REP January 2022 by BOC design Inc

vol.30 no.1 • January 2022

Six Sigma Doctors Fortune 500 execs get leadership training. How about physicians?

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IMMUNOASSAY SYSTEM

JANUARY 2022 • VOLUME 30 • ISSUE 1

Six Sigma Doctors Fortune 500 execs get leadership training. How about physicians?

16 PUBLISHER’S LETTER

TRENDS

“It’s Nice to be Back”.................... 2

PHYSICIAN OFFICE LAB Women’s Health Important health categories, and their accompanying diagnostic tests, to keep in mind when discussing women’s health with your physician office lab customers.... 4

TRENDS The Healthcare Rules That Need To Be Broken...........10

Together at Last! Now is a good time for medicine and public health to put their acts together........22

Antibiotic Stewardship an Uphill Battle Nursing homes have the greatest need ... but the fewest resources..........................28

Adding the Element of Patient Choice The urgent care model continues to evolve as patient needs and technologies emerge...............................32

Virtual-First Care

IDN OPPORTUNITIES

Insurers are investing in virtual-first health plans as a way to provide more options, convenience for consumers........36

Purchasing Power and Impact Spending How Kaiser Permanente leverages its purchasing power to create a more equitable and healthy society through working with local, diverse suppliers..........14

HIDA

Disruptions in Supply Chain Supply chain experts discuss the challenges, complications – and opportunities – that the pandemic has created for medical distribution...........................46

MARKETING MINUTE Sales Strategy for 2022: Offer Advanced Demonstrations of Complex Products...................48

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

DISTRIBUTION Delivering the Goods Dukal celebrates 30 years of building trusted partnerships in medical distribution............................52

“Fast Pass” HIDA advocates expediting medical supplies through ports and transportation..................................38

WINDSHIELD TIME Automotive-related news........40

TRENDS How Providers’ Needs Have Changed Mary Beth Lang

One GPO executive explains how today’s suppliers can compete with the challenges brought on by the pandemic......42

INDUSTRY NEWS Advancing Access to Diabetes Care..............................55 Industry News...................................56

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January 2022

PUBLISHER’S LETTER

“It’s Nice to be Back” In December we hosted our first live National Accounts meeting in almost two years.

We had close to 100 paid attendees and 10 amazing speakers talking all things National Accounts. My hope is this will be the beginning of a trend back to live events. It appears most of the distributors have national sales meetings scheduled for 2022, as well as many of the manufacturers and the GPOs. As I sat in the meeting last month looking around, it struck me how much we as human beings need one another and enjoy one another. Listening to the conversations, almost everyone started with, “It’s just nice to be back out and on the road seeing everyone.” I couldn’t agree more. We are an industry of relationships. It’s the key ingredient that keeps us going and allows us to serve America’s caregivers. One of the speakers made a comment to the National Accounts executives, “If you put our patients first, and you value/respect the relationship, we will have a long and fruitful partnership.” So simple, yet so true. As we move forward in 2022 and we start seeing each other at meetings and in the field, let it sink in how important the relationships you have with your manufacturers are to you and how important your relationship is to your accounts. Relationships will take us all further than we could possibly imagine. I’m excited to see how we all react this year as we get to shake hands, hug, laugh, and learn in the new and improved 2022.

Scott Adams

Have a wonderful first month to the year! Dedicated to the industry, R. Scott Adams

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PHYSICIAN OFFICE LAB

Women’s Health Important health categories, and their accompanying diagnostic tests, to keep in mind when discussing women’s health with your physician office lab customers. In researching this month’s column, I spent some time reviewing the 2021 monthly health

observances, which often points to issues on our customers’ minds. January is, among other things, recognized as “cervical health awareness month.” While the topic of cervical cancer and other reproductive diseases is important, I’ve frequently observed that women’s health encompasses reproductive health, but so much more. In this column, I plan to discuss women’s health from a broader perspective and look at women’s health concerns by both age and race to shed light on issues to help us to understand which tests may make sense for women based upon age and race. There are meaningful differences as we will see.

By Jim Poggi

January 2022

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PHYSICIAN OFFICE LAB Cervical health First off, an update on cervical health and diagnosis. There is a growing body of evidence showing that most cervical cancers are related to human papilloma virus infections. What does this mean to us, the POL and our customers? The National Cancer Institute recognizes three diagnostic approaches for women between 21 and 65 years of age: ʯ Traditional Pap smear alone every 3 years ʯ HPV testing alone ʯ A combination of both every 5 years The US Preventive Services Task Force is currently updating their recommendations, but at present they include PAP smears every 3 years or HPV testing every 5 years or a combination of both tests every 5 years for women ages 21-65.

Thyroid screening with TSH and Free T4 has become more common as a diagnostic tool for women in their adult years. A range of highquality immunoassays test systems is available for you and your customers to consider. From our POL perspective this leads to opportunity for Pap smear slides and sample collection kits for essentially every OB/GYN practice and the potential to offer HPV screening for larger practices where the use of a molecular testing system makes sense. As you think of the molecular opportunity for HPV testing, think broadly, understand your customer’s patient and test mix and consult with your trusted lab manufacturer to find the best solution. At the same time, for those of you whose companies offer HPV 6

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vaccines, be sure to round out your discussion with a recommendation to consider them for both younger girls and boys, before they reach their reproductive years. The CDC recommends vaccination starting at 11 or 12 for both boys and girls.

The big picture So, then, what about the bigger picture: women’s overall health? For this question, I refer to the list of the leading causes of morbidity and mortality. For women, heart disease and cancer are number 1 and 2 respectively. But

there are differences from men, and age-related differences as well. First, cancer death rates are rising for all women. In my review of the data, it appears the increase is more likely due to the larger number of women in their elder years now than 30 years ago. But, the take home message remains: screening for heart disease risk factors with lipids and A1C is equally important for women and men and BNP and other cardiac assays need to be considered based on the demographics of the practice and their appetite for more sophisticated testing. HPV/Pap testing clearly falls into the cancer screening category, along with FOBT/FIT and some tumor markers including CA 15-3 and others. Your top immunoassay suppliers will have a comprehensive listing of screening and tumor marker tests to consider recommending.

lipids, A1C and albumin/creatinine ratio are the top tier of tests you should consider discussing. Most manufacturers offer these tests as CLIA waived on simple-to-acquire programs for placement agreements or simple disposable meters. Alzheimer’s makes the list for all women. While there is presently no definitive screening or monitoring test available, there is tremendous progress being made in this area and you need to be on the lookout for both lab tests and other diagnostic options coming to the market in the next few years. Hypertension and kidney disease are related, and both are firmly on the list of leading causes of death. Clearly, in addition to fostering effective blood pressure control and overall good health habits, your customers need to consider routine screening for kidney disease. You have a wide range

Cancer death rates are rising for all women. In my review of the data, it appears the increase is more likely due to the larger number of women in their elder years now than 30 years ago. Beyond the top two leading causes of death, the ranking changes based on age, race and geographical factors. Diabetes is on the rise and some patient groups have a higher predisposition to type 2 diabetes than others. Rural populations and those who are overweight are particularly susceptible. Either way, diabetes makes the list of diseases worth testing for in the physician office. It is worth your time to remind your customers that effective screening for diabetes and pre-diabetes is key to better patient health, particularly for their older population. Glucose,

of urinalysis and chemistry tests for creatinine, BUN and other tests to assure kidney health and to diagnose troubling signs earlier before they become more serious.

Other health considerations In addition to consulting your customers to consider lab testing to effectively implement patient testing programs for their female patients for the leading causes of death, there are other important health considerations that women experience more frequently than men to be considered. Thyroid screening with TSH and Free T4 has

become more common as a diagnostic tool for women in their adult years. A range of high-quality immunoassays test systems is available for you and your customers to consider. Autoimmune disease also disproportionately impacts women, and RF, CRP and a range of autoimmune tests are available, usually on specialty testing systems. In addition to automated autoimmune test systems, there are also latex agglutination assays for RF and CRP to consider. Knowing both how frequently your customer encounters these conditions and the extent to which they want to consider a full-service laboratory will guide your recommendations. Septicemia made the list of leading causes of death in 2018 and is number 9 in Black women and number 10 in Caucasian women. Most tests for sepsis will be performed in acute care facilities and include procalcitonin, lactate and IL-6. They are likely to be more pertinent in free-standing ER centers and urgent care centers than your typical primary care practice, but the use of these assays is growing, fueled by concern for MRSA, Clostridium difficile, urinary tract infections, and other common causes of sepsis. Customers most concerned about antibiotic stewardship are likely to be interested in knowing more, either for their own use or the knowledge of management of their patients in the acute care setting and in their practice for follow up post sepsis. Finally, I need to remind you of osteoporosis, which is also far more common in women than men. In addition to imaging diagnostic procedures, there are a number of bone markers to consider on immunoassay systems. As you think of women’s health, be sure to keep the big picture in mind and you will be sure to provide superior service and consultation to your customers. www.repertoiremag.com

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January 2022

TRENDS

The Healthcare Rules That Need To Be Broken

The coronavirus pandemic is what academics would label a “strategic inflection point,” an

By Dr. Robert Pearl

unforeseen event that causes the world to change dramatically and irrevocably. As a result of COVID-19, people everywhere have experienced major changes in the ways they conduct business, communicate, educate their children and plan for the future. In the United States, perhaps no industry has been more affected by the pandemic than healthcare. From the earliest days of the outbreak to the recent rise of the Omicron strain, the virus has turned American medicine upside-down. As the New Year dawns, and as year three of the pandemic begins, a COVID-weary industry is aching for change.

Already, some of healthcare’s longest-standing “rules” – the unwritten norms and assumptions that govern the role of doctors, the experience of patients and the health of the country – are being tested and even broken. As one example, doctors had long subscribed to this belief: Excellent medical care can only be delivered in-person. That assumption quickly evaporated when Americans were forced to shelter in place and physicians had to close their offices in fear for their health. Within mere months, the use of telemedicine skyrocketed from 1% of all doctorpatient visits to nearly 70% while the hospital-at-home concept flourished as inpatient facilities became overwhelmed. 10

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Once the rule against virtual medicine was broken, doctors were astonished at how much care they could deliver via smartphone or computer. Patients, meanwhile, were delighted by the convenience and speed of techpowered healthcare. The old rule suddenly felt outdated, disadvantageous and obsolete. Of course, not all medical care can be provided virtually, but telemedicine is already starting to redefine the doctor-patient relationship. Instead of searching for the best specialist in the community or accepting a local referral, patients can be instantly connected with leading experts anywhere in the country.

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TRENDS The emergence and proliferation of telemedicine is just one example of the healthcare rule-breaking this column will explore over the next several months. In each installment, a new healthcare “rule” will be placed under the proverbial microscope and examined in detail. This column will trace the origins of medicine’s most stubborn and outdated norms, often handed down from one generation of physicians to the next. It will shine a light on how to break the rules safely and smartly. Finally, this column will predict the winners and losers once new standards replace the old ways.

Half of all U.S. patients say that one large medical bill would force them to borrow money, sell their home or declare bankruptcy. The rules of healthcare economics must be broken, but how best to do so without compromising clinical quality? One upcoming installment will venture inside America’s most prestigious medical schools, where admissions officers and faculty use absurd and outdated methods for selecting and training future doctors. The current rule goes something like this: The best doctors are those who excel at memorizing facts and taking tests. By the end of the article, readers will see how much time is wasted teaching the medical approaches of the past century rather than the skills physicians need in the twenty-first. Another article in this series will challenge the longstanding assumption that doctors should be paid for each medical service (test, treatment, procedure) they provide, regardless of whether any of it helps the patient. Part

of this analysis will examine a norm nearly every doctor is taught: Doctors must provide patients with the best medical care with no concern for what it costs. However, as readers will learn, “best care” is too often confused with “most care,” a fallacy that leads to redundant testing, needless treatments, preventable complications and soaring healthcare costs. A century ago, patients feared a bad diagnosis because it meant having to endure physical pain and suffering. Today, a bad diagnosis often results in a different kind of suffering: financial ruin. Half of all U.S. patients say that one large medical bill would force them to borrow money, sell their home or declare bankruptcy. The rules of healthcare economics must be broken, but how best to do so without compromising clinical quality? This series isn’t about breaking rules for the sake of irreverence. It’s about making American healthcare once again the best in the world. Long before the pandemic, American medicine was facing a dire cost and quality crisis. Now there is a financial imperative for reforming healthcare and a national desire for better clinical outcomes. In 2021, the Commonwealth Fund once again ranked U.S. healthcare dead last among 11 of the world’s wealthiest nations. Despite spending twice as much on medical care as its international counterparts, the United States is home to the lowest life expectancy, highest infant- and maternal-mortality rates, and most preventable deaths per capita. Americans are sick of healthcare as usual. It’s not that doctors aren’t working hard and trying their best. The problem is that they must follow outdated rules that stifle industry progress and yield embarrassing results. This series will leave like-minded readers eager for change and better equipped to break the rules of the past. Hopefully, they will find the courage, knowledge and inspiration needed to join together and lead the transformation process. That is the goal of this series.

Dr. Robert Pearl is the former CEO of The Permanente Medical Group (1999-2017), the nation’s largest medical group, and former president of The Mid-Atlantic Permanente Medical Group (2009-2017). In these roles he led 10,000 physicians, 38,000 staff and was responsible for the nationally recognized medical care of 5 million Kaiser Permanente members on the west and east coasts. Named one of Modern Healthcare’s 50 most influential physician leaders, Pearl is an advocate for the power of integrated, prepaid, technologically advanced and physician-led healthcare delivery. He is the author of “Mistreated: Why We think We’re Getting Good Healthcare—And Why We’re Usually Wrong,” a Washington Post bestseller that offers a roadmap for transforming American healthcare. His new book, “Uncaring: How the Culture of Medicine Kills Doctors & Patients” is available now. All proceeds from these books go to Doctors Without Borders. For more information, visit robertpearlmd.com 12

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DIVERSITY EQUITY INCLUSION

NURTURING OUR DIFFERENCES MAKES US STRONGER We believe Diversity, Equity and Inclusion (DEI) is recognizing, respecting and valuing differences which foster and sustain a workplace culture of belonging and empowerment. DEI is not only the right thing to do; it‘s a critical business imperative that accelerates innovation and drives results for our customers and the patients they serve.

IDN

Purchasing Power and Impact Spending How Kaiser Permanente leverages its purchasing power to create a more equitable and healthy society through working with local, diverse suppliers. Kaiser Permanente’s spending decisions are aimed at building healthy, equitable and sustainable economies.

They address economic and environmental disparities and create positive health outcomes through three focus areas: supplier diversity, sustainability and economic impact.

“We help address inequities by making deliberate choices about the purchases we make – from hospital supplies to countless other goods and services,” said Mary Beth Lang, chief of supply chain and procurement for Kaiser Permanente. “This focus on impact spending involves seeking out and using small suppliers and businesses owned by women, people of color and other underrepresented groups as a way to improve the economic health and well-being of the communities we serve and contribute to their success and resilience.” Kaiser Permanente is an active member of local, regional and national organizations chartered to advance business opportunities, support and advocate for the growth and welfare of small, minority, women, LGBTQ+, veteran and disabled-owned business enterprises, and connect them to corporate members and their buyers. To make a larger impact in equitable spending across the industry and to improve community health throughout the country, Kaiser Permanente worked with Healthcare Anchor Network to create an industry initiative: the Impact Purchasing Commitment. Kaiser Permanente and 11 other hospitals and health systems signed on. The Impact Purchasing Commitment includes collectively increasing spending with Minority and Women Owned Business Enterprises (MWBEs) as well as local and employee-owned, cooperatively owned and/or nonprofit-owned enterprises, by at least $1 billion over five years. The institutions also agree to work with at least two of their large existing vendors to create hiring pipelines in the disinvested communities that they serve and to commit to specific sustainable procurement goals. Participants who signed the commitment promise to help build healthy, equitable and climate-resilient local 14

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Mary Beth Lang

economies with how they spend their dollars,” Lang said. “Improving the health of our members and the communities we serve is core to our mission and the work we do every day. This focus is heightened during a pandemic that is disproportionately affecting both low-income individuals and communities of color.”

Kaiser Permanente’s diverse supplier spend Kaiser Permanente increased its spend with diverse suppliers by 27% in 2020 to $2.56 billion. It also spurred

$510 million in diverse spending by suppliers on their behalf in 2020. Its approach includes collaboration with community anchors and large-scale purchasers to optimize collective impact. It provides capacity-building opportunities for diverse and local entrepreneurs in its footprint to create wealth and employment and targets local spending to invigorate local markets. “Organizations can make an impact in their communities by applying a sustainability and social impact lens to their procurement practices,” Lang said. “I encourage all organizations to leverage their organizational assets and shift their spending strategies in order to create a more equitable society.”

Local spending aims to have a multiplier effect beyond just one purchase that can increase local economic activity. “When local businesses are awarded contracts, they are able to employ local residents and provide stable wages that allow employees to consistently afford food, housing, healthcare and other necessities,” Lang said. Kaiser Permanente’s strategy focuses on partnerships and an impact beyond its own walls. “It focuses on collaborations as drivers and amplifiers of meaningful and measurable commitments that advance concrete business strategies that both strengthen and create equitable local economies.”

Kaiser Permanente promotes organizations to get started on their impact spending journey through: ʯ Using vendors with sustainable products and practices, when possible, to reduce climate impact and harmful pollutants. ʯ Contracting with women-owned and minorityowned vendors to address gender, racial and economic inequity created by historical disinvestment and discrimination. ʯ Using local vendors, when possible, to improve the economy within the local community. ʯ Supporting community wealth-building by working with or fostering employee-owned enterprises to promote financial security.

During the past four years, the Kaiser Permanente-sponsored ICCC program has trained 1,043 businesses over 14 cohorts. Of those, 61% were minority-owned businesses and 56% were women-owned businesses.

“I encourage and invite all health systems to join us in leveraging their purchasing power to improve the health of communities by signing the Impact Purchasing Commitment,” Lang said. “There is an undeniable urgency – that now, more than ever, we as anchors – need to hold ourselves and each other accountable by reimagining our procurement practices so that we’re leveraging our assets and purchasing power collectively to build an inclusive economy.”

Upstream determinants of health “Healthcare is a foundational component of equity,” Lang declared. “The health implications for the individuals and communities we serve, as a result of the economic consequences brought on by the pandemic, are unlike anything we’ve ever seen.” Lang added that health status is directly correlated to the socioeconomic and environmental upstream determinants of health. “We cannot solve for one without addressing the other,” Lang said.

Its partnership with the Initiative for a Competitive Inner City (ICIC), Kaiser Permanente supports the Inner City Capital Connections (ICCC) Program, an executive education and training program for small businesses with the goal of promoting economic prosperity in underserved communities. During the past four years, the Kaiser Permanente-sponsored ICCC program has trained 1,043 businesses over 14 cohorts. Of those, 61% were minority-owned businesses and 56% were women-owned businesses. Participants witnessed an average revenue growth of 45% with $67 million total capital raised and 1,361 jobs created. And the pandemic only bolstered the program. In 2020, 776 businesses participated with 73% being minority-owned businesses and 60% being owned by women. “We are in precipitous moment. One that will go down in history,” Lang concluded. “It is impossible to do this work alone. As such, we have a responsibility to ourselves, each other and our communities to be bold in our thinking and actions, innovative in our practices, and collaborative in our work.” www.repertoiremag.com

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Six Sigma Doctors Fortune 500 execs get leadership training. How about physicians? When was the last time you came upon one of your

physician customers poring over their copy of “7 Habits of Highly Effective People,” “Good to Great,” “Wooden on Leadership” or “Jack: Straight from the Gut,” by the late chairman and CEO of GE, Jack Welch? Reading materials like these may be what’s needed, as today’s physicians face all kinds of leadership challenges that earlier generations of doctors did not – quality and outcomes ratings, safety audits, automation, managing mid-level providers, nasty social media reviews ... COMPLEXITY. Are they up to the task? Some are natural-born leaders. Traits like kindness, empathy, respect, listening, inclusiveness, decisiveness and teamwork come naturally to them. But experts in physician leadership believe leadership is a skill that can be learned and must always be practiced – and practiced some more. They believe that failure to do so hurts patients and leads to disengagement on the part of the staff as well as the physician leader.

A shock to the system Brian Bolwell, M.D., describes in his blog “Straight Talk” a leadership shock he received some time ago. “My interest in leadership principles began when I received my personal 360 evaluation about my leadership skills about 20 years ago,” he writes. “I thought I was a wonderful leader and that I knew it all. Well, I received a 25-page evaluation about my leadership skills, and 24.5 pages of it were highly critical. I thought I was a good leader, but in reality, I was nowhere close to being the leader I wanted to be. I knew very little about the entire concept. But it was a wonderful opportunity for me to learn and get better.” Today he is director of physician leadership and development for Cleveland Clinic. www.repertoiremag.com

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Six Sigma Doctors

“A lot of psychological studies have found that adults have built wonderful defense mechanisms,” he tells Repertoire. That may be especially true for physicians, who throughout their young lives were top-of-the-class students and accustomed to success. “To hear that their leadership style may be lacking in one area or another usually comes as a surprise.” Some embrace the opportunity to improve. Others don’t. After receiving a review identifying leadership shortcomings, the latter may say, “That’s taken out of context,” or “I’ve been to leadership classes and I have an MBA, and I don’t need this stuff,” he says. “One of the hardest things is getting people to realize that most of the work they have to do is inward – reflecting on who they want to be as a leader and a person.” Do you want to live with integrity, live with values? Are you doing so? If not, are you willing to change?

“I would hope the vast majority of physicians see themselves as leaders, even if they’re not interested in becoming department chairs or CEOs.’ Joseph Hopkins, M.D., M.M.M., clinical professor of medicine at Stanford University School of Medicine and director of the Stanford Leadership Development Program, believes physicians can learn leadership skills the same way they learn about new methods of diagnostics and therapy. But they need the will to do so. “It starts by becoming aware that you need to learn something to do it better, whether that means catching up on the latest way to treat medical conditions or learning how to better lead a medical group or clinic,” he says. “The awareness that you need development in this area is a critical foundational step. It’s a factor of how you think about yourself and your professional role.” Once the physician has made a commitment to be a more effective leader, he or she looks for ways to acquire the skills needed, either through continuing education, coaching or both. “As you acquire new skills, you put them into practice, and as you do that, you gain confidence in them,” says Hopkins. “And then, at some point, you become aware there’s something else to work on, so you do that. It’s an iterative process.” 18

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One direction Strong leadership benefits everyone in the practice, according to those with whom Repertoire spoke. Effective leadership leads to well-functioning teams, says Hopkins. Effective physician leaders welcome involvement from a business manager and staff. “In a well-oiled team, people are engaged. They feel free to speak up if they see something that could be done better. The leader welcomes their suggestions and has a dialogue with them regularly. “Lacking this, you find people aren’t as dependable as they could be, and they may drop the ball because they’re not quite sure what they’re supposed to do. The team lacks efficiency and effectiveness, and can even cause harm.” Stephen Swensen, M.D., M.M.M., senior fellow, Institute for Healthcare Improvement and former CQO and director of leadership and organization development for Mayo Clinic, believes that leadership systems and processes are much more likely to blame for burnout, dismay and distress than the oft-cited suspects – electronic health records, ill-informed administrators, unbending payers. In successful practices, everyone is pointed in the same direction – toward the patient and their families, and the community, he says. “If everybody in healthcare looked at things that way, there would be better care, more professional meaning and purpose, and lower rates of professional burnout.”

Is it about power? One of the important fundamentals of leadership taught in Stanford’s Physician Leadership Certificate program is “power.” But it must be understood and exercised judiciously, says Hopkins. “A powerful leader is one who gets things done,” but not by brute force or authoritarian actions, he says. “As a leader, you can influence people, you can engage people, so they become willing to do what you believe needs to be done for the good of the practice. When that happens, they feel good about their role, recognized for their efforts, and confident they are making a difference.” He refers to a concept called “transformational leadership,” which focuses on the meaning people derive from their work. In an environment where effective leadership exists, people look beyond themselves for that meaning. “There’s a huge difference between feeling like a gerbil on a wheel and being a partner who is contributing to how things are done and the higher mission.” Bolwell believes effective leadership is about relationships, whereas poor leadership is almost always about

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command and control. “Leaders not only have to believe teams are important, they have to live it,” he says. “They have to ‘upend the pyramid,’ so their role becomes supporting the team, giving them credit for the work they do. The key word is trust. If you have trusting relationships with your team, and those on the team have trusting relationships with others on the team, you’ll have a great environment.” Effective leaders are transparent, he adds. “When they make a mistake, they admit it and apologize. These principles sound simple, but they can be difficult to put into practice. One thing that has always helped me – especially during COVID – is authenticity. When the leader acts as if they are reading from a script, employees pick up on it immediately.”

‘If you think you’re smarter than the collective, you’re performing at a subpar – and maybe even a dangerous – level.’ “I would hope the vast majority of physicians see themselves as leaders, even if they’re not interested in becoming department chairs or CEOs,” says Swensen. In decades past, solo practitioners could function well and produce top-quality medicine by themselves, with the aid of a professional network. “But that’s impossible today. Medicine is a team sport. No one has the expertise or knowledge to [succeed] on their own.” Effective physician leaders welcome the expertise of nurses, pharmacists and others. “If you think you’re smarter than the collective, you’re performing at a subpar – and maybe even a dangerous – level.”

A hunger to lead “Our experience has been that a growing number of people appreciate they can be more effective if they have leadership skills, whether they are on the clinical team in the operating room, or leading a division or group of physicians, or taking on a leadership role in a professional organization,” says Hopkins. “Not everybody wants to do that, but others have what one of our speakers – Tom Gilmore at the Center for Applied Research – calls a ‘hunger for leadership.’ It’s a combination of ambition and desire to make things better. It’s the physician who can’t 20

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look at a problem without trying to figure out a way to make it better.” Peer-to-peer coaching has proven effective at Cleveland Clinic, whose coaching program has two core components: the Center for Excellence in Coaching and Mentoring, which offers physician-led peer physician coaching; and the Mandel Global Leadership and Learning Institute, which features coaches who are not physicians. Physicians who coach other physicians are said to get as much value from the experience as those they are coaching. “One of my roles is to be a mentor and coach to an ever-increasing number of physicians,” says Bolwell. “It is a lot of fun for me.” But coaching works best for those who are open to change. “You want to start out by asking yourself, ‘Why is it important that I change, that I go from Point A to Point B?’” he says. “If you really want to be a better leader, that’s enough of a reason. In my case, the negative review I received 20 years ago was highly motivating. I was devastated at the time, because I care very much about my team. I don’t like to fail, and I certainly didn’t want to be anything but a very good leader.” That hunger for leadership has been explored and encouraged in industry and startups, but not so much in healthcare, he says. “And that’s one reason Cleveland Clinic is doing what we’re doing. But ultimately, I believe two fundamental principles lie at the bottom of all of this. First, there’s this concept of serving your team. It’s not about you, your resume or your fame; it’s about doing everything you can to hire great people and then support them. And second, it’s about improving yourself, living your values, getting feedback from others, having the courage to be vulnerable, and being honest, authentic and trustworthy.” Says Swensen, human beings have three basic needs: ʯ Camaraderie, that is, social connectedness, without which people can actually experience physiological harm, such as hypertension, as well as burnout. ʯ Agency, that is, a sense of control over one’s life and decision-making. Collective decision-making promotes a sense of connectedness. ʯ Coherence, that is, a sense of seeing how one personally fits into the puzzle of life. “If teamwork helps make you a better doctor or pharmacist, you will believe you have great value in life.” “Leadership is about supplying those three things.”

TRENDS

Together at Last! Now is a good time for medicine and public health to put their acts together

Prior to COVID-19, did you know the names of the medical officers of your state or county public health depart-

ments? Did the physicians you call on know their names? It was the lack of coordination between medical providers and public health that led to failures in testing and vaccination during the pandemic, writes healthcare expert Atul Gawande in an August 2021 New Yorker article, “Costa Ricans Live Longer Than We Do. What’s the Secret?” In many cases, public health departments “were forced to launch their own operations, such as drive-through testing sites and stadium vaccination clinics – and they had to do so from scratch, in a mad rush.” More proof, he says, that the U.S. healthcare system “is designed for the great breakthrough – not the great follow-through.” And it’s been that way for a long time.

Separate ways From the start of the 20th century, public health and medicine developed as separate disciplines, notes the American Public Health Association (APHA). Medical and public health practitioners were educated in separate schools and upon graduation, the two disciplines went their separate ways. 22

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But with escalating healthcare costs, continuing growth in the ranks of the uninsured, increasing emphasis on healthcare quality and outcomes, chronic disease, ever-widening health disparities, and outbreaks of emerging infectious diseases, greater collaboration between the two professions is not an option, but a pressing mandate, concluded researchers from the

Florida State University College of Medicine in a study 15 years ago. That’s just as true – or more so – today.

A matter of perspective Here’s the problem: The two disciplines – medicine and public health – look at health very differently. In 1996, Donna Shalala, Secretary of Health and Human Services under President Clinton, compared them to trains on parallel tracks, with windows facing opposite directions. Those on the medical train see individual trees, with subtle differences in size, color, age and health, she said. Those aboard the public health train see a forest, that is, populations of similar trees, growing together and weathering the same storms. Put another way, public health agencies define “population” on the basis of residential location, divided up by demographic factors such as race, ethnicity, gender, age, language, disability, or disease status, explains the American Academy of Family Physicians (AAFP) in its 2015 position paper on “Integration of Primary Care and Public Health.” Meanwhile, the medical community defines “population” as those individuals to whom a healthcare entity provides care – in other words, the practice panel. (And payers look at “population” in terms of the members of their insurance plans.)

What kind of a world would it be? If a primary care practice were to become more integrated with the local public health department, physicians would consider more carefully the social and physical environments in which their patients live, and then work to improve health outcomes, says AAFP. It might also lead to advocacy – even community activism – on the part of doctors. “There is a growing and exciting understanding that much of what determines health happens outside the exam room,” Mark Del Monte, J.D., CEO of the American Academy of Pediatrics (AAP), told Repertoire. “Medicine can play an incredibly important role collaborating with public health, community-based organizations, schools and local governments and working on the social drivers that are powering health disparities.” In its Advocacy Guide, the AAP defines advocacy as “taking the care, the information, and the resources that you provide to individual children and families and sharing those stories and experiences at the community, state, or federal level to help create systemic change. Community advocacy takes into consideration the environmental

and social factors influencing child health, such as exposure to violence, safe places to play, poverty, child abuse, and access to healthy foods, and addresses ways in which child advocates – including pediatricians – can work with community partners to address these issues.”

A data-driven approach Advances in information technology, including medical records systems and geographic information systems (GIS), make collaboration between medical and public health professionals more feasible than ever. Researchers from RAND Corp. point out that mapping hospitalizations for ambulatory-care-sensitive admissions, such as asthma or cellulitis, can identify small geographic areas in which community-level intervention may be needed. Health insurers can play a role too. The National Health Plan Collaborative, a group of health insurers aiming to reduce disparities in care, says that by geocoding the addresses of health plan enrollees and linking them to quality-of-care data, plans can identify “hot spots” of poor quality.

‘Even though funding for housing, transportation, and education can improve health, there isn’t an appetite for healthcare to transfer money to other sectors.’ The RAND researchers found that one insurance carrier determined that Hispanic members with diabetes were less likely to receive LDL testing. Initially, they contemplated sending a mass, Spanish-language mailing to all Hispanic members with diabetes, reminding them of the importance of lipid testing. But using GIS, the plan mapped the distribution of members with diabetes in a predominantly Hispanic region, then focused on a small hot spot with many members who had not received LDL testing. They found that the neighborhood was linguistically isolated and as a result, they decided to focus their resources on a language-appropriate intervention in that area. In October 2021, the Primary Care Collaborative, a nonprofit organization working to advance primary care, and the Robert Graham Center, a family medicine and primary care research organization, released a report, “Primary Care and COVID-19: It’s Complicated – Leveraging Primary Care, Public Health and Social Assets.” www.repertoiremag.com

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TRENDS “A key innovation of this report for both public health and primary care is this notion of the community health index,” says Del Monte, who in addition to his duties at AAP is vice chair of the Primary Care Collaborative, “They used a data-driven analytical process to describe the interrelatedness between primary care and public health. It’s very clear that if we don’t have a strong primary care system and a strong public health system, we fail to optimize either one of them.”

‘Wrong pockets’ Tradition and history aside, money – or the lack thereof – is one of the biggest factors preventing medical and public health professionals from collaborating. “Public health and primary care both try to prevent illness and even address the upstream conditions – the social determinants of health – that cause poor health, but there is not enough funding for this type of integrated approach,” Seiji Hayashi, MD, MPH, FAAFP, chief transformation officer and medical director for Mary’s Center, a federally qualified health center in Washington, D.C., told Repertoire.

‘Medicine can play an incredibly important role collaborating with public health, communitybased organizations, schools and local governments.’ Commenting on the PCC/Graham Center report, Hayashi points to siloed funding as one of the biggest barriers. “Stuart Butler from the Brookings Institution and other policy researchers have been writing about the ‘wrong pockets’ problem, where even though funding for housing, transportation, and education can improve health, there isn’t an appetite for healthcare to transfer money to other sectors,” he says. “Investing in primary care and public health that tries to prevent illness is counter to most parts of the healthcare industry, where more care means more money.” “Funding is unfortunately a large barrier and often holds back progress,” says Julie Wood, M.D., MPH, AAFP’s senior vice president for research, science and health of the public. “Public health and primary care are both underfunded by disparate ... systems that often have common interests but are not structured to work well together.” 24

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Financially, public health has been particularly hard hit for the past 10 years or so. Since 2010, spending for state public health departments has dropped by 16% per capita and spending for local health departments has fallen by 18%, according to a KHN and Associated Press analysis of government spending. At least 38,000 state and local public health jobs have disappeared since the 2008 recession, and more than three-quarters of Americans live in states that spend less than $100 per person annually on public health. In California, “public health nurses, microbiologists, epidemiologists, health officers and other staff members ... are abandoning the field,” according to the analysts. “It’s a problem that temporary boosts in funding can’t fix.”

Bright spots No one said it would be easy to integrate medicine and public health. But there are bright spots. “It’s not a moment in time; it’s a transition,” says Wood. “There are exemplary practices and communities, but the most exciting progress we are seeing is a transition in training. Family medicine residents are training from this perspective now, longitudinally, throughout their residency – looking at the data of their community and applying it to how they practice both at the community and individual practice level. They are coming out of training already prepared with knowledge and skills of how to work with their public health colleagues and with community information.” Says Hayashi, “The unprecedented expansion of community health centers through the Affordable Care Act and subsequent federal support increased primary care capacity in underserved communities. Many public health departments leveraged these new primary care access points to tackle public health crises. For example, public health and primary care have been working together to address the opioid epidemic. Reducing environmental hazards like lead poisoning is a public health/ primary care success story with screening and remediation. We still have much to do, though.” There are bright spots around the world from which U.S. medical and public health practitioners can learn. “The concept used in the U.S., however, comes from principles of Community-Oriented Primary Care (COPC), which was developed in rural South Africa,” says Hayashi. “Community health centers in the U.S. were founded on this principle, and they are accustomed to the idea of serving a geographically defined area. In fact, this is one of the grant criteria for health centers receiving money

Pediatricians in the community Since 1993, the Community Access to Child Health (CATCH) program of the American Academy of Pediatricians has given grants to support pediatric residents and pediatricians in planning or implementing community-based child health initiatives. According to AAP, potential roles that pediatricians can play at the community advocacy level include:

ʯ Initiating a community project

or forming a partnership, alliance, or coalition to address a problem. ʯ Informing community leaders, about issues affecting children in the community.

ʯ Inviting decision-makers to visit

their professional setting. ʯ Providing testimony and telling their story at community forums, events, and in the local media. ʯ Serving on the board of organizations that support

from HRSA, the federal agency that funds and oversees community health centers.” In his New Yorker article, Gawande speaks about the Costa Rican healthcare system, which, he says, “braids together public health and individual health.” In that Central American country, the “ATAP” is a clinician who has the skills of a medical worker and a public health aide. A local primary care team called an “EBAIS,” consisting of a physician, nurse and ATAP, are assigned to groups of several thousand people, and call on them regularly at their homes.

Lessons from the pandemic Experts believe that the time to integrate medical and public health is now, while the lessons of the pandemic are still fresh. One in 500 Americans has died from the virus, and the U.S. COVID-19 death toll accounts for nearly 20%

children’s health well-being or interests, such as a school board. ʯ Offering medical expertise to schools, youth organizations or institutions, and child care centers.

‘Family medicine residents are looking at the data of their community and applying it to how they practice both at the community and individual practice level.’ of the world’s deaths, despite the U.S. being just over 4% of the world’s population, point out the authors of the PCC/Graham Center report. This even though the U.S. had one of the earliest and most robust supply of vaccines. “It does not matter that vaccines are developed if communities cannot access them or individuals do not want them,” the authors write. “This is where public health and primary care integration can help.” www.repertoiremag.com

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TRENDS Two perspectives Editor’s note: This table, from the Harvard School of Public Health, demonstrates how differently medicine and public health view healthcare.

Public health

Medicine

Primary focus on populations

Primary focus on individual

Emphasis on disease prevention and health promotion for the whole community

Emphasis on disease diagnosis, treatment and care for the individual patient

Interventions aimed at the environment, human behavior, lifestyle and medical care

Every Predominant emphasis on medical care years

Lines of specialization organization by: ʯ Analytical method (epidemiology, toxicology) ʯ Setting and population (occupational health, global health) ʯ Substantive health problem (environmental, health, nutrition)

Lines of specialization organized by: ʯ Organ system (cardiology, neurology) ʯ Patient group (obstetrics, pediatrics) ʯ Etiology and pathophysiology (infectious disease, oncology) ʯ Technical skill (radiology, surgery)

Research moves between laboratory and field

Research moves laboratory and bedside

Population sciences and quantitative disciplines essential features of analysis and training

Numerical sciences increasing in prominence, but still a relatively minor part of training

Source: Harvard T.H. Chan School of Public Health

But amidst the failures during the pandemic lay glimmers of progress. In communities with the most robust primary care, the strongest public health infrastructures, and the fewest social vulnerabilities, residents were 42% less likely to die from COVID-19 and 12% less likely to get infected with the virus, as compared to communities on the other end of the spectrum, according to the PCC/Graham Center report. The COVID-19 pandemic showed how primary care and public health together can save lives, says Hayashi. “Public health provided expertise, resources, and supplies like test kits and vaccines. Primary care was the vehicle to deliver the testing and vaccines. Hospitals played a large role, but primary care was the trusted source of information and care to keep people from needing to go to ERs and hospitals. I can’t call most of this a model of public health-primary care integration, but it’s a start.” “There is opportunity for improvement in infrastructure across the country as we begin to consider recovery,” says Wood. “We are certainly thinking about the important role of primary care and especially collaboration with our public health colleagues and how we rebuild that partnership to be stronger together.” 26

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“With a new shared understanding of the definition of population, the integration of primary care and public health can foster an effective collaboration that understands that the health of a population is not simply a product of functionality or funding of healthcare services,” says the AAFP in its position paper. “Rather, it includes the conditions in which people are born, grow, live, work, and age, and encompasses inequities in power, money, and resources.” Says Wood, “Ideally, a practice is already a team, but when integrated with public health, the team is even bigger, with more resources and services to offer patients and the community. There’s also the opportunity to have more information, show outcomes and often seek funding to support these programs.” Some state AAFP chapters already work with their local or state public health departments to help with tobacco prevention and cessation programs and other wellness programs. “Incremental changes make a difference as well. Partnering with community health workers or the public health department can broaden the reach beyond the walls of the clinic and be helpful to patients, the primary care physician, and their team.”

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TRENDS

Antibiotic Stewardship an Uphill Battle Nursing homes have the greatest need ... but the fewest resources Since the mass production of penicillin began in the 1940s, antimicrobials have drastically improved human

health, preventing death from bacterial infection and lowering the risk associated with surgery and other lifesaving medical procedures, point out the authors of a recent report from the National Academy of Medicine, “Combating Antimicrobial Resistance and Protecting the Miracle of Modern Medicine.” But almost as quickly as the first family of antibacterials was introduced, its usefulness declined. Within six years of the introduction of penicillin, roughly a quarter of staphylococcal infections in hospitals (where the drug was often used) were no longer susceptible to it. Penicillin resistance continued to spread, and by the 1970s was as common in community-acquired infections as in hospitals. 28

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Hospitals still face an uphill battle against antimicrobial resistance today, but post-acute and long-term-care facilities even more. That’s because unlike hospitals, nursing homes typically lack the expertise of a full-time infection prevention staff or an onsite medical director. Nor do they have the information systems that could help staff identify potential misuse of antibiotics.

Foggy guidelines Sadly, antibiotic resistance is a fact of life. In its report, the NAM points out that microbes are constantly responding to selective pressures, including the pressures from antimicrobial medicines. “One response is a classic, Darwinian evolution wherein beneficial traits are passed from one generation to another. ... The genetic adaptability of microbes contributes to the emergence of resistance.” The misuse or overuse of antibiotics exacerbates the problem. Claims data suggest that roughly 17% of antibiotic prescriptions in the United States are made in the absence of any diagnosis of infection, while another 20% to 30% are not associated with any clinical visit at all, according to the NAM. Confusion over treatment guidelines is another problem. Long treatment regimens with antimicrobials were common historically, driven partly by a limited understanding of their effectiveness. The optimal duration of antibiotic therapy even for common infections, such as community-acquired pneumonia, was not established for decades, according to the NAM authors. And the results? In 2019, the Centers for Disease Control and Prevention estimated that every year, 2.8 million resistant infections in the United States lead to 35,900 deaths, with C difficile infection killing another 12,800 people. The Organisation for Economic Co-operation and Development estimates that 1.75 million years of healthy life are lost to antimicrobial-resistant infections every year among its 33 European member countries.

Urinary tract infections Older Americans make up 15% of the U.S. population but account for more than one-third of the deaths from antibiotic-resistant bacterial infections, according to a recent study from The Pew Charitable Trusts, University of Utah, and Infectious Diseases Society of America. In nursing homes – which accommodate an estimated 1.3 million Americans, about 80% of whom are over age 65 – antibiotic usage is common, according to the NAM researchers.

Suspected urinary tract infection (UTI) could be the most common indication for antibiotics in U.S. nursing homes, a group of researchers reported in August 2021. But some of those prescriptions are, at best, unnecessary, and at worst, contributory to antibiotic resistance. “The clinical suspicion of UTI among nursing home residents is most often triggered by subjective changes in behavior or falls, which can also be caused by many noninfectious conditions common to older adults,” according to the NAM researchers. Accordingly, NAM recommends that in the absence of fever or symptoms localized to the urinary tract, providers avoid urine cultures and antibiotic treatment. “Automatically reaching for that antibiotic isn’t a benign decision,” Christopher Crnich, M.D., PhD, Infectious Diseases Faculty, Veterans Administration Hospital in Madison, Wisconsin, told Repertoire. (Crnich was one of two authors of an editorial in JAMA in April 2021 titled “Opportunities to Improve Antimicrobial Use in US Nursing Homes.”)

There is a growing body of evidence to inform practices in nursing homes that will protect residents from the harms due to antibiotic resistance. “There has been a lot of misinformation in clinical training, particularly around the presentation of infection in older adults, and that has led to or promoted overutilization of antibiotics for nonspecific geriatric manifestations,” he says. “That’s a tough nut to crack because you have to ‘de-implement’ decades of training. Building systems that force clinicians to consider alternative explanations for a resident’s condition or situation is necessary.” The good news, he says, is that a new generation of clinicians is learning that subtle behavior changes among nursing home residents don’t necessarily point to UTI.

Antibiotic stewardship programs Most experts believe that healthcare providers – including long-term-care facilities – need to address antibiotic resistance with antibiotic stewardship programs, intended to measure and improve how antibiotics are prescribed by clinicians and used by patients. Among those experts are the federal government. www.repertoiremag.com

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TRENDS In 2015, the CDC released its “Core Elements of Antibiotic Stewardship for Nursing Homes,” and in 2016, the Centers for Medicare & Medicaid Services finalized a rule requiring that nursing homes have antimicrobial stewardship programs in place by late 2017. In addition, The Joint Commission standards require nursing care centers to develop antimicrobial stewardship programs based on the core principles published by the CDC. But it’s not clear how many nursing homes have such programs in place, or how well-developed those programs are. The Joint Commission reports that, based on its survey of accredited organizations, only 2% were scored for non-compliance related to the requirement. However, in 2020 researchers reported in the American Journal of Infection Control that among 861 nursing homes surveyed, just 33% had “comprehensive” antibiotic stewardship programs and 41% had “moderately comprehensive” plans.

Hospitals have a leg up on long-term-care because they have onsite expertise in infectious diseases and pharmacy. Crnich believes that those figures – particularly the 33% with comprehensive programs – “are probably a best-case estimate, given how the sampling was conducted,” as those surveyed were in the CDC’s National Healthcare Safety Network, a widely used healthcareassociated infection tracking system. “But it’s premature to criticize nursing homes, given this is a relatively new regulatory requirement, even though the clinical need has been longstanding.” Hospitals – where stewardship programs began – have a leg up on long-term-care because they have onsite expertise in infectious diseases and pharmacy, as well as automated data systems to help them monitor and improve their stewardship activities, he says. It’s true that every nursing home is required by regulation to have a medical director, but not every medical director is engaged in facility operations in a meaningful way. Similarly, every nursing home has a consultant pharmacist, but again, whether that person is engaged in antibiotic stewardship is variable, depending on the facility. In many cases, it is up to the director of nursing or infection preventionist – who are often one and the 30

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same, given staffing challenges facing long-term-care – to implement an antibiotic stewardship program. Nevertheless, Crnich sees progress. “The fact that CMS in collaboration with other public health agencies decided to explicitly incorporate stewardship into the regulatory language will help drive change,” he says. And, if there is a silver lining to COVID, it may be growing recognition that infection prevention in long-term care is a serious issue. Crnich also believes that information technology infrastructure in nursing homes is improving, which should help staff direct their efforts toward antibiotic resistance more precisely.

Up and running “High staff turnover and challenges in training staff on antibiotic stewardship protocols may present obstacles to comprehensive stewardship programs in [the long-termcare] setting,” says Sarah Kabbani, M.D., medical officer at

the CDC in the National Center for Emerging and Zoonotic Infectious Diseases, Office of Antibiotic Stewardship. Another barrier is limited access to facility antibiotic use data. “Tracking and reporting antibiotic use are important to identify opportunities for improving antibiotic use and engaging healthcare professionals to improve prescribing practices.” Nevertheless, Kabbani sees increasing awareness of the importance of antibiotic stewardship in nursing homes, and points to a recently published study by the CDC’s Office of Antibiotic Stewardship that reflects growing usage of its “Core Elements” program.

which is focused on improving care of residents with indwelling-medical devices at risk for antibiotic-resistant infections. ʯ The SHIELD Orange County quality improvement project led by Susan Huang, University of California-Irvine in collaboration with Orange County Public Health, to evaluate use of an antibacterial bathing strategy to reduce prevalence of antibiotic-resistant organisms in nursing homes, long-term acute care hospitals and hospitals caring for patients and residents in the same community.

Nursing homes around the country are engaged with academic partners in innovative programs to identify residents at risk for multidrug-resistant pathogens and reduce the spread of these germs, she says. Two examples: ʯ The Targeted Infection Prevention program led by Lona Mody from the University of Michigan,

“Through these experiences, there is a growing body of evidence to inform practices in nursing homes that will protect residents from the harms due to antibiotic resistance,” she says. CDC is investing $2.1 billion to improve infection prevention and control activities across the U.S. public health and healthcare sectors, a portion of which will be dedicated to antibiotic stewardship. Funds will support state data analyses of antibiotic use and programs to improve antibiotic prescribing across communities and address health disparities related to antibiotic use, including in long-term care settings.

Bringing hospitals into the picture Long-term-care facilities can’t do it alone, wrote Crnich in his JAMA editorial. To have any chance of reducing antibiotic resistance among the post-acute-care nursing home population, they must work with referring hospitals. Researchers in the JAMA study found that higher antimicrobial usage was observed among short-stay residents admitted for post-acute skilled nursing or rehabilitation care, and among residents most recently admitted to the nursing home. They found that residents receiving antimicrobials during days 1 and 2 of their stay were most likely initiated before nursing home admission. “It definitely is an area that requires focused attention,” says Crnich. “We are collaborating with investigators at Oregon Health and Science University to identify opportunities and targets for intervention. Whether those are identified prior to the patient’s discharge from the hospital or during post-discharge monitoring by the acute-care provider is not entirely clear. My initial bias is that there will have to be ongoing post-discharge monitoring by acute care, but that can only be accomplished through collaboration between acute and post-acute care. I hope we see these types of models emerging.” www.repertoiremag.com

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TRENDS

Adding the Element of Patient Choice The urgent care model continues to evolve as patient needs and technologies emerge

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The Urgent Care Association (UCA) is an organization of leaders, providers

and suppliers in on-demand healthcare. It supports success through advocacy, education, research and collaboration. Its CEO Lou Ellen Horwitz recently spoke with Repertoire about the organization, some of the biggest changes in the urgent care marketplace since its inception in 2004 and how urgent care centers were affected by the pandemic.

Repertoire: The Urgent Care Association was started in 2004. Can you tell us the reason behind its creation, and the number of initial members? Horwitz: UCA was started by a group of urgent care owners who wanted to connect with and share best practices with other owners across what was then a nascent industry. Urgent care was the first “walk-in” medicine outside of the emergency room, which added the element of patient choice and patient experience into an existing ecosystem of how we delivered healthcare in the U.S. Initially, there were a few hundred members – we do not have an exact count. Repertoire: What are some of the biggest changes in the marketplace since 2004 that UCA has helped its members navigate? Horwitz: The biggest changes have been the introduction of retail clinics (drugstores), the interest in our sector by external investors from private equity to large health insurers, and the growing presence of health system ownership. The introduction of retail clinics was initially met with concern about fragmenting the walk-in care space, but it became clear that urgent care centers and retail clinics have different scopes and goals and can work well together in a community. The investments have led to exponential growth in the number of centers, increased sophistication

in operations, and increased visibility of urgent care centers across the nation by all stakeholders. Health system ownership – either directly or through JV-type relationships – has grown from almost nothing to almost half the industry.

Lou Ellen Horwitz

Repertoire: Walk through the most common ownership models. Horwitz: The most common ownership model is through health systems or closely affiliated. Some de novo but mostly through acquisition or joint ventures. The second most common is privately held with private equity backing. Some of these also have health system affiliations without ownership. And third is privately held by individual owners – single/double site locations make up almost half of the centers in the country. www.repertoiremag.com

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TRENDS were unaware of urgent care’s significant role in communities prior to the pandemic.

Repertoire: When did you begin to see health systems take an interest in acquiring/owning urgent care centers? Horwitz: Health systems first tried urgent care in the mid-1990s but backed away after limited success. Interest resurged in approximately 2010 when acquisitions began in earnest, but in a different model from the 1990s version. It has met much more success. Repertoire: Where do today’s urgent care centers fit in services and care for patients? What are their strengths? Horwitz: Urgent care centers handle a wide variety of non-emergent illness and injury on a walk-in or appointment basis. Their scope is typically well beyond that of a retail clinic, somewhat beyond a primary care office, and slightly under an emergency room. Their strengths begin with good medicine and safe patient care, of course, but their distinctive elements are a broad scope of care capabilities and an elemental focus on the patient experience. This has led to extremely high patient satisfaction with the model because systems are set up to make it easy and convenient to access high-quality care across a wide variety of conditions. Repertoire: How were urgent care centers affected by the pandemic? Horwitz: Urgent care centers were tremendously affected – both medically and financially. Visit volumes have tripled or more and remain at extraordinary levels even today. Operationally, they had to navigate: ʯ PPE shortages ʯ Varying medical guidance ʯ Confused and unhappy patients 34

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Repertoire: What do you forecast the marketplace to look like in five years? Ten years? Horwitz: Urgent care has long adapted to, and even led through, change throughout its existence. It’s a model for forward-thinking care and continues to evolve as consumer needs and technologies emerge. Adoption of telemedicine, in some form, is fairly ubiquitous and geographically there are still underserved communities that could benefit from urgent care. The payer landscape, however, has not yet caught up with the potential

In some ways it has been an opportunity for urgent cares to show what they can do, from their ability to adapt and pivot quickly, to form partnerships easily, and to stay open in extremely difficult circumstances. ʯ Fluctuating requirements for physical plant changes

ʯ Variations in regulations from state to state

ʯ Staffing shortages ʯ Inconsistent payer reimbursement for visits ʯ Instantaneous telemedicine adoption and more In some ways it has been an opportunity for urgent cares to show what they can do, from their ability to adapt and pivot quickly, to form partnerships easily, and to stay open in extremely difficult circumstances. The willingness to jump in and participate from day one of the pandemic has been lauded by federal and state stakeholders, who

of urgent care to serve rural communities and lower overall costs of care from treating the non-emergent cases currently seen in the emergency room. Experimentation with hybrid urgent care/primary care models continues, as does the primary care shortage, so there is potential there as well. Value-based care has yet to include urgent care, but it’s a natural opportunity to proactively move non-emergent care into lower cost sites, so it’s expected in the future. Private equity interest remains strong, as does consolidation via merger and acquisition activity. With the right shifts from the payer community, urgent care’s potential is promising for many years to come.

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TRENDS

Virtual-First Care Insurers are investing in virtual-first health plans as a way to provide more options, convenience for consumers. By Pete Mercer

All it took was a pandemic. Among many other things, the coronavirus pandemic revealed the fragility of our

healthcare infrastructure in the face of a massive disruption. Accessibility weaknesses laid bare, primary care and physician offices had to think of a creative way to ensure that their patients received the care that they required, while maintaining COVID safety protocols. In an effort to keep people as safe as possible, many primary care offices moved services to virtual appointments that allowed patients to be seen at the height of the COVID-19 surges.

Virtual health care is a precious commodity in a time when access to health care is more strained than ever. McKinsey conducted a study in July that found that “telehealth utilization has stabilized at levels 38 times higher than before the pandemic.” Not only is telemedicine a valuable resource for those who need it, but it’s becoming more popular as people see the benefits of leveraging virtual care for their needs. Cigna recently announced that it is significantly expanding access to covered virtual care services for millions of customers. After the recent acquisition of MDLIVE by Evernorth, Cigna’s health services business, Cigna is pushing to be an 36

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innovative provider of virtual care services at a time when people are most interested. In a media release, Dr. Cynthia Zelis, chief medical officer at MDLIVE, said, “Together, we are creating a best-in-class, coordinated virtual care experience for millions of patients – improving each person’s unique health journey with support from a wide network of providers.” Despite its inherent limitations, virtual health care provides patients and providers with a unique opportunity to maintain a consistent level of care in a time rampant with inconsistency. In the height of the pandemic, telehealth was a critical tool for primary care practitioners who

had to close their offices. Even if the standard of care isn’t quite the same as when patients are in the office, virtual care affords the patients an opportunity to be seen from the comfort of their own home and the convenience of their own schedule. Heather Dlogolenski, senior vice president, Solutions, Cigna, said in a media release, “At Cigna, we are constantly innovating our plan designs to meet the needs of our customers while continuing to make health care more affordable, predictable and simple. Expanding into virtual-first health plans is the next step in providing a convenient and comprehensive care experience.”

How it works Beginning in January 2022, all Cigna customers who are enrolled in employer-sponsored plans will have access to MDLIVE’s network of virtual primary care providers for routine care visits, sick visits, prescription refills, or to follow up on a condition that wasn’t addressed during a wellness visit. In addition to the virtual care visits that Cigna customers can schedule at their convenience, it will also seamlessly transition to an in-person visit as needed.

MDLIVE will refer to Cigna’s network of high-performing providers when face-to-face care is needed, with in-network specialists, lab work, and biometrics at in-network facilities. MDLIVE will also utilize the data provided by Cigna to proactively work with patients to close gaps in care, offer better care coordination and overall meet clinical medical needs. This coordination between MDLIVE providers or brick-and-mortar providers will be a critical component to ensure customers have a connected health care experience. Dr. William Lopez, the national director of Virtual Care at Everworth, explained that MDLIVE is designed to make the patient experience seamless between virtual and in-person visits. “The partnership we have with brick-and-mortar providers in Cigna’s network remains an important tenet of our virtual care strategy, and our core commitment to them remains the same – to ensure they can continue to deliver care how, when, and where they want to,” he said. “That’s why we also offer our network of brick-and-mortar providers – including primary care physicians – the ability to leverage virtual care as part of their care offering through our Virtual Care Reimbursement Policy.”

Addressing the challenges in healthcare One of the most significant and consistent challenges in healthcare is accessibility. Whether it’s geographic challenges in rural areas or transportation barriers for low-income people, accessibility is one of the hot button issues facing healthcare. Virtual care provides a unique opportunity for greater access across the spectrum, creating convenience for a wider range of people. “The substantial expansion in MDLIVE services provides even

more choices to our customers, continuing our trend of removing access-to-care limitations that some consumers face,” Lopez said. “Customers who have relationships with in-person providers will not be required to switch to a virtual provider. For many, virtual care offers another convenient way to receive care, and allows them to access care when are where they need it.” Virtual care presents its own set of challenges for patients and primary care physicians. Despite the convenience and ease of access that a telemedicine call affords the patient, it’s impossible to address all of the patient’s needs using a remote service. While it still allows the patient to be seen by a medical professional, some appointments are simply better for in-person visits. MDLIVE is addressing the challenges of virtual care by ensuring that their customers are offered the best choices for what they need. Additionally, Cigna customers will be able to use the MDLIVE services to address their mental health needs. “Since 2020, Cigna customers have had access to MDLIVE’s behavioral health care team in addition to the many other virtual providers within Cigna’s vast behavioral health care network,” Lopez said.

Virtual care in a post-pandemic world While virtual care has become an invaluable resource to patients during the pandemic, what will happen once we move past COVID-19? In a post-pandemic world, will there still be a need for virtual care? Lopez believes that virtual care options “will remain a preference of customers, clients, and providers in a post-pandemic environment.” In fact, that’s part of why Cigna has

implemented the virtual-first benefit plan pilot, as well as the permanent coverage of certain virtual services for their network of brick-and-mortar providers. “The massive acceptance and adoption of virtual care during the pandemic has reshaped the delivery of medical and behavioral health care,” he said. “In addition, consumers have come to expect the same level of convenience in health care as they see in other industries such as finance and retail. Our customers and clients value convenient access to high quality care and are increasingly finding virtual care is a great way to meet their health needs. We also know that virtual provides an access point to health care, allowing customers to have more flexibility when it comes to care. In fact, more than 75% of Cigna customers who had an MDLIVE virtual wellness screening in 2020 did not have a PCP – and two-thirds identified a health condition as a result of the virtual screening.” In the post-pandemic world, there will still be a need for easy access to healthcare for rural communities and low-income families, as well as a variety of choices for customers who have come to expect a virtual health solution to their needs. “Our customers value convenient access to high-quality care and are increasingly finding virtual care is a great way to meet their health needs. This substantial expansion in MDLIVE services provides even more of those choices to our customers,” Dlogolenski said. “Not only will this give more people an additional entry point to the health care system, but patients will be able to build lasting relationships with their preferred MDLIVE provider just as they would in a traditional office setting.” www.repertoiremag.com

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HIDA

“Fast Pass” HIDA advocates expediting medical supplies through ports and transportation By Linda Rouse O’Neill

Transportation disruptions have become major international news – ships anchored off ports for weeks, rising

transportation costs, delivery delays. HIDA’s message to policymakers is that these challenges are a major healthcare issue, threatening providers’ ability to care for patients. Our recommendation: find a way to “fast pass” medical supplies through the many current supply chain bottlenecks.

HIDA members reported an average delay of 38 days has been added to the transportation of medical products. To put that in a holiday perspective, medical supplies arriving at a U.S. port on Christmas Eve won’t be delivered to hospitals until February 2022. Life-saving medical supplies should be given priority over other cargo waiting outside U.S ports. HIDA has taken that message to the highest levels of the federal government. We’ve been working with the White House Supply Chain Disruption Task Force to identify impactful ways to expedite medical supplies and equipment. We’ve written to the Secretaries of the Departments of Transportation, Commerce and Agriculture, urging them to prioritize critical medical supplies and align transportation operations to support healthcare during public health emergencies. The Administration’s recent work to align the ports to 24/7 operations is an essential first step to alleviate transportation bottlenecks. But more needs to be done.

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Linda Rouse O’Neill, Vice President, Supply Chain Policy and Executive Branch Relations, Health Industry Distributors Association

HIDA has advocated for a Critical Cargo Program that would essentially create a “fast pass” for medical supplies at our ports to prioritize critical medical supplies for container access and sea freight space and for priority handling of medical supplies at ports. Such a “fast pass” system was used early in the pandemic, when containers of medical products were successfully peeled off at U.S. ports for expedited transport. This private sector initiative was effective, but short-lived. It urgently needs to be revived and expanded to rail and truck transportation. We’re also collaborating with other private sector stakeholders to investigate additional solutions. And progress is happening. Port leadership, terminal operator SSA Marine and its technology partner eModal are working to find solutions to today’s supply chain challenges, starting with a pilot program to implement a “fast pass” system at the Ports of Los Angeles and Long Beach. We invite you to visit our webpage to learn more about transportation challenges and HIDA’s efforts and access infographics and other resources. Together, we are finding ways to get medical supplies and equipment into the hands of healthcare providers and frontline workers more quickly and efficiently.

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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.

Mazda CX-50

Automotive-related news Santa’s new helper? Self-driving truck pilot program launches during the holidays TechCrunch reported that Waymo Via, the delivery division of Alphabet’s self-driving arm, is expanding its existing partnership with UPS to carry freight via autonomous Class 8 trucks. The six-week pilot, which kicked off in November and will continue until the end of the year to support the holiday season, was to take place in Texas between Houston and Dallas-Forth Worth. Waymo is not sharing the specific number of trucks it will use for the pilot, but it did say “multiple trucks” from its test fleet of Peterbilts that are equipped with its fifth-generation Driver will be delivering goods for UPS’s North American Air Freight (NAAF) unit. The trucks will have two autonomous specialists onboard – one driver with a commercial 40

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driver’s license and one software technician – who will monitor Driver’s operations while in autonomous mode. The trucks will be self-driving only on highways, and will switch back to manual mode for surface street portions, a spokesperson for Waymo told TechCrunch.

Used car market putting a dent in consumers’ wallets According to a recent Washington Post report, the unraveling of the used-car market is the most tangible result of a problem that has plagued the global economy for the past year: a dire shortage of computer chips that has hobbled auto manufacturing. The lack of new cars hitting the market has caused a shortage of used cars, too, raising prices and crimping sales. The crisis has created

a political headache for the Biden administration, fueling inflation and knocking more than two percentage points from GDP growth in the third quarter. It’s also hurting consumers, who face long waits for new cars and can’t fall back on the used-car market as a low-price alternative. “It’s going to be really, really tough for consumers to buy a vehicle in 2022, a used or a new car. You’re going to have to pay a very high sticker price,” automotive dealer Brad Wimmer told the Post.

The 10Best After reviewing a market of more than 300 vehicles, Car and Driver named its 10Best Cars and Trucks for 2022. They are: ʯ Cadillac Ct4-V Blackwing ʯ Cadillac CT5-V Blackwing ʯ Chevrolet Corvette ʯ Ford Bronco ʯ Honda Accord ʯ Kia Telluride ʯ Porsche 718 Boxster/Cayman ʯ Ram 1500 ʯ Subaru BRZ/Toyota GR 86 ʯ Volkswagen Golf GTI. To read their reviews, visit: caranddriver.com/ features/a38254154/10best-2022.

Mazda announces new model Mazda North American Operations recently announced the debut of its first-ever Mazda CX-50. A completely new model, CX-50 is the first Mazda vehicle to be built at the new Mazda Toyota Manufacturing (MTM) plant in Huntsville, Alabama, with production beginning in January 2022. “This new Mazda vehicle has been developed for North America, particularly to support the active and outdoor lifestyles of customers in this region,” Jeff Guyton, President and CEO of Mazda North American Operations said. “The CX-50 encourages people to immerse themselves in nature without compromising on the premium design and outstanding on-road performance Mazda is known for.” As a new addition to the Mazda lineup, CX-50 maintains key attributes expected of all Mazda vehicles, including superior driving dynamics and beautiful design, the company said in a release. In addition, Mazda has extended this vehicle’s capability to enable drivers to venture further into the outdoors and various terrains. The first-ever CX-50 emphasizes Mazda’s trademark natural driving experience to help create greater confidence

on and off-road. Enhancing this experience, it will be equipped as standard with the latest i-Activ All-Wheel Drive (AWD) technology and new Mazda Intelligent Drive Select, or Mi-Drive. The new drive modes can be selected with the Mi-Drive switch and will help the crossover SUV drive naturally in a wide variety of conditions, such as in exciting off-road terrain or providing reliable towing capabilities. At launch, CX-50 will be available with Mazda’s efficient powertrains, Skyactiv-G 2.5 naturally aspirated engine or Skyactiv-G 2.5 Turbo engine and paired with a responsive six-speed automatic transmission. In the coming years, the CX-50 will also be offered with electrified powertrains, including a traditional hybrid model. More information about electrified models will be shared at a later date.

Ford collaborates with GlobalFoundries to address auto chip supply GlobalFoundries Inc., and Ford Motor Company announced a strategic collaboration to advance semiconductor manufacturing and technology development within the United States, aiming to boost chip supplies for Ford and the U.S. automotive industry. The companies have signed a non-binding agreement that opens the door for GF to create further semiconductor supply for Ford’s current vehicle lineup and joint research and development to address the growing demand for feature-rich chips to support the automotive industry. These could include semiconductor solutions for ADAS, battery management systems, and in-vehicle networking for an automated, connected, and electrified future. GF and Ford also will explore expanded semiconductor manufacturing opportunities to support the automotive industry. “It’s critical that we create new ways of working with suppliers to give Ford – and America – greater independence in delivering the technologies and features our customers will most value in the future,” said Jim Farley, Ford president and CEO. “This agreement is just the beginning, and a key part of our plan to vertically integrate key technologies and capabilities that will differentiate Ford far into the future.” “GF is committed to building innovative alliances with the world’s leading companies to enable the features in products that are pervasive throughout people’s lives,” said Tom Caulfield, GF CEO. “Our agreement with Ford is a key step forward in strengthening our cooperation and partnership with automakers to spur innovation, bring new features to market faster, and ensure longterm, supply-demand balance.” www.repertoiremag.com

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TRENDS

How Providers’ Needs Have Changed One GPO executive explains how today’s suppliers can compete with the challenges brought on by the pandemic. By Pete Mercer

John Pritchard, Share Moving Media

Understanding and meeting the needs of the customer has never been so complex, especially for the healthcare

industry. We are continuing to see an unprecedented level of challenges at every front in healthcare: staffing, capacity, burnout, quality of care, and supply. How can today’s suppliers possibly compete with the challenges brought on by the pandemic?

Rand Ballard, chief customer officer at Vizient, Inc., recently spoke at Share Moving Media’s Healthcare Supply Chain and Distribution Summit, sharing his insights on how customer needs have changed, how to meet those needs, and what characteristics providers are looking for in suppliers. 42

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Vizient is the nation’s leading healthcare performance improvement company, serving more than half of the healthcare organizations across the United States. Vizient partners with a variety of healthcare organizations, ranging from large integrated delivery networks and academic medical

centers to community hospitals, pediatric facilities, and non-acute providers. Describing Vizient’s reach, Ballard explained, “We have 55% of all acute care hospitals, 67% of all integrated delivery networks, 98% of all Academic Medical Centers, and 98% of all standalone children’s hospitals.”

The needs of the customer One of the most critical ways to serve your customers, especially during stressful times, is to meet them where they are with what they need. Part of that equation is understanding what they need from the beginning, but it also requires that you listen to your customers and assess where you can best serve their needs on a daily basis. Ballard said, “We meet the customer where they are.” For example, the team at Vizient has found that large IDNs are looking to maximize their GPO throughput. “They are giving us 100% of the med/surg, pharmacy, and indirect spend that they have saved and converting those to GPO contracts.” When it comes to making a contract with Vizient, members are currently deciding what actually goes in the contract. Not only are they meeting the needs of the customer, but they are letting the customer write up the contract. It’s all about the cost and quality of the services. It hasn’t been an easy process to meet those needs. Without the aid of solid supplier relationships, Vizient would have struggled to maintain productivity and efficiency for their members. Ballard said, “Suppliers have really stepped up with us. They’ve given us very good pricing in return for the market share, and our obligation is to drive market share for the suppliers. I don’t think our competitors necessarily want to do that, but that’s what we do.” Vizient works to tailor solutions and technologies every year to meet the dynamic and changing needs of their members. Each year, Vizient holds an online forum where members can vote on which piece of new technology they want to integrate

into their contracts. If something is new, improving costs and quality, and members believe in it, they can add it to their contracts with Vizient. Allowing an open forum for member input gives Vizient deeper insights into what their customers are looking for.

How Vizient got through the pandemic Vizient pushed through the worst of the pandemic by implementing a sort of war room with 80 people in it, operating 24 hours a day. Because of their diligence, Vizient was able to support its clients and still service most of their needs. Ballard described the processes of obtaining supplies for Vizient’s customers as a “maverick” approach, but that they “accomplished what [they] needed to accomplish” and got everyone what they needed.

Without the help of Vizient’s suppliers, they might not have been as successful in pushing through the height of the supply chain disruption. Ballard said, “It goes back to the suppliers, working 24 hours a day to take care of us. Squeezing something else out somehow, finding solutions where there didn’t seem to be any.” This collaborative effort between Vizient and the suppliers ensured that Vizient’s members had what they needed to take care of their patients. Not everyone had it so easy though. In the wake of the supply chain disruptions, some people saw it as an opportunity to flood the market with fraudulent PPE materials that did not meet the regulations for use in healthcare facilities. Some even sought out these counterfeit items as a way for their employees to have some measure of protection,

Suppliers that are passionate about driving their business from the moment they wake up in the morning will make a powerful partner for your organization. By choosing to focus on things like productivity, growth, efficiency, and results, these types of people will work tirelessly to find a solution for what you need.

“A two-star general came to me with about 8 hospitals that needed help. He told me that it wasn’t really the federal government’s job to help them, but he knew that they needed support. So, he gave me the names and my team reached out to see how we could help. And we were able to help those hospitals. It was not about us; it was about doing the right thing for healthcare systems that were in need.”

but these items would continue to fail frontline healthcare workers. “We had members that did not go through us and got burned,” Ballard said. “They went to the black market and stuff happened. They purchased materials and supplies that turned out to be fake. PPE did not meet the necessary standards. We were able to turn in a lot of masks, there was a lot of bad stuff out there.” www.repertoiremag.com

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TRENDS

Rand Ballard, chief customer officer at Vizient, Inc.

Great characteristics of suppliers When looking to partner with suppliers, it is important to identify characteristics of organizations that you want to work with. With partnerships, you need a mutually beneficial relationship that allows for flexibility on either side. The supplier relationship is a critical piece of the puzzle, laying a better foundational value for your business and greater efficiencies for both sides. Ballard shared some characteristics of suppliers that his team at Vizient is looking to partner with. 1. People that wake up with a passion for driving their business “If you work for us and let us work for you, you will find that we will increase your 44

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market share.” Suppliers that are passionate about driving their business from the moment they wake up in the morning will make a powerful partner for your organization. By choosing to focus on things like productivity, growth, efficiency, and results, these types of people will work tirelessly to find a solution for what you need. 2. People that are in tune with the account management structure “On our portal, it tells you every hospital that we have and who the account representative is. Good suppliers use that, they know how our accounts are structured.” Seek out the partnerships with suppliers who understand how your organization works and

respect those processes. When your supplier partners respect how your account management structure is organized, you can trust that they are taking the initiative to follow the procedures you have established. 3. People that step up to meet the needs of their customers “We are looking for suppliers that are stepping up, helping our members, and meeting them where they are.” Look for people that care just as much about meeting the needs of your customers as you do. When you partner with a supplier that cares about the needs of your customers and will step up to the plate to make sure those needs are met, you can just focus on the client relationship.

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TRENDS

Disruptions in Supply Chain Supply chain experts discuss the challenges, complications – and opportunities – that the pandemic has created for medical distribution By Pete Mercer

Over the last year and a half, the medical distribution supply chain has seen numerous challenges and complica-

tions, resulting in massive disruptions throughout the supply chain. Billy Harris, CEO of Sri Trang USA, Inc., and Mark Seitz, President and CEO of NDC, Inc., recently spoke in a joint session at Share Moving Media’s Healthcare Supply Chain and Distribution Summit, sharing their insights on the current state of the medical distribution supply chain and how the industry can move forward.

Sri Trang USA (STU) is headquartered in Tampa, Florida with distribution centers throughout the United States. STU serves the general purpose and exam disposal glove markets, including healthcare, dental, veterinary and food service, and others. Sri Trang USA is wholly owned by Sri Trang Gloves Thailand (STGT). As one of the world’s leading glove production companies, and the manufacturer of Ventyv brands, STGT has five state-ofthe-art production facilities with its first factory established in January 1989. Currently the largest glove producer in Thailand, Sri Trang has 12 glove manufacturing facilities on five campuses producing 35-billion disposable gloves and exports to 160+ countries. Ventyv is a full line of disposable hand protection products, including Polymed, one of the longest-standing global brands in the hand protection category. NDC is a leading global provider of both upstream and downstream healthcare supply chain products and support. By offering unique solutions and services, NDC helps their healthcare distributor partners compete in an increasingly complex marketplace. They partner with over 46

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700 manufacturers to bring operational efficiency through customized supply chain solutions.

Current state of the medical distribution supply chain While it’s certainly no surprise that the global supply chain was facing

to approximately $30,000 at the height of the pandemic. Additionally, there is a significant infrastructure compromise with serious labor constrictions and exploding demand. Many organizations do not have the resources to support the new demand levels.

Diversifying sourcing and manufacturing capabilities could greatly benefit the supply chain by not relying on the same suppliers for everything you need, which can relieve pressures on suppliers. a lot of challenges, Seitz and Harris went into detail on the global challenges that emerged with the pandemic. Harris said, “This pandemic has been different from the bird flu, swine flu, Y2K, SARS and anything else that can create any kind of disruption in the supply chain. This was a world issue.” Seitz explained that during the pandemic it became harder and more expensive to secure a shipping container. Prior to COVID, the average cost for a shipping container was $3,000; however, that cost increased

For Sri Trang, glove production skyrocketed. “We experienced a similar situation back in 1988, which was when the FDA issued universal precautions and said, ‘If you come in contact with bodily fluids, you must glove, gown, and mask,’” Harris explained. “That was all related to the AIDS virus. Between then and current day, there have been 20 other events that have occurred. In 1980, we would estimate the US market was about 15 billion gloves – disposable and exam – that were probably used. In today’s market, we’re looking at about 70 billion.”

With a massive spike in manufacturing, it creates tension throughout the supply chain. Additionally, the shortage of containers to get gloves to the US further complicated matters. Harris explained how the AIDS epidemic in the 1980s affected glove production, saying, “What happened during the universal precaution days, we had two factors to account for. The demand came suddenly because of the regulations that the FDA was enforcing. And the second part of that was manufacturing was migrating to other parts of the world. So, if you went from a basis of having a supply nearby to now you are having to deal with lead times that most of the buyers were not prepared for. It took the market about four years to recover. For NDC, they are experiencing a surge in backorders that can’t be fulfilled. Seitz said, “We usually run about $5 million in back orders, it’s fairly consistent. Right now, we have $28 million, on average, back ordered. At one point, backorders were as high as $65 million.” Are there any remedies that can address the current state of the medical distribution supply chain? Seitz broke down several methods that could potentially remedy the current situation. Legislative initiatives and tariff exemptions could simplify and expedite the international shipping processes, which have been a significant part of the problem. Reshoring efforts would relocate the international production operations back to the United States, making it cheaper to produce, assemble, and distribute the materials. Additionally, an expansion of the supply chain infrastructure would allow for more movement of the high demand goods that healthcare systems so desperately need. Even with these remedies in place, it seems unlikely that we could

return to the normalcy of pre-pandemic operations. Seitz said, “There won’t be a new normal, but there will be new standards and it will be more expensive to get products into this country.”

Commitment to a less lean supply chain What can we do to make a difference? Seitz believes we should commit to a less lean supply chain with respect to all the goods and services the economy depends on. “I’ve heard some supply chain leaders say, ‘Never again will we be caught in a situation where we don’t have those fundamental products for our healthcare providers’.” Safety stock is a great way to ensure that your products don’t fall out of circulation in the supply chain. Keeping a safety stock handy could help your customers get out of a quick bind and provide some very much needed relief. Diversifying sourcing and manufacturing capabilities could greatly benefit the supply chain by not relying on the same suppliers for everything you need, which can relieve pressures on suppliers. Additionally, factories could find ways to manufacture items that you wouldn’t normally focus on. Diversifying manufacturing capabilities gives your team new opportunities to keep the supply chain moving. Seitz said, “Historically, we’re a master distributor. We really were at the mercy of what’s happening with independent distributors and markets.” At Sri Trang, Harris and his team adjusted their methods and focused on serving their customer base. “What we did is we shifted to a communication focus with our customers about every single purchase order, especially on the logistics side” Harris said. “These were different

Zoom calls, spending time doing nothing but identifying every single line item on every single PO. We wanted to identify what we’re going to ship, whether you buy a pallet of gloves or whether you were getting a container of gloves. It’s all about credibility because there was so much misinformation along those lines.” That push to slow down and focus on Sri Trang’s customer base also allowed his team to address the counterfeit gloves that suddenly appeared in the market. “People were coming into the space because the dollars were so attractive. One of the byproducts of the disruption was something that I never personally participated in. I certainly didn’t think that I would ever encounter counterfeit gloves. We had this very swift acting group of people that took packaging of popular brands, stuffed that packaging with bulk purchased gloves, shipped them here in the US and sold them at premium prices. They were using our packaging and we had people calling to authenticate that it was our product.” Maybe the best way to commit to a less lean supply chain is to watch our innovative tendencies. Innovation saves times and money, but how many of these new tools are addressing the problems they were created to fix? Seitz said, “Are we getting carried away as an industry with how we innovate? How many new products are really addressing the problem?” At the end of the day, it comes down to whether the customer is being served or not. Healthcare systems are having to ration items that were once taken for granted. Once the worst of COVID and the supply chain disruptions are in the rearview mirror, let’s make sure not to forget the hard lessons we’ve learned along the way. www.repertoiremag.com

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January 2022

MARKETING MINUTE

Sales Strategy for 2022: Offer Advanced Demonstrations of Complex Products As a medical supplier, you sell medical supplies to improve the lives of patients. You work hard to provide hospi-

tals, doctors, and other healthcare organizations with the critical supplies and tools they need to care for patients. Whether you are a seasoned medical sales representative or new to the role, you should always be ready to learn new strategies. The following sales strategy can help you improve your medical sales as you look towards 2022 and the incredible progress of the healthcare industry.

to carry around. Modern technology can help you get past this roadblock. Consider using some of these advanced visualization options: ʯ Medical Animation: A medical animation can show healthcare professionals a detailed view of how your product works, even on a cellular level. It can show off the inner workings of a product. This gives information to your clients that they might not know even if they are holding the product in their hands.

ʯ Augmented Reality: Augmented Reality (AR)

Offer Advanced Demonstrations of Complex Products Some of the medical supplies you sell are complicated. Offering your potential customers a brochure or one sheet for these products will not give them adequate information. These types of materials will not effectively demonstrate all the product’s features, and they have the potential to include outdated information. To improve your chances of making a sale, you want hospitals and physicians to visualize your products in their facilities. If they can’t imagine this, you will have a harder time closing the sale. Showing off your products, and even letting your clients experience them for themselves, is one of the most effective selling strategies. Unfortunately, some of your most valuable equipment is large, expensive, and not practical 48

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is when digital objects are superimposed on top of real-world objects. It is used in everyday apps, such as with chatting filters that make your face look like an animal. In a medical setting, AR is interactive and can be used with a smartphone, tablet, or virtual reality headset. In a demonstration, AR can show digital details and facts on top of a real-world view.

ʯ Virtual Reality: Virtual Reality (VR) is similar to AR, except all the images are digital. A VR demonstration of a medical product allows physicians and other medical personnel to try out the product for themselves. Advanced visualizations like this are a powerful tool that can help bring products to life. Doctors and hospitals can see a clear image of how your products will work in their facility. To read about five other sales strategies, visit 6 Strategies that Work to Sell Medical Supplies in 2022 – Share Moving Media.

NEW PRODUCT SPOTLIGHT

DETECTO

DETECTO’s New SOLO-RI Scales DETECTO announced that its new SOLO-RI Scales are in stock and available now for quick shipments. The new SOLO-RI portable low-profile clinical scale has a 7.25 ft/2.2 m cable to the remote display allowing for flexible patient weighing use. Other features include:

ʯ The display may be

wall-mounted or set on a countertop (mounting bracket included). The SOLO-RI features 550 lb x 0.2 lb / 250 kg x 0.1 kg capacity, 14.2 in W x 15.8 in D x 2.4 in H / 36.0 cm W x 40.2 cm D x 6.1 cm H platform size, Body Mass Index, 6 AA batteries (included), USB port, audible beep confirmation, OneWeigh units locking in to LB or KG, and can be used in a wide range of medical weighing applications.

ʯ The Mother/Baby mode

factors the weight of infants and toddlers held by an adult.

ʯ The compact size, lightweight,

and battery operation allows it to be moved quickly wherever needed in medical facilities.

SOLO-RI Components.

The SOLO-RI is in stock and available now for immediate shipment from DETECTO.  Learn More: bit.ly/2YGEYPt

SOLO-RI Batteries.

www.repertoiremag.com

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January 2022

HEALTHY REPS

Health news and notes Fitness company launching primary care service Crossfit, known for its high intensity group workouts, recently announced the launch of Crossfit Precision Care. According to Crossfit, the program combines genomic medicine, biomarker testing, biometric tracking, and the personal goals of each patient to develop a holistic health plan. “Unlike traditional medicine, we recognize each patient is unique, and your health plan should be as well,” the company said on its website. Crossfit CEO Eric Roza told TIME Magazine that the subscription-based telemedicine program is meant to replace traditional primary care, offering clients access to both a physician and a health coach who can help patients draft and follow personalized plans in pursuit of their fitness, nutrition and overall health goals. According to the company, clients can select a plan that fits their lifestyle. Then, they’ll complete testing that includes an intake questionnaire, bloodwork, genetic biomarkers, 50

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wearable data, and more. Once the testing is complete, clients will be able to review their health plan by receiving personalized recommendations on diet, movement, recovery, and more, all tailored to their biomarkers and goals. Then, they’ll be able to receive ongoing care by meeting with a health coach and doctor to track progress. As of press time, Crossfit was directing those interested to sign up on a waiting list on its website.

Airline partners with Peloton Delta Airlines announced it has partnered with leading interactive fitness platform Peloton to offer a new “Classes in the Clouds” collection of well-being-focused content exclusively for Delta customers. “Decompress at your seat with guided meditations and stretches led by Peloton Instructors – a perfect way to prepare for that getaway or family reunion this holiday season,” Delta said on its website. The collection marks the first time Peloton content will be available on a non-Peloton platform. The

many people with chronic loss of sense of smell report a poorer quality of life, and feelings of depression as well. Exactly how COVID-19 can rob you of your ability to smell isn’t fully understood yet, but many viral illnesses cause similar symptoms, MSN reported.

WHO, CDC report high risk of measles outbreaks as pandemic disrupts vaccinations The world faces a higher risk of measles outbreaks as the pandemic has disrupted routine vaccinations, a World Health Organization (WHO) and Centers for Disease Control and Prevention (CDC) report found. According to The Hill, although annual measles cases dropped 82% from 2019 to last year, the report determined that routine vaccinations and surveillance of measles cases also dropped in 2020 as countries faced the start of the COVID-19 pandemic. A total of 75 countries reached more than 90% coverage for the initial measles vaccine last year, in a 13% drop from 2000 and a 37% decrease from 2019. Countries need at least a 95% vaccination rate of both doses of the measles vaccine to ensure “high population immunity,” the WHO and CDC noted.

classes range from 5 to 20 minutes and will help you relax, recharge, fall asleep or stretch mid-flight.

Chronic loss of smell due to COVID a reality for many during the holidays Many people who’ve recovered from COVID were partaking in the holiday meals this past November and December without truly being able to enjoy their food. That’s because, according to a new paper published in the journal JAMA Otolaryngology – Head & Neck Surgery estimates that up to 1.6 million people in the United States lost their sense of smell for at least six months as a result of a Covid-19 infection, reports Denise Mann for MSN. “Given the surge in acute COVID-19 infections last fall and winter and the ongoing cases, there is a pending tidal wave of new cases of chronic olfactory dysfunction that deserves our attention,” said study author Dr. Jay Piccirillo, a professor of otolaryngology – head and neck surgery at Washington University School of Medicine in St. Louis. “We have to try to figure out what to do for these people, and the sad news is that we don’t have any effective treatments for chronic COVID-19-related loss of smell yet.” Without the ability to smell, you can’t taste food or detect harmful odors such as gas and smoke. Like Stern,

Other key findings of the report include: ʯ Approximately 22.3 million infants did not receive the initial measles vaccine last year – an increase of 3 million from the previous year. ʯ Coverage with the initial measles vaccine in the past 20 years reached its highest point of 86% in 2019 before dipping to 84% last year amid the pandemic. ʯ The vaccination rate for the second measles shot almost quadrupled between 2000 and 2019 before slipping 1 percentage point last year. ʯ Five of the six WHO regions experienced a drop in the first measles vaccine coverage between 2019 and 2020. ʯ The number of specimens sent to the WHO Global Measles and Rubella Laboratory Network hit its lowest point in more than a decade, as 35 countries did not report rates for the first measles shot and 50 did not report rates for the second measles dose. The past two decades have seen progress with the estimated number of measles deaths falling 94%. Since 2000, the health organizations calculated that measles vaccination prevented about 31.7 million deaths worldwide. Despite a goal to eliminate measles in 5 of the 6 WHO regions by 2020, no region has reached and maintained measles elimination. www.repertoiremag.com

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January 2022

DISTRIBUTION

Delivering the Goods Dukal celebrates 30 years of building trusted partnerships in medical distribution.

2020 new Dukal warehouse in Savannah.

1991 Rockville Centre, NY home where Dukal was founded.

Thirty years ago, the health care marketplace was in a

much different place. The major trend was national brands; there was a lot of consolidation at the time, where national brands were buying up other entities. In 1991, Gerry LoDuca saw an opportunity in the marketplace for distributors selling to physicians and nursing homes to have a generic product against these national brands, at a reduced cost – where they could enhance their profitability and pass on their savings to the enduser. Through this vision, Dukal was born. The manufacturer celebrated its 30th anniversary in November 2021. “Our 30th anniversary is a celebration of our journey and a tribute to our employees and valued customers,” LoDuca said. “We understand our success is built upon trusted partnerships and the belief that enhancing family and community health is the way to a better future.” 52

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Dukal’s first distribution center.

Repertoire asked Dukal to share some of the most notable company milestones over the last three decades. They include: ʯ 1991: The early days. LoDuca founded Dukal in 1991. Beginning in LoDuca’s basement, the company started with a single product and the belief that people like to do business with those they know, like, and trust. ʯ 2005: Acquisition of Hermitage Hospital Products. Bringing together the extensive line of wound care, surgical and burn dressings, tapes, and personal protective apparel products, Hermitage Hospital Products expanded Dukal’s ability to serve the entire continuum of care. Acquisitions have not only grown Dukal’s footprint and product portfolio but have also brought new talent and skills to the company.

ʯ 2010: Headquarters moved to Ronkonkoma, New York. From the humble beginnings of founder

Gerry LoDuca’s basement, the headquarters of Dukal has transformed throughout the years. In 1993, Dukal set up shop in a mobile trailer on cinder blocks inside 10,000 square feet rented from a Syosset, New York sterilization company. The company then moved to Hauppauge, New York, and to its current location in 2010, Ronkonkoma, New York, with 15,133 square feet of office space. ʯ 2011: Awarded best companies to work for by the Medical Device and Diagnostic Industry.

Committed to a world where all Dukal team members feel a sense of pride in themselves and their impact on society, Dukal was recognized by Medical Device and Diagnostics Industry (MD+DI) as one of the best companies to work for. ʯ 2012: With the acquisition of Donovan Industries, Dukal adds East Coast and West Coast distribution facilities. With the acquisition of

Donovan Industries, Dukal added a West Coast

distribution center in Riverside, California. With East and West coast distribution centers, and a combined size of 350,000 square feet, all U.S. customers are now within 3 to 5 days of ground transportation, and Dukal’s team can ship orders within 24 hours. ʯ 2015-2016: Dukal’s continued growth through acquisition. Recognizing acquisition as a strong growth strategy, Dukal’s family of brands grew rapidly between 2015 and 2016 with the acquisition of Bioadaptive LLC, Tech-Med, and American White Cross. Further in 2016, Dukal acquired an impregnated dressing line from AlbaHealth, and announced a strategic partnership with Bray Healthcare expanding its product line to include Silver Nitrate Applicators. ʯ 2018: HIDA announces Gerry LoDuca the recipient of the John F. Sasen Leadership Award. In 2018, the Health Industry Distributors Association (HIDA) announced Gerry LoDuca as the 2018 John F. Sasen Leadership Award recipient. The

2019 - First surgical solution from Dukal, the BDC-15.

2018 - Gerry receiving HIDA Award.

Prior to 2010 - Dukal team in front of Happauge Office.

Gerry and members of Dukal leadership.

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January 2022

DISTRIBUTION

2021 - Shanghai team members celebrate Dukal rebrand. Gerry and Ellenmary (Vice President of Business Development) in China.

Gerry LoDuca and Pat Lamb (VP International Operations) in China.

award recognizes exceptional individuals who demonstrate the qualities of leadership, commitment, and service that made John Sasen an icon in the industry. In the same year, Dukal was recognized as one of Long Island’s top workplaces, and again in 2019 and 2020. ʯ 2019: LoDuca inducted into Share Moving Media’s 2019 Medical Distribution Hall of Fame Class.

Each year, Share Moving Media inducts an industry leader into the Medical Distribution Hall of Fame. Those inducted into the Hall of Fame must be truly outstanding individuals who have played a key role in bringing the industry to where it is today. 2019’s theme of entrepreneurship focused on those who have created businesses, grown people, and provided jobs for individuals across the U.S. in healthcare. ʯ 2019: New capabilities in surgical innovation with the launch of the Capseus bone dust collection (BDC-15). Designed to easily provide cost-

effective local autograft generated at the surgical site during spinal fusion surgery, the Capseus BDC-15 reduces hospital costs, time, and infection risk, while providing higher-quality bone. 54

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LoDuca family.

ʯ 2020: Increasing capacity. Dukal’s new distribution center in Savannah, Georgia, increased inbound and outbound capacity by 100%, allowing Dukal to meet the growing needs of healthcare providers. ʯ 2020 – 2021: Pandemic resilience. In response to COVID-19, Dukal along with its trusted partners delivered over 50 million masks to frontline healthcare workers.

2021 and beyond With national healthcare expenditure (NHE) estimated to reach $6.2 trillion by 2028, there are mounting concerns about the country’s ability to provide financially responsible care while attaining acceptable levels of quality, effectiveness, and equity. “As a leader in the development and manufacturing of medical products, Dukal recognizes the tremendous need to play a significant role in using innovation to improve care while lowering the overall costs to our partners,” LoDuca said. “With a new vision of Better Health. Better Future. – we’re leveraging our R&D, manufacturing, and regulatory expertise to bring innovative solutions to the market.”

NEWS

Advancing Access to Diabetes Care Abbott (Abbott Park, IL) and the American Diabetes Association (ADA) announced the launch of their first joint

community health partnership. The community initiative, which is the first program under the ADA’s Health Equity Now platform, will launch in Columbus, Ohio, and be conducted in partnership with the National Center for Urban Solutions (NCUS) (Columbus, OH), an organization focused on providing solutions in workforce development, education and wellness.

The program seeks to better understand and address healthcare disparities for people of color living with diabetes, while fostering accessibility of diabetes care technology within the community. “At Abbott, we believe that the best health care product is the one that helps the most people,” said Badia Boudaiffa, divisional vice president of U.S. commercial operations for Abbott’s diabetes business. “That’s why this partnership is so important – it will improve health outcomes by building access to affordable, integrated diabetes solutions. There is a strong connection between the health of a community and its overall wellbeing.” As part of the program, NCUS will provide up to 150 Black adults living with diabetes in the Columbus community with health education and access to Abbott’s FreeStyle Libre flash glucose monitoring technology. “Engaging the community in prevention programing and health awareness campaigns is key to saving lives while strengthening our communities as a whole,” said John Gregory, president of NCUS. “We look forward to the participation of members of our community to help strengthen the health and wellbeing of Columbus residents.” “Black individuals across Ohio are twice as likely to die from diabetes

compared to non-Hispanic whites,” said Dr. Joshua Joseph, M.D., assistant professor of endocrinology, diabetes and metabolism, The Ohio State University. “New technologies such as continuous glucose monitors make diabetes management easier and lead to better control of glucose and may close the disparities in diabetes mortality. Unfortunately, Black populations have lower access and usage of such devices. Thus, approaches like the ADA’s Health Equity Now, getting continuous glucose monitors to those who need them most, are critical to advancing diabetes equity.” Abbott’s FreeStyle Libre technology was built with access and affordability in mind to make it broadly available to all people with

diabetes. This aligns to Abbott’s 2030 Sustainability Plan, which has a clear focus on innovating for access and affordability with the goal of improving the lives of one in every three people on the planet every year by 2030. “Diabetes is one of the most pressing health issues of our time, particularly for people of color,” said Charles Henderson, chief advocacy officer of the American Diabetes Association. “Our Health Equity Now platform serves to tear down the healthcare barriers for historically underserved communities. The program in Columbus will gather real-time data that will help us understand the challenges preventing healthcare equity and uncover solutions to minimize disparities.” www.repertoiremag.com

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January 2022

NEWS

Industry News Michael Abney to receive HIDA Sasen Leadership Award The Health Industry Distributors Association (HIDA) announced Michael D. Abney Jr., SVP, North America for Quidel Corporation as the recipient of the 2021 John F. Sasen Leadership Award. The Sasen award recognizes individuals who demonstrate exceptional leadership, commitment, and service to the healthcare products distribution industry and HIDA. “As an industry, we thank Mike Abney for his leadership in championing the role of distribution in healthcare,” said HIDA President & CEO Matthew J. Rowan. “Mike worked with John Sasen for many years and that connection makes his receiving this award all the more special.” Abney joined the HIDA Educational Foundation Board of Directors in 2014 and has served as treasurer since 2015. He is a founding member of HIDA’s Healthcare Supply Chain Collaborative Steering Committee. Prior to joining Quidel, he served in executive roles in manufacturing and distribution including VP, Channel and Distribution for ConvaTec and VP Supplier Management at PSS World Medical. He holds a Bachelor’s degree in Finance from the University of Florida. The 2021 John F. Sasen Leadership Award will be presented at the 2021 HIDA and HIDA Educational Foundation joint Board meeting, December 7. 56

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BD acquires Venclose, Inc. to extend treatment innovations in chronic venous disease BD (Becton, Dickinson and Company) (Franklin Lakes, NJ) has acquired Venclose, Inc., a provider of solutions for the treatment of chronic venous insufficiency (CVI) – a disease that is the result of malfunctioning valves and can lead to varicose veins. Venclose is a leader in CVI treatment through its innovative Radio Frequency (RF) ablation technology platform designed for versatility, efficiency and simplicity. RF ablation is the predominant treatment of CVI and has wide acceptance among physicians. The Venclose System is compactly designed and provides two heating length sizes (2.5 cm and 10 cm) in one 6 FR sized catheter. This dynamic dual heating length catheter provides multiple operational benefits to physicians.

Sri Trang USA hires Erica Halligan as Director – Health Systems Sri Trang USA announced it has hired Erica Halligan as Director – Health Systems. Halligan previously was working to prevent contamination of infant nutrition for Ameda, Erica Halligan Inc. as a Capital

& Disposable Consultant, and in CLABSI infection prevention with Becton Dickinson (BD) CareFusion Infusion Disposables as an Account Executive. “We are excited to be working with Ms. Erica Halligan as our newest member of Sri Trang USA, Inc. and will be working in Acute Care Sales as the Director – Health Systems. Erica will be responsible for working with our IDN/GPO customers to extend the value of our infection prevention products to customers across the Acute Care Segment, with current hospital customers while expanding and developing new customers, as well.” said Billy Harris, CEO of Sri Trang USA. Proper hygiene and hand protection are the first line of defense in a variety of different industries, including healthcare, dental, veterinary, food service, and others. Sri Trang makes it easy for providers on the front lines to use hand protection by removing primary challenges that often inhibit proper glove use. Sri Trang’s disposable gloves are comfortable and easily accessible from packaging to foster disciplined habits when using hand protection to prevent larger health issues such as hospital acquired infections (HAI). A full line of disposable nitrile, latex, and vinyl hand protection products will be available by Sri Trang.

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REP January 2022

Articles inside

Industry News

to Diabetes Care

in medical distribution

Health news and notes

of Complex Products

for medical distribution

challenges brought on by the pandemic

Automotive-related news

but the fewest resources

working with local, diverse suppliers

health plans as a way to provide more options, convenience for consumers

public health to put their acts together

with your physician office lab customers

technologies emerge

The Healthcare Rules That Need To Be Broken