vol.27 no.7 • July 2019
Face-to-Face Selling It still counts, especially in an e-commerce world
repertoiremag.com
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SEKISUI DIAGNOSTICS IS YOUR PARTNER IN HEALTHCARE / 800-332-1042 / WWW.SEKISUIDIAGNOSTICS.COM © 2019 Sekisui Diagnostics, LLC. All rights reserved. OSOM® is a registered trademark of Sekisui Diagnostics, LLC. Silaris™ and Because every result matters™ are trademarks of Sekisui Diagnostics, LLC. FastPack® is a registered trademark of Qualigen Inc.
JULY 2019 • VOLUME 27 • ISSUE 7
PUBLISHER’S NOTE Reps Matter More Than Ever..................... 6
PHYSICIAN OFFICE LAB Multiple Choice Which tests your customers should consider, and why..........................................................8
IMCO CONVENTION
22
Face-to-Face Selling
IMCO Convention
Ready, Set, GROW!..................................................... 12
IDN OPPORTUNITIES
It still counts, especially in an e-commerce world
INNOVATION IN HEALTHCARE
Pitt leads creation of global infectious disease data system
47
Voice. Service. Leverage. Thirty-five-year-old RPC upping its game with technology.......................... 18
TRENDS Primary care in CMS’s spotlight Primary Cares Initiative is a further step in physician payment reform..................................... 30
Vaccines: They’re everywhere! That said, the vast majority of immunizations still take place in physician offices..................................... 42
repertoire magazine (ISSN 1520-7587) is published monthly by Share Moving Media, 1735 N. Brown Rd. Ste. 140, Lawrenceville, GA 30043-8153. Copyright 2019 by Share Moving Media. All rights reserved. Subscriptions: $49.00 per year for individuals; issues are sent free of charge to dealer representatives. If you would like to subscribe or notify us of address changes, please contact us at the above numbers or address. POSTMASTER: Send address changes to Repertoire, 1735 N. Brown Rd. Ste. 140, Lawrenceville, GA 30043-8153. Please note: The acceptance of advertising or products mentioned by contributing authors does not constitute endorsement by the publisher. Publisher cannot accept responsibility for the correctness of an opinion expressed by contributing authors. Periodicals Postage Paid at Lawrenceville, GA and at additional mailing offices.
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JULY 2019 • VOLUME 27 • ISSUE 7
HEALTHY REPS
TRENDS Cybersecurity: Under control Contracting professionals seek to shore up defenses against cyber criminals..................... 48
What does real innovation look like? It’s time we examine healthcare innovation from the ground up.................................................................. 54
HIDA INSIGHTS Collaboration: Key to Improving Supply Chain Efficiency............................ 56
INDUSTRY NEWS
Health news and notes
62
News.......................................................................... 66
WINDSHIELD TIME
64 4
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Automotive-related news
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We go together like… You play a vital role in B. Braun Medical’s success. And our success depends on each other. Thank you for supplying the products healthcare professionals critically need and making B. Braun a leading healthcare provider.
B. BRAUN AND YOU
Sales representatives in your area are ready to discuss how to further improve your customer experience.
B. Braun Medical | Bethlehem PA | 1-800-227-2862 | BBraunUSA.com ©2019 B. Braun Medical Inc., Bethlehem PA. All rights reserved.
PUBLISHER’S NOTE
Reps Matter More Than Ever Sometimes, timing is everything. About three weeks ago, I received a long, well writ-
ten e-mail from an individual I will leave unnamed, expressing to me his feelings about Repertoire. He believed we have moved away from our core focus because of the stories we covered, such as current events, IDNs, vendor credentialing, GPOs, and other topics. We do cover those trends because they impact your lives as salespeople in healthcare. We try and do this with each market in mind, including acute care, alternate site, post-acute, and ASC. However, he made the comment that we don’t care about the average rep anymore. That couldn’t be further from the truth. Repertoire was founded on the principle that reps matter, which is the focus of this month’s cover story. I not only took this e-mail serious, I took it personal. The two founders of Repertoire (as well as myself) grew up in this industry and had success on the backs of distribution reps. I’m eternally grateful for the work that you preform day in and day out. Our team spends hours working on topics that we hope inspire you and help you do your job better while improving your career. In the last two months, I’ve done over 50 interviews on tradeshow floors with manufacturers, and the reoccurring theme by all of them was, you matter! When I asked the question: “What is the one thing you need from dealer reps in 2019 to be successful?” manufacturers responded that they need time in the field with reps calling on their accounts. For me, it was nice to hear manufacturers still want to do ride days and work with you. It’s why we do the magazine, to help bring manufacturers closer to distributors. I believe reps matter today more than ever in our industry’s history. Please take the time to read Face-to-Face Selling. This article could not have come at a better time. Even after 25 years, Repertoire magazine still has one goal in every issue, your continued success. Thank you for supporting the magazine and the new podcast “Road Warriors and Their Untold Stories”
Scott Adams
Happy Fourth of July! R. Scott Adams
repertoire is published monthly by Share Moving Media 1735 N. Brown Rd., Suite 140, Lawrenceville, GA 30043 Phone: (800) 536-5312, FAX: (770) 709-5432; e-mail: info@sharemovingmedia; www.sharemovingmedia.com
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Vice President of sales
Katie Educate keducate@sharemovingmedia.com (800) 536.5312 x5271 sales executive - West
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publisher
Scott Adams sadams@ sharemovingmedia.com (800) 536.5312 x5256 founder
Brian Taylor
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2019 editorial board Richard Bigham: IMCO Eddie Dienes: McKesson Medical-Surgical
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Joan Eliasek: McKesson Medical-Surgical
circulation
Doug Harper: NDC Homecare
Ty Ford: Henry Schein
Laura Gantert
Mark Kline: NDC
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Bob Ortiz: Medline Keith Boivin: IMCO Home Care
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PHYSICIAN OFFICE LAB Is lab technique a reason for the lower than expected number of positive flu tests?
Multiple Choice By Jim Poggi
Which tests your customers should consider, and why
According to the Centers for Disease Control and Prevention (CDC) influ-
enza season data from 2017-2018, the positivity rate for flu tests performed in the United States was only 15%. It ranged from a low of 13.4% in one region, to a high of 25.5% in another. These tests were all done on patients with upper respiratory infections, fever and other symptoms classic of influenza. And, due to flu re-classification and introduction of multiple new molecular and reader based flu tests, test methods have never been better. Even with the flip of a coin, you have a 50% chance of being right. From that perspective, being right 15% of the time does not seem to be especially impressive. And, as account managers, we and the suppliers we support invest a lot of time and energy into flu season, from providing vaccines to selling flu and other test kits to supporting and gaining revenue from the far higher customer spend on exam room and hygiene supplies during a more severe season. So, it pays to know what’s going on and to be able to articulate it to our customers in a meaningful way. Since the lab technology behind flu and other respiratory test kits has improved dramatically over the past ten years, and the number of new tests is also growing quickly, we owe it to ourselves and our customers to engage in new thinking and challenge which tests they should consider and why. I’m providing some thoughts for you to consider.
Flu in the broader context Why was the positive flu test rate so low? First of all, we need to remember that flu does not take place in isolation. Typically, many infective agents circulate at the same time flu peaks in the late fall through early spring in the United States. It’s more appropriate to think of this time of year as “upper respiratory disease season”. This change of focus broadens our thinking and allows us to help our customers think in more global terms than just flu, or just flu and strep. There are over 25 different causative agents circulating at the same time as flu, so, in theory at least, the chance of “it being flu” is actually closer to 4%. However, the symptoms of respiratory severity vary, and initial patient presentation does provide some clues whether the disease is flu, strep or another agent.
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While molecular tests are far less susceptible to a poorly performed swab with a low yield of virus or bacteria, a good swab is table stakes for a proper diagnosis. We need to remember that non-molecular lateral flow and reader-based tests still represent over 50% of all flu tests performed in the United States, so a good swab is a critical requirement for a proper result.
How does the number and type of other upper respiratory infection agents influence diagnosis? As reported by the CDC and others, about 98% of all upper respiratory infections are caused by viruses, not bacteria, so correct differential diagnosis is important to patient health, and to prevent unnecessary antibiotic prescriptions and foster better antibiotic stewardship. While there are no CDC surveillance statistics for group A strep infection, avoidance of complications including rheumatic fever, rheumatic heart disease, development of pneumonia and sepsis make an accurate and timely diagnosis critical. CDC provides an excellent resource you may want to share with your key customers when discussing respiratory season and which tests to choose. Their webpage is entitled “Unexplained Respiratory Disease Outbreaks” (URDO) and has a great deal of valuable information including a list of the most common respiratory pathogens and recommended differential diagnosis approaches. The link is: www.cdc.gov/urdo/index.html
A representative sample of some of the more serious causes or upper respiratory infection Causative Agent
Treatment Plan Impact
Possible Outcome Improvements
Group A streptococcus
✔ prescribe antibiotic or not ✔ isolate patient
• Prevent rheumatic fever and complications •U ntreated may lead to sepsis
Influenza
✔ prescribe antivirals ✔ other supportive treatment ✔isolate patient ✔ immunization opportunity
• S horten duration of disease •P revent complications such as pneumonia
Respiratory Syncytial Virus
✔ fluids and supportive treatment
Bordetella pertussis
✔ supportive treatment ✔ immunization opportunity
Mycoplasma pneumoniae
✔ supportive treatment
•A void development of “walking pneumonia” or arthritis
Adenovirus
✔supportive treatment ✔ antiviral in rare instances for immunocompromised patients
• S upportive treatment only
Coronavirus
✔ supportive treatment
• S upportive treatment only
Parainfluenza viruses
✔ supportive treatment
• S upportive treatment only
Human metapneumovirus
✔ supportive treatment
• S upportive treatment only
Rhinovirus
✔ supportive treatment
• S upportive treatment only
How does “provide point of care testing if the result can lead to initiation or modification of a treatment plan” fit with the wide range of possible infectious agents? There are different schools of thought around screening for a large number of possible causes of respiratory illness. For most point-of-care tests, I advocate testing based on whether a treatment plan can be initiated or modified based on the result. For respiratory tests in otherwise healthy adults, which excludes people with compromised immune systems, COPD sufferers and those with significant co-morbidities, I believe testing for most of the organisms for which there is no established treatment beyond “supportive treatment” involving fluids, management of aches and fever by
•P revent serious complications especially in younger children •A void development of pneumonia
over the counter medications has limited value. Most of these illnesses are self-limiting and tend not to result in more serious complications in healthy adults. The other school of thought would advance the argument that “ruling out” specific sources of infection has diagnostic value. Time and the advancement of testing and treatment methods will determine which approach is right. Ultimately, the decision of where to draw the line rests with your customer. What approach should you consider in consulting with your customers? Ask to learn, as always. Find out their view and suggest appropriate solutions in collaboration with your most trusted suppliers to meet the diagnostic and patient care need.
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Sofia 2 Lyme FIA: CLIA-waived Results in minutes, not days. Diagnosing Lyme disease is hard. Symptoms are broad and generic, mimicking many other conditions. Patients feel horrible and want answers. It doesn’t help that current testing methods may take hours or days for results. Not anymore! Sofia 2 Lyme FIA uses a fingerstick whole blood sample to provide accurate, objective and automated results in as few as 3 minutes, getting doctor and patient on a path to treatment much sooner. Sofia 2 Lyme FIA is the only rapid, near-patient testing solution that provides IgM and IgG differentiated results in a single test. It has demonstrated accuracy on par with current testing methods — all with less than 1 minute hands-on-time. And as you’ve come to expect from Sofia 2, our Lyme assay functions in WALK AWAY and READ NOW modes, providing flexible workflow options based on your needs.
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IMCO CONVENTION
IMCO Convention Ready, Set, GROW!
IMCO and its members are focused on growth. Hence
the theme of its recent national convention in Orlando, Florida: Ready, Set, GROW! With nearly 500 attendees, over 80% of IMCO members were represented. The trade show had 102 vendor booths. “IMCO believes that the independent medical distributor is a vital link in the healthcare supply chain, and we are committed to their success,” said President Bill McLaughlin. “With that idea in mind, we provided the setting for our members to GROW their businesses through
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education, roundtable discussions and idea-sharing while bettering themselves personally in the process. “There is so much power in connecting and collaborating with fellow members and vendor partners who understand the opportunities and challenges as well as have a desire to learn new ways to compete in our ever-evolving industry.” Daytona Beach, Florida-based IMCO added 10 new member distributors since the 2018 Convention, and surpassed $4.2 billion in sales in 2018, said McLaughlin. “Based on Q1 of 2019, we are on track to exceed this number again.”
Initiatives and programs IMCO highlighted several new projects at the Convention, including: a new e-commerce platform, and the Fulfillment by IMCO (FBI) program. The e-commerce platform provides members access to a database of products built into an e-commerce website that can connect with their ERP and financial software programs. Each member’s website can be tailored to fit the specific needs of the member. Fulfillment by IMCO (FBI) provides the opportunity for members to order small quantities of product to be delivered either directly to the member or their customer, said McLaughlin. “The program is in its early stages but provides the opportunity for members to be as efficient and competitive as possible, as shipping charges continue to increase.” Other initiatives addressed at the Convention included: • T he Equipment Performance Incentive Contest (EPIC), which generated over $6 million in sales and 3,000 pieces of equipment sold with eight supporting vendors. • T he Member Incentive Program, which saw over 95% of members earn incentives in 2018. “Many members saw record earnings from the programs and are on track to surpass that in 2019,” said McLaughlin.
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IMCO CONVENTION • T he IMCO Saving Center business resource program, which continues to build its portfolio and provide savings on everyday business, operational and personal expenses for members, their employees and customers. • IMCO’s distance learning program, Pathway to Profit, which offers 30-minute webinars that provide information and discussion of key questions. The webinars are hosted every other Wednesday at noon EST. • IMCO Home Care (IHC), which continues to grow and provide IMCO members opportunities to expand into this growth market. IHC added Lee Wheatley as membership coordinator and Lisa Cope as the key customer service representative. IMCO also announced it will release a best practices guide for hiring and onboarding new sales reps. The organization also named Anthony Battaglia from Pocket Nurse as its newest board member.
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IT’S NOT TOO EARLY TO TEST FOR HEART DISEASE. PEDIATRIC LIPID TESTING IS ON THE RISE The epidemic of childhood obesity continues to grow. But with the identification of early indicators of high cholesterol, clinicians can help fight the epidemic by conducting more lipid testing.1 The Alere Cholestech LDX® System offers exactly what your pediatric customers need. nn
Complete lipid panel for fasting patients
nn
TC/HDL panel for non-fasting patients
nn
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CONTACT YOUR ABBOTT REPRESENTATIVE TO LEARN MORE. 1. Expert Panel on Integrated Guidelines for Cardiovascular Health and Risk Reduction in Children and Adolescents: Summary Report. Pediatrics 2011;129(suppl 5):S1-S44. pediatrics.aappublications.org/content/128/Supplement_5/S213.full © 2019. All rights reserved. Cholestech LDX is a trademark of the Abbott group of companies. Any photos displayed are for illustrative purposes only. Any person depicted in such photos is a model. CVD248209 10004984-01 06/19
IMCO CONVENTION Other highlights The Convention began with 10-minute talks on key topics by five experts: • “ How to be Effective and Produce Results,” Eric Papp of Productivity at Work. • “What’s So Big About Small,” Elizabeth Hilla of HIDA. • “ How to be a Great Boss Without Being a Jerk,” Chris White of Traction Florida. • “ Building Your Professional Brand,” Heather Llorca-Kropp of DUKAL Corporation. • “ It’s About Connection, Not Perfection,” JD Clockadale of Speechworks. Each of these short sessions set the stage for the educational sessions that followed, said McLaughlin. “With many of these breakout sessions at capacity, every member in attendance gained valuable information to apply to their businesses and are ready to continue to Grow!” This year’s keynote speaker was artist Phil Hansen, who discussed how to “Embrace the Shake” by not limiting
oneself, and by teaching oneself to rise above any challenge through creativity and innovation. The Tuesday evening event – the IMCO Barn Party – featured entertainment from Kaleb Lee and Prior Baird of NBC’s The Voice, who performed original songs as well as timeless favorites. IMCO’s 2020 Annual Convention will take place April 26-29 in Orlando, Florida.
IMCO award-winners IMCO Exclusive – SEL Scholarship. (All-expense-paid trips to the Convention, awarded to people who stand out for their support of IMCO programs and vendors, as nominated by vendors and members.) • David Wilson, Atlantic Medical Solutions • Gloriana Feddema, Canada Medical • Jodi Silverman, Cornell Surgical • Jason Taboh, Omni Medical Supply • Austin Marcus, Supreme Medical Fulfillment EPIC (Equipment Performance Incentive Contest), whose winners received $27,000 in travel vouchers. • Brian Hodgson, Omni Medical Supply • Angi Reed, Booth Medical • David Gordon, Unimed (USA) Ltd.
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• Sanjay Shah, Alpha Medthrift Scientific Co. •P am Gall, Foremost Medical Equipment, A Cignet Company • Victor Amat, American Medical Supplies & Equipment • Larry Wenthe, Shared Service Systems • David Ellis, Atlantic Medical Solutions • Shawna Briscoe, Canada Medical Ltd. • Gerry Volponi, Canada Medical Ltd. IMCO 2018 Vendor of the Year: • Dynarex Other finalists for Vendor of the Year: • DUKAL Corp. • Innovative Healthcare (IHC) • Optimal Healthcare • Tuttnauer
NEW PAMA CPT codes now available in the app
Pama updated CPT codes 2018 Infectious Disease Tests Test - Panels Basic Metabolic Panel (9 tests) Comprehensive Metabolic Panel (17 tests) Electrolyte Panel (4 tests) Hepatic Function Panel (10 tests) Lipid Panel (6 tests) Renal Function Panel (12)
CPT 80048/QW 80053/QW 80051/QW 80076 80061/QW 80069/QW
2017 Fee $11.60 $14.49 $9.62 $11.21 $18.37 $11.91
2018 Fee $10.44 $13.04 $8.66 $10.09 $16.53 $10.72
Change -10% -10% -10% -10% -10% -10%
Cardiac/Liver/Other Tests Albumin (Serum) Albumin (Urine) ALP ALT Aspirin Therapy AST Bilirubin, direct Bilirubin, total BNP CK,MB CK/CPK GGT LD Microalbumin (Quantitative) Microalbumin (Semi-quantitative) Total Protein Troponin I
82040/QW 82042/QW 84075/QW 84460/QW 85576/QW 84450/QW 82248 82247/QW 83880/QW 82553 82550/QW 82977/QW 83615 82043/QW 82044/QW 84155/QW 84484/QW
$6.79 $7.10 $7.10 $7.27 $29.47 $7.10 $6.88 $6.88 $46.56 $15.84 $8.93 $9.88 $8.28 $7.93 $6.28 $5.03 $13.50
$6.11 $7.78 $6.39 $6.54 $26.52 $6.39 $6.19 $6.19 $41.90 $14.26 $8.04 $8.89 $7.45 $7.14 $6.23 $4.53 $12.47
-10% 10% -10% -10% -10% -10% -10% -10% -10% -10% -10% -10% -10% -10% -1% -10% -8%
Lipid Tests HDL LDL Lp(a) Apolipoprotein Total Cholesterol Triglycerides
83718/QW 83721/QW 82172 82465/QW 84478/QW
$11.24 $13.09 $21.26 $5.97 $7.88
$10.12 $11.78 $21.09 $5.37 $7.09
-10% -10% -1% -10% -10%
Diabetes Tests Fructosamine Glucose on home use meter-type device Glucose Tolerance Test, each additional specimen > 3 Glucose Tolerance Test, initial 3 specimens Glucose, quantitative blood type Hemoglobin A1c
82985/QW 82962 82952/QW 82951/QW 82947/QW 83036/QW
$20.68 $3.21 $5.38 $17.66 $5.39 $13.32
$18.61 $3.28 $4.84 $15.89 $4.85 $11.99
-10% 2% -10% -10% -10% -10%
Renal Function Tests BUN Creatinine Creatinine (Urine)
84520/QW 82565/QW 82570/QW
$5.42 $7.03 $7.10
$4.88 $6.33 $6.39
-10% -10% -10%
Individual Tests Amylase Calcium Ferritin Iron
82150/QW 82310/QW 82728 83540
$8.89 $7.08 $18.70 $8.88
$8.00 $6.37 $16.83 $7.99
-10% -10% -10% -10%
Find the new codes in The Black Book
Other tools available for distributors are: vol.26 no.1 • January 2018
repertoiremag.com
January 2018
2 Minute Drill Videos
Podcasts
PAMA: The Stage is Set — How will the new rates impact providers, distributors and manufacturers?
PAMA: Jim Poggi, Tested Insights, LLC
The Stage is Set
How will the new rates impact providers, distributors and manufacturers?
IDN OPPORTUNITIES
Voice. Service. Leverage. Thirty-five-year-old RPC upping its game with technology Yankee Alliance has been identifying opportunities
for savings and high-quality care on behalf of its members since 1984. But the Andover, Massachusetts-based GPO does more than identify opportunities. It helps its members realize them, that is, make them happen. Yankee Alliance comprises more than 16,000 members in 50 states. The majority of its acute care members are in the Northeast, while its non-acute members can be found throughout the country. As a Premier owner, Yankee Alliance offers its members access to Premier national contracts. But it also offers its members Yankee aggregations, as well as a portfolio of committed contracts and Yankee-exclusive agreements, says Amy Campbell, chief administrative officer. “Yankee negotiates with vendors to offer our members enhanced pricing based on our aggregated volume, which is currently over $4 billion annually,” Amy Campbell she says. “We also negotiate other
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value-adds as part of our aggregations, such as rebates and clinical education.” Recently Yankee delivered to its members a $1.1 million savings opportunity and a growth rebate program for disposable non-sterile protective apparel.
Making contracts work Yankee earns pricing concessions thanks to the resources it devotes to contract implementation. “We know our members very well; we’re close to them,” says Campbell. Yankee clinicians sit on members’ value analysis committees to help weigh the merit of potential contracts and product utilization opportunities. Clinicians guide members through the implementation process. Yankee’s committed contracting program continues to respond to industry changes, says Campbell. “Yankee Alliance recognizes that in order to drive best-in-market price, moving market share and member contract commitment are key. We continue to evaluate opportunities and welcome open discussions with suppliers that can offer additional value through price and other offerings.” One example is a pharmacy wholesaler agreement, which was signed in 2017.
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IDN OPPORTUNITIES Yankee also negotiates contracts exclusively for Yankee members. Many of these contracts are regional in nature. For example, the GPO has purchased-services contracts to address members’ needs in staffing, plumbing, energy, IT consulting and other areas. “Members are at the center of all we do,” says Campbell. The Partners Advisory Committee (PAC) is Yankee’s strategic committee and consists of supply chain representatives from the five largest Yankee owner/members. A number of sub-committees (e.g., lab, IT, pharmacy, foodservice, biomedical, nursing, and OR) provide feedback and support in the contract decision-making process.
“Upping our technology game is really important.” – Amy Campbell, chief administrative officer.
“The PAC sets the tone of cooperation for the membership by ensuring the members are treated equally, and it serves as the voice of the larger group,” says Campbell. “It provides oversight of Yankee initiatives and provides input into the GPO’s strategic planning and direction,” she continues.
Technology For some time, that strategic direction has led Yankee to be a source of actionable business intelligence for its members. “Upping our technology game is really important,” says Campbell. Yankee’s SUITEview family of offerings includes: • S UPPLYview, which focuses on contracting utilization, price benchmarking, conversions and standardization. •C LINICALview, which focuses on clinical utilization and value analysis. • S ERVICEview, which focuses on purchasedservices contract analysis, benchmarking and best practices. • PHARMACYview, which focuses on pharmacy utilization, cost impact and clinical implications of a particular drug or therapeutic class. “Yankee Alliance members have a support team comprised of dedicated resources, contracting, analytics,
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and clinical subject matter experts that maximizes the value of the contract portfolio and uncovers hidden savings opportunities,” says Campbell. “These are provided through a service bureau model, where Yankee proactively runs member data on a monthly basis to highlight opportunities and pushes this information out to the membership.” Yankee Alliance’s Member Services and Clinical teams assist with implementation. In addition, Yankee Alliance uses Blue.Point (www. bluepointscs.com) to give health systems visibility into the products they use on their patients, and how they use them. It can help members (and non-Yankee subscribers) answer such questions as: • “How do my hospital’s product usage and clinical practices compare to other hospitals?” • “What are the industry-accepted best practices and how do my hospital’s practices compare?” • “How do we generate a pipeline of savings opportunities for our value analysis teams to work on?” • “What is the step-by-step roadmap to implementing change?” • “How do I track implementation progress over the short term and long term?” In March 2018, Cathy Spinney – who has been with Yankee Alliance for 28 years – was named president and CEO. Under her leadership, Yankee Alliance continues to transform its technology platform and invest in the human resources required to assist its members implementing savings opportunities. Says Campbell, the differentiators for Yankee Alliance are – and will continue to be – the following: •V oice. “As a member-owned organization, our members are at the center of everything we do and drive strategic decisions through our Board of Managers, Partners Advisory Committee and our departmental committees.” • Service. “Providing members with inside account support, field resources, specialists (such as clinicians and pharmacists) and an analytical support team to turn data into actionable information to implement savings.” • Leverage. “Combined volume of over $4 billion, working together as an Alliance.”
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Usage matters Clinical product utilization allows hospitals to see the full picture of how products affect patient care and outcomes, as well as how various features of products can increase the cost of care without providing evidence-based value, says Amy Campbell, chief administrative officer, Yankee Alliance. Here are two examples. •P atient cleansing. A provider uses benchmarking to get the best price for pre-packaged bathing products. However, based on clinical product utilization and peer benchmarking, the provider finds it is using a pre-packaged bath two to three times more often than other facilities around the country. By categorizing products the way they are clinically used, the provider views other options for patient cleansing, as well as how cleansing practices vary within the hospital, across the health system, and across the country. The provider also applies best-practices research to guide
nursing practice to prevent hospital-acquired infections and maintain skin integrity while using the most cost-effective method for the patient. • External patient warming (i.e., forced-air warming products for the OR). A provider gets the best price for warming products, but benchmarking shows that caregivers are using two products per patient when guidelines state that warming products are not needed for every procedure. Further, forced-air gowns often get in the way during surgery and are discarded, because the patient needs a new one in the postop phase. Using Blue.Point, the provider sees how the increased usage and product mix affect total cost of care. Using peer benchmarking and clinical evidence, the provider gains insight into alternative practices and data-driven practice for cost savings and improved outcomes.
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Face-to-Face Selling It still counts, especially in an e-commerce world
W
hy is it that, 20 or 25 years after the introduction of e-commerce, successful sales reps still spend so much time out of their offices for face time with existing and potential customers? And why do so many manufacturer reps continue to seek ride-days with their distributor counterparts? First of all, it works. “There is a lot of information that can be obtained on websites and business done via phone or email,” says Jim Macholz, president, Atlantic Medical Solutions, Charlotte, North Carolina. “However, in-person calls on a medical office are extremely valuable. A face-to-face call really helps enhance the relationship. Some might call that ‘old-fashioned’ type of selling, but we find it very effective.” Second, it’s what providers want. “Customers expect reps to be knowledgeable and to bring them value,” says Macholz. “The day of the ‘milk run’ type of sales calls is gone. I don’t think customers need a rep to pick up orders as much as they look to reps for information and new ideas in the industry. They look to our reps to bring ideas to help generate additional revenues to their practices.” And third, it’s what manufacturers want. “Everybody is trying to figure out how they can incrementally grow their business and achieve their sales goals,” says Steve Martin, senior vice president of supplier management for NDC. “Manufacturers’ expectations of distribution have always been around the question, ‘How can you help me grow vs. share shift?’ They really want to figure out how the distributor can help them grow their
business. If they come out with a new product or technology and there’s value for healthcare providers, they expect distributors’ field salespeople to help entrée that product into accounts and communicate the value proposition of that new technology.” What’s more, says Martin, manufacturers rely on distributors and their field reps for increased efficiencies. “Manufacturers are relying on distributors to be their goto-market channel for growth and efficiency in their operations,” he says. “They often lack the ability to service all their customers, particularly in the non-acute market.”
Ask a customer, ‘How do you want me to work with you?’ and they’ll often say, ‘I never want to see you. Just email me.’ But if you do that, you can make yourself obsolete quickly. Balance: An art form Atlantic Medical Solutions continues to add field reps to its team. “We are always looking for good, qualified field sales reps,” says Macholz. “It’s a difficult job, being on the front line in a sales position, and we have a lot of talented people on our team. We have both outside and inside sales reps, and they all do an outstanding job.” Face-to-face visits are an essential part of that job, he says. “We are a regional distributor. We’re not small, but we’re not one of the nationals. We can’t afford to sit
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Face-to-Face Selling back, because we’re not necessarily going to be on the big group contracts. We won’t have orders pushed our way. That’s why the sales rep is integral to what we do. And that’s why I tell [prospective reps], ‘If you are not comfortable with a face-to-face, it’s going to be a tough road.” That’s not to say that every customer wants a regularly scheduled in-person visit from their distributor rep, he says. But reps won’t know how to interact with their customers until they ask each one. That said, they should be wary of the answer. “Ask a customer, ‘How do you want me to work with you?’ and they’ll often say, ‘I never want to see you. Just email me,’” says Macholz. “But if you do that, you can make yourself obsolete quickly.”
weren’t just order-takers, but people who were making outbound, proactive sales calls.” Since the early 2000s, the Internet – and e-commerce – have gained prominence. Consequently, go-to-market strategies aren’t as simple as they were 25 years ago, says Martin. Nevertheless, field reps remain an important component of most of those strategies. As efficient as e-commerce can be, the fact is, busy healthcare providers don’t always have time or energy to stop what they’re doing, log onto a website, and begin a search for new technologies, says Martin. Nor are they well-suited to handle the complexities of returns. A valued rep, however, has a history with the customer, knows what he or she has purchased in the past, and often can anticipate what he or she wants or needs. “A rep can shorten the order cycle for the customer, who is typically not a professional buyer, and take away the burden of creating and placing orders.” Perhaps even more important, a field rep can present opportunities for customers to improve their practice or healthcare facility, he continues. Those opportunities can come in the form of equipment, devices or business practices that can lead to improved patient care and outcomes. “E-commerce is great when you know exactly what you want,” says Martin. “But not if you don’t.” Smaller or new manufacturers that lack name recognition among providers find it difficult to break into the market with an e-commerce-only strategy, he continues. And without support from distributor salespeople, neither big nor small manufacturers can grow market share or service accounts in a very fragmented market. Successful distributors employ multiple go-to-market strategies, says Martin. NDC has done the same, using inside sales reps, field reps and e-commerce to deliver what their distribution customers expect. “They don’t always need a live body to show up,” he says. “What they need are solutions to their problems, and answers to their questions.”
Customers don’t always need a live body to show up. What they need are solutions to their problems, and answers to their questions. In fact, many customers do want to see their reps face to face, says Macholz. Many depend on reps to introduce them to new, exciting technologies. But at the same time, they demand rapid responses to their questions, and that calls for text and email messaging. “It calls for balance,” says Macholz. “It’s an art form.”
What manufacturers want And manufacturers? What do they want from their distribution counterparts? Steve Martin began his medical sales career in 1992 for a manufacturer (Kodak), but has been working in distribution for the past 25 years, including more than 17 years in vendor relations – first with PSS, and, since 2014, NDC. “When I started in the industry, the typical go-to-market strategy for many manufacturers was a heavy reliance on distributor field reps, well supported by outside manufacturer field reps,” he says. The 1990s saw the growth and development of telesales among distributors. “These
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Face-to-Face Selling Solving pain points For 15 years, Mark Kline worked for Invacare, first as vice president of national accounts and international accounts, and later, as vice president of homecare and long-term care. In 2016, he joined NDC where, as chief commercial officer, he leads the sales department and oversees all sales-related activities. Repertoire asked Kline for his perspective on manufacturer/distributor relationships, particularly the role of the distributor field rep. Kline: Many manufacturers have reduced their field sales teams, putting more responsibility into the hands of med/surg distributor field reps. There is the expectation that field-based sales teams remain important, but technology has also enabled new ways to connect with the customer. For example, NDC has realized positive results by establishing an inside sales team to supplement existing relationships
Mark Kline
Repertoire: Since 2000, have manufacturers changed their expectations of med/surg distributors in light of the rise of e-commerce? Mark Kline: Manufacturers have come to expect that distributors will provide effective downstream communication to the end-user about their product line, using resources and information provided by the manufacturer or available on their website, etc. They also expect distributors to be flexible and agile, which is what it takes to succeed in the fast-moving marketplace. Distributors are expected to be knowledgeable about the channels they can sell product into and the compliance factors for specific products, and they are also expected to adhere to Minimum Advertised Price (MAP) programs. Repertoire: In the past 20 years or so, have manufacturers changed their expectations of distributor field reps?
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Repertoire: How have successful distributors made the changes that manufacturers are asking for? Kline: Distributors who have embraced technology to expand their online services and capabilities have been the most successful at making the changes manufacturers are looking for. Repertoire: Without using the word “relationship,” how would you describe the advantage that distributor field reps bring to the table (versus e-commerce sites) for customers and/ or for medical manufacturers? Kline: Distributor field reps can provide value by applying specific selling techniques, such as: • Teaching unique insights that are tailored to the customer’s needs. • Sharing their in-depth knowledge of products and the industry. • Seeking out opportunities in an assertive and authoritative way. • Anticipating the customer’s needs and proactively providing solutions. • Offering new, innovative solutions to solve customer pain points.
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What makes this line of column scales so unique? Designed to meet the requirements of both primary care and acute care markets, the seca 777/787/797 offer the perfect combination of precision, durability, and future-proof technology—all at great margins for the dealer and competitive price points for the customer. Jeff Mayes, Executive Vice President of seca North America stated, “With the seca 777 we wanted to ensure that no compromises had to be made when it came to a precise and a cost-efficient scale. When designing the product line we knew that we had to provide the North American market with enhanced features that satisfy the clinical demands in today’s modern healthcare environment, all the while making it appealing and profitable for the distributor to sell. This line of column scales does exactly that by giving healthcare professionals three variations to choose from based on their specific needs.”
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TRENDS
Primary care in CMS’s spotlight Primary Cares Initiative is a further step in physician payment reform Primary care physicians are cautiously optimistic
about a new primary-care payment program unveiled in April by the Centers for Medicare & Medicaid Services. The new model – Primary Cares Initiative – is intended to build on CMS’ prior programs to reimburse primary care physicians on the basis of health and outcomes rather than on a per-procedure basis. “APC members have expressed a lot of interest and desire to participate in these types of innovative new payment models that reward clinicians for keeping patients healthy,” says Robert McLean, M.D., FACP, president of the American College of Physicians, a specialty organization for internal medicine physicians. “Up until now, one of the main criticisms we’ve heard and one that we’ve repeatedly relayed to CMS is that we need more [alternative payment models]. So, at a high level, we’re certainly excited to see the CMS Innovation Center start to come
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out with new models, and hope that is just the tip of the iceberg and we have more coming.” The CMS Primary Cares Initiative will provide primary care practices with five new payment model options under two paths: Primary Care First (PCF) and Direct Contracting (DC). The five options are: 1. Primary Care First (PCF) 2. Primary Care First – High Need Populations 3. Direct Contracting – Global 4. Direct Contracting – Professional 5. Direct Contracting – Geographic
Primary Care First The Primary Care First model will be tested for five years and is scheduled to begin in January 2020. (A second application round is planned for participants
starting in January 2021.) Eligible practitioners are those in internal medicine, general medicine, geriatric medicine, family medicine, and/or hospice and palliative medicine. CMS says it will encourage other payers – including Medicare Advantage Plans, commercial health insurers, Medicaid managed care plans, and State Medicaid agencies – to align payment, quality measurement, and data sharing with CMS in support of Primary Care First practices. Both paths under PCF are intended to incentivize providers to reduce hospital utilization and total cost of care by potentially rewarding them through performance-based payment adjustments, says CMS. These models seek to improve quality of care, specifically patients’ experiences of care and key outcomes-based clinical quality measures, which may include controlling high blood pressure, managing diabetes mellitus, and screening for colorectal cancer. PCF payment model options “will test whether financial risk and performance-based payments that reward primary care practitioners and other clinicians for easily understood, actionable outcomes will reduce total Medicare expenditures, preserve or enhance quality of care, and improve patient health outcomes,” said CMS in a statement. PCF will provide payment to practices through a total monthly payment. It will also include a payment model option that provides higher payments to practices that specialize in care for high-need patients, including those with complex, chronic needs and seriously ill populations.
that allows beneficiaries to align with the healthcare provider of their choosing. Depending on the DC payment option in which an organization is participating, the model participant will receive a fixed monthly payment that can range from a portion of anticipated primary care costs to the total cost of care. Participants in the global payment model option will ultimately bear full financial risk, while those in the professional payment model option will share risk with CMS.
“ These models will test out paying for health and outcomes rather than procedures on a much larger scale than ever before.” –Alex Azar
Direct Contracting option While the two PCF models are focused on individual primary care practice sites, the three Direct Contracting payment model options aim to engage organizations that have experience taking on financial risk and serving larger patient populations, such as accountable care organizations, Medicare Advantage plans, and Medicaid managed care organizations, according to CMS. The DC options are designed to financially reward organizations that offer greater efficiencies and better quality of care, the agency says. The options include a focus on care for patients with complex, chronic needs and seriously ill populations, as well as a voluntary option
CMS anticipates these five payment model options administered under the Primary Cares Initiative will: •P rovide better alignment for over 25 percent of all Medicare fee-for-service beneficiaries. More than 11 million Medicare beneficiaries would potentially be included (5 million beneficiaries in the DC payment model options and 6.4 million in PCF payment model options). •O ffer new participation and payment options for an estimated one in four primary care practitioners as well as other healthcare providers. • Create new coordinated care opportunities for a large portion of the 11-12 million beneficiaries dually eligible for Medicare and Medicaid, specifically those in Medicaid managed care and Medicare fee-for-service.
Builds on CPC+ Primary Care First borrows underlying principles from the Comprehensive Primary Care Plus (CPC+) model, which was introduced in January 2017, says CMS: • Prioritizing the doctor-patient relationship • Enhancing care for patients with complex chronic needs and high need, seriously ill patients • Reducing administrative burden • Focusing financial rewards on improved health outcomes
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TRENDS More than 2,900 primary care practices and 56 aligned payers participate in CPC+ in 18 regions: Arkansas, Colorado, Hawaii, Greater Kansas City Region of Kansas and Missouri, Louisiana, Michigan, Montana, Nebraska, North Dakota, Greater Buffalo Region of New York, North Hudson-Capital Region of New York, New Jersey, Ohio and Northern Kentucky Region, Oklahoma, Oregon, Greater Philadelphia Region of Pennsylvania, Rhode Island, and Tennessee.
Twenty-six regions for new program
What’s next? “For years, policymakers have talked about building an American healthcare system that focuses on primary care, pays for value, and places the patient at the center,” said Health and Human Services Secretary Alex Azar, when the Primary Cares Initiative was unveiled in April. “These new models represent the biggest step ever taken toward that vision. “Building on the experience of previous models and ideas of past administrations, these models will test out paying for health and outcomes rather than procedures on a much larger scale than ever before.” CMS is seeking public comment on one DC payment model – the Geographic Population-Based option – with an expected launch in January 2021. The option is designed to offer organizations the opportunity to assume responsibility for the total cost of care and health needs of a population in a defined target region. Driving accountability to a local level empowers communities to devise strategies best designed to meet their health care needs, according to CMS.
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Primary Care First model options will be offered in 26 regions for a 2020 start date: • • • • • • • • • • • • •
Alaska (statewide) Arkansas (statewide) California (statewide) Colorado (statewide) Delaware (statewide) Florida (statewide) Greater Buffalo region (New York) Greater Kansas City region (Kansas and Missouri) Greater Philadelphia region (Pennsylvania) Hawaii (statewide) Louisiana (statewide) Maine (statewide) Massachusetts (statewide)
• • • • • • • •
• • • • •
Michigan (statewide) Montana (statewide) Nebraska (statewide) New Hampshire (statewide) New Jersey (statewide) North Dakota (statewide) North Hudson-Capital region (New York) Ohio and Northern Kentucky region (statewide in Ohio and partial state in Kentucky) Oklahoma (statewide) Oregon (statewide) Rhode Island (statewide) Tennessee (statewide) and Virginia (statewide)
TRENDS
An internists’ view of new payment model Editor’s note: Robert McLean, MD, FACP, president of the American College of Physicians, says ACP is enthusiastic about the Primary Cares Initiative from CMS, but that the organization is reserving judgment until it can see more details. His comments to Repertoire have been lightly edited for brevity. Repertoire: In announcing the Primary Cares Initiative, CMS refers to lessons learned from and experiences of the previous models, (presumably, CPC, CPC+). From the American College of Physicians’ perspective, what are some of those “lessons learned?” Robert McLean: The first CPC+ comprehensive annual report (based on 2017 performance) came out around the same time the Primary Care First model was announced. According to the report, there were “few” and “small” differences in service use and quality outcomes. The report itself notes that with any model, downstream outcomes and spending changes take time to realize, so it’s not surprising that the results were modest in the very first performance Robert McLean year of the model. ACP remains supportive of this model and the positive changes that investments in enhanced primary services and other advanced patient care can have on downstream health outcomes and costs. That said, with any alternative payment model, getting the details right – from setting financial benchmarks, to risk adjusting, to attributing patients – is what matters. ACP is still waiting on a lot of those details and we look forward to evaluating them. Repertoire: In what ways do you expect the Primary Cares Initiative to take ACP members (as well as payers and patients) beyond the Comprehensive Primary Care Plus program?
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McLean: The separate track for clinically complex and/or high-risk patients could be an important addition that doesn’t exist in CPC+. As CMS points out, these types of patients absorb a disproportionate proportion of practice resources and finances, so targeting these particularly vulnerable patient populations is really important when we discuss ways to improve value. From the quality measure side, CMS can stand to improve the validity, accuracy, and clinical relevance of the individual quality and outcomes measures it uses – something ACP has repeatedly called for. CMS notes more generally that the new models will focus on relevant, actionable and outcomesfocused measures. We hope they will, but it’s hard to tell if measures really meet the mark until we actually see them. There is a real risk of patients experiencing poor outcomes and even harm if they are making decisions based on potentially flawed or unclear information. Additionally, patient participation in such programs should be voluntary, and participants should not have financial penalties imposed simply for failing to achieve health goals and outcomes. ACP has repeatedly argued that if CMS wants clinicians to participate in these models, they need to make a compelling value proposition, particularly when we’re talking about higher risk models. The type of asymmetric reward-torisk that we see in the Primary Care First model
seems like a promising way to go about that, but we need a more complete picture of the payment amounts before we can make that assessment. Harold Miller [president and CEO of the Center for Healthcare Quality and Payment Reform] recently raised some red flags that the level of reimbursement for these models might actually come in below previous models for the vast majority of participants, which is obviously a concern. The 50% sharing rate is only useful if participants are actually achieving it, and that all comes down to the benchmark. It is premature to say whether in fact these models make a compelling value proposition until we have that type of information. CMS has said it is considering beneficiary incentives for Primary Care First, which were not a piece of CPC+. ACP feels that engaging the patient in his/her own care is critical when talking about value and improving outcomes. Incorporating some type of beneficiary incentives could be another powerful way to make any [alternative payment model] more effective. Of course, with any patient incentives, it is important that patient choice is not restricted. Certainly we hope patients can benefit from positive incentives to align with the model … such as additional services and better care or increased access … that they would not otherwise have through traditional Medicare. But it is important that these models do not swing the pendulum the other way and design payment or coverage structures in a way that restricts patient access to certain clinicians or treatment options. Repertoire: CMS has said the Primary Cares Initiative will “test out paying for health and outcomes rather than procedures on a much larger scale than ever before.” Do you expect that to be the case? Why or why not? McLean: Primary Care First has 26 regions versus 18 for CPC+. That alone would hopefully mean wider participation, but of course it will
depend on the level of uptake. We will need more information on the payment methodology, attribution, and other core elements of the model before we can have a full sense of how attractive this model will be to potential participants. As with the existing CPC+ model, we’d like to see models generally available on a national scale to promote innovation and better patient care in all areas of the country. Another important element of this question is control groups. ACP understands the importance of being able to evaluate the effectiveness of a program where Medicare dollars are at stake. However, we urge the Innovation Center to consider options other than the way they approached it for CPC+, which unnecessarily restricts participation by sorting willing participants into a control group and depriving them, and more importantly their patient populations, from participating in and benefiting from the program. Repertoire: CMS says that Primary Care First “seeks to improve quality of care, specifically patients’ experiences of care and key outcome-based clinical quality measures, which may include controlling high blood pressure, managing diabetes mellitus and screening for colon cancer.” Given all the quality benchmarking programs that already exist, does ACP consider Primary Care First to be a new way to improve quality of care? McLean: Improving patient outcomes through reporting meaningful quality metrics is not a new concept, but ACP believes it is important to keep in mind that the effectiveness of the model or performance program is only as good as the metrics you are using. ACP’s Performance Measurement Committee has reviewed internal medicine performance measures for the Merit-Based Incentive Payment System [MIPS] and found half of them to be inappropriate for use. Physicians are also (Continued on next page)
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TRENDS
dealing with “noise” from being evaluated on dozens of quality and cost metrics. ACP firmly believes in the importance of aligning syncing metrics across alternative payment models and performance-based programs from all payer types. Intending PCF to be a multi-payer model is a great step in that direction, but it also depends on how many payers actually sign up to participate in PCF first. Repertoire: CMS says that Primary Care First will reduce administrative expenses or time on the part of the primary care physician. How do you feel about that? McLean: Through our “Patients Before Paperwork” initiative, ACP has consistently advocated for reducing administrative burden in billing, compliance, documentation, and valuebased program reporting, and has noted that
an opportunity to drastically reduce billing, reporting, and other administrative burdens. It’s also important to keep in mind that Medicare is just one payer. For this to really make a meaningful dent in reducing administrative burden, we’ll need more payers to come to the table and agree to revise their own billing and reporting requirements. Repertoire: How prepared are ACP members to embrace the concepts behind the Primary Cares Initiative, namely, delivering valuebased care using population health management techniques? Will the Primary Cares Initiative help them be more prepared? McLean: ACP members have expressed a lot of interest and desire in participating in these types of innovative payment models, which reward clinicians for keeping patients healthy. Up until now, one of the main criticisms we’ve heard – and one that we’ve repeatedly relayed to CMS – is that we need more alternative payment models. So, at a high level, we’re certainly excited to see the CMS Innovation Center come out with new models and hope that is just the tip of the iceberg and we have more coming. We’re also encouraged to see alternative payment models, particularly in the primary care space, recognizing the critical role internists play in delivering high-value medicine, and how investing in advanced, comprehensive preventative services can contribute to improved outcomes, reduce the risk of downstream complications, and achieve utilization and cost savings. Additionally, there is a lack of availability of even existing models (like CPC+) in many areas of the country. That said, with any model, a lot of the devil is in the details, so ACP is looking forward to reviewing all the facts before we can say for certain exactly how much interest there will be in these new models.
For this to really make a meaningful dent in reducing administrative burden, we’ll need more payers to come to the table and agree to revise their own billing and reporting requirements. alternative payment models in which clinicians are already being held financially accountable for cost and utilization outcomes are a particularly viable vehicle to make this happen. It’s encouraging to hear that CMS seems to be listening and has at least expressed a desire to leverage these models to streamline billing. That said, they also note that fee-for-service billing will continue, so it remains to be seen how much of an actual burden reduction these models will entail. ACP is certainly hopeful that any model that is already holding clinicians accountable for outcomes, utilization and costs in a substantial way, particularly capitation models, can and should be leveraged as
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TRENDS
Employed physicians outnumber self-employed AMA reports that younger physicians and women physicians are more likely to be employed
For the first time in the United States, employed physicians outnumber selfemployed physicians, according to a study released in May by the American Medical Association. This milestone marks the continuation of a long-term trend that has slowly shifted the distribution of physicians away from ownership of private practices, according to AMA. Employed physicians were 47.4% of all patient care physicians in 2018, up 6% points since 2012. In contrast, self-employed physicians were 45.9% of all patient care physicians in 2018, down 7% points since 2012. Changes of this magnitude are not unprecedented, said AMA. Older AMA surveys show the share of self-employed physicians fell 14% points during a six-year span between 1988 and 1994. Given the rate of change in the early 1990s, it appeared a point was imminent when
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employed physicians would outnumber selfemployed physicians, but the shift took much longer than anticipated, according to AMA. The majority of patient care physicians (54%) worked in physician-owned practices in 2018 either as an owner, employee, or contractor. Although this share fell from 60.1% in 2012, the trend away from physician-owned practice appears to be slowing since more than half of the shift occurred between 2012 and 2014. Concurrently, there was an increase in the share of physicians working directly for a hospital or in a practice at least partly owned by a hospital. Physicians working directly for a hospital were 8% of all patient care physicians, an increase from 5.6% in 2012. Physicians in hospital-owned practices were 26.7% of all patient care physicians, an increase from 23.4%
®
in 2012. In the aggregate, 34.7% of physicians worked either directly for a hospital or in a practice at least partly owned by a hospital in 2018, up from 29% in 2012. Younger physicians and women physicians are more likely to be employed. Nearly 70% of physicians under age 40 were employees in 2018, compared to 38.2% of physicians age 55 and over. Among female physicians, more were employees than practice owners (57.6% vs. 34.3%). The reverse is true for male physicians: More were practice owners than employees (52.1% vs. 41.9%).
Family practice was the specialty with the highest share of employed physicians. As in past AMA studies, physicians’ employment status varied widely across medical specialties in 2018. The surgical subspecialties had the highest share of owners (64.5%) followed by obstetrics/ gynecology (53.8%) and internal medicine subspecialties (51.7%). Emergency medicine had the lowest share of owners (26.2%) and the highest share of independent contractors (27.3%). Family practice was the specialty with the highest share of employed physicians (57.4%). Despite challenges posed by dynamic change in the health care landscape, most physicians still work in small practices, says AMA. This share has fallen slowly but steadily since 2012. In 2018, 56.5% of physicians worked in practices with 10 or fewer physicians compared to 61.4% in 2012. This change has been predominantly driven by the shift away from very small practices, especially solo practices, in favor of very large practices of 50 or more physicians.
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TRENDS
Report card for CPC+ In April 2019, the Centers for Medicare & Medicaid Services issued a report covering the first year of the Comprehensive Primary Care Plus (CPC+) program, which CMS calls the largest and most ambitious primary care payment and delivery reform ever tested in the United States. In 2017, CMS partnered with 63 public and private payers and 2,905 primary care practices in 14 regions across the United States. The practices included 13,209 primary care practitioners, which together served approximately 15 million patients. Participating practices were diverse, ranging in size from one to 80 primary care practitioners. CMS expanded the program to an additional four regions in 2018, partnering with a total of 79 public and private payers. CMS and other payers agreed to provide CPC+ practices with enhanced and alternative payments, data feedback, and learning activities to support primary care transformation. Health information technology (health IT) vendors also partnered with CPC+ practices to help them use health IT to improve primary care. The goal of CPC+ is to increase access to – and improve the quality and efficiency of – primary care, ultimately resulting in better health outcomes at lower cost. CPC+ also aims to enhance primary care practitioners’ experience. To meet this goal, CMS requires CPC+ practices to transform across five Comprehensive Primary Care Functions: • Access and continuity • Care management • Comprehensiveness and coordination • Patient and caregiver engagement • Planned care and population health In 2017, the median care management fees practices received for participating in CPC+
from CMS and other payers – over and above what they already receive for providing care – exceeded $88,000 per Track 1 practice, which translates to $32,000 per practitioner on average; and $195,000 per Track 2 practice, which translates to $53,000 per practitioner on average. (Compared to Track 1, practices in Track 2 are required to make more advanced care delivery changes to improve the care of complex patients and, to support that work, they receive more financial support and a greater shift from fee-forservice toward population-based payment.) CMS paid higher care management fees per patient than other payers, in part to compensate for the higher needs of Medicare fee-for-service beneficiaries. Some CPC+ practices, known as “deep-dive practices” were selected for intensive qualitative study. The deep-dive practices reported that enhanced payments were the most critical support for improving primary care in 2017. Most deep-dive practices reported that they used CPC+ care management fees to improve their care delivery, most commonly by hiring new staff such as care managers. However, on the 2018 CPC+ Practice Survey, only 41 percent of Track 1 practices and 51 percent of Track 2 practices indicated that CPC+ funding from Medicare FFS was adequate or more than adequate for them to complete the work required by CPC+. Practices were more concerned about payment levels from non-Medicare FFS payers. Only one-third of practices in each track reported that payments from these payers were adequate. Deep-dive practices noted that non-Medicare FFS payers often did not provide additional support unique to CPC+ and that their care management fees were generally lower than practices anticipated.
To view the report, “Independent Evaluation of Comprehensive Primary Care Plus (CPC+): First Annual Report,” go to https://www.mathematica-mpr.com/our-publications-and-findings/publications/ independent-evaluation-of-comprehensive-primary-care-plus-cpc-first-annual-report
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IDENTIFY, MONITOR, PREVENT
Improve quality with in-house testing Providers can perform in-office testing in a variety of care settings including general and specialty practices. Family Practice
With accuracy, reliability, and efficiency, near patient testing with the ACE Axcel® clinical chemistry system can identify diseases such as diabetes, heart disease, metabolic syndrome, anemia, and others. • Process up to 285 tests per hour; load and run up to 75 samples at once. • Perform single or panel tests from an extensive test menu. Open reagent system enables custom assays.
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TRENDS
Vaccines: They’re everywhere! That said, the vast majority of immunizations still take place in physician offices
Editor’s Note: Bill Smith, president of Main Street Vaccines (MSV), discussed the vaccine market with Repertoire in the following article. He has over 18 years of experience in the vaccine industry and has held key positions in corporate management, account management, and marketing. MSV, an NDC Company, is a physician buying group servicing approximately 7,500 physicians across the nation.
Repertoire: It’s July, which means it will soon be back to school for many people. How does a successful distributor rep prepare for the season? How does he/she prepare their customers for it? Bill Smith: Back to school is certainly a very busy time for offices that immunize. To prepare, I would recommend that all distributor reps review the immunizations schedules on the Centers for Disease Control and Prevention (CDC) website, particularly the Child and Adolescent
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Immunization Schedule, as well as the Adult Immunization Schedule. Distributors can print the schedules and see what vaccine is recommended by age. This will help reps work with offices on needed vaccines by age group within the office. Repertoire: What – if anything – will be different about Back to School 2019 versus Back to School 2018 or 2017? How will that affect distributors?
Smith: This has certainly had an impact on physicians that immunize the adult population. However, I prefer to view this not as a challenge, but rather another access point to receive immunizations. Most notably, influenza vaccines and a few other adult vaccines are heavily promoted in pharmacies and grocery stores. The vast majority of all immunizations still take place in physician offices, providing excellent sales opportunities for distributor reps. Repertoire: What is on the horizon for childhood vaccinations? Smith: In general, there are a lot of exciting developments for vaccines in the coming years and decades. First off, in December 2018, the FDA approved Vaxelis (diphtheria and tetanus toxoids and acellular pertussis adsorbed, inactivated poliovirus, haemophilus b conjugate [meningococcal protein conjugate] and hepatitis B [recombinant] vaccine) which is a pediatric hexavalent vaccine. This vaccine is the first of its kind in the United States and is indicated for the active immunization in children who are 6 weeks old through 4 Bill Smith years old. Additionally, there are
“ There are a lot of exciting developments for vaccines in the coming years and decades.� Smith: There will not be much difference in this back-toschool season compared to previous years. A key area to work with offices on is the completion of needed adolescent vaccines. For example, the second dose immunization rate for meningococcal A, C, Y, W135 vaccine remains relatively low for 16-18-year-olds, and this patient population is about to enter peak risk for potential exposure to the disease. Working with offices on solutions to help complete the meningococcal series is important to public health. Repertoire: Today, vaccinations are administered at retail clinics (CVS, Walgreens), grocery stores, etc. How has this affected physicians? How are they meeting the challenge? And how are successful med/surg distributors dealing with this challenge?
currently over 200 vaccines in clinical trial development in the United States targeting many diseases and age populations. The current and future state of vaccines remains a significant factor in public health worldwide. Repertoire: What can you tell us about expected availability of influenza vaccine for the 2019-2020 season? What are manufacturers telling you? How will this upcoming flu season differ from those of the past, say, five years? Smith: Currently, it looks like there will be ample supply of the influenza vaccine for clinicians to immunize their patients during the upcoming flu season. In the last several years, there has been more supply than demand, providing plenty of opportunity for patients to get
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TRENDS immunized. For the upcoming season, we will have to wait and see how it unfolds. It is always interesting to see which strain predominates disease activity and if activity is high, low or on par with the national baseline throughout the season. From Oct. 1, 2018, through April 27, 2019, the CDC estimates that there were between 37.2 million and 42.7 million flu illnesses, along with 36,100 to 59,600 deaths. Comparatively, the CDC estimated 48.8 million flu illnesses and 79,400 deaths during the 2017-2018 season. Repertoire: CDC recommends that all 11-to-12-yearolds be vaccinated with a meningococcal conjugate vaccine, with a booster dose given at 16 years old. All teens may also be vaccinated with a serogroup B meningococcal vaccine, preferably at 16 through 18 years old, according to CDC. What are your customers (either physicians themselves or NDC members) telling you about the demand for these vaccines?
Smith: There is a lot of demand for both meningococcal vaccines (ACYW135 and B). Since the meningococcal vaccines are given in a series, there is great opportunity for distributor reps to work with offices on solutions to complete each series. Disease education and reminder and recall systems to bring patients back have been successful ways of helping patients and their parents see the importance of completing the series for each vaccine. Repertoire: The CDC reports that HPV infections and cervical pre-cancers have dropped significantly since the vaccine has been in use. HPV types that cause most HPV cancers and genital warts have dropped 71% among teen girls. What are your physician members or NDC members telling you about the demand for these vaccines? Smith: Our members report that demand from healthcare providers for the HPV vaccine remains high. These figures are a true testament to the value of vaccines and achieving high immunization rates so we can work to prevent disease. This is not just for the HPV vaccine, but for all vaccines in general.
“ In the last several years, there has been more supply than demand, providing plenty of opportunity for patients to get immunized. For the upcoming season, we will have to wait and see how it unfolds. It is always interesting to see which strain predominates disease activity and if activity is high, low or on par with the national baseline throughout the season.”
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Repertoire: As of May 10, the CDC reported 839 individual cases of measles in 23 states – the greatest number of cases reported in the U.S. since 1994. Has the publicity about measles affected demand for MMR vaccines? If so, how? Smith: It will be difficult to quantify demand; however, with the CDC, the American Academy of Pediatrics (AAP), and the American Academy of Family Physicians (AAFP) all recommending immunization, we can expect demand to be high. The CDC recently developed an effective toolkit for healthcare providers to have meaningful conversations with parents about this and vaccines in general. The toolkit and more information can be found here: www.cdc.g ov/measles/toolkit/ healthcare-providers.html
The 1st podcast about sales reps for sales reps. Hosted by Repertoire Magazine’s Publisher Scott Adams.
Episode 1 Brian Taylor
Episode 3 Brad Connett
Episode 2 Eddie Dienes
Episode 4 Tony Melaro
Episodes can be found at www.repertoiremag.com/resources/podcasts
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How should a doctor respond? Given the current press about anti-vaxxers, your physician customers may be asked some challenging questions about vaccinations during this ‘back to school’ season.
Parents may question their pediatricians’ recommendations, but that does not necessarily mean they will not accept vaccines, says the Centers for Disease Control and Prevention. After all, parents often consider their kids’ doctor the most trusted source of information when it comes to vaccines. Sometimes parents simply want answers to their questions. Parents may ask: Can it harm my child to get several vaccines at one time? Does my child need all of the vaccines recommended? To respond, the doctor can: • Share that no evidence suggests that receiving several vaccines at one time will damage or overwhelm a healthy child’s immune system. • Explain what antigens are (parts of germs) and emphasize the small amount of antigens in vaccines compared to the antigens babies encounter every day in their environment. • Remind parents that they must start each vaccine series on time to protect their child as soon as possible, and their child must complete each multi-dose series for the best protection. There are no data to support that spacing out vaccines offers safe or effective protection from these diseases. Parents may ask: Are these diseases that dangerous? Is it likely that my baby will catch this disease? Will ingredients in vaccines hurt my baby more than possibly getting the disease could? To respond, the doctor can: • Share his or her experience of how these serious diseases still exist and explain that outbreaks still occur in the U.S. For example: From year to year, measles cases in the U.S. can range from roughly less than 100 to a couple hundred. However, in 2014, health departments reported
cases in 667 people from 27 states. Between 1970-2000, health officials reported fewer than 8,000 cases of whooping cough each year in the U.S. But since 2010, health officials have reported between 15,000 and 50,000 cases of whooping cough each year to CDC. • Teach parents that diseases eliminated in the U.S. can infect unvaccinated babies if travelers bring the diseases from other countries. • Remind parents that many vaccine-preventable diseases can be especially dangerous for young children, and there’s no way to tell in advance if their child will get a severe or mild case. Without vaccines, their child is at risk for getting seriously ill and suffering pain, disability, and even death from diseases like measles and whooping cough. Parents may ask: I’ve heard some parents say their child’s behavior changed after vaccines. How do you know vaccines don’t cause autism? Many rigorous studies show that there is no link between MMR vaccine or thimerosal and autism. If parents raise other possible hypotheses linking vaccines to autism, doctors should: • O ffer patient and empathetic reassurance that they understand their infant’s health is their top priority, and it also is the doctor’s top priority, so putting children at risk of vaccinepreventable diseases without scientific evidence of a link between vaccines and autism is a risk the doctor is not willing to take. • Share that the onset of autism symptoms often coincides with the timing of vaccines but is not caused by vaccines. • Give their personal and professional opinion that vaccines are safe.
To view “Preparing for Questions Parents May Ask about Vaccines,” go to www.cdc.gov/vaccines/hcp/ conversations/downloads/prepare-infants-508.pdf
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INNOVATION IN HEALTHCARE
Pitt leads creation of global infectious disease data system
Wilbert van Panhuis, MD, PhD
The University of Pittsburgh Graduate School of Public
Health plans “to lead a culture shift in data-sharing rippling through scientific fields and harness it to improve global knowledge of infectious diseases.” The initiative will be backed by a five-year, $6.7 million NIH grant. Pitt Public Health will lead a multidisciplinary group of computer scientists, biostatisticians and biomedical informatics experts to direct the inaugural Network Coordination Center for the Models of Infectious Disease Agent Study (MIDAS), a collaborative research network originally launched by the NIH in 2004 to assist the nation in preparing for infectious disease threats. Wilbert van Panhuis, MD, PhD, assistant professor of epidemiology at Pitt Public Health and biomedical informatics at Pitt’s School of Medicine, will lead the new center. “The scientific community is increasingly recognizing that sharing research data and software not only benefits individual research projects, but increases the impact of science and innovation on the greater good. However,
nobody’s figured out exactly how to do this for global infectious diseases,” Van Panhuis said. “What we’re going to do is leverage that interest in ‘open science’ to create a framework that will make it easy to share, find and use research data and software to combat infectious diseases.” In its first year, the MIDAS Network Coordination Center will largely concentrate on standardizing and uploading hundreds of existing infectious disease datasets into its platform, as well as reaching out to scientists who use such data to ask how MIDAS data and software can best serve them. “Our hope is that after that first year, the MIDAS network will be able to demonstrate the benefits of open science and open data for making new discoveries,” Van Panhuis said. “We’ll also be going after new data ourselves, on behalf of MIDAS, collecting datasets from health organizations and government entities worldwide, so that the scientists have to spend less time obtaining data and can instead concentrate on making discoveries with it.”
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Cybersecurity: Under control Contracting professionals seek to shore up defenses against cyber criminals Had you been at the big healthcare technology expo
– HIMSS 2019 – this winter, you would have noticed a few things. For example, about 400 people attended the all-day Cybersecurity Forum. You would have seen that the Cybersecurity Command Center – where vendors of technologies designed to protect healthcare organizations against cyber adversaries – was much bigger than last year’s. And you would have had your pick of about 70 sessions on cybersecurity, some with unsettling titles, including: • “Dealing with the tsunami of unmanaged devices.” • “Levers of human deception.” • “Buried under an avalanche of medical device special snow flakes.” • “I will hack your laptop in 30 seconds.”
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“We’re seeing more awareness and resources going to the Internet of Things,” says Kevin McDonald, director of clinical information security for Mayo Clinic (and presenter of the “avalanche” session at HIMSS 2019). Medical devices are at the center of it. In addition to his work at Mayo, McDonald is cochair of the Joint Cybersecurity Working Group, a standing group of the Healthcare and Public Health Sector Coordinating Council. In January 2019, the group published its “Medical Device and Health IT Joint Security Plan.”
No silver bullets Technology no longer exists in a silo, says McDonald. Rather, it interacts intimately with clinical processes – often multiple processes. Think of infusion pumps, ventilators
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How about that legacy equipment? Addressing the cybersecurity of medical devices and equipment at the time of acquisition is one thing. But monitoring and minimizing the risks over the life of that equipment is another. In its “Medical Device and Health IT Joint Security Plan,” published in January 2019, the Joint Cybersecurity Working Group summed up the dilemma: The relatively short lifespan for operating systems and other relevant platforms such as commercial off-the-shelf software is inherently misaligned in health care, as medical devices and EHRs may be utilized for 10, 15, 20, or more
or ICU telemetry. That’s a lot of technology, and a lot of devices and equipment. “There are no shortcuts [to achieving cybersecurity],” he says. “This is really one of those people, processes and technology things,” which demands ongoing cooperation among those in contracting, IT, biomed and the clinical staff, not to mention vendors.
“ There are no shortcuts. This is really one of those people, processes and technology things.” “Integrating cybersecurity into an organization necessitates organizational and process changes that come with considerable time and monetary investments,” the Working Group concluded. Its Joint Security Plan is intended to provide a framework for making necessary organizational and process-related changes. It’s true that some software firms have developed tools to help providers identify the devices and equipment that present risks. But these tools aren’t silver bullets, says McDonald.
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years. This misalignment may occur for a variety of reasons. Hospitals operate on thin budgets and cannot replace capital equipment like MRIs as quickly as new operating systems are released. Product vendors have a product development lifecycle that may take several years, and they may start development using one operating system and by the time the product comes to market, newer operating systems may be available. Creative ways of addressing the aforementioned challenge areas may be found by engaging key clinical and cybersecurity stakeholders, including software vendors.
“The main thing that the software does is to listen to the communications on your network and, from the messages the devices send, infer what the device is. Some of the more mature companies that are doing this can have a pretty high identification rate based upon what they have ‘profiled’ in the past, but specialized devices may come back with no or limited information. “These are good tools and serve a purpose, but they are limited by what is in the network messages sent and the communication patterns,” he continues. “The rest of the value comes from how the company can augment it with additional data from other sources.”
Providers’ priorities Nor will such software prioritize devices based upon risk, he adds. “Risk needs to be based upon the inherent risk of the device, what additional compensating controls [the provider] can put in place, the threats the hospital may have, and what the patient impact of a vulnerability would be.” No provider facility has the resources to thoroughly assess and monitor the cybersecurity risk associated with every piece of equipment and every device in its possession. Only by developing a robust prioritization program can inroads be made. And common sense can help, says McDonald. For example, a piece of equipment that produces ionizing radiation, which has the potential to harm
patients, would be a higher priority than, say, an automated blood pressure cuff. Resources are available to help with prioritizing a facility’s cybersecurity activity. One example is the Australian Cyber Security Centre, which is the Australian government’s lead on national cybersecurity. It has identified what it calls the “Essential Eight,” that is, eight activities which, if implemented, can eliminate a large portion of a facility’s cybersecurity risk. These “Essential Eight” can be implemented even by smaller facilities: 1. Application whitelisting, to control the execution of unauthorized software. 2. Patching applications, to remediate known security vulnerabilities. 3. Configuring Microsoft Office macro settings, to block untrusted macros. 4. Application hardening, to protect against vulnerable functionality. 5. Restricting administrative privileges, to limit powerful access to systems. 6. Patching operating systems, to remediate known security vulnerabilities. 7. Multifactor authentication, to protect against risky activities. 8. Daily backups, to maintain the availability of critical data. Other examples include the work done by the Center for Internet Security (https://www.cisecurity. org) and the Healthcare Sector Coordinating Council (https://healthsectorcouncil.org).
Contracting For providers, a strong, well-thought-out contract with medical device and equipment vendors can be an important, early line of defense against cyber criminals. Monitoring cybersecurity “should be built into your purchasing process,” says McDonald. It needs to be another bullet point in the process, just as an RFP. “Make sure the tollgates or controls are in place. That’s the only way I’ve seen it work well. “It doesn’t work with individual heroics.” The Joint Security Plan urges vendors of devices and equipment to create and distribute to customers what it refers to as “customer security documentation,” which describes all pertinent security information related to
their products, including a software “bill of materials,” data flow diagrams and patch management plans. “Customers … are responsible for processing vendor-provided customer security documentation to complete questionnaires, agreements, and/or risk assessments during product procurement phases, and incorporating results into a risk management platform as well as an asset management platform for ongoing management,” according to the authors of the Plan. When researching device and equipment purchases, providers can narrow down their cybersecurity-related questions using various standards that are available, including that from the ISO, says McDonald.
Monitoring cybersecurity “should be built into your purchasing process,” says McDonald. It needs to be another bullet point in the process, just as an RFP. “Make sure the tollgates or controls are in place. That’s the only way I’ve seen it work well. Often-used standards are ISO 80001(Application of risk management for IT-networks incorporating medical devices, https://www.iso.org/standard/44863.html) and AAMI TIR 57 from the American National Standards Institute (https://www.aami.org/productspublications/ProductDetail.aspx?ItemNumber=3729). The latter standard was developed by the Association for the Advancement of Medical Instrumentation and is called Principles for Medical Device Security. “It’s doable, but it can’t be fit it in over someone’s lunchtime,” says McDonald. “The way to make it work is to make someone responsible for the outcomes.” At Mayo Clinic, these are the people working in McDonald’s areas of information security and specialized areas in clinical equipment. “You really need to fit this into your institution’s processes.”
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Questions your customers may ask
Vendors of medical devices and equipment should provide customers with security documentation to enable risk assessments, to identify security controls, and to better protect their systems. The following are examples of the types of information that may be included in documentation of security for medical devices or health IT: • Product description. (Basic description of function.) • Hardware specifications. (List of hardware components and specs.) • Operating systems. (List of hardware operating systems and versions.) • Third-party software. (Also referred to as a “bill of materials,” includes a list of third-party software and version numbers. Should be provided upon purchase and after significant software or hardware upgrades.) • Network ports and services. • Sensitive information and data transmitted (including personally identifiable information and protected health information.) • Sensitive information and data stored (including personally identifiable information and protected health information.) • Network and data flow diagram (showing system components, types of connectivity, types of data in transit and rest, and how these are secured). • Malware protection. (Anti-malware measures available.) • Patch management. (Describes and recommends method by which vendor maintains, provides and deploys patch updates.)
• Authentication and authorization. (Describes and recommends the controls that customers have with user’s authenticating and granting permissions to features and functionality, including the ability to disable user accounts.) • Network Controls. (Firewall rules, browser Internet access restrictions, etc.) • Encryption. (Describes and recommends where and how encryption is applied on the system.) • Audit logging. (Describes audit logging process, who has access to audit logs, etc.) • Remote connectivity (e.g., ports, protocols, URLs). • Service handling. (Describes routine maintenance performed by service personnel, including security policies and procedures they follow.) • End-of-life and end-of-support. (Describes when product will no longer be sold, updated and supported.) • Secure coding standards. • System hardening standards. •R isk summary. (Summary of risks found within a penetration test, remediation report, or other topics and compensating controls that correspond to additional risks outlined in the product security white paper.)
Source: Medical Device and Health IT Joint Security Plan, Healthcare & Public Health Sector Coordinating Councils, January 2019 (https://healthsectorcouncil.org/wp-content/uploads/2019/01/ HSCC-MEDTECH-JSP-v1.pdf )
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What does real innovation look like? It’s time we examine healthcare innovation from the ground up By Bruce Stanley
Technological innovations are surfacing all across
our healthcare world. Many entrepreneurs, clinicians and patients are searching and waiting for the holy grail of cures to appear. Have you ever wondered how all these innovations stack up to each other? Will they ignite the course of better health, or are they just other vehicles to extend the life of an existing idea, product or company? Do they lead to real reform of the system? Is innovation just a buzzword for more costs, more operating challenges, more work for clinicians and just plain old more of everything (except, often, for more care)? Opinions differ on how healthcare innovations actually affect systemic costs. What most patients experience is that their costs usually go up and rarely come down. The prevailing rationale is that the inventors need to be
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compensated for all their expensive research and development. Over time even the cost of generic products ends up moving higher. While many innovations lead to improved care, they can become so costly that patients are unable to afford them and decide not to undergo the treatments or take medications as prescribed. It has become a binary system choice of picking either A or B, all the while using the same tired economic models for creating, delivering and paying for care. When we debate universal care, does it really matter, since the economic model never changes? Given that our delivery and economic model for healthcare came about after World War II, one would think it’s time to re-exam how we approach the issue from the ground up. Our industry needs to embrace and encourage a real innovation challenge. Why not
encourage our leading-edge innovators to create an entirely new economic model that sets our healthcare system and structure on a futuristic course better suited for the 21st century? More than 50 years ago, the United States set an aggressive and even somewhat naïve space exploration strategy. That effort led to more innovation and new technology than anyone could have imagined. Why can’t we do the same with healthcare, rather than constantly arguing the merits of an old model? We should envision a new system of economics, clinical training, technology, product creation, delivery and sales, and innovation design that starts at the heart of all patients’ care. This new economic healthcare model should be accessible and affordable for patients and still be profitable for the industry. This idea is not to be confused with government-provided healthcare in the current framework. Some of the potential new core clinical competencies and technologies may not even exist today. The discussion need not be socialism or capitalism, just healthcare. To be fair, many product innovations do save lives and do affect the care and costs in the system. Industry developers create some pretty terrific robotics, techno devices, software and apps. However, when industry leaders discuss these innovations, they inevitably talk about sales projections and financial opportunities for investors. What they rarely talk about is how these ideas might revolutionize care and lower costs in the entire system, and specifically for each patient. We are expected to believe that profitable returns equal better patient outcomes. Implementing change using a tired model is just less effective clinically and economically. Many times, the self-described innovations produce results of care that are mixed. EHR is one example. Even with this technology, patient records are lost or corrupted,
clinicians are exhausted from the tedious hours of data manipulation, and insurance coding confusion grows at unprecedented rates while patient healthcare is declining. Creating a new healthcare economic model won’t be easy. But with all the energy being put on “innovation of things,” one has to wonder, are we afraid of what a new economic model might look like? I’m not criticizing the investments or the innovators. What I am suggesting is that in and of itself, these activities don’t drive systemic economic innovation. So where do we look for the real economic innovation in healthcare? Any clinician will tell you we need to
Is innovation just a buzzword for more costs, more operating challenges, more work for clinicians and just plain old more of everything? stop and reevaluate what is really occurring. We’ve never answered the fundamental question: Is healthcare a privilege or a right, or for that matter, is it like breathing air and necessary to sustain our society? We need to flip the process on its end and challenge how we can fundamentally change the system. Real transformation of care and economics may be uncovered when examining the industry through a completely new lens. That said, the question remains: Can the economic underpinning materially change, and is innovation in that new model evolutionary or non-existent? Can this industry rally in support of its own headline – Health and Care? When the industry better balances this with profitability, then quite possibly a new model will emerge where innovative healthcare will lead all aspects of care while guaranteeing its own long-term economic viability.
Bruce Stanley is a global supply chain, business development and contracting operations advisor and consultant with over 30 years in the healthcare industry. In 2011, he co-founded The Stanley East Consulting Group, a consulting practice specializing in supply chain, contracting, business development, order fulfillment and project management for small and medium-sized companies, startups, and companies in transition or divestiture. He is also a published author of many commentaries on healthcare processes, and an adjunct MBA professor teaching global supply chain, contracting and healthcare informatics and regulations. He previously served as senior director, contracting operations, for Becton Dickinson. He can be reached at brucejstanley@gmail.com.
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HIDA INSIGHTS
By Elizabeth Hilla, Senior Vice President, HIDA
Collaboration: Key to Improving Supply Chain Efficiency
I’m a huge advocate for the value of distribution.
I think that both manufacturers and providers benefit when they partner with a distributor to improve their supply chain efficiency. Still, some supply chain issues are too big and complicated for distribution alone to solve. That’s why HIDA has formed the Healthcare Supply Chain Collaborative. Our aim is to pull together leaders from across the end-to-end supply chain – health systems and other providers, group purchasing organizations, distributors, manufacturers, and technology companies – to address difficult issues. I had the chance to witness collaboration in action in April, when we hosted three conferences: Contract Administration, E-Commerce, and Supply Chain Visibility. Each event brought folks together from different types of organizations to share their successes and their pain points, and to look for improvement opportunities.
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What Do We Mean By Supply Chain Visibility? “Supply chain partners collaborating and sharing information to better match supply and demand, avoiding shortages and overruns/waste.”
I moderated the new Supply Chain Visibility Conference – part of a larger initiative aimed at better aligning supply and demand, reducing both shortages and waste. I can’t say we solved all the problems, but we made real progress at understanding each other’s perspectives and identifying areas we can work on. One big focus area was everyday demand planning. We heard from a business forecasting expert about the technical methods major companies use to project demand. We all quickly realized that most healthcare organizations
are light years behind such companies. Is that because healthcare demand is so much more unknowable than, say, demand for groceries or razor blades? Steve Kiewiet, Chief Commercial Officer of Intalere, didn’t think so. He pointed out that healthcare supply chain leaders tend to believe that everything done inside a hospital is unpredictable. “In reality about 90% of what happens in a hospital is predictable if we put the right processes in place,” he said. Russell Royer, Director of Heart and Vascular Services for Loma Linda University Medical Center, agreed that while there is a mystique around the unpredictability of healthcare demand, it’s really not that much of a surprise: “We can predict the length of a procedure, and the supplies that are needed. Almost everything is algorithmic – if not A, then B.” Some pointers I took away from the discussion: •P re-approve substitutions: Ron Collins, Vice President of Supply Chain with the University of Tennessee Medical Center, asked suppliers to proactively identify the best subs when a product is back-ordered. “We have to take care of patients, so please tell us what alternative products will work, even if they’re from your competitor.” •B uild trust: Participants noted that utilization management methods don’t work if clinicians fail to trust the system to ensure product availability. If users expect shortages, they tend to hoard, which exacerbates the problem. •M ake demand more forecastable: Experts noted that common practices like end-of-quarter promotions introduce volatility into the supply chain and make it harder to align supply and demand. While we were working on product availability challenges, participants at our co-located conferences on Contract Administration and E-Commerce were laserfocused on addressing challenging issues in those areas. Participants called it “an important platform for providers, distributors, and manufacturers to learn from one another and instigate collaborative problem solving.” That’s what we’re trying to do, and we’re looking for more folks to get involved. If you’d like to get to work on a thorny industry issue – like chargeback reconciliation practices, establishing common definitions for industry terms like back order and fill rate, or developing best-practice resources, please contact me at ebh@hida.org.
We make needles that make everyone comfortable.
A lot hinges on having the right needles. That’s why Terumo’s SurGuard®3 offers some very convincing benefits. Sharper – Patients benefit from a more comfortable injection, as our needles are 10%* sharper than the market leader and sharpest on average among major brands Safer – Safety mechanism includes a lock for both the needle and the hub, and is designed to minimize the ability to be removed Smarter – Clinicians can choose how they activate the safety mechanism using their finger, thumb or hard surface as dictated by the clinical situation We make some great points. Whatever you’re looking for in a safety needle, SurGuard®3 from Terumo has you covered. For more information, call Terumo at 800-888-3786 or visit terumotmp.com to find your Terumo representative.
TERUMO and SurGuard are trademarks owned by Terumo Corporation, Tokyo, Japan, and are registered with the U.S. Patent and Trademark Office. ©2018 Terumo Medical Corporation 6/18. All rights reserved. PM-00628. *Data on file. Terumo Medical Products, April 2016.
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STREAMLINING HEALTHCARE
EXPO & BUSINESS EXCHANGE SEPTEMBER 24–26, 2019 • CHICAGO, ILLINOIS
HIDAStreamlining.org
Distributors, Manufacturers, GPOs & IDNs
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Your Opportunity To Connect With All Your Important Trading Partners
Why Attend? More Ways To Meet Meet and strategize with your most important partners at the Innovation Expo, Executive Business Exchanges, and Reverse Expos.
More Types Of Companies To Meet With Take advantage of the new opportunities to meet with group purchasing organizations, integrated delivery networks, and regional purchasing coalitions.
Large And Small Companies Meet national, regional, specialty, minority-owned, and independent companies during the 2 1/2 days in Chicago.
Who Attends?
More Face Time, Less Travel Time
Distributors
In a single event, you can meet face to face with nearly 1000 decision makers, strategize with current partners, make new connections, keep up with the latest trends, and stay competitive!
Manufacturers and Service Providers
Register: HIDAStreamlining.org
Group Purchasing Organizations and Regional Purchasing Coalitions IDNs and Health Systems
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More Ways To Network
Walk-Up Meetings At The Innovation Expo And Reverse Expos For more information visit HIDAStreamlining.org/expos
Wednesday, September 25 11:00am–4:00pm
Thursday, September 26 8:00–10:00am
Thursday, September 26 11:30am–1:30pm
Connect with 50+ manufacturers and service providers on the Expo floor
Meet leaders from more than 50+ national, independent and specialty distributors
Connect with 30+ group purchasing organizations and integrated delivery networks on the Expo floor
Pre-Scheduled Meetings At The Executive Business Exchanges Register before July 31, 2019. For more information visit HIDAStreamlining.org/EBE
Wednesday, September 25 | 8:00–11:00am Pre-scheduled 20-minute meetings led by distributor teams
Wednesday, September 25 | 4:00–6:00pm Pre-scheduled 20-minute meetings led by GPO & IDN teams
Networking Events
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Register: HIDAStreamlining.org
Welcome Reception Tuesday, September 24 | 6:00–8:00pm HIDA/PWH Premier Networking Reception Wednesday, September 25 | 9:00–11:00pm Expo Floor Networking
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Wednesday, September 25 | Breakfast, 7:30am | Lunch, 11:00am Thursday, September 26 | Breakfast, 8:00am | Lunch, 11:30am
Network and Learn
Contracting Trends And Best Practices Tuesday, September 24 | 3:00–5:00pm
Innovative Strategies For Managing The Non-Acute Supply Chain
• Provider supply chain leaders’ perspectives on trends in national, regional, and local contracting • Insights on how suppliers can best work with health systems to win contracts and drive compliance
Wednesday, September 25 | 9:45–10:45am
Independent Distributors Summit
HIDA Government Affairs Update: Reimbursement And Regulation Impacting Your Customers
Tuesday, September 24 | 3:00–5:30pm • Exclusively for independent distributors with 50 employees or less • Topics will include measuring customer satisfaction and creating a unique value proposition
Improving Distribution And Logistics In Health Systems Wednesday, September 25 | 8:30–9:30am • Insights from providers on their biggest operational challenges (back orders are just the beginning) • New distribution and logistics models and their advantages and drawbacks
ShareGroups
• Creative approaches to servicing non-acute provider locations • Strategic partnerships between suppliers and providers to increase efficiency and reducing costs
Wednesday, September 25 | 4:00–5:15pm • Key changes in payment models impacting acute, post-acute, and non-acute providers • The future of the ACA and what it means for suppliers, providers, and patients
IDN & GPO Education Session: Technology Trends For Healthcare Supply Chain Thursday, September 26 | 9:00–10:00am • Real-life examples from health systems on supply chain technologies they are adopting or upgrading • Potential solutions for challenges in sourcing, clinical utilization, and inventory tracking
Vendor Relations ShareGroup
Join discussion groups focusing on topics of common interests in the supply chain.
Medical Sales Leader ShareGroup
Thursday, September 26 | 10:15–11:15am For supply chain professionals who manage manufacturer-distributor relationships
Tuesday, September 24 | 1:15–2:45pm
GPO & IDN ShareGroup
For leaders and managers of sales teams
Thursday, September 26 | 10:15–11:15am For GPO and IDN attendees
Diversity Supplier ShareGroup Tuesday, September 24 | 1:15–2:45pm
Strategic Accounts Leader ShareGroup
For business leaders from minority-owned, woman-owned, and veteran-owned companies
Thursday, September 26 | 10:15–11:15am For strategic accounts professionals
Register: HIDAStreamlining.org www.repertoiremag.com
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HEALTHY REPS
Health news and notes
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How much screen time?
Wait and see
How much screen time – smartphones, videos, online games – should little kids have? The World Health Organization says that kids in their first year of life should have ZERO time in front of a screen, and very little in year 2. Those aged 2 to 4 should spend no more than an hour a day in front of a screen, says WHO. The international health agency drew on emerging – but as yet unsettled – science about the risks screens pose to the development of young minds, reports The Washington Post. Experts in child development say the acquisition of language and social skills, typically by interacting with parents and others, are among the most important cognitive tasks of childhood. But there is disagreement about how screen time interferes with that. “The more guidelines we give, it just seems like there’s going to be more of a mismatch between what experts say … and what it feels like to be a parent in the real world every day,” said University of Michigan pediatrician Jenny Radesky, author of 2016 screen-time guidelines for the American Academy of Pediatrics.
People with good vision despite having center-involved diabetic macular edema can safely forego immediate treatment of their eye condition as long as they are closely monitored, and treatment begins promptly if vision worsens, according to clinical trial results. The findings were published in the Journal of the American Medical Association. Diabetic macular edema is the most common cause of vision loss among people with diabetic eye disease in the United States. Diabetes can result in the development of leaky blood vessels in the retina – the light-sensing tissue at the back of eye. Diabetic macular edema is the result of fluid build-up in the central area of the retina, called the macula, which is important for sharp vision. Swelling of the macula can distort vision required for reading and driving.
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Lightning strikes Just as lightning can strike the same target more than once in a given storm, hip fractures can and do happen again to the same person, according to New York Times
health writer Jane Brody. Yet, more often than not, people who fracture a hip do not get follow-up treatment that could prevent another fracture. Anyone who breaks a hip, unless from a severe trauma like a car accident, is considered at high risk for further fractures, including breaking the other hip. To reduce the risk, orthopedic experts recommend that following a fracture, patients should have a bone density test, evaluation of calcium and vitamin D levels and, in nearly all cases, medication to protect against further bone loss. Writing in JAMA Geriatrics last year, University of California San Francisco internist Dr. Douglas Bauer wrote about “really depressing, hocking data” revealing that only a small – and steadily declining – fraction of hip fracture patients are being treated with medication that might forestall future broken bones.
HPV vaccine has impact Cervical cancer is the most common human papillomavirus (HPV)-associated cancer in women, and high-grade cervical lesions (CIN2+) have been used to monitor HPV vaccine impact, reports the CDC. During 2008– 2016, CIN2+ rates in a population-based surveillance system declined in women aged 18–24 years, the agency reported. The estimated numbers of U.S. CIN2+ cases were 216,000 (2008) and 196,000 (2016), with an estimated 76% attributable to 9-valent HPV vaccine types. “The reduction in CIN2+ attributable to vaccine types in young women demonstrates impact of the HPV vaccination program,” says CDC. “Continued efforts to increase coverage and encourage vaccination at the routine ages (11–12 years) can increase vaccine impact on cervical disease in the United States.”
Sickle cell therapy is tested An experimental gene therapy being tested at the National Institutes of Health Clinical Center in Bethesda, Maryland, has shown some positive results in eliminating sickle cell disease (SCD). The approach involves using gene editing to increase levels of fetal hemoglobin (HbF) in the red blood cells of people with SCD. Significant quantities of HbF have been found to provide protection against sickling. Sickle cell disease is caused by a specific point mutation in a gene that codes for the beta chain of hemoglobin. People with just one copy of this mutation have sickle cell trait and are generally healthy. But those who inherit two mutant copies of this gene suffer lifelong consequences of the presence of this abnormal protein. Their red blood
cells – normally flexible and donut-shaped – assume the sickled shape that gives SCD its name. The sickled cells clump together and stick in small blood vessels, resulting in severe pain, anemia, stroke, pulmonary hypertension, organ failure, and far too often, early death.
How valuable are vitamins? More than half of U.S. adults take dietary supplements, according to Dr. Francis Collins, director of the National Institutes of Health. But does popping all of those vitamins, minerals, and other substances really lead to Significant a longer, healthier life? A quantities of nationwide study published in the Annals of Internal Medicine HbF have been found to provide suggests it doesn’t. Based on an analysis of survey protection against data gathered from more sickling. Sickle cell than 27,000 people over a disease is caused six-year period, an NIHby a specific point funded study found that individuals who reported mutation in a taking dietary supplements gene that codes had about the same risk for the beta chain of dying as those who got their nutrients through food. of hemoglobin. What’s more, the mortality benefits associated with adequate intake of vitamin A, vitamin K, magnesium, zinc, and copper were limited to food consumption.
Sensor for diabetic foot ulcers Somerville, Massachusetts-based Podimetrics is tackling the problem of diabetic foot ulcers through a smart sensor mat that is designed to be placed in a patient’s home and can analyze foot temperature variations to predict and prevent the occurrence of a potential ulcer, according to MedCity News. Podimetrics users stand on the mat for about 20 seconds, and the data gets analyzed and sent to the Podimetrics care team, which examines and triages the data and works with the patient’s physician on preventative treatments and coaching. A study published in Diabetes Care found that the company’s technology could detect 97 percent of developing foot ulcers an average of five weeks before they could be detected otherwise. Podimetrics has reportedly raised around $16 million in funding since its founding in 2011.
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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.
Hyundai Venue
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Entry-level crossover One of the toughest decisions by product planners working on the Hyundai Venue was to engineer the subcompact crossover with front-wheel drive only – forgoing claims as an occasional off-road vehicle capable of spinning all four wheels in mud or snow, reports Automotive News. But what the planners gave up in allwheel-drive grip, they gained in carving out a niche of
their own, according to the editors. “The Venue is built from the ground up as a stylish urban crossover for the U.S. at the price of a ho-hum economy car – a play that could even convert some used-car shoppers into newvehicle buyers and bring them into the Hyundai fold.” At its size, it’s the first of its kind, but not likely the last, Michael O’Brien, vice president for product, corporate and digital planning at Hyundai Motor America, told the magazine.
Customizing electric cars’ performance
and includes creation of a citywide lighting management system. When it becomes operational, the system will alert the city when lights need service.
A dashboard-centric operating system Google is opening up Android Automotive OS – the dashboard-centric version of its mobile platform – to third-party media apps. Android Auto has long allowed
The city of Chicago announced it would install an additional 40,000 new LED lights on residential streets, alleys and viaducts as part of its four-year project to modernize its lighting system.
Hyundai Motor Group has developed new technology that will allow drivers of electric cars to customize the vehicle’s performance using a smartphone application, reports TradeArabia. The industry-first innovation can adjust seven performance features, including the maximum torque output of the motor, ignition, acceleration and deceleration abilities, regenerative braking capacity, maximum speed limit, responsiveness, and energy use on climate control. As well as customizing for individual drivers, the application can optimize the settings for specific journeys. For example, on longer drives the app could analyze the remaining distance and electric energy requirement, and then adjust the settings for optimum range, while for short trips around town it can be more responsive in traffic. It can also accommodate sportier driving.
Chicago lights up The city of Chicago announced it would install an additional 40,000 new LED lights on residential streets, alleys and viaducts as part of its four-year project to modernize its lighting system. The city estimates it will save $100 million over the next 10 years due to the energy efficiency of the new lights, which consume 50% to 75% less electricity than high-pressure sodium street lights. The project will replace 270,000, or 85 percent, of Chicago’s streetlights with LED fixtures,
phones to project a customized version of their interface onto vehicle infotainment systems, offering access to navigation, multimedia, calls, messaging, and the Assistant, reports Slash Gear. But Android Automotive OS is said to go deeper. Control is via an 11-inch portrait orientation touchscreen in the center console, which resembles a propped-up Android tablet. It has a modular user interface, with different panes for multimedia, communication, navigation, and managing the vehicle’s drivetrain. Say “Hey Google,” and the Assistant can control vehicle features as well as answer questions. Android Automotive OS is scheduled to launch first on the Polestar 2 EV, the all-electric car from the new Volvo and Geely-backed Swedish automaker.
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Industry News
Alfa Wassermann Diagnostic Technologies receives 2018 Sales Collaboration Award
Midmark names Brian Vierra as director of sales, medical
Congratulations to Alfa Wassermann Diagnostic Technologies for receiving the 2018 Sales Collaboration Award at the Medline Industries, Inc., National Sales Meeting for Specialty Sales in Orlando, Florida on April 10, 2019. Presented by Medline Group President of Lab & Diagnostics, Diana LeFebvre, Alfa Wassermann received the award for their efforts in working with Medline to grow their lab business in the Education and Research market.
Midmark Corp., announced Brian Vierra was promoted to director of sales, medical. In this leadership position, Vierra will lead, manage and develop the Midmark medical salesforce through his connected team of region directors effective July 1, 2019. Vierra has been Brian Vierra with Midmark for 14 years, and in that time has held roles in the medical division as a sales representative for the Pittsburgh territory and region director for three different regions. Most recently, he has held the position of field sales leader for the past eight years.
B. Braun announces $1B investment to alleviate IV fluid shortages in the U.S.
(From left to right: Stephen Burns, Medline Executive Vice President of Sales; Phong Tran, Alfa Wassermann Director of Business Development; Diana LeFebvre, Medline Group President of Lab & Diagnostics; Mark Gnagy, Alfa Wassermann Vice President of Sales)
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B. Braun Medical Inc (Bethlehem, PA) announced Solutions for Life, a $1 billion investment in new and enhanced IV therapy manufacturing facilities to help ensure a reliable and consistent supply of vital IV fluids that American healthcare providers need every day. The investments include a new state-of-the-art manufacturing facility in Daytona Beach, FL, and modernizations to existing facilities in Irvine, CA, and Allentown, PA. B. Braun obtained FDA approval of IV fluids from European facilities should the need arise in the future. Several years ago, B. Braun prioritized and began investments to support longterm and ongoing supply capacity.
Say hello to the NEW Midmark Workstations. Spending time hunched over a computer screen can have big impacts on a caregiver’s body and a health system’s bottom line. Midmark Workstations are the only products on the market today that truly support the range of motion needed for 95% of users in the clinical setting. Offer your customers an exclusive solution while increasing revenue potential in the exam space—better care is better business. midmark.com/workstationsREPjul
© 2019 Midmark Corporation, Miamisburg, Ohio USA
A Full Spectrum of Ventilation Monitoring Solutions
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PLCO-002861/PLMM-11068A-0519 PLLT-10838B © 2019 Masimo. All rights reserved.