had a heart attack or stroke. • People with mental and/or substance use disorders.

In 2016, hospitalization and mortality rates were highest among men (989.6 and 172.3 per 100,000, respectively) and non-Hispanic blacks (211.6 per 100,000, mortality only), and they increased with age, reports the Centers for Disease Control and Prevention. Among adults aged 18-64 years, 805,000 hospitalizations and 75,245 deaths occurred. Without preventive intervention, it is possible that 16.3 million events and $173.7 billion in hospitalization costs could occur from 2017-2021.

Source: Centers for Disease Control and Prevention, https://www.cdc.gov/mmwr/volumes/67/wr/ mm6735a3.htm?s_cid=mm6735a3_w

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Heart Disease

The Pediatrician’s Office: A Good Place to Start Heart disease begins early in life obesity may not be the reason a child visits the pediatrician, “it’s what we see. If we want to move the needle and help Health New Orleans School of Medicine, passed away in people live longer, we have to attack it.” November. He was 96. Berenson is best known for the BoThat’s a tall order, given popular culture, which still galusa Heart Study, a multi-decade study of the developprizes tasty but unhealthy food, as well as today’s more ment of heart disease, diabetes and metabolic syndrome. sedentary lifestyles. A primary finding of the Bogalusa Heart Study, In 2011, the American Academy of Pediatrics endorsed which began in 1972, is that the major causes of adult guidelines by the National Heart, Lung and Blood Institute heart diseases begin in childhood – including atheroscle(NHLBI), part of the National Institutes of Health, which rosis, coronary artery disease, hypertension, type 2 diaberecommended universal cholesterol screening at ages 9-11 tes and obesity. and 17-21 years, and selective choles“The impact of the Bogalusa terol screening in children ages 2-21 Heart Study cannot be overstated,” “Pediatricians have to years with risk factors. noted Dr. Frank Smart, LSU Health make the time to talk But long-term change calls for: New Orleans chief of cardiology, in to families about how 1) willingness on the part of the the LSU Health obituary. “The study child and his/her parents to adopt was landmark research because it obesity can affect life established a link between diet, exexpectancy, high blood a healthy lifestyle, and 2) help from professionals, such as dieticians and ercise, and genetics and the developpressure and diabetes.” fitness experts, says Snyder. ment of coronary heart disease.” “The doctor has to make time to In fact, Berenson believed that talk to the child and the parents,” he says. Obesity is ususchoolchildren should be routinely tested for blood presally a family affair; that is to say, pediatricians seldom see sure, cholesterol and body mass. “This internationally acan obese child with two parents of healthy weight. “You claimed research project is the foundation for diet and can’t just walk into the exam room, tell the child and his lifestyle interventions that are commonly employed today,” parents that he’s obese, and then leave. You have to help Smart was quoted as saying. them set goals and continue working toward them.” Again, that is often more easily said than done, he The pediatrician says. Some families can’t afford the price of healthy food, One of the greatest risk factors for heart disease among and so opt for cheaper junk food instead. Some live in unchildren today is obesity, notes Christopher Snyder, M.D., safe neighborhoods, where kids are unable to play outside FAAP, University Hospitals, Cleveland, and chair of the with friends. American Academy of Pediatrics Section on Cardiology “Obesity is an epidemic,” says Snyder. “We cannot and Cardiac Surgery. ignore it, even though it can be really difficult. “Obesity is dangerous, it limits kids’ lives, and it’s a “Pediatricians have to make the time to talk to families public health issue which we have to recognize,” he says. about how obesity can affect life expectancy, high blood Obesity is more common among adolescents today than pressure and diabetes. If we don’t do it, who will?” in years past, says Snyder. And even though overweight or Gerald Berenson, M.D., professor of cardiology at LSU

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Heart Disease

Cholesterol Guidelines Released Editor’s note: The AHA/ACC/AACVPR/AAPA/ABC/ACPM/ADA/AGS/APhA/ASPC/NLA/PCNA Guideline on the Management of Blood Cholesterol: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines,” was published Nov. 10, 2018, in Circulation. It can be viewed at https://www.ahajournals.org/ doi/10.1161/CIR.0000000000000625 Repertoire readers may find renewed interest in lipid test-

ing on the part of their customers as a result of new cholesterol guidelines from the American Heart Association (AHA) and American College of Cardiology (ACC). The guidelines were presented at the AHA’s 2018 Scientific Sessions in November, and published in Circulation (the AHA journal) and the Journal of the American College of Cardiology. “They build on the major shift we made in our 2013 cholesterol recommendations, to focus on identifying and addressing lifetime risks for cardiovascular disease,” Ivor Benjamin, M.D., FAHA, president of the AHA, was quoted as saying. In addition to talking to patients about traditional risk factors, such as smoking, high blood pressure and high blood sugar, the guidelines urge doctors to talk about “risk-enhancing factors,” which can provide a more personalized perspective of a person’s risk. Such factors include family history and ethnicity, as well as certain health conditions, such as metabolic syndrome, chronic kidney disease, chronic inflammatory conditions, premature menopause or pre-eclampsia and high lipid biomarkers. This additional information can make a difference in what kind of treatment plan a person needs. When high cholesterol can’t be controlled by diet or exercise, the first line of treatment is typically statins, mostly available in generic forms and long-proven to safely and effectively lower low-density lipoprotein cholesterol (LDL-C) levels and cardiovascular disease (CVD)

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risk. For people who have already had a heart attack or stroke and are at highest risk for another and whose LDLC levels are not adequately lowered by statin therapy, the guidelines recommend the use of other cholesterol-lowing drugs that can be added to a statin regimen.

Ongoing testing advised Once treatment has been started (either lifestyle modifications or medication therapy), adherence and effectiveness should be assessed at four to 12 weeks with a fasting lipid test, then retested every three to 12 months based on determined needs. Selective cholesterol testing is appropriate for children as young as two who have a family history of heart disease or high cholesterol, according to the guidelines. In most children, an initial test can be considered between the ages of nine and 11 and then again between 17 and 21. Because of a lack of sufficient evidence in young adults, there are no specific recommendations for that age group. Nearly one of every three American adults has high levels of LDL-C, considered the “bad” cholesterol because it contributes to fatty plaque buildups and narrowing of the arteries, according to the American Heart Association. About 94.6 million, or 39.7 percent, of American adults have total cholesterol of 200 mg/dL or higher, while research shows that people with LDL-C levels of 100 mg/ dL or lower tend to have lower rates of heart disease and stroke, supporting a “lower is better” philosophy.

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HIDA GOVERNMENT AFFAIRS UPDATE

Distributors Can Play Key Role for Community Emergency Preparedness

When is the last time you had a conversation with your customers about emergency

By Linda Rouse Oâ&#x20AC;&#x2122;Neill, Vice President, Government Affairs, HIDA

February 2019

â&#x20AC;˘

preparedness? Healthcare facilities as well as state and local preparedness organizations must meet federal preparedness requirements. Additionally, federal programs provide funding to these entities for preparedness planning. Specifically, the Centers for Medicare and Medicaid Services (CMS) has regulations on preparedness that providers must comply with in order to be eligible for Medicare and Medicaid payments. The Office of the Assistant Secretary for Preparedness and Response has a program that supports preparedness coalitions. While both providers and community groups have been taking steps to enhance preparedness, not many have had conversations with distributors. I recently discussed the importance of collaborating with the healthcare supply chain at the National Healthcare Coalition Preparedness Conference. The audience included hospital and nursing home staff with preparedness planning responsibility, state and local public health officials, as well as local/community preparedness coalition leaders. However, only a handful of attendees knew who the primary distributor was for the large facilities in their community. Additionally, most of them were unaware of what their distributor partners could do for them. This is an opportunity to bridge a gap in preparedness efforts. HIDA has numerous partnerships on preparedness at the federal level and has secured supply chain language in the preparedness bill that will reauthorize federal programs. Also, the Centers for Medicare and Medicaid Services now requires providers to have emergency preparedness plans in order to be eligible for Medicare and Medicaid payments.

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This provides distributors an opportunity to learn who at the local level has community coalition responsibility and start a conversation. In my presentation, I highlighted the following, but I’m sure there is more!

maintain a dedicated stockpile of supplies for their customers, in exchange for a fee. Providers that pay for this service know their suppliers will be able to supply goods that would otherwise be harder to obtain during a disaster.

Develop alternate communication and delivery plans. Natural disasters may leave main roads unusable or restricted to emergency vehicles. Similarly, emergency events could shut down power or cellular service. By providing emergency or alternate contacts, and finding alternative delivery routes, you can ensure your customers can receive information and needed supplies during a crisis. Also, make sure you understand their evacuation plan, so supplies can still be delivered.

Use purchasing data to predict future needs. During a crisis, many different things can go wrong, and providers may not be able to communicate what they need from their distributors. To help with this, some distributors

HIDA has numerous partnerships on preparedness at the federal level and has secured supply chain language in the preparedness bill that will reauthorize federal programs.

Pre-identify and pre-agree on substitutions. During crises, providers will often panic-order certain goods. By working with your customer to identify substitutes for the most commonly-needed item, you can give them more flexibility during a crisis, and avoid exacerbating shortages. Maintain a “cushion” of products for customers. Similar to the previous example, some distributors will

look at their customers’ purchasing data and make predictions about what they need. That way, during an emergency, they can be prepared to help their customers, even if communications break down. If you would like to learn more about HIDA’s efforts, or have questions about what providers need to do to comply with new regulations, please contact me at HIDAGovAffairs@HIDA.org.

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February 2019

POST ACUTE CARE

Home Care Changes Ahead Feds try to steer home care toward technology, value-based care Editor’s note: To view the final home care rule (“Medicare and Medicaid Programs; CY 2019 Home Health Prospective Payment System Rate Update and CY 2020 Case-Mix Adjustment Methodology Refinements; Home Health Value-Based Purchasing Model; Home Health Quality Reporting Requirements; Home Infusion Therapy Requirements; and Training Requirements for Surveyors of National Accrediting Organizations,”), go to https://www.federalregister.gov/documents/2018/11/13/2018-24145/medicare-and-medicaid-programs-cy-2019-home-health-prospective-payment-system-rate-update-and-cy

Expect cheers, complaints or (most likely) both from your

Remote patient monitoring

home care accounts this year. That’s because changes are coming to the industry in 2019, 2020 and 2021, including: • “ Remote patient monitoring” has been defined under the Medicare home health benefit, and the costs of such monitoring will be an allowable administrative cost. In addition, the Centers for Medicare & Medicaid Services implemented health and safety standards for qualified home infusion therapy suppliers. •C MS finalized changes to the Home Health ValueBased Purchasing (HHVBP) program. •T he Medicare Advantage program now reimburses for adult day care and other home services. •B eginning in CY 2020, home health agencies will be reimbursed per the Patient-Driven Groupings Model (PDGM), intended to reimburse providers based on patient characteristics rather than on volume of services offered. •M edicare’s DMEPOS Competitive Bidding Program will introduce what CMS calls “market-oriented reforms,” though they probably won’t take effect until January 2021.

CMS Administrator Seema Verma announced in October that Medicare would allow home health agencies to report the cost of remote patient monitoring as allowable costs on the Medicare cost report form. “This is expected to help foster the adoption of emerging technologies by home health agencies and result in more effective care planning, as data are shared among patients, their caregivers and their providers,” she said. Earlier in the year, CMS had defined remote patient monitoring as the collection of physiologic data (for example, ECG, blood pressure, glucose monitoring) digitally stored and/or transmitted by the patient and/or caregiver to the home health agency. In addition to remote monitoring, the final home care rule, issued in November 2018, established a new Medicare home infusion therapy benefit, covering professional services, including: nursing services furnished in accordance with the plan of care; patient training and education (not otherwise covered under the durable medical equipment benefit); and monitoring services for the provision of home infusion therapy and home infusion drugs furnished by a qualified home infusion therapy supplier.

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EARLY BIRD DEADLINE: MARCH 1ST!

June 5–7, 2019 | Minneapolis, MN

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THIS YEAR’S SPEAKER LINE-UP INCLUDES: Dannellia G. Green, Ph. D Director of Supplier Diversity, Owens & Minor

K.C. Meleski Vice President, Sales, CME

Mike Kaufmann & Rayona Sharpnack Mike Kaufmann, Chief Executive Officer, Cardinal Health Mike is a passionate advocate for diversity and inclusion and often speaks about gender equity. His support of women leaders in healthcare led to the Healthcare Businesswomen’s Association naming Kaufmann as its 2012 “Honorable Mentor” and the Institute for Women’s Leadership awarding him the 2014 “Guys Who Get it Award.” Rayona Sharpnack, Founder & CEO, Institute for Gender Partnership™ and Institute for Women’s Leadership Rayona has been teaching and consulting on Women’s Leadership, Diversity/Inclusion, and Gender Partnership for 25+ years. She is one of the first in the nation to foresee that “more women” isn’t the sole solution to an organization’s problems. Rather, it is more women and men working in partnership and leveraging each other’s strengths that will make a difference in the profits and productivity of our companies—and our world.

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POST ACUTE CARE The health and safety standards for qualified home infusion therapy providers establish requirements for the plan of care to be initiated and updated by a physician; call for 7-day-a-week, 24-hour-a-day access to services and remote monitoring; and call for patient education and training regarding their home infusion therapy care. To view the final CMS rule regarding remote patient monitoring and other topics, go to https://s3.amazonaws. com/public-inspection.federalregister.gov/2018-24145.pdf.

Home Health Value-Based Purchasing CMS finalized the following changes to the HHVBP model: •R emoval of two Outcome and Assessment Information Set (OASIS)-based measures from the set of applicable measures: Influenza Immunization Received for Current Flu Season, and Pneumococcal Polysaccharide Vaccine Ever Received.

Medicare Advantage For 2019, CMS expanded its definition of “primarily health-related” (and therefore reimbursable) benefits for Medicare Advantage enrollees. (Medicare Advantage is Medicare’s private-plan option, which is said to cover about a third of all Medicare beneficiaries. Such plans can include HMOs, PPOs, private fee-for-service plans and medical savings account plans.) An item or service is now considered “primarily health-related” if it is used to diagnose, compensate for physical impairments, ameliorate the functional/psychological impact of injuries or health conditions, or reduce avoidable emergency and healthcare utilization. Examples include: • Adult day care services. • Home-based palliative care. • In-home support services (e.g., to assist individuals

The current home care payment system pays for 60-day episodes of care and relies on the number of therapy visits a patient receives to determine payment, according to CMS. •R eplacement of three OASIS-based measures (Improvement in Ambulation-Locomotion, Improvement in Bed Transferring, and Improvement in Bathing) with two new composite measures based on changes in self-care and mobility. •C hanges to how CMS calculates the Total Performance Scores by changing the weighting methodology for the OASIS-based, claims-based, and Home Health Care Consumer Assessment of Healthcare Providers and Systems (HHCAHPS). In the final rule, CMS also provided an update on progress toward developing public reporting of performance under the HHVBP Model. For more information on changes to the HHVBP, go to https://www.federalregister.gov/ documents/2018/11/13/2018-24145/medicare-andmedicaid-programs-cy-2019-home-health-prospectivepayment-system-rate-update-and-cy

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with disabilities and/or medical conditions in performing activities of daily living). • Support for caregivers of enrollees (i.e., respite care for caregivers, including counseling and training courses). • Medically approved non-opioid pain management, including therapeutic massage furnished by a statelicensed massage therapist. • Stand-alone memory fitness benefit. • Home and bathroom safety devices and modifications, including shower stools, handheld showers, bathroom and stair rails, grab bars, raised toilet seats, temporary/portable mobility ramps, night lights, and stair treads. Plans may also offer installation. • Transportation, including rides to physician office visits. The plan may include a health aide to assist the enrollee to and from the destination. (Transportation is limited to the provision of medical

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POST ACUTE CARE services – not for items and services such as groceries or banking.) • Over-the-counter benefits, including assistive devices, such as pill cutters, pill crushers, pill bottle openers, and personal electronic activity trackers.

For an overview of the Patient-Driven Groupings Model, go to https://www.cms.gov/Medicare/Medicare-Feefor-Service-Payment/HomeHealthPPS/Downloads/ Overview-of-the-Patient-Driven-Groupings-Model.pdf.

DMEPOS competitive bidding For more information on changes to Medicare Advantage, go to https://www.aarp.org/content/dam/ aarp/ppi/2018/10/reinterpretation-of-primarily-healthrelated-for-supplemental-benefits.pdf

PDGM Beginning on Jan. 1, 2020, CMS will implement a new, budget-neutral case-mix system called the Patient-Driven Groupings Model (PDGM), intended to focus on patient needs rather than volume of care. The current home care In November, CMS payment system pays for Administrator 60-day episodes of care Verma announced and relies on the number that upcoming of therapy visits a patient receives to determine paychanges to the ment, according to CMS. DMEPOS competiThe PDGM eliminates the tive bidding prouse of “therapy threshgram “will reduce olds” in determining payburden on suppliers ment, and changes the unit by simplifying the of payment to 30-day peribidding process.” ods of care. The 30-day periods are categorized into 432 case-mix groups, which are calculated based on the following criteria: •A dmission source (i.e., community or institutional). •T iming of the 30-day period (i.e., early or late). •C linical grouping. The 12 subgroups are: musculoskeletal rehabilitation; neuro/stroke rehabilitation; wounds; medication management, teaching, and assessment (MMTA) – surgical aftercare; MMTA – cardiac and circulatory; MMTA – endocrine; MMTA – gastrointestinal tract and genitourinary system; MMTA – infectious disease, neoplasms, and blood-forming diseases; MMTA - respiratory; MMTA – other; behavioral health; or complex nursing interventions.) •F unctional impairment level (low, medium, high). • Comorbidity adjustments (none, low or high, based on secondary diagnoses).

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In November, CMS Administrator Verma announced that upcoming changes to the DMEPOS competitive bidding program “will reduce burden on suppliers by simplifying the bidding process.” (“DMEPOS” is an acronym for Durable Medical Equipment, Prosthetics, Orthotics and Supplies.) The new rule on DMEPOS competitive bidding – expected to become effective in January 2021 – establishes lead item bidding, which means suppliers will only need to submit one bid per product category. The rule also finalizes increases in DMEPOS fee schedule rates, using a blend of adjusted and unadjusted fee amounts, “in order to protect access to needed durable medical equipment in rural areas that are not subject to the DMEPOS CBP,” said Verma. All Medicare DMEPOS competitive bidding program contracts were set to expire on Dec. 31, 2018. A temporary gap in the program began on Jan. 1, 2019, and was expected to last until Dec. 31, 2020. During the temporary gap, suppliers are required to furnish: • Capped rental items (such as wheelchairs, hospital beds, and continuous positive airway pressure devices) through the remainder of the 13-month rental period. Title to the equipment must be transferred from the supplier to the person with Medicare using the equipment after the end of the 13th month. • Oxygen and oxygen equipment through the remainder of the 36-month rental period. After the 36th continuous month of Medicare payment, the supplier is required to continue providing the oxygen and oxygen equipment during any period of medical need for the remainder of the five-year reasonable useful lifetime of the oxygen equipment. For more information on changes to DMEPOS competitive bidding, go to https://www.cms.gov/Outreachand-Education/Outreach/Partnerships/Downloads/ DMEPOS-Temporary-Gap-Period-Fact-Sheet.pdf.

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Value is the name of the game in to-

day’s healthcare industry – and now Dynarex is providing their distributor partners with more value than ever before by launching a full Durable Medical Equipment (DME) line to round-out its already robust product portfolio. Dynarex considers the distributors it works with to be more than just customers. To Dynarex, its distributor partners are like family. When Dynarex’s family communicated the need for enhanced value in the DME arena, Dynarex listened. The company has had a strong footprint in the disposable market since 1967 and expanding its offering made sense.

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Dynarex is proud to sponsor Friend of Disabled Adults and Children (FODAC). Donated DynaRide wheelchairs ready for delivery.

When Zalman Tenenbaum, Dynarex’s CEO, reflected upon the current environment–the cost of inventory and operations, combined with declining reimbursement, he noted, “Everyone is challenged to cut every penny in half. Dynarex’s goal is to offer efficiencies in terms of cash flow, receiving and warehouse management for our partners. With the addition of DME, there’s no need to overstock or meet the minimums of multiple vendors.” With its bold entry into the DMEarena, the company offers a complete, one-stop-shop experience for distributors. Their complete DME line encompasses hundreds of products across the following categories: • Bathroom Safety • Wheelchairs • Rollators • Mobility Items • Beds, Rails & Mattresses • Patient Rooms • Life improvement and more

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While the company has just entered the DME space, they are far from the “new kids on the block,” says John Moulden, SVP of Sales. “End users know us. They know our name. They know our products. That’s going to make it much easier for our distributors to introduce this line of equipment.” Dynarex believes offering the right product at the right value is important. But how they operate is just

as important. Dynarex sells directly to distributors and only sells to distributors, meaning they don’t compete with their customers for business. With many distributors operating on razor-thin margins, Dynarex makes it easier than ever to reach minimum purchase quantities. Now distributors can place their standard order for Dynarex disposables and add the amount of DME items they actually need. No overstocking to meet minimums and with six distribution centers strategically located around the United States, orders arrive promptly and accurately. The value created by combining consumables and DME from the same source cannot be overstated. As a true “one-stop-shop” Dynarex provides unprecedented savings to distributors without compromising on product quality. That’s how you take care of family. To learn more about Dynarex visit www.dynarex.com

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February 2019

MACRA UPDATE

Physician Practices Question MACRA Reporting is cumbersome, and clinical benefits and financial rewards are lacking, they say The Centers for Medicare & Medicaid Services is pleased

with the way its new payment policy for physicians – better known as MACRA – is working out. But some physician groups don’t share the government’s sunny assessment. The Medicare Access and CHIP Reauthorization Act of 2015, or MACRA, was intended to reward high-value, high-quality Medicare clinicians with payment increases, while reducing payments to those who aren’t meeting performance standards, points out Mollie Gelburd, associate director of government affairs, Medical Group Management Association (MGMA). But there’s a lot of work to be done for it to truly pave the road to value-based payment, she says. In November, CMS Administrator Seema Verma said she was “pleased to announce” that 93 percent of MIPSeligible clinicians received a positive payment adjustment for their performance in 2017, and 95 percent overall avoided a negative payment adjustment. (“MIPS” refers to the Merit-based Incentive Payment System, a key provision of MACRA.) CMS calculated that 1.06 million MIPS-eligible clinicians were on track to receive a MIPS payment adjustment – positive, neutral, or negative. Broken down, the numbers were: • 7 1 percent earned a positive adjustment and an adjustment for exceptional performance. • 22 percent earned a positive payment adjustment only. • 2 percent received a neutral adjustment (no increase or decrease). • 5 percent received a negative payment adjustment.

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“Admittedly, the MIPS positive payment adjustments are modest,” said Verma. “It is important to remember that the funds available for positive payment adjustments are limited by the budget neutrality requirements in MIPS, as established by law under the Medicare Access and CHIP Reauthorization Act of 2015. Moreover, 2017 served as a transition year to help ease clinicians into the program and encourage robust participation.”

Physician practice perspective “There is a lot of MIPS fatigue among MGMA members,” says Gelburd. “We’ve gotten plenty of feedback on the program, but the main takeaway is that MGMA members view MIPS as a reporting program without a clear link to actual quality improvement.” An MGMA survey taken last year found that 88 percent of respondents felt MIPS was very or extremely burdensome with little clinical benefit. CMS must reduce the reporting burden, says Gelburd. “Our concern is that rather than addressing fundamental issues with program complexity so that everyone has the opportunity to succeed, CMS is just excluding practices from MIPS.” CMS should also take another look at the financial incentives associated with MACRA, she adds. Under statute, MIPS payment adjustments could have been as high as 22 percent, considering the annual adjustment plus two additional payment adjustment factors. “In actuality, the payouts for MIPS positive performance adjustments are very low, at less than 2 percent, even for those that earned a perfect score.

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“The lack of clinical relevance and the reporting burden, coupled with the prospect of low positive performance payouts, are causing physician group practices to assess the return on investment for robust participation in the program.” MGMA believes CMS should accommodate more voluntary “MGMA alternative payment models, or members APMs. (An APM is a payment view MIPS as approach that gives added incena reporting tive payments to provide highquality and cost-efficient care. program APMs can apply to a specific without a clinical condition, a care episode, clear link to or a population.) actual quality “CMS should work toward recognizing innovative care improvement.” delivery and payment reforms – Mollie Gelburd in the marketplace, and encourage physician-led, value-based transformation,” says Gelburd. “There are not enough models available right now to account for the diversity of group practices in varying specialties and geographic regions. “The APM pathway veers further from fee-for-service toward value-based payment,” she says. “This is what the industry as a whole wants. Yet this track has not become the robust payment pathway that we had hoped for.”

Percentage of MGMA respondents who reported the issue as very or extremely burdensome •8 8 percent: Medicare Quality Payment Program (MIPS/APMs). •8 2 percent: Prior authorization. •8 0 percent: Lack of electronic health record (EHR) interoperability. • 77 percent: Government EHR requirements. •6 8 percent: Audits and appeals. Source: Medical Group Management survey of 426 medical practices, October 2018, https:// www.mgma.com/getattachment/721b533abccd-4a83-a72a-1e077b3ef9f1/2018-RegBurden-Summary-of-Findings-Final.pdf. aspx?lang=en-US&ext=.pdf

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February 2019

MACRA UPDATE

MACRA basics Clinicians choose one of two tracks in Medicare’s Quality Payment Program (created as part of MACRA), based on their practice size, specialty, location, or patient population: • Merit-based Incentive Payment System (MIPS). • Advanced Alternative Payment Models (APMs). MIPS The Merit-based Incentive Payment System consolidates components of three prior programs: the Physician Quality Reporting System

(PQRS), the Physician Value-based Payment Modifier (VM), and the Medicare Electronic Health Record (EHR) Incentive Program for Eligible Professionals. For MIPS, physicians earn a payment adjustment based on evidence that they provided high-quality, efficient care supported by technology. To do so, they must submit information in the following categories: • Quality (50 percent of final score), which measures health care processes, outcomes, and patient care experiences. • Promoting interoperability requirements (25 percent of final score), which promotes patient engagement and electronic exchange of information using certified electronic health record technology. (This category was formerly referred to as “Advancing care information,” which

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itself replaced the Medicare EHR incentive program, also called “Meaningful Use.”) • Improvement activities (15 percent of final score), a category that gauges participation in activities that improve clinical practice, such as expanding practice access, improving care coordination and promoting patient safety. •C ost (10 percent of final score). This category – new in 2018 – measures resources that clinicians use to care for patients, and the Medicare payments for care (items and services) given to a beneficiary during an episode of care. APMs Alternative Payment Models, or APMs, are payment approaches that provide added incentives to deliver high-quality and costefficient care. APMs can apply to a specific clinical condition, a care episode, or a population; and they allow the provider an opportunity to earn an incentive payment for participating in an innovative payment model. Advanced APMs are a subset of APMs, and let practices earn more for taking on some risk related to their patients’ outcomes. In performance year 2018, the following models were considered Advanced APMs: •B undled Payments for Care Improvement Advanced Model. •C omprehensive ESRD (end-stage renal disease) Care. •C omprehensive Primary Care Plus. • Medicare Accountable Care Organization (ACO). •N ext Generation ACO Model. • S hared Savings Program. •O ncology Care Model. •C omprehensive Care for Joint Replacement (CCJR) Payment Model.

NEW PAMA CPT codes now available in the app

Pama updated CPT codes 2018 Infectious Disease Tests Test - Panels Basic Metabolic Panel (9 tests) Comprehensive Metabolic Panel (17 tests) Electrolyte Panel (4 tests) Hepatic Function Panel (10 tests) Lipid Panel (6 tests) Renal Function Panel (12)

CPT 80048/QW 80053/QW 80051/QW 80076 80061/QW 80069/QW

2017 Fee $11.60 $14.49 $9.62 $11.21 $18.37 $11.91

2018 Fee $10.44 $13.04 $8.66 $10.09 $16.53 $10.72

Change -10% -10% -10% -10% -10% -10%

Cardiac/Liver/Other Tests Albumin (Serum) Albumin (Urine) ALP ALT Aspirin Therapy AST Bilirubin, direct Bilirubin, total BNP CK,MB CK/CPK GGT LD Microalbumin (Quantitative) Microalbumin (Semi-quantitative) Total Protein Troponin I

82040/QW 82042/QW 84075/QW 84460/QW 85576/QW 84450/QW 82248 82247/QW 83880/QW 82553 82550/QW 82977/QW 83615 82043/QW 82044/QW 84155/QW 84484/QW

$6.79 $7.10 $7.10 $7.27 $29.47 $7.10 $6.88 $6.88 $46.56 $15.84 $8.93 $9.88 $8.28 $7.93 $6.28 $5.03 $13.50

$6.11 $7.78 $6.39 $6.54 $26.52 $6.39 $6.19 $6.19 $41.90 $14.26 $8.04 $8.89 $7.45 $7.14 $6.23 $4.53 $12.47

-10% 10% -10% -10% -10% -10% -10% -10% -10% -10% -10% -10% -10% -10% -1% -10% -8%

Lipid Tests HDL LDL Lp(a) Apolipoprotein Total Cholesterol Triglycerides

83718/QW 83721/QW 82172 82465/QW 84478/QW

$11.24 $13.09 $21.26 $5.97 $7.88

$10.12 $11.78 $21.09 $5.37 $7.09

-10% -10% -1% -10% -10%

Diabetes Tests Fructosamine Glucose on home use meter-type device Glucose Tolerance Test, each additional specimen > 3 Glucose Tolerance Test, initial 3 specimens Glucose, quantitative blood type Hemoglobin A1c

82985/QW 82962 82952/QW 82951/QW 82947/QW 83036/QW

$20.68 $3.21 $5.38 $17.66 $5.39 $13.32

$18.61 $3.28 $4.84 $15.89 $4.85 $11.99

-10% 2% -10% -10% -10% -10%

Renal Function Tests BUN Creatinine Creatinine (Urine)

84520/QW 82565/QW 82570/QW

$5.42 $7.03 $7.10

$4.88 $6.33 $6.39

-10% -10% -10%

Individual Tests Amylase Calcium Ferritin Iron

82150/QW 82310/QW 82728 83540

$8.89 $7.08 $18.70 $8.88

$8.00 $6.37 $16.83 $7.99

-10% -10% -10% -10%

Find the new codes in The Black Book

Other tools available for distributors are: vol.26 no.1 • January 2018

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January 2018

2 Minute Drill Videos

Podcasts

PAMA: The Stage is Set — How will the new rates impact providers, distributors and manufacturers?

PAMA: Jim Poggi, Tested Insights, LLC

The Stage is Set

How will the new rates impact providers, distributors and manufacturers?

Twitter

QUICK BYTES Editor’s note: Technology is playing an increasing role in the day-to-day business of sales reps. In this department, Repertoire will profile the latest developments in software and gadgets that reps can use for work and play.

Technology news

Amazon Echo Show

Consumer Reports gives a thumbs-up to the new Echo Show from Amazon. The $230 speaker features a 10-inch HD touchscreen and a Zigbee smart home hub. The previous Show sounded OK, but the new model takes a substantial step forward, featuring robust bass and smooth trebles, says Consumer Reports. Most of all, it delivers effective imaging – the sense that the instruments and voices extend beyond the speaker’s physical enclosure, as though the music is being performed in the same room with you. Note to

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YouTube addicts: You might want to stick to your laptop for those videos; the Show doesn’t offer voice commands for YouTube, which is owned by Google (which has its own smart speakers).

Smartphone magnifier Want to display a video, PowerPoint or website for an account? Slip your smartphone into the Smartphone Magnifier from Uncommon Goods (www.uncommongoods. com) and view at about double the size of your display.

The portable magnifier measures 7.5 inches long, 4.9 inches wide, and 7.7 inches high, and costs about $30.

iPhone photo printer The iPhone printer from Hammacher Schlemmer is said to produce photo quality pictures as it charges an iPhone. In as little as 55 seconds, it prints 300-dpi resolution 4-by-6-inch color pictures using a thermal ink ribbon and special paper that makes photos waterproof, fingerprint-proof, and fade-resistant, according to the company. A free app lets users print photos from an iOS or Android smartphone or tablet, while a USB slot allows printing directly from memory cards, flash drives, and PictBridge-capable digital cameras. It comes with removable 20-sheet capacity paper tray, ink ribbon cartridge, and 40 sheets of photo paper. The printer is compatible with iPhone 5 and iPod 5th generation and later, including X and 8. The app is compatible with iOS 6.0 and Android 4.0 and later. Cost: About $160.

Better-quality photos For smartphone photographers concerned about high-quality, print-ready results, Moment lenses are worth the investment, according to product-review website Wirecutter. The wide lens is said to expand the iPhone’s field of view just enough to feel like a fresh perspective (about 0.63x magnification). The 2x telephoto lens extends the iPhone’s optical zoom a bit farther without degrading image quality as digital zoom can, even with a dual-lens iPhone, according to the reviewers. Both lenses are said to produce clear images with little to no distortion across the entire frame. Both lenses require a Moment case to mount to, which is an additional $30 purchase available for iPhones 6 to X, as well as Samsung Galaxy S8 and Google Pixel compatible models.

Home cooking … fast “The microwave oven did not revolutionize home cooking,” writes Florence Fabricant, a food and wine writer in the New York Times. “Nor did sous-vide gadgetry.” Now there’s a new contender: the Brava oven, a countertop appliance that essentially uses light bulbs to cook food – a system called Pure Light, which was originally developed in the solar industry. Writes Fabricant, “At a demonstration a few months ago, I was struck by the ease of use and the results, which include the ability to cook a steak that’s invitingly seared on the outside and properly rosy within. The oven can reach 500 degrees in seconds, without preheating. What was really impressive was how several ingredients, like proteins and vegetables, can be precisely cooked simultaneously. This is not an appliance that I would want to own, and it teaches you nothing about cooking. But someone who wants robotically prepared food may find it to be a blessing.”

Digital petsitter

Lost your wallet?

The Petcube Play monitoring camera is said to quell pet owners’ concerns when they’re working late and don’t have an on-call pet sitter, reports The New York Times. A wide-angle lens sees the entire room, and the camera offers crystal clear night-vision mode and an app-controlled laser pointer. Of course, one thing the app can’t do – get your cat to stop tearing apart your fabric ottoman. Cost: About $150.

The lost-wallet locator from Hammacher Schlemmer is a homing device that slips into a credit card slot. It connects to a smartphone via Bluetooth and uses a free iOS/Android app to display your wallet’s location on a map and activate the phone’s ringer when your wallet is near. If out of the locator’s 100-foot range, your wallet’s last known location is displayed on the app’s interactive map. Charges via micro USB cable. Cost: About $40.

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February 2019

WINDSHIELD TIME Chances are you spend a lot of time in your car. Here’s something that might help you appreciate your home-away-from-home a little more.

Automotive-related news Smart headlights Smart headlights – which offer a lot of light and visibility without blinding oncoming cars or cars in front of you – will become reality, but it may not be for a couple of years. Traditionally, the National Highway Traffic Safety Administration has mandated that vehicles in the U.S. have distinct high and low beams, but not lights that can dynamically

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adjust, writes Eric Taub in the New York Times. But NHTSA is proposing a rule that would allow the new headlights – called “adaptive driving beam” headlights, or A.D.B. – on the road. Modern vehicles already contain most of the software, sensors and cameras to make A.D.B. lights a reality. Industry experts expect they will become legal in the United States in 18 to 24 months, and available shortly thereafter.

Grocery pile-up? Costco run at the end of the day? This is just a patent, mind you, but Ford SUVs may some day have a conveyor belt system for their SUVs, allowing you to put down a bag of groceries and let the conveyor bring it to the far reaches of the cargo hold, reports The Drive. When it’s time to unload, the belts would do the same thing, in reverse. Since these are simply patent filings, this in no way to confirm that the technology will actually come to production on Ford or Lincoln SUVs, comments the magazine. It’s also not fully thought-out yet. For example, how would this system prevent a grocery pile-up against the back of the second-row seats?

The Accord still looking good Americans are increasingly flocking to crossovers at the expense of conventional cars, but cars still represent millions of annual sales, notes cars.com. The publication analyzed three mid-sized sedans, all costing between $28,000 and $32,000 – and selected the 2018 Honda Accord EX-L as the prize. (Two top-sellers, also rated highly, were the 2018 Toyota Camry XLE and the 2019 Nissan Altima 2.5 SV.) Why the Accord? Cargo volume, spacious legroom in the rear seats, comfy front seats, a nice ride and a sharp multimedia system. The Altima, meanwhile, is said to have a low seat profile, which can be a turnoff with all the tall crossovers on the road; and its continuously variable transmission (CVT) is reported to have laggy performance.

on. The BMW i3 limits its power intake to 50 kilowatts, while the battery-powered iX3 will triple that to 150 kilowatts when it rolls out in 2020.

Your dog rides in comfort If you had a very successful 2018 sales year AND you like to take your dog with you on sales calls, here’s a deal for you: British automaker Jaguar has announced a range of pet accessories designed for the E-, F- and I-Pace crossovers and the XF Sportbrake wagon, reports Motor Trend. The options include a spill-resistant water bowl, a foldable carrier, and a rear-access ramp that can help ease access for big dogs that weigh up to 187 pounds. There’s also a tony quilted luggage compartment liner and a portable shower. Like its vehicles, Jaguar’s pet products don’t come cheap. They’re available in four packages that range from $338 for a rear-seat protection liner up to $1,302 for the entire set of accessories.

If you had a very successful 2018 sales year AND you like to take your dog with you on sales calls, here’s a deal for you: British automaker Jaguar has announced a range of pet accessories designed for the E-, F- and I-Pace crossovers and the XF Sportbrake wagon, reports Motor Trend.

Power charging for electric vehicles BMW AG and Porsche unveiled a charging station that in less than three minutes can jolt electric vehicles with enough power to drive 62 miles – pushing ahead of Tesla Inc. in the race to make battery-powered cars more convenient, reports Automotive News. The ultra-fast prototype charger has the capacity of 450 kilowatts, more than triple Tesla’s Superchargers. Test vehicles developed to take that much power were recharged to 80 percent capacity in 15 minutes. Tesla’s stations need about 30 minutes for a similar charge, according to its website. One drawback: The charger offers more power than current models can take

Electric vehicle for Volkswagen Volkswagen board of management member Jürgen Stackmann revealed details about the first EV in the company’s anticipated I.D. line via social media in December, reports The Drive. The I.D. will be a hatchback whose productionready body will be revealed in 2019, possibly in the spring, when Stackmann states orders for the model will open. It will be the first of VW’s models to pioneer a streamlined ordering process wherein customers select their desired model, its range, its color, and any other options. VW was reported in November to be preparing a sub-$23,000 EV for mass production, and given Stackmann’s statement that the I.D.’s price will be comparable to a Golf GTi, the I.D. is a candidate for that price point. The I.D. will have an estimated maximum range of 550 kilometers (342 miles) in WLTP testing.

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February 2019

LEADERSHIP

Indulging Your Creative Spirit Why watching movies can help make you a better businessperson By Lisa Earle McLeod

How often do you indulge your creative spirit?

Jumpstart innovation

Creativity makes you happier and successful. Yet for many people, their work is devoid of creativity. Sometimes it seems like organizations specialize in sucking the creative spark out of people. Roles and departments get siloed and with no outside creative energy, people wind up just going through the motions.

Thatâ&#x20AC;&#x2122;s where movies, music and art can help. In the program we run for leaders at the Noble Purpose Institute we use a five sensory approach to jumpstart innovation.

February 2019

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Our group wrote for 8 solid minutes to Come Alive. For leaders who don’t think of themselves as creative or writerly types, the first few minutes are painful. One VP said, “At first I was just writing, ‘Where does my team need to come alive?’ over and over again. But then, part of my mind unlocked, the words poured out of me. I starting writing, ‘Why do our people seem so bored? Why don’t they smile anymore?’ Then I found myself writing, ‘I want them to come alive in meetings. I want my managers to strut through the office excited.’ I don’t even know where that came from. I had no idea I felt that way until I just started writing.” That’s the point. When a leader realizes he wants his managers to strut through the office on fire, it’s more powerful than, “Let’s work on employee engagement.” With the vision of his team strutting through the office on fire, we then asked, “What will it take to get your people strutting?” The ideas poured out. “We can run our – Julia Cameron meetings differently, we can change our reward programs, and we can lift up customer compliments. We can have dance classes, we can have a strut contest.” All this from someone who only 30 minutes early said, “Our business isn’t that exciting.” Watching Hugh Jackman and the circus performers Come Alive, helps people envision a new reality. Other leaders had similar epiphanies.

“Creativity is God’s gift to us. Using the creativity is our gift back to God.”

One of our favorite techniques is free writing to music. Here’s how it works: 1. Choose your song – We put the video clip of Come Alive from the Greatest Showman on a repeating loop. With the crazy costumes and dancing, it’s a visual, emotional and auditory experience. 2. Pick a prompt – Ours was: Where does your team need to come alive? 3. Write nonstop – Put pen to paper or hands on keyboard and, this is the hard part; DON’T stop writing, not even for one second. No self-editing, you just keep going, even if it means you’re writing things like, Why is she making us do this? I have nothing to say, this is so stupid.

The Picasso model People are often afraid to go for a creative edge, because they worry about application too early in the process. I prefer the Picasso model. During Picasso’s career he went through a blue period, a rose period and an African period. He did a deep dive into one thing. He went crazy with it. Then in the next phase he refined it. Pushing the edge on the crazy enabled him to define it and later assimilate it. Julia Cameron, author of The Artist’s Way, a process and book considered essential by many creatives says, “Creativity is God’s gift to us. Using the creativity is our gift back to God.” We all have creative coursing through our veins. The question is, are you willing to let your inner artist show up at work?

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February 2019

HIDA INSIGHTS

Provided by the Health Industry Distributors Association (HIDA)

Rising Costs, Revenue Pressures

Shape Physician Practice Priorities

Financial concerns continue to be a leading challenge

for physician practices. Thirty-five percent of physician office managers list reimbursement as a top concern, while a sizeable portion identify collecting co-payment and deductibles (30 percent) and lowering operating costs (21 percent) as priorities. These needs are shaping provider priorities, and inform decisions physician practices make. HIDA’s provider survey “The Evolving Physician Office: Revenue Pressure Determines Practice” contains an in-depth look at the financial pressures these providers face, as well as the steps physicians are taking to address them. These are just a few insights from the report.

Providers invest in technology, staff to strengthen reimbursements Survey respondents discussed a number of investments they plan to make to improve their revenue cycle. Examples of this include credit and debit card systems, so patients can be charged at the time of service, and new technology to determine what a patient’s deductible will be at the time of service. One practice manager added that they are training front desk personnel on professional collection strategies.

Hiring Additional Office Staff A Priority

Medical Supply Budget Will Increase For Nearly Half Of Offices

Staffing remains a priority Aging population drives up medical supply budgets Forty-five percent of physician offices plan to spend more on medical supplies, with 14 percent planning to increase their budgets by more than 6 percent. Key drivers of this trend include greater patient volume due to an aging population, higher costs, and a greater incidence of chronic conditions.

Physicians increase on-site offerings Thirty-five percent of physician offices provide at least moderately complex clinical lab testing on site, an eight percentage point increase from 2016. Among the providers that do not provide on-site lab testing, 35 percent said that regulations are too burdensome, and 27 percent said reimbursement is not adequate.

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Staffing remains a key priority for physician office practices, although the majority (55 percent) are focused on hiring non-clinical office staff. Less than one-third (29 percent) plan to hire physicians, while 26 percent plan to hire nurse practitioners, and 14 percent are recruiting physician assistants. Larger physician practices tend to employ more nonphysician clinical staff, such as nurse practitioners and physician assistants. Practices with 11 or more physicians have, on average, five nurse practitioners and two physician assistants. By comparison, offices with two to five physicians employ a single physician assistant and two nurse practitioners. These are just some of the insights contained in the provider survey. For more information, or to learn about HIDA’s primary research, visit www.HIDA.org/ProviderSurvey.

EDUCATIONAL F O U N DAT I O N

EXECUTIVE CONFERENCE

March 26–29, 2019

The Ritz-Carlton, Amelia Island, Florida

Alan Beaulieu Economist

Senator Barbara Boxer

Governor Bobby Jindal

Democrat Leader

Republican Presidential Candidate

Matthew J. Rowan HIDA

Javeed Siddiqui, MD Telehealth Innovator

Linda Rouse O’Neill HIDA

STRATEGIC EDUCATION & NETWORKING FOR EXECUTIVES Healthcare Trends | Economic Insights | Business and Leadership

HEALTHY REPS

Health news and notes Sickle cell treatment shows promise Scientists from the National Institutes of Health in December presented early results from a human clinical trial testing a novel gene replacement therapy in people with severe sickle cell disease. The experimental treatment involves removing hematopoietic stem cells from the patients’ bone marrow or blood and adding a therapeutic beta globin gene, which is defective in people with sickle cell disease. The cells are then returned to the patient, leading to the production of anti-sickling hemoglobin (T87Q). People with sickle cell disease often suffer severe pain because the sickled red blood cells clump together and become stuck in blood vessels. The condition can cause stroke, organ failure and early death. More than 100,000 people in the United States and 20 million worldwide suffer from the disease. Based on preliminary findings, researchers believe the new gene replacement therapy will enable the patients’ bone marrow to produce normal red blood cells consistently.

Gestational diabetes and the Mediterranean diet Women with gestational diabetes assigned to medical nutrition therapy based on the Mediterranean diet for three

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months experienced an improvement in glycemic profile at delivery that was comparable to pregnant women with normal glucose tolerance, study data show. “Mediterranean diet-based medical nutrition therapy should be considered as a universal, first-line therapy in gestational diabetes treatment to improve glycemic control and perinatal pregnancy outcomes,” Alfonso Luis Calle-Pascual, MD, PhD, of the endocrinology and nutrition department of Hospital Clinico San Carlos in Madrid, told Endocrine Today.

Organic food: It really is good for you! People who buy organic food are usually convinced it’s better for their health, and they’re willing to pay more for it, reports The New York Times. But until now, evidence of the benefits of eating organic has been lacking. Now a French study that followed 70,000 adults, most of them women, for five years has reported that the most frequent consumers of organic food had 25 percent fewer cancers overall than those who never ate organic, according to a study in JAMA Internal Medicine. Those who ate the most organic fruits, vegetables, dairy products, meat and other foods had a particularly steep drop in the incidence of lymphomas, and a significant reduction in postmenopausal breast cancers.

OK to induce labor after full term

High body fat levels and breast cancer risk

For healthy pregnancies, inducing labor after full term (39 weeks) rather than waiting for natural labor does not increase the risk of major complications for newborns, reports the National Institutes of Health. (Prior research has shown that inducing labor before 39 weeks of pregnancy puts the baby at risk of serious health problems.) A research team under the direction of William Grobman of Northwestern University enrolled 6,000 pregnant women in the study. Participants were randomly assigned to two groups. Half of the women waited to have a natural labor. The other half were induced at 39 weeks. The two groups of babies had similar survival rates and chances of serious health problems, such as needing help with breathing, having a seizure, or getting an infection. Inducing labor also reduced the mothers’ chances of a C-section and lowered their blood pressure.

In postmenopausal women with normal body mass index (BMI), relatively high body fat levels were associated with an elevated risk of invasive breast cancer and altered levels of circulating metabolic and inflammatory factors, in a study of 3,460 postmenopausal women published in Jama Oncology. Obesity has been associated with an increased risk of breast cancer, including the estrogen receptor (ER)–positive subtype in postmenopausal women. Whether excess adiposity is associated with increased risk in women with a normal body mass index is unknown.

ADHD may be overdiagnosed in younger kids

A French study that followed 70,000 adults, most of them women, for five years has reported that the most frequent consumers of organic food had 25 percent fewer cancers overall than those who never ate organic, according to a study in JAMA Internal Medicine.

Could a child’s birthday put them at risk for an ADHD misdiagnosis? The answer appears to be yes, at least among children born in August who start school in states with a Sept. 1 cutoff enrollment date, according to a study led by Harvard Medical School researchers. The findings, published Nov. 28 in The New England Journal of Medicine, show that children born in August in those states are 30 percent more likely to receive an ADHD diagnosis, compared with their slightly older peers enrolled in the same grade. “Our findings suggest the possibility that large numbers of kids are being overdiagnosed and overtreated for ADHD because they happen to be relatively immature compared to their older classmates in the early years of elementary school,” said study lead author Timothy Layton, assistant professor of health care policy in the Blavatnik Institute at Harvard Medical School. In states with a Sept. 1 cutoff, a child born on August 31 will be nearly a full year younger on the first day of school than a classmate born on Sept. 1, he points out. At this age, the younger child might have a harder time sitting still and concentrating for long periods of time. That extra fidgeting may lead to a medical referral, followed by diagnosis and treatment for ADHD.

But this study suggests that normal BMI categorization may be an inadequate proxy for the risk of breast cancer in postmenopausal women.

Sleep apnea and hypertension among African-Americans African-Americans with moderate or severe sleep apnea are twice as likely to have hard-to-control high blood pressure when their sleep apnea goes untreated, according to a new study funded mainly by the National Heart, Lung, and Blood Institute (NHLBI), part of the National Institutes of Health. The findings, which researchers say may partially explain why African-Americans suffer hypertension at rates higher than any other group, point to screening and treatment of sleep apnea as another important strategy for keeping uncontrolled high blood pressure at bay. The results were published in Circulation, a journal of the American Heart Association.

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February 2019

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Walk a Mile

Empathy trumps apathy, says Will Cambardella Really understanding and sharing in another person’s

emotions and thoughts takes time, effort and attention, says Will Cambardella, strategic account executive, government, for Midmark Corp. Cambardella has exercised all three, recently completing an eight-year reserve tour at AFRICOM, the U.S. Africa Command, which included deployments to Chad, Niger, Senegal, Ethiopia and Burkina Faso. Cambardella is of military lineage. His grandfather, Sargente Raffaele Cambardella, fought on the Italian Front in World War I and was a prisoner of war. His mother, Beadie, was an Air Force flight nurse in Georgia. And his father, Gennaro Cambardella, was a woodshop teacher as

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well as an Air National Guardsman at Dobbins Air Reserve Base in suburban Atlanta. “They are my lifelong role models,” says Cambardella. “Married for 46 years.” An ROTC cadet at Jacksonville State University, he received an English degree and commission as a Second Lieutenant. “I received and rendered my first salute from Dad in 2000,” he recalls. Shortly after graduation, he served on active duty at Hunter Army Airfield near Fort Stewart, Georgia, as an Ammunition Magazine Platoon Leader. “We supplied the ordnance for the 3rd Infantry Division (Rock of the Marne!) during the initial invasion of Operation Iraqi Freedom in 2003.”

Leadership lesson in Iraq It was somewhere near Karbala, Iraq, that he gained a valuable lesson in leadership – and, in a sense, salesmanship. The United States had declared war on Saddam Hussein, and began its campaign with what was called “shock and awe,” that is, an overwhelming demonstration of firepower intended to demoralize and neutralize the enemy. “My commanding officer had to execute a maneuver that took him away from the ammunition company I was in,” recalls Cambardella. “He told me, ‘You have to get the company to Baghdad.’ With the help of my enlisted – the backbone of the Army – this young lieutenant led a company of 200 to our objective, right outside of Baghdad. We hit our milestone, we executed the maneuver. “It was the first time I had to ‘sell’ lots of people in duress on something, and execute a plan to make this ‘orchestra’ of war sing. I was battletested to be a leader in 2003. You really don’t have a choice, though. You have to just jump into the fire.” Back in the United States, Cambardella received training at the Defense Information School, which is charged with training those in the military on documenting and communicating the actions of the U.S. military services. He served as a public affairs officer in an F-16 fighter wing based in Dannelly Field, an Air National Guard base in Montgomery, Alabama. Because of his training, as well as his experience in and knowledge of both the Army and Air Force, he became director of strategic communications at the Air Force Culture and Language Center (AFCLC), which is charged with developing language, region and cultural learning programs for what it refers to as “Total Force Airmen.”

“ An apathetic Veterans Healthcare System is a stain on the taxpayer. What can you do to make things better? Volunteer locally for a few hours per month at the nearest VA hospital.” “Go back to 2005 or 2006, when you had hundreds of thousands of young, 20-year-old types who knew very little about how to communicate with the local populations in Afghanistan and Iraq,” he says. He credits Army General David Petraeus, who was commander of coalition forces in Iraq, for impressing the importance

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of learning about local cultures, so troops could interact sensitively with the local people.

Africa

“I was battletested to be a leader in 2003. You really don’t have a choice, though. You have to just jump into the fire.”

Cambardella’s boss at AFCLC, Dr. Dan Henk, was a military anthropologist whose research was instrumental in the creation of the United States Africa Command, or AFRICOM, one of the Department of Defense’s regional military headquarters. “He encouraged me to cross the pond,” says Cambardella, who was selected to serve as a public affairs action officer for AFRICOM in 2010. Established in 2008 and based in Stuttgart, Germany, AFRICOM has administrative responsibility for U.S. military support and U.S. government policy in Africa, including military-to-military relationships with 53 African nations. Every year, U.S. Special Operations participates in an operation called Flintlock, which is an African-led

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military exercise sponsored by an African country on a rotating basis. Part of Flintlock’s mission is the provision of temporary health services for the local population. “We provide triage stations for screening, general medicine, women’s health, pediatrics, dental, optometry and pharmacy,” says Cambardella. “Special Operations medics and allied countries integrate with local doctors and healthcare workers to treat patients from different tribes, to include Hausa, Tauregs, Fulani, Djerma, Wolof, Fula, Mossi, Bobo, Sara and others. “People show up on donkeys, camels, horses, and scooters.” Cambardella’s primary responsibility was to embed international news media in AFRICOM’s activities. “We take them everywhere they want to go,” he says. “I remember being in Chad in 2015, when Boko Haram was a major threat.”

“Violent extremist threats in the region, like Boko Haram and a potpourri of bad actors, obscure efforts to provide food, aid and medicine to those in need.”

He also directed the dissemination of information about the clinics and other civil military operations throughout villages with flyers, radio, television, call-to-prayer, mosques, leaflets, wordof-mouth and other means. Malnutrition, malaria, fissures, dehydration, pneumonia and garden-variety ailments are the greatest healthcare challenges for the people in the Sahel, the name given to the southern portion of Northern Africa between the Atlantic Ocean and the Red Sea. “It’s a tough existence for some of these souls. How can I make it better for them? How can you make it better for them?” says Cambardella. “I asked myself these questions, and give my money to Doctors Without Borders. These people are true heroes. They are frontline medical care providers serving in adverse places under duress, long after troops’ exfil,” the term used by the military to refer to the removal of personnel from hostile areas. “Violent extremist threats in the region, like Boko Haram and a potpourri of bad actors, obscure efforts to provide food, aid and medicine to those in need,” he says. Migration due to conflict, terrorism, public health crises, political instability and accelerated environmental degradation contribute to the difficulties. Nevertheless, Cambardella is optimistic that if the U.S. government continues to devote the necessary resources, health security for the people of the Sahel can be achieved.

Medical sales Since the end of his enlistment in active duty Army in 2004, Cambardella has been in medical sales, first as a territory sales manager for Allergan, the pharmaceutical company. “It was a great opportunity for my transition from active Army,” he says. “I was petrified of sales at first,” he says. But Allergan gave him the classroom and field training he needed to become a successful salesperson. Following Allergan, he worked as government accounts manager for Bausch + Lomb. In 2016, he

joined Midmark as strategic account executive – government. “Given its sterling reputation as a league leader in the industry, Midmark is the lion’s pride of the industry and a real winner,” he says. In his current position, Cambardella has “the privilege of calling on over 3,000 federal medical facilities, including Veterans Health, which constitutes our biggest customer. “I enjoy providing healthcare excellence to our veterans, government clinics and overseas clinics to help those who need it the most.”

Empathy is the neutralizer of apathy, he adds. “An apathetic Veterans Healthcare System is a stain on the taxpayer. What can you do to make things better? Volunteer locally for a few hours per month at the nearest VA hospital.” Cambardella recently left AFRICOM and started a new position in October as the Reserve Public Affairs Officer (PAO) for Joint Forces DLA at Ft. Belvoir, Virginia. Midmark has been the “epitome of support,” he says. “They sell state-of-the-art medical equipment to the U.S. government, and recycle used equipment by sending it downrange to several underserved African countries, thanks to Midmark’s Mitch Eiting and the company’s global philanthropic efforts. And I get to sell to my comrades in the DoD, VA and PHS. Winning!” Another support? Cambardella’s wife, Tara. “She has been my rock.”

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February 2019

Industry news IMCO names new director of extended care IMCO announced that Jay Butler will join the company as director of extended care. Butler previously worked for Nestle Health Science, where he held multiple positions in sales and leadership selling adult and infant nutrition, pharmaceuticals, and equipment, most recently as director of distribution and extended care.

Owens & Minor announces new leadership appointments Owens & Minor Inc (Richmond, VA) appointed Robert K. Snead as EVP and CFO, effective December 6, 2018. Snead has served as interim CFO since June 2018. Snead joined Owens & Minor in 2010 as VP of corporate development, increasing his responsibility and experience as he assumed additional roles, including leading strategy, investor relations, and financial planning and analysis. Owens & Minor also appointed Joseph S. Pekala as SVP and chief information officer (CIO), effective December 10, 2018. As CIO, Pekala will lead Owens & Minor’s global technology organization with a focus on driving transformation and growth. He will be responsible for the overall technology direction of Owens & Minor’s products, services, and internal initiatives. Pekala and his team will be responsible for global IT services, platform delivery, and technology. Pekala most recently was SVP and CIO for ACCO Brands Inc.

Bovie Medical announces name change to Apyx Medical Corporation, appoints new CFO Bovie Medical Corporation (Clearwater, FL) announced a corporate rebranding and company name change to Apyx Medical Corporation, effective January 1, 2019. The company will also move its stock exchange listing to the

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NASDAQ Global Select Market from the New York Stock Exchange, and expects that its common stock will commence trading on the NASDAQ Global Select Market on January 2, 2019, under the new ticker symbol “APYX.” The rebranding and name change is the final milestone resulting from the previously announced divestiture and sale of the core business segment and Bovie brand to Symmetry Surgical Inc. Bovie also announced it appointed Tara H. Semb as CFO, effective January 2, 2019. Prior to joining Bovie Medical, Semb was CFO for AVAIL Vapor LLC, a manufacturer and retailer of e-liquid for use in electronic vapor devices, from 2015 until 2018.

GE quietly files IPO to spin off its health unit General Electric confidentially filed to take its healthcare unit public, progressing its plans to spin the company out into a separate entity, according to Bloomberg. GE revealed plans to spin off its healthcare business into a standalone enterprise in June, concluding a yearlong strategic review of the company’s operations and financial strength. The company is working with Goldman Sachs Group, Bank of America Corp., Citigroup, JPMorgan Chase and Morgan Stanley for the initial public offering, which is expected in spring 2019.

DJO to move headquarters to Dallas from San Diego DJO, a global provider of medical technologies designed to get and keep people moving, announced plans to relocate its global headquarters from San Diego, CA to Dallas, TX by early 2019. The company’s Bracing and Supports business unit and Consumer business unit will remain in San Diego in a new and

improved contemporary space. DJO stated that it plans to expand its presence into a market with a strong and larger pool of talent, gain greater and more efficient customer access, and take advantage of what it believes is a better corporate environment.

PeaceHealth to acquire 37 clinics PeaceHealth (Vancouver, WA) entered a definitive agreement to acquire Zoom+Care (Portland, OR), a provider of on-demand retail and digital healthcare. Under the deal, PeaceHealth will acquire Zoom+Care’s 37 neighborhood clinics in Oregon and Washington. Zoom+Care, which offers urgent care, primary care, specialty care, mental health and telemedicine, will have a separate leadership team and board of directors. The transaction was expected to close December 31.

Cardinal Health acquires Mirixa Corporation Cardinal Health Inc (Dublin, OH) acquired Mirixa Corporation (Reston, VA) from the National Community Pharmacists Association (NCPA). Mirixa is a provider of technology-enabled solutions for the provision of medication therapy management (MTM) services. The business will integrate into OutcomesMTM at Cardinal Health. Through the platform, clinical services such as comprehensive medication reviews, medication adherence consultations and other important interventions can be deployed. A priority of the transaction is to merge the technology platforms deployed by Mirixa and OutcomesMTM. This expanded portfolio from Cardinal Health will bring payers an enhanced pharmacy services network and will standardize care delivery, documentation and billing for MTM services, the company said. Terms of the transaction were not disclosed. “For many years, OutcomesMTM and Mirixa have shared a common vision to increase healthcare quality and decrease cost through the appropriate use of medication,” said Tom Halterman, vice president of Medication Therapy Management Solutions at Cardinal Health and founder of OutcomesMTM. “We are excited about this opportunity to unite these two companies and continue to advance this shared vision under the Cardinal Health umbrella.” Merging the technology platforms deployed by Mirixa and OutcomesMTM is an important priority of the

transaction. In addition, this combination simplifies the workflow for pharmacy staffs in retail, clinic and longterm care settings, allowing them to more effectively deliver services to patients. “When the integration is complete, pharmacists will no longer need to sign in to multiple portals to navigate their MTM opportunities,” added Halterman. “A single, standardized platform will enable any health plan to connect their members with over 100,000 US pharmacists.”

Hill-Rom partners with Microsoft to expand digital health capabilities Hill-Rom Holdings Inc (Chicago, IL) announced a collaboration with Microsoft to bring advanced, actionable point-of-care data and solutions to caregivers and healthcare provider organizations. The combined offerings use Microsoft Azure® and are intended to analyze real-time sensing data from medical devices and historical medical record information, and communicate potential patient risk and hospital protocol actions directly to caregivers at the point of care. The Hill-Rom digital solution offerings will be available to hospitals beginning later in 2019.

Opioid overdoses costing U.S. hospitals an estimated $11B annually A recent Premier Inc (Charlotte, NC) analysis found that total care for patients who experienced an opioid overdose resulted in $1.94 billion in annual hospital costs across 647 healthcare facilities nationwide. Premier found that these costs were concentrated among nearly 100,000 opioid overdose patients with nearly 430,000 total visits across ED, inpatient, and other care settings. Sixty-six percent of the patients were insured by public programs (33 percent Medicare and 33 percent Medicaid), 16 percent used a commercial payer, 14 percent were uninsured and 3 percent were covered under other programs, such as workers’ compensation. Annual hospital care for overdose patients represents a significant portion of healthcare expenditures and can be detrimental to providers in regions with high addiction rates. For instance, by extrapolating the cost trends Premier identified in its analysis, the total added costs to the U.S. healthcare system are estimated to amount to $11.3 billion annually, or 1 percent of all

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NEWS

hospital expenditures. If the payer mix remained constant, $7.4 billion of the expense would be borne by the federal Medicare and Medicaid programs. “Opioid addiction has been a public health problem for some time, but we’ve yet to show exactly how hospitals – the entities that treat most of these patients – are financially impacted,” said Roshni Ghosh, MD, MPH, Vice President and Chief Medical Information Officer, Premier. “This analysis shows that on top of losing family members and friends to this epidemic, it’s costing consumers and taxpayers, as well as hospitals. There is an urgent need to provide health systems and emergency caregivers with frontline solutions that they can use to stem the tide of opioid addiction in our communities.” Opioid overdose patients that present to the ED are at a high risk for multiple organ failure, hospitalization, increased costs due to ICU stays and unplanned readmissions following discharge. According to the Premier analysis, caring for all overdose patients treated in the ED alone amounted to more than $632 million in costs to hospitals. Approximately 47 percent of patients were treated and released, and 53 percent were treated and admitted. Of those that were admitted, nearly 40 percent experienced organ failure. The average cost for an overdose patient who was treated and released totaled $504, but the average cost rose to $11,731 for those that were treated and admitted and to $20,500 for those that required ICU care. Adding these costs – ED, inpatient and ICU – totaled the $1.94 billion in annual hospital charges.

Best Buy names executive for Best Buy Health According to Digital Commerce 360, consumer electronics chain retailer Best Buy Inc. has a new executive dedicated to digital healthcare. In December, Best Buy appointed Asheesh Saksena as president of Best Buy Health. He will be tasked with “implementing our health strategy, with particular focus on ways to use technology and our in-home capabilities to help seniors live independently in their homes,” Best Buy says. Best Buy promoted Saksena from within the ranks of its senior management to head healthcare. Prior to his new appointment Saksena worked as Best Best Buy’s strategic growth office. He previously served as the executive vice president of strategy and new business development at

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Cox Communications and as the deputy chief strategy officer for Time Warner Cable. He has also held management roles at Accenture and Tata Group.

ONC advisory group cancels January meeting amid government shutdown The federal Health IT Advisory Committee canceled its January meeting due to the government shutdown. The 25-member committee was created under the 21st Century Cures Act, which former President Barack Obama signed into law December 2016. The committee of experts is appointed by Congressional leaders, the HHS secretary, and the comptroller general of the Government Accountability Office and works to provide policy recommendations to the ONC related to interoperable health IT infrastructure. The cancelation may create challenges for the committee’s task forces, such as its interoperability standards and annual report groups, which are scheduled to finish work around this time.

Capstone Health Alliance announces launch of new subsidiary: Capstone Solutions Inc Capstone Health Alliance (Asheville, NC) announced the launch of its subsidiary company, Capstone Solutions Inc (CSI). CSI will provide business and industry customers with new and creative savings opportunities through partnerships with industry-leading suppliers. CSI’s focus to “Do More. Learn More. Save More.” will empower businesses of all industries through e-Learning Solutions, Health Plan savings opportunities and training programs with world class leaders, the company said. Visit www.capstonesi.com for more information.

Medicare underpaid hospitals by $53.9B in 2017 According to data from the American Hospital Association’s Annual Survey of Hospitals, Medicare underpaid hospitals by $53.9 billion in 2017, and Medicaid underpaid hospitals by $22.9 billion. In 2017, hospitals received payment of 87 cents for every dollar they spent caring for Medicare and Medicaid patients, according to the AHA. Underpayment occurs when the reimbursement hospitals receive is less than the amount paid for personnel, technology, and other goods and services required to provide care.

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