Rep june18 by BOC design Inc

vol.26 no.6 â&#x20AC;˘ June 2018

Step Up! In a point-and-click world, itâ&#x20AC;&#x2122;s up to the rep to make a difference

repertoiremag.com

MACRA Quality Measures— Are Your Customers Ready?

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JUNE 2018 • VOLUME 26 • ISSUE 6

PUBLISHER’S LETTER

Step Up!

Both Sides of the Equation.....................................6

PHYSICIAN OFFICE LAB Infection Prevention and the POL

Everybody wants to prevent infection; what about detecting infections?..........................................8

In a point-and-click world, it’s up to the rep to make a difference

DISTRIBUTION

‘Power of Partnership’ on Display NDC Exhibition 2018 brings together medical, physical page rehab and home care market-makers

POST ACUTE

Length of Stay

CONTRACTING EXECUTIVE PROFILE

States finding out that the shorter the nursinghome stay following hospitalization, the better for the patient

For Chris Torres and her team at Main Line Health, supply chain management and clinical resource management are a package deal.......................................... 16

repertoire magazine (ISSN 1520-7587) is published monthly by Share Moving Media, 1735 N. Brown Rd. Ste. 140, Lawrenceville, GA 30043-8153. Copyright 2018 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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June 2018

JUNE 2018 • VOLUME 26 • ISSUE 6

POST ACUTE CARE: HIDA INSIGHTS

LEADERSHIP

Health Systems Look to Strengthen Partnerships with Distributors........................ 38

INFECTION PREVENTION Infection prevention: It never sleeps.......... 50 Hep C screening still low...................................... 52

HEALTHY REPS Health news and notes.......................................... 54

WINDSHIELD TIME Automotive-related news.................................... 58

People Before Problems How to encourage through difficult situations

HIDA GOVERNMENT AFFAIRS UPDATE MedPAC Recommends Key Reimbursement Changes.......................... 62

PEOPLE

QUICKBYTES

Marv Stevens: The man to see

Marvin Caligor: School was always in session

Technology news 60 4

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64 INDUSTRY NEWS News........................................................................................... 66

OnGuard® CSTD (Closed System Transfer Device) meets the NIOSH1,2, ASHP 3, and ONS 4 definitions of a CSTD. Plus, it has FDA clearance under the ONB Product Code5 and will help healthcare institutions meet USP <800>6 requirements. Today, OnGuard remains the only CSTD that has been tested with commonly used chemotherapy drugs.7 1. The NIOSH definition is a performance standard, and does not prescribe how to meet the definition. 2. NIOSH Definition of Closed-System Drug-Transfer Devices, Ann Occup Hyg. 2009 Jul; 53(5): 549. Published online 2009 May 27. doi: 10.1093/annhygmep030\; 3. ASHP Guidelines on Handling Hazardous Drugs; 4. ONS Safe Handling of Hazardous Drugs; second edition 2011, M. Polovich; 5. FDA cleared with ONB product code: K141448 http://www.accessdata.fda.gov/cdrh_docs/pdf14/K141448.pdf 6. General Chapter <800> Hazardous Drugs—Handling of Drugs in Healthcare Settings Published February 1, 2016.; 7. Prevention of Hazardous Drug Vapor Release by the Tevadaptor® Vial Adaptor, Third-party lab testing performed at Analyst Research Laboratories, Ltd. Rehovot, Israel, Reference reports 2007-001 Et001C and Nextar Chempharma Solutions, Ltd. Rx only. ©2017 B. Braun Medical Inc., Bethlehem, PA. All rights reserved. 8/17

Meeting the Deﬁnitions of a CSTD

www.OnGuardEdge.com

18-6429 0518

NIOSH ASHP ONS ONB USP <800>

PUBLISHER’S LETTER

Both Sides of the Equation For the better part of this year, my Publisher’s Letter has repeatedly referenced the

value of the field rep. I have been short sided to this point and only written about the distribution rep. So in this month’s issue, we decided to focus on both sides of the equation and how you can compete in a point-and-click world. “ In a point-and-click world, it’s up to the rep to make a difference,” Repertoire Editor Mark Thill writes. “Healthcare providers have more information and power at their fingertips today than ever before. Online sellers, most recently, Amazon, are making a bid for their business. What does a sales rep bring to the table?

Scott Adams

“ A sense of understanding, empathy and compassion. A desire to learn and to serve, and a sense of accomplishment when they help their customers succeed. Throw in some technology, and you have a sales force that providers can’t be without.” Repertoire talked to three manufacturers who agree. They are: • Shawn Austin, vice president of sales, BD Diagnostic Systems Non-Acute Business. • Jason Dukarm, group marketing manager, Point-of-Care, cobas Liat & Channel Marketing, Roche Diagnostics Corp. • Jack Moran, managing partner, MedTech/MedCare, LLC. Whether you’re a manufacturer rep or a distribution rep, this story is for you. Please spend a few minutes and really digest what the folks we interviewed are saying. At the end of the day, all of us are in this together. Dedicated to the industry, R. Scott Adams PS: Be sure to read the top 10 list at the end of the story …. Good selling tips for today’s environment repertoire is published monthly by Share Moving Media 1735 N. Brown Rd., Suite 140, Lawrenceville, GA 30043 Phone: (800) 536-5312, FAX: (770) 709-5432; e-mail: info@sharemovingmedia; www.sharemovingmedia.com

editorial staff editor

Mark Thill lthill@sharemovingmedia.com managing editor

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

Alan Cherry acherry@sharemovingmedia.com art director

Brent Cashman bcashman@sharemovingmedia.com

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vice president of sales

Jessica McKeever

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

Alicia O’Donnell

aodonnell@sharemovingmedia.com (800) 536.5312 x5261 sales executive

Tyler Moss

tmoss@sharemovingmedia.com (800) 536.5312 x5279 sales executive

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

publisher

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

Brian Taylor btaylor@ sharemovingmedia.com circulation

Laura Gantert lgantert@ sharemovingmedia.com

Subscriptions

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2018 editorial board Richard Bigham: IMCO Eddie Dienes: McKesson Medical-Surgical Joan Eliasek: McKesson Medical-Surgical Ty Ford: Henry Schein Doug Harper: NDC Homecare Mark Kline: NDC Bob Ortiz: Medline Pam Wedow: Independent consultant Keith Boivin: IMCO Home Care

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PHYSICIAN OFFICE LAB

Infection Prevention and the POL Everybody wants to prevent infection; what about detecting infections? By Jim Poggi Whatâ&#x20AC;&#x2122;s all the fuss about infection prevention? We had

a record flu kit season, so we did our part in the physician office lab. Besides, most infections are diagnosed and treated in the hospital, not the physician office, right? Nope, not even if you sold a few strep and RSV kits along the way and placed some of the new, exciting molecular testing platforms that are out there. Physician practices, with or without labs, are bombarded with concerns about infection prevention, antibiotic stewardship and sepsis every day. From peer reviewed journals, internet blogs, consumer magazines and newspapers to questions being raised by patients themselves, concerns about preventing, diagnosing and treating infections are Every practice will need to make becoming top of mind. The very an informed realistic concerns about emergdecision about ing strains of antibiotic resistant the range of bacteria make the prospect of tests appropriate living in a world without effecto perform, tive antibiotics a frightening from patient, prospect and one that just might personnel, be on the horizon. In addition, equipment and sepsis, which can quickly turn an risk tolerance infection into a deadly situation, considerations. is gaining a lot of attention. It progresses rapidly, and urgent diagnosis and treatment are critical to save lives and prevent organ damage and other complications. Urgent care centers and free-standing emergency rooms face a higher percentage of acutely ill patients and deal with these challenges to an even greater degree.

The distributor rep and infection prevention So whatâ&#x20AC;&#x2122;s the role of the distributor account manager? You have a lot of responsibility to know the issues, stay

June 2018

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well informed, and help your customers understand available solutions for the entire continuum of infection management, from prevention to diagnosis to treatment and management in the post-acute stages including wound care. This article will focus on diagnosis, since that is clearly the role of lab for our physician customer base. There is a LOT to know, and this article will provide some useful facts and suggestions, but is by no means a comprehensive resource. Since many acute infections (rapid onset, high fever, muscle aches and even delirium) end up in the emergency room, what is the role of infection diagnosis in primary care, urgent care centers and free-standing emergency rooms? Ten years ago, the answer would have been that CLIA waived practices should test for flu and strep. CLIA moderate complexity practices should consider CBCs to help differentiate between viral and bacterial infections. Few physician practices were testing for RSV, and there were no simple-to-perform tests for Clostridium difficile and MRSA. STD testing was largely confined to hospitals and community health clinics and HIV and hepatitis C (HCV) testing was clustered in a few communities with a concentration of high risk individuals and concerned clinicians. Since plated microbiology media are CLIA high complexity, take highly trained personnel and results require one day or more, they had very little acceptance or applicability in primary care practices.

The need for early detection With the advent of new reader-based rapid tests and molecular technologies broadening the range of available infectious disease tests, increased awareness of the need for early detection and accurate identification of the cause of infection and new effective treatments for hepatitis C,

MAYBE THERE YOU NEED BETTERTEST TEST IS AABETTER FOR NEXT FLU SEASON Were your customers able to confidently diagnose and treat their patients during one of the most challenging flu seasons on record?1 Recent data shows that traditional rapid testing methods have only 50-70% sensitivity, which may lead to more false negatives when influenza activity is high.2 With 100% sensitivity for Flu A/B, the CLIA-waived cobas® Liat® PCR system can help your customers better detect flu and treat with confidence and speed, when it matters most.3

Visit go.roche.com/betterequipped for more information. 1 CDC Weekly U.S. Infl uenza Surveillance Report. Available at: https://www.cdc.gov/fl u/weekly/. Accessed on March 12, 2018. 2 Rapid diagnostic testing for infl uenza: Information for health care professionals. Centers for Disease Control and Prevention website. http://www.cdc.gov/flu/professionals/diagnosis/rapidclin.htm#table Accessed March 12, 2018. 3 Roche cobas® Liat® Infl uenza A/B Package Insert COBAS and COBAS LIAT are trademarks of Roche Diagnostics. © 2018 Roche. MC-US-00263-0418

PHYSICIAN OFFICE LAB

Infections and diagnosis facts •O rgan panel tests (ALT, AST, CMP and BMP) are important follow up tests after an acute sepsis episode to understand the extent of organ damage caused by sepsis • There are more than 30 different pathogens (viral or bacterial) that can cause respiratory infections; differential diagnosis is critical to treatment plans • Only about 20 percent of all the flu tests performed in the past flu season were positive • Cure rates for hepatitis C in the United States are now over 95 percent using newer medications • Sepsis is NOT an infection; it is the body’s reaction to an infection • Urinary tract infections, E. coli, influenza, strep and MRSA are leading causes of sepsis • The CDC recommends HIV and HCV screening in healthcare settings for specific patient populations • HCV for baby boomers – adults born from 1945 through 1965 • HIV: The CDC recommends HIV screening for patients aged 13-64 years in all health-care settings

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the picture has changed dramatically in recent years. Every practice will need to make an informed decision about the range of tests appropriate to perform, from patient, personnel, equipment and risk tolerance considerations. But the range of options has expanded dramatically. Some thoughts on applicable tests for a variety of infections is provided below to give you some food for thought as you approach your customers and help them to deliver appropriate solutions to the challenges of infection diagnosis. Your category or marketing team, lab suppliers and specialists are also in an excellent position to guide you in delivering solutions for your customers and prospects. Be sure to use all the resources at your disposal.

Some diagnostic tests for common infections Type of infection Respiratory

Available tests Flu, strep, RSV, adenovirus

Enteric

C. difficile, H. pylori (antigen), E. coli, many others Syphilis, gonorrhea, chlamydia, HIV, others

STD

Hepatitis

HAV, HBV, HCV

Skin wound

Specific pathogens including strep Urinalysis, specific pathogen tests Conjunctivitis (adenovirus) CBC, specific pathogen tests Lactate, procalcitonin

Urinary tract

Eye Bacterial v Viral Sepsis detection

Formats Visual rapid, reader rapids, molecular Visual rapids, molecular

CLIA waived? Most are

Some

Visual rapid, latex Some agglutination, plated media, molecular Visual rapid HCV rapid (HCV), molecular Plated media, No molecular Urinalysis, plated media, molecular Visual rapid

Urinalysis

CBC, molecular

New CBC

Chemistry and immunoassay systems

Yes

The literature and available tests for infections are undergoing rapid and exciting changes. The range of choices of tests and test methods you have available today suits many more physician practice needs than ever before and continues to improve. We have faster, more accurate and easier to use tests for more sources of infection than ever before. While antibiotic resistance and sepsis are daunting prospects, you, your manufacturers and the laboratory community are better armed than ever before to combat these challenges.

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DISTRIBUTION

Jan Hargrave

‘Power of Partnership’ on Display

Molly Fletcher

NDC Exhibition 2018 brings together medical, physical rehab and home care market-makers

The NDC Exhibition 2018: Power of Partnership host-

ed a record number of attendees at the Gaylord Opryland Resort & Convention Center in Nashville, Tennessee, March 25–27. Show producers report a 30 percent increase in attendance over the prior year, with over 900 distributor and manufacturer representative attendees. This year’s Exhibition ran concurrently with the NDC Physical Rehab Sales Meeting, bringing together a display of the NDC network across the medical, physical rehab and home care markets. The Exhibition built upon the “Power of Partnership” theme, which NDC initiated in 2015. By bringing together independent distributors, manufacturers and GPOs, NDC is able to showcase the “simply powerful” opportunities that are available within the NDC network, says Ian Fardy, vice president of marketing. In his opening remarks, NDC President and CEO Mark Seitz provided an update on NDC initiatives and unveiled new strategies and investments in the core business. Seitz reaffirmed NDC’s commitment to independent distribution and announced that NDC will continue to put the pieces of the puzzle together to provide meaningful fulfillment solutions to distributors looking to expand

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into new markets, such as home care and pharma. Midmark Corporation sponsored this year’s featured keynote speaker, Molly Fletcher. In her address, “Peak Performers,” she shared Mark Seitz the unconventional techniques that made her one of the first female agents in the world of professional sports and a successful entrepreneur. One of the nation’s top 5 speakers of 2017, Fletcher left attendees energized, excited and inspired. Bryan Offutt, vice president for global branding, Under Armour, shared the company’s journey from a t-shirt maker based out of a garage, to a $5 billion sports performance company. Offutt reinforced the importance of continually building your brand to “Protect Your House.” In addition, Conor Cunneen, IrishmanSpeaks, presented the “Gift of GAB: Goals, Attitude and Behavior,” and Jan Hargrave shared her knowledge as a forensic body language expert in her sales session on understanding nonverbal selling power.

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DISTRIBUTION

Award winners Recipients of 2017 Medical Awards were: •M ember of the Year: US MedSource, LLC •F ast Track: United Medical Supply • Medical Trendsetter: Mountainside Medical Equipment • Outstanding Performance Vendors: BD, GMAX, Metrex, PDI, Quidel Recipients of 2017 Physical Rehab Awards were: • Member of the Year: Advanced Rehab Systems • Equipment Trendsetter: Isokinetics Inc. • Warehouse Performance: Cornish Medical Electronics •V endor of the Year: PrePak Products Inc. BD sponsored the closing night party at the world-famous Wildhorse Saloon, featuring Barrett Baber, finalist of NBC’s “The Voice.” Baber came up with a mix of original and cover songs, including the first encore in NDC Exhibition history. Next year’s NDC Exhibition 2019 will return to the Gaylord Opryland Hotel & Convention Center, Nashville, Tennessee, April 7–9.

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Member of the Year: Medical

Member of the Year: Physical Rehab

IDN OPPORTUNITIES

Bridge-builder For Chris Torres and her team at Main Line Health, supply chain management and clinical resource management are a package deal

To tackle those issues, the supply chain executive and his or her team have to work hand in hand with clinicians, with trust, openness and respect, she says. That is every supply chain executive’s duty. Some – like Torres – had a head start.

Clinical resource management

Chris Torres

The supply chain executive as a utilization and waste management con-

sultant? “Yes,” says Chris Torres, system vice president, supply chain and biomedical engineering for Main Line Health, Radnor, Pennsylvania. “Some folks focus on cost,” says Torres, who was named 2018 Contracting Professional of the Year by the Journal of Healthcare Contracting, sister publication to Repertoire. “In my mind, it’s not the price [of supplies and equipment] that’s most important. It’s how we use it and how we can not waste it.”

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Founded in 1985, Main Line Health (MLH, the System) is a not-forprofit health system serving portions of Philadelphia and its western suburbs. At its core are four of the region’s respected acute care hospitals – Lankenau Medical Center, Bryn Mawr Hospital, Paoli Hospital and Riddle Hospital. MLH also includes Bryn Mawr Rehab Hospital, Mirmont Treatment Center for drug and alcohol recovery, and MLH HomeCare & Hospice, a home health service. Additionally, MLH consists of Main Line HealthCare (MLHC), one of the region’s largest multispecialty physician practices; the Lankenau Institute for Medical Research, a non-profit biomedical research organization; and five outpatient health centers. As the system vice president of supply chain management and biomedical engineering, Torres oversees more than 250 employees in biomedical engineering, contracting, inventory control and logistics. The supply chain management

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IDN OPPORTUNITIES team is responsible for approximately $300 million in spend. The program encompasses an in-house biomedical equipment management program, strategic sourcing, supply chain management technology and data analytics, clinical resource management aligned with clinician engagement, and systemized logistics management. For the past two years, Torres and her team have been redesigning Main Line Health’s value analysis/technology assessment program. “The Clinical Resource Management program (CRM) is an important foundation for our performance excellence work,” she says. The program is a systemized approach to reviewing new products, services and technology, and is guided by the Institute of Medicine’s STEEEP principles, where STEEEP is an acronym for six aims of healthcare – Safe, Timely, Effective, Efficient, Equitable, Patient-centered. CRM provides Main Line Health with tools and data to address the standardization of care and optimize patient outcomes, says Torres. “A key to success is our clinician engagement process. We have open communication with our clinicians, we are transparent with our cost data, and we share the responsibility of the ‘total value of care.’ “We are embarking upon the difficult journey of ‘bending the Medicare cost curve,’” she continues. The team is looking at variations in care, outcomes, and a more holistic approach to delivering high-quality care to patients. “Our hope is that this work will result in a sustainable model, which reduces variation in care, focuses on utilization and waste, and shows reduction in the total cost of care.” Using STEEEP principles, for example, Main Line Health is trying to answer questions such as, For a certain patient population, do we need order sets that require an X-ray q8 hours when evidence-based medicine demonstrates that q24 hours is a safe and effective practice? “In the supply arena, we will work with our clinicians to determine if we really need 15 shoulder anchors, when perhaps four would deliver the same results.”

Just several months into the CRM program, Torres lists these accomplishments: • Increased physician engagement, evidenced by their participation in work groups and in vendor negotiation meetings. • Increased awareness of everyone’s accountability for managing the supply chain. (“We are getting ideas directly from front-line staff as they relate to waste and utilization management opportunities,” she says.) • Identification of standardization/utilization management opportunities, such as review and standardization of custom surgical packs and expansion of Main Line Health’s reprocessing program. • Implementation of a much more stringent vendor management program related to access to surgical suites. • Issuance of multiple RFPs in the physician-preference arena, targeting vendor consolidation as well as price reductions.

“ A key to success is our clinician engagement process. We have open communication with our clinicians, we are transparent with our cost data, and we share the responsibility of the ‘total value of care.’”

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Utilization consultants There’s no doubt that her clinical background has helped Torres build the clinical resource management program. (She became certified as a surgical technician while still in college.) But every supply chain executive has the tools to become utilization consultants for their health systems, she says. “The first place to start is with relationships built on trust and respect. Providing ‘actionable data’ to your clinicians is key. “You don’t have to be the expert in the clinical arena,” she continues. “As a supply chain leader, you have access

Clinical resource management What clinical resource management is Clinical resource management is a conscious, consistent and expedient decision-making process, explains Chris Torres, system vice president, supply chain and biomedical engineering, Main Line Health, Radnor, Pennsylvania. It: • Uses interdisciplinary teams across the continuum of care. • Has executive engagement and support. • Uses STEEEP principles (Safe, Timely, Effective, Efficient, Equitable, Patient-centered). •U ses DMAIC principles, a process improvement strategy whose acronym stands for Define, Measure, Analyze, Improve, Control. • Uses a “system lens” for all discussions. • Focuses on utilization, standardization and waste management. • Ensures that training, education and communication on new products, services and

to a plethora of connections in the end user space. Leverage those contacts to assist in understanding the landscape of use.” Supply chain executives should capitalize on the expertise of their VAC/TAC team members, she says. “Aligning with your CNO and CMO is a great place to start. They lead the teams that use the products, services or technologies, and they can be champions for your projects. “If your data is accurate and if it provides a path to action, your clinicians will follow, as they are scientists and use rational thinking skills in problem-solving.”

Grooming tomorrow’s leaders Over the past five to seven years, Torres has focused on building a team of “stars,” who are empowered to think outside the box, make decisions, feel confident that she will always have their back, and celebrate their successes. “Supply chain management is hard work, if you do it correctly,” she says. “It’s not about chasing price. It’s

technology are completed prior to introduction into the care continuum. (Focus is maintained on patient safety; enhanced staff education and inservicing.) What clinical resource management is not Clinical resource management is not: •A wish list. Rather, products, services and technologies are evaluated based on their total value to care, not just because they are the latest and greatest. • S imply a product review committee. CRM forces the team to look beyond product cost, to the outcomes associated with the product, service or technology. •A path to find the cheapest product. Price is the last factor considered. • A means to delay product approval. Rather, it is a process to make informed decisions.

about understanding the life cycle of the products, services and technologies we use; the total cost of ownership; measurable outcomes; engaging partners; and doing the right thing for patients.” Selecting people with that frame of mind and heart is one of the supply chain executive’s most important functions, she says. Supply chain management is by no means unique to healthcare, but healthcare does present some unique demands. “The big question [when considering bringing on new people] is, ‘What are the traits needed in a healthcare supply chain professional?’” Given the urgency of healthcare, where the stakes can be life or death, “you need people with heart as well as common sense,” says Torres. “I can teach tasks, such as how to stock a unit or place an order. But does my contract manager know the importance of what they do every day? We talk about Lean Six Sigma, but ‘heart’ doesn’t fall in those guidelines.”

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June 2018

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Step Up! In a point-and-click world, it’s up to the rep to make a difference

ealthcare providers have more information and power at their fingertips today than ever before. Online sellers, most recently, Amazon, are making a bid for their business. So, what does a sales rep bring to the table? A sense of understanding, empathy and compassion. A desire to learn and to serve, and a sense of accomplishment when they help their customers succeed. Throw in some technology, and you have a sales force that providers can’t be without. Repertoire talked to three manufacturers who agree. They are: •S hawn Austin, vice president of sales, BD Diagnostic Systems Non-Acute Business. • J ason Dukarm, group marketing manager, Point-of-Care, cobas Liat & Channel Marketing, Roche Diagnostics Corp. • J ack Moran, managing partner, MedTech/MedCare, LLC.

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Repertoire: Name a few ways in which tomorrow’s manufacturer rep must demonstrate their value to the millennial-generation customer, who’s used to a convenient, point-and-click world. Shawn Austin: First, reps have to be prepared and skilled in offering specific market insights and professional consultation services outside what can be reached on the web and in the general market domain. Customers are much better informed than they have ever been. Second, reps should be able to demonstrate a personal investment and customized knowledge of solutions for each customer. Whether realized or perceived, customers require a higher level of customized consultation for their account specifics. They require customized solutions. And third, reps should be open to responding and communicating outside the traditional business times and communication paths. Customers expect near realtime responses and actions. Overall, our millennial customers value relationships, but they view response time and access to their representatives with different expectations.

well as understand the potential influence of adversaries on adoption or acquisition of their products. Third, this dramatic evolution in the buying process reinforces the need for reps to shift their understanding of their role. They need to evolve from simply facilitating a transaction to being a value-based consultant who can clearly articulate messages that differentiate their solutions in a way that enables customers to translate that value back to their own organizations, especially as it relates to financial savings or operational impact. Jack Moran: Relationships matter, but today’s customers place less value on those relationships and more on data. Reps can gain credibility with their accounts by using that data to learn more about them prior to the sales call.

“ Sales representatives have to be able to demonstrate insight into a customer’s largest challenges, reimbursement trends, upcoming market changes and be able to positively impact their customer’s bottom line.”

Jason Dukarm: First, because information is available at customers’ fingertips today, tomorrow’s manufacturer rep must be able to understand the social and digital forces that are influencing this audience. For example, my view is that millennial-generation customers form opinions quickly, given their high adoption of social media platforms such as Twitter, Instagram, Pinterest and others. As a result, it’s important for manufacturer reps to adopt a similar level of engagement with social platforms in order to be seen as “relevant” to those audiences, but even more so, to create their own level of professional promotion to garner their own circle of influencers. Second, reps need to grasp the influence of the broader digital world of purchasing and e-commerce. This generation of buyers seeks peer-reviewed opinions before entering any buying decision, so the manufacturing rep would be wise to monitor and leverage the power of strong online customer networks and advocates, as

–Shawn Austin

Repertoire: What new skills will your reps need to acquire, particularly those who have been used to one way of working with customers and potential customers? Austin: A sales representative’s agility and breadth of knowledge outside the traditional product features/benefit are a must. It is no longer good enough to simply know your product and the competitors. Sales representatives have to be able to demonstrate insight into a customer’s largest challenges, reimbursement trends, upcoming market changes and be able to positively impact their customer’s bottom line. Dukarm: Expediting the evolution to being a valuebased consultant has been critical for our reps, so we’re

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Step Up continuously stepping up our game across our level of sales execution. For instance, we’ve made key training investments to help our teams better understand the impact of healthcare reforms and other market forces, so that they can turn these customer challenges into opportunities. As part of the evolution to selling solutions instead of products, we have also created crossportfolio initiatives related to what we call clinical focus areas, such as antibiotic stewardship, where deeper conversations can be held with a broader spectrum of buying influences about issues of concern that are related to more than individual products. We want our customers to thrive in this new healthcare environment and look to Roche to help them solve their problems. In terms of skills, we never stop emphasizing the basics of blocking and tackling on the front lines.

about products and forming relationships. Yes, we need to do all that today. But doing our homework is critical. Repertoire: What new skills will be needed on the part of your distributor partners? Austin: We continue to see additional value in the distribution partners who are training and guiding their teams on strategic planning and targeting with their manufacturers. The ability for distribution reps to efficiently point to strategic opportunities for the manufacturer and demonstrate a command of their local market helps with time management and the resource limitations. Dukarm: We’re all in this together, and our reliance on distribution partners to help position our solutions is vital to our growth in the market. We hear from our partners every day of their willingness to stay educated on how the payer landscape and regulatory environment are changing and impacting buying decisions. I think service delivery will continue to be the single most valuable requirement to the customer. Distributor reps know this, as many of them have long-standing relationships with –-Jack Moran their customers. Having said that, remaining static in knowledge is not an option for them. It’s critical to continue seeking out new and inventive ways to bring enhanced value to customers, and the reps that can elevate conversations beyond the product to a solution sale, which addresses higher-level problem, will be most successful in this environment.

“ Reps can gain credibility with their accounts by using that data to learn more about them prior to the sales call.” But beyond this, our reps are sharpening their engagement skills and moving outside of the lab to other key stakeholders who are driving core health system initiatives. For healthcare providers, the move from fee-for-service reimbursement to value-based care is as much about cost avoidance as it is about revenue generation. So our teams are trying to form consultant partnerships with our customers, enabling us to gain deeper insights, ask them tough questions, and present alternative ways to help them envision their new state. Moran: In the past, we would show up at an account with the distributor rep, then spend a lot of time learning more about the account. Today, before such meetings, our reps have already invested time in the office to learn about the customer. They’re saying, “If I’m going to that meeting, I need to make sure I know more than I have to know.” That’s very much a new skill, versus just being really good at talking

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Repertoire: Some manufacturers are stressing the importance to their reps of ride-days with distributors. Can you talk about the value of ride-alongs in today’s point-and-click world? Austin: BD Diagnostic Systems has very much evolved our approach and focus with distribution in the non-acute space. We have recently formed a Non-Acute Diagnostic Systems sales force. We entered into that investment with a mindset of treating our distributors like a customer and expanding our reach via a focused, disciplined approach with distribution. All aspects of the healthcare continuum are being asked to do more with less, and medical technology companies are

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Step Up no different. Our ability to partner with distribution partners from the local field level to a corporate level allows for enhanced efficiency and focus. We simply needed to change with the market demands and leverage the value of distribution better in our space.

distribution. As the team began to understand the value and importance of distribution, they developed co-travel plans as an intuitive part of developing field partnerships. The value of co-travel for both the local relationships and education allows our distributors to hear and see how we establish value around our solutions. This experience often prepares our distribution partners to carry that message to the end customers.

Dukarm: Lately Roche has been emphasizing the importance of ride-days with distributor reps because they provide many great benefits to both parties. Business reDukarm: During our national sales meeting in January, lationships start with common interest, trust, and feeling the Roche teams were hungry to gain insights from our confident that both parties have shared goals. Ride-days distribution panel on how they can best provide value to also present the chance for reinforcement of strategic tertheir distributor peers. We have a shared commitment ritory planning. Getting in the car together creates the best to invest in this critical business relationship, and we are setting for all of those things to happen, and whether it’s a hearing success stories across the cold call or pre-planned sales call, drivcountry. Good news travels fast, and ing the sales opportunity forward is alwe are optimistic that this beneficial ways a positive experience. practice will continue. We recognize that our distributor partners are juggling a million balls and Repertoire: How are your distributhousands of products. Beyond just tor partners responding to your getting “air-time” with them, it’s truly reps’ requests for ride-days? about winning together and solving cus– Jason Dukarm Austin: We went into it with an “eyes tomer problems. That can only happen wide open” approach and knowing when strong collaboration occurs and a that we all have a very precious resource in time. It was shared understanding of roles and ownership is in place. The important for us to understand and appreciate that our areas where we are winning the most with distribution are distribution partners also have very limited time in their where those things are happening on a consistent basis. days, and co-travel had to be a value-added experience. As we have created more value in the field and with our Moran: The complexity of the sales cycle increases as prodistributors, we continue to see more opportunities for viders get larger. The more complex accounts have mulco-travel. It’s a fairly simple formula: The more value we tiple stakeholders, and the distributor knows who they are. create in the field for distributors, the more open our partYes, we have access to more data than ever before. But on ners are in sharing their limited time resources with us. ride-days – especially in the more complex accounts – we want to be with a distributor rep who has a good map of Dukarm: The response from our distribution partners the relationships within the customer’s organization. has varied across the distributor networks we work with, The other thing is, there is growth within the specialist in part because each organization has very specific sales segment of the market. Many of those specialists are not objectives and product focus areas, and in some cases they part of the more complex IDNs. And distributors know may not align completely with ours. That’s normal, but specialists very well. That’s where we’re driving our team. the Roche Channel Account Managers that support our distribution relationships are working with each of them Repertoire: How are your salespeople responding to to identify shared goals and opportunities to collaborate. your call for more ride-days? What reservations do It’s safe to say that where we are both winning, it’s due to they have, if any? the time investment that distributor reps are making to Austin: We began with establishing a distribution playpartner with their Roche counterparts, and vice versa. book that outlined how and why it’s important to win with

“This generation of buyers seeks peerreviewed opinions before entering any buying decision.”

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Step Up Step up: A distributor’s perspective How are distributor reps demonstrating their value

in the point-and-click world? Repertoire asked Richard Bigham, vice president, primary care market, IMCO, for his thoughts. Repertoire: Name three ways in which tomorrow’s distributor rep must demonstrate his or her value to the millennial-generation customer, who’s used to a convenient, point-and-click world. Richard Bigham: Successful distributor reps will need to understand and gain proficiency with the communication preferences of millennials. Rep activities will need to be adjusted to meet buyer requirements. Millennials tend not to talk on the phone, and they expect real time exchanges through text messaging and social media. Failure to meet

one-size-fits-all. Choice and connectivity have created an empowered customer who is looking for a new type of customer experience, which highlights and rewards collaboration, customer care and the overall procurement process. Reps and their organizations must strive to provide a seamless buying experience with efficient processes and systems that do not slow the buyer down. Repertoire: What new skills will that require on the part of the field rep, particularly the older rep who has been used to one way of working with customers and potential customers? Bigham: Tenured sales representatives were trained and have spent much of their selling career following a traditional sales approach comprised of lead generation, lead qualification, proposal, negotiation and close. Traditional sales presentations and product demonstrations are being utilized less frequently due to the proliferation of product information available to today’s buyer. These buyers utilize multiple platforms and networks to research potential products and suppliers, resulting in a highly informed consumer and nontraditional sales cycle. Adoption and utilization of social media for communication with their customer base and to provide visibility to potential customers will be a necessary skill set and behavior for these tenured reps.

Choice and connectivity have created an empowered customer who is looking for a new type of customer experience, which highlights and rewards collaboration, customer care and the overall procurement process. these expectations will create the potential of a lost customer or opportunity. Millennial buyers expect sales representatives to be extremely knowledgeable about their customer’s business. Historically, reps have relied on traditional one-toone relationships during the sales process. As multiple influencers are now involved in buying decisions, the successful rep must thoroughly research and understand the needs of these sometimes disparate parties. Reps should understand the clinical, financial, regulatory, workflow and patient satisfaction implications of potential solutions and be able to clearly enunciate these to the influencers. Millennial buyers will expect a customized solution for their needs as opposed to the traditional

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Repertoire: Will the wants and needs of tomorrow’s customer require field reps to work differently with manufacturer reps? If so, how? Bigham: Given the millennial customer, distributor reps will still require the partnership and technical support of manufacturer reps. Delivery of information will change from an in-person meeting to delivery of required information through an online modality. We are currently seeing the effective utilization of webinars to

detail some types of capital equipment. The expectation of real-time responses will require enhanced cooperation and service level expectations for both distributor and manufacturer. Buyers expect the ability to research products online, which will necessitate the enhancement of many distributors’ online resources. Coordination with manufacturers to populate these sites with pertinent documentation has become a necessity. Repertoire: How are successful IMCO members preparing their reps for this future?

Bigham: Millennial buyers tend to seek out smaller enterprises that can provide flexible solutions specific to their needs. IMCO members are expanding their social media presence and continually refining their e-commerce platforms to mimic those utilized by buyers in their personal consumer activities. Member reps are continually provided learning opportunities on how to incorporate social selling as a component of their value proposition to current and potential customers. In addition, training is provided on reaching and addressing decision-makers outside of historical call points in customer organizations.

Selling in the point-and-click world Want to step up? Here’s what manufacturer and distributors recommend.

• Do your homework. Before a face-to-face meeting, learn more about your customer than you’ll need to know. • Rely less on phone contact, and focus on text messages, email and social media. • Be prepared to offer your customers market insights and professional consultation beyond what can they can find on the web or the general market. • Be prepared to offer customized solutions. • Provide near-real-time responses to customer requests. • Be as familiar around social media as your customers are, in order to be seen as “relevant.” • Monitor strong customer networks, including advocates as well as adversaries of your company and its products and services. • Elevate conversations beyond the product to a solution sale, which addresses higher-level problems. • Understand the clinical, financial, regulatory, workflow and patient satisfaction implications of potential solutions, and be able to clearly enunciate these to the influencers. • Provide a seamless buying experience with efficient processes and systems, which do not slow the buyer down.

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June 2018

POST ACUTE CARE

Length of Stay States finding out that the shorter the nursing-home stay following hospitalization, the better for the patient Policymakers are not only interested in reducing length of stay in hospitals but also nursing homes. An October 2017 report from the AARP Public Policy Institute explains why and how several states are working to reduce the percentage of older adults who receive long-term nursing home care after a hospitalization. The report, titled “State strategies to reduce the risk of long-term nursing home care after hospitalization,” describes strategies used in four highly ranked or significantly improved states – Connecticut, Maine, Minnesota, and Oregon. The paper also includes a toolkit of resources that can help others learn more and potentially replicate these practices. Following is an edited summary of that report, presented with permission from the AARP Public Policy Institute.

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Long-term nursing home residence can be a poor out-

come for residents and their families. Few people want to live in a nursing home, and most family caregivers want to do whatever they can to ensure that their family member does not remain in the nursing home any longer than necessary. People residing in nursing homes also may face much higher out-of-pocket costs than they would for community-based long-term services and supports (LTSS). Long-term nursing home stays may pose a cost problem for states as well, because long-stay residents are likely to spend down their resources and become eligible for assistance from Medicaid. Nursing home residents who are not discharged to the community within a few months are particularly at risk of a long-term stay. The likelihood of a nursing home resident returning to a community setting declines sharply after 90 days. Because most nursing homes provide both SNF care and long-term custodial care, transitions to longterm residence can be relatively easy. The good news is, older adults today are less likely to undergo longterm institutionalization after a hospital stay than they were a decade ago. They are more likely to receive supportive services at home or in community settings due to changing expectations about the role of nursing homes, the growing contributions of family caregivers, and the expansion of residential alternatives, such as assisted living.

State policies can make a difference. The ability of low-income older adults to make a successful transition to community living depends on the availability of personal care assistance services and other home-based supports. States, however, vary widely in how they use Medicaid state plan benefits and waiver programs – as well as statefunded programs – to meet the needs of older adults who are at risk of long-term nursing home stays. Some states and communities have robust home- and community-based services (HCBS) systems that enable people with LTSS needs to live independently and avoid nursing home placement. In one recent study of nursing home use in Medicaid, nursing home stays were shorter in states with higher HCBS spending and use. The AARP study describes how state policies in four states – Oregon, Maine, Minnesota and Connecticut –

Nursing home social workers remain responsible for discharge planning, but community living specialists collaborate with them to help residents and their family caregivers identify goals and needs, and plan for care in the community.

Better planning shows results Changes in the post-acute-care landscape – largely driven by changes in Medicare – also may be influencing the trends in long-term nursing home use, according to the AARP Public Policy Institute. In some states and communities, hospitals are giving greater consideration to discharge destinations and outcomes. Accountable care, value-based purchasing, and bundled payment programs are bringing increased attention to the role of post-acute care in helping people transition back into a community setting. Because nursing facility quality varies widely, hospitals are creating preferred provider networks to improve transitions and avoid preventable readmissions.

may reduce long-term nursing home care after a hospitalization and ensure timely and effective transitions back to community living. The first three states – Oregon, Maine, and Minnesota – are among the highest performing on this indicator. They also have relatively low Medicare SNF admissions and low overall nursing home use among older adults. Connecticut had a higher percentage of long stays posthospitalization in 2012 than the other three states (16.3 percent) and a higher rate of SNF admissions in Medicare (103 admissions per 1,000 enrollees), but its percentage of long stays declined significantly, from 18.2 percent in 2009 to 16.3 percent in 2012.

Minnesota’s Return to Community Initiative Minnesota’s Return to Community Initiative (RTCI) focuses on nursing home residents who are on Medicare and paying privately for long-term nursing home care (when they no longer qualify for Medicare’s skilled

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POST ACUTE CARE nursing facility benefit) and who may be at risk of spending down to Medicaid. The RTCI program identifies nursing home residents who fit a community discharge profile, but who remain in the nursing home after 60 days. Community living specialists – who are nurses or social workers employed by local AAAs – inform residents whose names appear on a list (produced weekly) about assistance that can help them plan for a successful transition home. Nursing home social workers remain responsible for discharge planning, but community living specialists collaborate with them to help residents and their family caregivers identify goals and needs, and plan for care in the community. The community living specialist assesses needs and helps residents and families understand the community resources that are available to them. Specialists, residents, and family caregivers develop a community living support plan that all agree can enable successful transition to the community that aligns with the resident’s goals and preferences. A community living specialist follows up with clients who have left the nursing home for their own home,

an assisted living facility, or another community setting. The program includes check-ins at specified intervals (a phone call or in-person visit within 72 hours, an in-person visit within 10 days, a 30-day and 60-day check-in, a 90-day check-in, and subsequent check-ins every 90 days for up to five years). This schedule can be modified to fit individual and family needs and preferences. During these follow-up calls or visits, the specialist assesses how well the plan is working and makes needed changes to enable people to live successfully in the community, and avoid rehospitalization or readmission to the nursing home. Since RTCI’s launch in April 2010, RTCI-assisted discharges have steadily increased – roughly 390 transitions per year and a total of 4,551 transitions as of May 2017. Most of the roughly 400 nursing homes in Minnesota have some RTCI-assisted discharges, although most facilities had five or fewer. Most of the people who returned to the community with support from the program fit the community discharge profile, that is, they preferred to reside in the community, had entered the nursing home as a post-acute admission, were relatively independent,

By the end of 2016, the Homeward Bound program had a total of 92 transitions, in line with the projected number of transitions from the program’s launch.

Nursing homes diversify Connecticut’s “Strategic Plan to Rebalance Long-Term Services and Supports” describes an agenda to support older adults, people with disabilities, and family caregivers in choosing how and where to receive services and supports. Nursing home diversification is an important part of the plan. To help nursing home operators diversify, the state created a grant program to help facilities fund new investments: to redesign their business models to accommodate the shift to community living, reduce the number of beds

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in the state, and reduce the percentage of discharges from hospitals to nursing facilities. The Connecticut Department of Social Services, in conjunction with the Connecticut Departments of Housing and Public Health, solicited proposals from nursing facilities and awarded $12 million in grants over a two-year period (2014–15). The nursing facilities receiving grant funds have invested in building an infrastructure for community services, including navigators, transition coordinators, affordable adult family living, and adult day services.

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POST ACUTE CARE and were not cognitively impaired or had only mild cognitive impairment. A year after discharge, half of the RTCI-assisted individuals lived in the community, 36 percent had been readmitted to a nursing home, and 14 percent had died. Only a small percentage (11 percent) had converted to Medicaid.

Maine’s Homeward Bound program Maine’s Homeward Bound program helps nursing home residents transition to community living through an approach that relies heavily on the state’s private, nonprofit Long-Term Care Ombudsman. The Ombudsman serves residents of nursing facilities and assisted

resident’s desire to return to the community]. Within a matter of days of receiving a referral, the Ombudsman makes in-person contact and provides general information about community living services and supports. The Ombudsman then makes referrals to the Center for Independent Living (Alpha One) and/or the local Aging and Disability Resource Center. By the end of 2016, the Homeward Bound program had a total of 92 transitions, in line with the projected number of transitions from the program’s launch. The program had made a total of 406 outreach contacts, exceeding its goal of 308 contacts from the beginning of the program, in 2013.

Oregon has among the lowest rates of nursing home use (3.3 percent of people ages 85+ reside in a nursing home) and low use of SNF care in Medicare compared with the national average. A recent initiative focuses on downsizing and diversifying the nursing home industry. housing programs, including residential care facilities and assisted living facilities, as well as people receiving services at home or in the community, such as adult day service settings. The Ombudsman is responsible for conducting outreach, initial eligibility screening, and completion of the Homeward Bound application form. Specifically, an advocate from the Ombudsman Program provides information about transition coordination, so an individual who is seeking services can choose one of the three agencies providing this service. Throughout the transition, Homeward Bound participants receive advocacy support from the Ombudsman. The Ombudsman Program also makes MDS section Q referrals [which address discharge planning and the

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Connecticut’s ‘Money Follows the Person’

Connecticut’s Money Follows the Person (MFP) demonstration program engages with people who need assistance with housing and services to achieve successful and sustained community living. Many MFP program participants have lived in a nursing home for three years on average. Since 2008, more than 3,900 people have transitioned from nursing homes to community living through MFP. Beginning in 2015, nursing homes are required to notify the Connecticut Department of Social Services when a resident is expected to qualify for Medicaid within a 180-day period. MFP program staff may then assess the resident to determine if he or she prefers, and is able, to live in the community; develop a care plan; and help the resident transition to the community. Connecticut strives to reduce the percentage of post-acute care discharges to SNFs. The state’s balancing plan calls for efforts to better inform and train hospital discharge planners about home- and community-based options for post-acute care. The percentage of Medicaid beneficiaries who were discharged from SNF to a community setting within six months increased from 27 percent in 2009 to 41 percent in 2015. Across all payers, the percentage of people needing supportive services discharged from the hospital to

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POST ACUTE CARE

Care transitions improved Minnesota is a national leader in setting policy standards for nursing home quality of life and quality of care. The nursing facility Performance-based Incentive Payment Program (PIPP) is one of many strategies designed to improve quality for people who need longterm services and supports. The program has funded projects designed to improve care transitions, including efforts to reduce hospitalizations and increase successful transitions to the community. Since 2007, 261 facilities (of the roughly 400 in Minnesota) have participated in the program. SNFs have focused on a wide variety of topics, including clinical quality (87

home increased from 47 percent in 2008 to 55 percent in 2016, while hospital discharges to SNFs declined from 53 percent in 2008 to 45 percent in 2016.

Oregon’s quality improvement program Some highly ranked states, including Oregon, Connecticut, and Minnesota, have incentivized quality improvement in nursing homes (including discharge planning and transitional care services) and have worked with nursing homes to close, downsize, and diversify into community care. Oregon has among the lowest rates of nursing home use (3.3 percent of people ages 85+ reside in a nursing home) and low use of SNF care in Medicare compared with the national average. A recent initiative focuses on downsizing and diversifying the nursing home industry. As Oregon has expanded its Medicaid HCBS programs, most recently with the implementation of its 1915(k) Community First Choice waiver program, nursing home caseloads have declined, falling from roughly 5,000 per year on average in 2005-07 to just over 4,000 per year

projects), psychosocial aspects of care (46 projects), organizational change (39 projects), technology (22 projects), and care transitions (20 projects). The PIPP projects focused on care transitions reflect the growing consensus that transitional care interventions can improve transfers from nursing homes to home for older adults. Improving care transitions, however, may require significant improvements in nursing home resources, including the availability of nursing and medical staff, diagnostic and pharmacological services, and adequate social services for resident and family engagement and follow-up.

in 2013-15. The resulting drop in nursing home spending offsets some of the increased spending on HCBS. But, unless some nursing homes close, the fixed costs associated with nursing facilities will reduce the savings associated with fewer nursing home residents. That’s why Oregon has pushed for reductions in nursing home bed capacity and opportunities to expand residential and supported housing alternatives to nursing home care. A 2013 law (Oregon House Bill 2216) provided incentives to the nursing home industry to reduce bed capacity by 1,500 beds by June 30, 2016 – changing the nursing facility rate calculation if the 1,500-bed reduction target is not met. The Oregon Department of Human Services works with local nursing facility providers that are considering taking advantage of the capacity-reduction initiatives to assess opportunities for more residential and supported housing capacity development. As of May 2017, the number of nursing home beds had been reduced by 1,210, 80 percent of the 1,500-bed target.

Editor’s note: The AARP Public Policy Institute’s “Long-Term Services and Supports Scorecard Promising Practices: State Strategies to Reduce the Risk of Long-Term Nursing Home Care after Hospitalization,” can be accessed at www.longtermscorecard.org/~/media/Microsite/Files/2017/reducingtheriskoflongtermnursinghomecareafterhospitalization.PDF

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Nursing facility statistics A recent report published by the Kaiser Family Foundation – “Nursing Facilities, Staffing, Residents and Facility

Deficiencies, 2009 Through 2016” – provides information on recent trends in nursing facilities in the United States, drawing on data from the federal On-line Survey, Certification, and Reporting system (OSCAR) and Certification and Survey Provider Enhanced Reports (CASPER). Here are a few highlights. • Nationwide, the number of nursing facility beds has been fairly consistent since 2009, reaching 1.6 million certified beds in 2016 (with an average of 109 beds per facility). However, nursing facility occupancy rates declined slightly from 2009 to 2016, from 84 percent in 2009 to 81 percent in 2016. • From 2009 to 2016, the share of nursing facilities that were for-profit increased slightly, from 67 percent in 2009 to 69 percent in 2016, while the share that were non-profit declined slightly, from 26 percent in 2009 to 24 percent in 2016. (The remainder – about 7 percent – were government-owned.) Ownership patterns vary widely across states, with states in the South and West having higher shares of facilities that are for-profit. • More than half of facilities over the 2009-2016 period were owned or leased by multifacility organizations (chains that have two or more facilities), though the share of nursing facilities that are chain-owned varies by state. • A year of nursing facility care typically costs over $82,000, and national spending on nursing facilities across all payers totaled $162.7 billion in 2016. • Medicaid is the primary payer source for most certified nursing facility residents, with more than six in ten (62 percent) residents – about 832,000 people – having Medicaid as their primary payer in

2016. States in the East, particularly the Southeast, have higher shares of residents with Medicaid as their primary payer than other states. • On average, in 2016, residents’ level of need for assistance with activities of daily living scored 5.8 on a scale from 3 to 9, and levels of need have been fairly stable since 2009. • While only 4 percent of residents were bed-bound in 2016, over six in ten (65 percent) of residents depend on a wheelchair for mobility or are unable to walk without extensive or constant support from others. • Nearly half (45 percent) of residents had a dementia diagnosis in 2016, and 32 percent had other psychiatric conditions such as schizophrenia, mood disorders or other diagnoses. In addition, nearly two-thirds (63 percent) of residents received psychoactive medications, including anti-depressants, anti-anxiety drugs, sedatives and hypnotics, and anti-psychotics, in 2016. • In 2016, the most common deficiencies given by state surveyors concerned failures in infection control, accident environment, food sanitation, quality of care, and pharmacy consultation. Of particular concern were deficiencies that cause harm or immediate jeopardy to residents. In 2016, more than one in five facilities received a deficiency for actual harm or jeopardy.

Source: Nursing Facilities, Staffing, Residents and Facility Deficiencies, 2009 Through 2016, Kaiser Family Foundation, https://www.kff.org/medicaid/report/nursing-facilities-staffing-residents-and-facility-deficiencies-2009-through-2016/

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POST ACUTE CARE: HIDA INSIGHTS

Health Systems Look to Strengthen Partnerships with Distributors By Ann Peters, Manager, Research & Analytics

Distributors are helping their health system custom-

ers rise to the challenge of reducing costs while improving the quality of care, according to HIDAâ&#x20AC;&#x2122;s 2018 Horizon Report: Health System Supply Chain Strategies. The vast majority (88 percent) of these providers are satisfied with their prime vendor distributor, and 40 percent say they plan to increase the role medical-surgical distribution plays in their supply chain. Drawing on a survey of 171 integrated delivery network executives, this new Horizon Report looks at how

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health systems work with their distributor partners. Key insights from this research include:

Hospitals and health systems rely on medical-surgical distribution Most (90 percent) health systems have a prime vendor distributor, and 24 percent purchase most or all of their physician preference items from distributors. Providers are also generally happy with their distributors, with only 4 percent reporting some level of dissatisfaction.

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Health systems highly value their distributor partners for driving supply chain efficiency by streamlining ordering and procurement, reducing supply chain costs, and managing demand spikes.

Most providers not planning to invest in self-distribution While many (71 percent) health systems perform some internal distribution of medical supplies to care settings, the majority are not planning to build new supply chain facilities. Only 8 percent of respondents say they will build new distribution centers within the next three years, and only 7 percent say they will build consolidated service centers in this time frame. A Director of Supply Chain from the Northeast commented that they look to source products through a distributor whenever possible, as it allows them to save on freight costs. A number of supply chain executives highlighted the value of distributors’ expertise, saying they were looking for a “partnership relationship” as they look to enhance efficiency and outsource non-acute distribution.

Cost-reduction at top of buyers’ agendas Cost reduction is top-of-mind for supply chain executives. Perceived cost reduction is the leading reason

11/30/17 11:27 AM

executives cite for purchasing direct, and the most common difficulty they have when purchasing direct. By working with distributors, supply chain executives can lower costs in a number of ways. Threequarters of respondents say working with distributors reduces their need for real estate or inventory, 66 percent say it lowers their supply chain costs, and 55 percent say it reduces the need for capital investment. While respondents rank cost reduction as the leading benefit of working with a distributor, there are several other factors that supply chain executives value when working with distributors. To learn more about this research, and what supply chain leaders value about their distributor partners, visit www.HIDA.org/HorizonReport.

By working with distributors, supply chain executives can lower costs in a number of ways. Three-quarters of respondents say working with distributors reduces their need for real estate or inventory, 66 percent say it lowers their supply chain costs, and 55 percent say it reduces the need for capital investment.

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June 2015

SPONSORED GOJO

Triclosan Hand Soaps are Banned in Healthcare What do you and your customers need to know?

If you haven’t already heard, in December 2017, the

Food and Drug Administration (FDA) issued a final rule on the safety and efficacy of certain active ingredients used in antiseptic hand soaps in healthcare. The biggest impact to healthcare facilities is that triclosan, the most commonly used soap active, is no longer permitted as an active ingredient. As a result, triclosan-based hand soaps can no longer be marketed and sold, and manufacturers will have one year to comply with the final rule by reformulating their products or removing them from the market.1 Sales representatives and distributors are uniquely positioned to guide customers and key decision makers who may not fully understand the final rule and its implications. There are three things you will want to do when approaching your customers on this topic: • First, verify that the facility is using a triclosan-based soap. Some facilities are unaware of the type of soap they are using. The focus of many hand hygiene programs is (rightfully so) hand sanitizer because it is the preferred method for cleaning hands that are not visibly soiled. Less attention has been given to soap in the past, so these changes are an opportunity to evaluate current products.

GOJO Offers a Full Line of Triclosan-Free Soap Solutions

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• If a triclosan soap is being used, determine how much product inventory is on-hand. The final rule does not state that healthcare facilities must immediately stop using triclosan; rather, it means that manufacturers must stop selling it within 1 year. If the facility has a large inventory of triclosan soap, the options are to discard it or use it up. Keep in mind that healthcare workers may have concerns around the FDA announcement and

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SPONSORED GOJO about ongoing use of the triclosan, so advise healthcare facilities that they should be prepared to answer questions, justify the rationale for continuing its use until inventory is gone, and discuss the planned course of action. At some point, suppliers will no longer provide triclosan soap. Make sure the customer is aware of that date and help them prepare.

Relative Efficacy of Different Hand Hygiene Preparations

Bacteria Reduction

Water Rinse

Antimicrobial ABHR Soap

Centers for Disease Control and Prevention. Guidelines for hand hygiene in health-care settings —2002. Recommendations of the Healthcare Infection Control Practices Advisory Committee and the HICPAC/SHEA/APIC/IDSA Hand Hygiene Task Force. MMWR 2002;51 (RR-16):1-45.

• Discuss triclosan alternatives. Some customers will want to stay with an antimicrobial soap and others may use this opportunity to explore switching to a non-antimicrobial soap. They may look to you for guidance, so it will be helpful to know how to walk them through that decision-making process.

Helping customers choose a soap Choosing a soap can be confusing, especially given current recommendations. Both the Centers for Disease Control and Prevention (CDC) and the World Health Organization (WHO) hand hygiene guidelines allow the use of either an antimicrobial or a non-antimicrobial soap, and due to a lack of evidence demonstrating clinical benefit (i.e. resulting reduction of infection rates), do not recommend one over the other.2,3 However, studies of bacterial reduction on the hands support that alcohol-based hand rub (ABHR) is most efficacious, followed by antimicrobial soap, followed by non-antimicrobial soap as least efficacious (see figure above).2 That said, healthcare facilities are permitted the choice between antimicrobial and non-antimicrobial soap, or may use a combination of the two. A good way to approach the decision of whether to choose an antimicrobial or a non-antimicrobial soap is to consider risk reduction. The greatest risk reduction will be achieved by using an antimicrobial soap, which will result in a higher log reduction of bacteria on hands. Non-antimicrobial soap will result in a lower log reduction of bacteria on hands and leave more bacteria behind, References:

Non-Antimicrobial Soap

which could potentially mean pathogens are transmitted to patients. Therefore, facilities seeking the highest level of risk reduction should choose an antimicrobial soap. There are other factors that should be considered Some facilities are when selecting a soap, such unaware of the as whether the product meets type of soap they FDA efficacy requirements, is are using. The focus gentle on skin, and whether of many hand hygiene programs is healthcare workers like aspects of the soap such as the lather, (rightfully so) hand scent, and rinsing factor. In sanitizer because addition, the logistics involved it is the preferred with potentially switching dismethod for cleaning pensers, disruptions to the hands that are not clinical workflow, and adjustvisibly soiled. Less ment to change for healthcare attention has been workers means it’s especially given to soap important to work with healthin the past, so care facilities to carefully select these changes the right product and the right are an opportunity dispensing solution. to evaluate For in-depth informacurrent products. tion on recent FDA regulatory changes and factors to consider when selecting a soap in healthcare, download this free whitepaper from GOJO by visiting http://gojo. com/HealthcareSolutions.

1. F DA issues final rule on safety and effectiveness for certain active ingredients in over-the-counter health care antiseptic hand washes and rubs in the medical setting [FDA In Brief]. Silver Spring, MD. U.S. Food and Drug Administration; December 19, 2017. https://www.fda.gov/NewsEvents/Newsroom/ FDAInBrief/ucm589474.htm. Accessed April 17, 2018 2. C enters for Disease Control and Prevention. Guidelines for hand hygiene in health-care settings—2002. Recommendations of the Healthcare Infection Control Practices Advisory Committee and the HICPAC/SHEA/APIC/IDSA Hand Hygiene Task Force. MMWR 2002;51 (RR-16):1-45. 3. W orld Health Organization. WHO guidelines on hand hygiene in health care. First global patient safety challenge: clean care is safer care. http://whqlibdoc.who.int/publications/2009/9789241597906_eng.pdf. Published 2009. Accessed April 6, 2018.

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INFECTION PREVENTION

Infection prevention: It never sleeps

Infection prevention has been top of mind for health-

care providers for years. Yet, The Joint Commission recently reported that in 2017, 60 percent of ambulatory care facilities, 72 percent of hospitals and 62 percent of officebased surgery practices still were “not compliant” with its standard to “reduce the risk of infections associated with medical equipment, devices and supplies.” Surprising? Maybe. Maybe not. “When you think of the sheer number of opportunities for cleaning and performing low-level disinfection of medical equipment, devices, and supplies daily within a healthcare facility, you can imagine how challenging it is to ensure that correct processes – Sylvia Garcia-Houchins are followed each and

“We’re not talking about cleaning and disinfecting scalpel blades and forceps.”

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every time,” says Megan DiGiorgio, MSN, RN, CIC, FAPIC, clinical manager for GOJO Industries. “In addition, many different healthcare workers might clean or disinfect items, and they have various levels of training, depending on their role. “Performing processes correctly all the time, every time, is critical to patient safety, and healthcare facilities are working towards meeting The Joint Commission Standard. But it’s not going to happen overnight. There must be a continuous focus on quality in order to see improvement.” Sylvia Garcia-Houchins, MBA, RN, CIC, director of infection prevention and control for The Joint Commission, says there are plenty of reasons for the recent statistics: • Instrumentation and equipment are more complex than ever before. • Manufacturers’ instructions for cleaning and disinfection need to be improved. • Cleaning and disinfecting surgical instruments is a tough, demanding job.

“Nobody goes to work to do a bad job,” she says. “We need to give people the resources to do a good one,” she says. Repertoire readers can help.

Exacting work “Today’s high-tech items can do things we never thought possible,” says Garcia-Houchins, pointing to ERCP scopes as just one example. “But with that comes incredible complexity. We’re not talking about cleaning and disinfecting scalpel blades and forceps.” On top of that, different types of equipment and instrumentation call for different processing techniques. Those in the OR and central sterile processing need to stay on top of all those requirements. Medical device manufacturers don’t always make it easy. “I have trouble reading the instructions for cleaning an endoscope from a leading manufacturer,” she says. In fact, she checked the readability stats of those instructions and found them to be at the 20th reading level. That’s the stuff that people with master’s degrees and PhDs read. Then there are simply the demands of the job, which are high, says Garcia-Houchins. “You’re asking people to take something with very high bacterial burden, and bring those levels down so the device can be disinfected. Cleaning is the key step.” Not everyone in the OR or central sterile uses the same technique or possesses the same skill levels. The workloads are demanding, and setting priorities in a busy OR can be difficult. “You’re depending on people to do the greatest job possible, over and over again, and that’s challenging. The devil is in the details – reading every single line of instructions, making sure you dot all the ‘i’s and cross all the ‘t’s. Then think about all the different types of medical equipment and devices in use, each with its own cleaning and disinfection instructions.” Challenging? Yes. Hopeless? No.

levels of the organization is critical to ensuring sustained improvement. The Joint Commission outlines the key elements of performance that healthcare facilities need to follow to demonstrate commitment to improvement, including training and competency, adequate staffing and supervision, process standardization and reinforcement, and ongoing quality management.” Distributor reps should take the time to ask their customers about their challenges, and then determine how their products can help customers overcome them. “In my experience, too often reps lead with their solution,”

“ Performing processes correctly all the time, every time, is critical to patient safety, and healthcare facilities are working towards meeting The Joint Commission Standard. But it’s not going to happen overnight.”

Solutions “As with any problem that is complex, there isn’t a single solution,” says DiGiorgio. “Education alone won’t solve the problem,” she says. “A multifaceted approach is needed, and support at all

– Megan DiGiorgio

she says “By taking the extra time to get to know the customer’s needs, you’ll establish a better relationship up front and going forward.” Garcia-Houchins believes it is up to the leaders in the processing area to help their employees do the best job they can. Some examples: • Make sure that lighting is adequate. • Rotate duties in the processing area, so people don’t have to bend over for hours at a time. • Give people a break. Who can wash dishes – let alone complicated medical devices – for eight hours straight? • Improve the workspace. Is there adequate counter space? How about sink access? Warm water? Garcia-Houchins suggests posting step-by-step processing instructions on wall charts. “Some people are visual, some are more auditory. Consider providing video or audio processing instructions. “Processing is not a job you can do quickly. People need the time to do it carefully and consistently. And that goes back to the hiring process. There is a certain kind of person you will need to hire.” Hire them and give them the support they need to succeed, she says.

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June 2018

INFECTION PREVENTION

Hep C screening still low vision of Population Science, Moffitt Cancer Center. “Most of the baby boomers who screen positive for in the United States in recent decades, data from 2015 indiHCV infection were infected over 30 years ago, before cates that less than 13 percent of individuals born between the virus was identified.” 1945 and 1965 are estimated to have undergone screening Because over 75 percent of HCV-positive individuals for hepatitis C virus (HCV), according to results published were born between 1945 and 1965, both the Centers for in Cancer Epidemiology, Biomarkers & Prevention, a journal of Disease Control and Prevention and the U.S. Preventive the American Association for Cancer Research. Services Task Force now recommend that baby boomers “In the United States, approximately one in 30 baby get screened for the virus. However, data from the 2013 boomers are chronically infected with HCV,” Susan VadaNational Health Interview Survey (NHIS) indicated that parampil, PhD, MPH, was quoted as saying. She is senior only 12 percent of baby boomers had been screened for author, senior member and professor, Health Outcomes HCV, Kasting explained. and Behavior Program, Moffitt Cancer Center, Tampa, The researchers wanted to study if HCV screening Florida. Almost half of all cases of liver cancer in the rates had increased following the FDA approval of several United States are caused by HCV, she added. well-tolerated and effective treatments for HCV infection. “Hepatitis C is an interesting virus because people Using NHIS data from 2013-2015, Kasting and colwho develop a chronic infection remain asymptomatic leagues analyzed HCV screening prevalence among four for decades and don’t know they’re infected,” said lead different age cohorts (born before 1945, born 1945-1965, author Monica Kasting, PhD, postdoctoral fellow, Diborn 1966-1985, and born after 1985). Participants were asked if “Hepatitis C is an had ever had a blood test for interesting virus because they hepatitis C. As the researchers were people who develop a interested in assessing HCV screenchronic infection remain ing in the general population, they excluded certain populations who asymptomatic for more likely to be screened for decades and don’t know were the virus, resulting in a total sample they’re infected.” size of 85,210 participants. Kasting and colleagues found – Monica Kasting that females were screened less often than males in every age cohort. Additionally, among baby boomers and those born between 1966-1985, HCV screening rates were lower among Hispanics and non-Hispanic Blacks. “This is concerning, because these groups have higher rates of HCV infection and higher rates of advanced liver disease,” noted Kasting. “This may reflect a potential health disparity in access to screening, and therefore treatment, for a highly curable infection.” Among baby boomers, HCV screening rates ranged from 11.9 percent in 2013 to 12.8 percent in 2015. Regardless of the federal screening recommendations, less than 20 percent of baby boomers reported that the reason for their screening was due to their age.

June 2018

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HEALTHY REPS

Health news and notes All is not lost

Go easy on yourself

Scientists from Columbia University presented new evidence that our brains continue to make hundreds of new neurons a day, even after we reach our 70s, in a process known as neurogenesis, reports The New York Times. That’s the good news. The not-so-good news? Researchers did uncover some differences in the brains of young people and older people. Specifically, they found that development of new blood vessels in the brain decreases progressively as people get older. They also discovered that a protein associated with helping new neurons to make connections in the brain decreased with age. This might explain why some older people suffer from memory loss or exhibit less emotional resiliency, according to researchers.

A healthy dose of self-compassion actually helps us form habits that support good health, reports the Washington Post. A 2017 study published in Health Psychology Open found that people who have higher levels of self-compassion tend to handle stress better – they have less of a physical stress response when they are stuck in traffic, have an argument with their spouse or don’t get that job offer – and they spend less time reactivating stressful events by dwelling on them. That’s important, because not only does chronic stress directly harm health – the physical responses to stress include spikes in blood pressure and blood sugar, along with suppression of the immune system – but if you also react strongly to stress, you’re more likely to use unhealthy short-term coping mechanisms such as smoking or numbing your feelings with food or alcohol. The study also found that self-compassionate people are more likely to adopt health-promoting behaviors and maintain them even if they don’t appear to be paying off in the short term.

The cost of loneliness Loneliness can hurt productivity and profits. The share of American adults who say they’re lonely has doubled since the 1980s to 40 percent, according to a report in the Washington Post. Though the U.S. doesn’t track the financial effect of disconnected workers, researchers in Britain estimate the penalty to businesses can reach $3.5 billion a year, accounting for higher turnover and heftier healthcare burdens. A recent study in the Harvard Business Review found 61 percent of lawyers surveyed ranked “above average” on a loneliness scale from the University of California at Los Angeles. Other particularly lonely groups were engineers (57 percent), followed by research scientists (55 percent), workers in food preparation and serving (51 percent), and those in education and library services (45 percent).

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Are you ready, boots? Exercise does not have to be prolonged in order to be beneficial, according to a study published in the Journal of the American Heart Association. It just has to be frequent. “Despite the historical notion that physical activity needs to be performed for a minimum duration to elicit meaningful health benefits, we provide novel evidence that sporadic and bouted [moderate-to-vigorous physical activity] are similarly associated with substantially reduced mortality,” write the researchers. “This finding can inform future physical activity guidelines and guide clinical practice when advising individuals about the benefits of

INNOVATION EXPO

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HEALTHY REPS physical activity. Practitioners can promote either long single or multiple shorter episodes of activity in advising adults on how to progress toward 150 minutes-per-week of moderate-to-vigorous physical activity]. This flexibility may be particularly valuable for individuals who are among the least active and likely at greater risk for developing chronic conditions.

Obesity and cancer Doctors can’t always explain why one person gets cancer and another doesn’t. But research has shown that certain risk factors may increase a person’s chance of getting cancer, reports National Institutes of Health. One risk factor is obesity, or having too much body fat. Many studies have found links between obesity and certain types of cancer. That doesn’t mean obesity is the cause of these cancers. People who are obese or overweight may differ from lean people in ways other than their body fat. Yet, studies have consistently linked obesity with an increased risk for several types of cancer. Researchers are now exploring what biological mechanisms might link obesity and cancer.

Sweet nothings

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A healthy look at kids’ sports: Participation over prowess In 2015, New York Times sportswriter Karen Crouse set out to study Norwich, Vermont, a small town that has placed at least one of its own on almost every United States Winter Olympics team since 1984. “What started out as a sports book evolved into what is essentially a parenting guide, as I came to realize that Norwich’s secret to happiness and excellence can be traced to the way the town collectively raises its children,” she writes. “It is an approach that stresses participation over prowess, a generosity of spirit over a hoarding of resources, and sportsmanship over one-upmanship. Norwich has sent its kids to the Olympics while largely rejecting the hypercompetitive joy-wringing culture of today’s achievement-oriented parents. In Norwich, kids don’t specialize in a single sport, and they even root for their rivals. Parents encourage their kids to simply enjoy themselves because they recognize that more than any trophy or record, the life skills sports develop and sharpen are the real payoff.”

Sugar is the driving force behind the diabetes and obesity epidemics. Health experts recommend that you focus on reducing added sweeteners – like granulated sugar, high fructose corn syrup, honey, maple syrup, stevia and molasses.

Added sugars are almost everywhere in the modern diet – sandwich bread, chicken stock, pickles, salad dressing, crackers, yogurt and cereal, as well as in the obvious foods and drinks, like soda and desserts, according to a report in the New York Times. The biggest problem with added sweeteners is that they make it easy to overeat. They’re tasty and highly caloric but they often don’t make you feel full. Instead, they can trick you into wanting even more food. Sugar is the driving force behind the diabetes and obesity epidemics. Health experts recommend that you focus on reducing added sweeteners – like granulated sugar, high fructose corn syrup, honey, maple syrup, stevia and molasses. You don’t need to worry so much about the sugars that are a natural part of fruit, vegetables and dairy products. A typical adult should not eat more than 50 grams (or about 12 teaspoons) of added sugars per day, and closer to 25 is healthier. The average American would need to reduce added-sweetener

consumption by about 40 percent to get down to even the 50-gram threshold.

Eye on stroke

Research into curious bright spots in the eyes on stroke patients’ brain images could one day alter the way these individuals are assessed and treated. A team of scientists at the National Institutes of Health found that a chemical routinely given to stroke patients undergoing brain scans – gadolinium – can leak into their eyes, highlighting those areas and potentially providing insight into their strokes. Gadolinium is a harmless, transparent chemical often given to patients during magnetic resonance imaging scans to highlight abnormalities in the brain. In healthy individuals, gadolinium remains in the blood stream and is filtered out by the kidneys. However, when someone has experienced damage to the blood-brain barrier, which controls whether substances in the blood can enter the brain, gadolinium leaks into the brain, creating bright spots that mark the location of brain damage.

The New GAMMEX® PI Glove-in-Glove System™ PRE-DONNED GLOVE-IN-GLOVE, READY FOR DOUBLE GLOVING Experience double gloving convenience like never before. Ansell’s new GAMMEX®PI Glove-in-Glove System™ delivers a world first: pre-donned outer and inner synthetic surgical gloves ready for double gloving in just one don. Don in half the time. Don once and you’re done! It‘s that simple and it takes just seconds from un-wrapping to donning. Reduces environmental impact. By combining the glove-in-glove pairs in one poly-pouch and one inner-wrap, there is 50% less inner packaging waste, decreasing your carbon footprint.

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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.

Automotive-related news Amazon in-car delivery More than 7 million owners of eligible Chevrolet, Buick, GMC and Cadillac vehicles in the United States can have their Amazon packages delivered inside their vehicle using Amazon Key. In-Car Delivery comes at no extra cost for Amazon Prime members with an active OnStar account, and is available in 37 U.S. cities and surrounding areas, with more cities to follow. Packages can be delivered to a vehicle when it’s parked in a publicly accessible area, such as on the street in front of an apartment building, at a workplace surface parking lot or in a home

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driveway. Delivery works with Same Day, Two-Day and Standard Shipping.

10 Best Interiors The WardsAuto 10 Best Interiors list for 2018 recognized outstanding achievement in aesthetics, comfort, ergonomics, materials usage, fit-and-finish and user-friendly electronics. The 10 winners (in alphabetical order) were: Chevrolet Equinox, Hyundai Kona, Infiniti QX50, Kia Stinger, Lexus LS 500, Lincoln Navigator, Porsche Panamera, Ram 1500, Range Rover Velar and Toyota Camry.

Cars talk Toyota Motor Corp. plans to start selling U.S. vehicles that can talk to each other using short-range wireless technology in 2021, according to Automotive News. Talking vehicles, which have been tested in pilot projects and by U.S. carmakers for more than a decade, use dedicated short-range communications to transmit data up to 300 meters, including location, direction and speed, to nearby vehicles. The data is broadcast up to 10 times per second to nearby vehicles, which can identify risks and provide warnings to avoid imminent crashes, especially at intersections. Toyota has deployed the technology in Japan in more than 100,000 vehicles since 2015. The U.S. Transportation Department must decide whether to adopt a pending proposal that would require all future vehicles to have the advanced technology.

Congestion pricing: An idea whose time hasn’t come, apparently Some time ago, New York Governor Andrew M. Cuomo set the stage for an ambitious congestion pricing plan when he declared that it was “an idea whose time has come,” reports the New York Times. But there was little about congestion pricing in the state budget negotiated March 30 by Cuomo and state lawmakers despite months of lobbying by advocates, a six-figure media campaign, and rallies by transit riders. The most significant development was a new surcharge that would be tacked on to every ride in for-hire vehicles in Manhattan south of 96th Street: $2.50 for yellow taxis; $2.75 for other for-hire vehicles, including Ubers and Lyfts; and 75 cents for car pool rides such as Via and UberPool.

Your next company car? Is the leather in your automobile from cows raised at higher elevations, where mosquitoes can’t bite imperfections into hides? It is, if your car is a Rolls-Royce Phantom,

reports the Chicago Tribune. Base price for a new Phantom is a modest $450,000, but with personalized touches, it climbs above $640,000. Example: An owner can commission one of a dozen Rolls-Royce artists to make a 3Dprinted metal interpretation of his or her DNA. If that doesn’t make you want to own one of these beauties, the car’s lightweight, aluminum frame will. “The ride is so deadened and soft that even ubiquitous Chicago potholes went unnoticed” in a test drive.

Alcohol interlocks for DUI offenders Laws requiring all impaired-driving offenders to install alcohol interlocks reduce the number of impaired drivers in fatal crashes by 16 percent, a study by the Insurance Institute for Highway Safety shows. If all states without such laws adopted them, more than 500 additional lives could be saved each year. Alcohol interlocks are in-vehicle breath-testing units that require a blood alcohol concentration (BAC) below a certain level, typically somewhere between 0.02 and 0.04 percent, before the vehicle can be started. Forty-five states require interlocks for at least certain impaired-driving offenders. Twenty-eight states, the District of Columbia and four California counties have some type of interlock requirement that applies to firsttime offenders.

J.D. Power and NADAguides.com J.D. Power consumer ratings, reviews and scores are now available on NADAguides.com, said to be the largest car-shopping site for vehicle pricing, deals and car-shopping tools. In the last 10 years, J.D. Power has surveyed more than 2 million vehicle owners, provided insights for nearly 2,000 vehicle models and awarded 555 awards. These comparisons are now available directly to car shoppers. NADAguides.com has also integrated Verified Owner Ratings and Reviews and clearly marked model award recipients.

Laws requiring all impaired-driving offenders to install alcohol interlocks reduce the number of impaired drivers in fatal crashes by 16 percent, a study by the Insurance Institute for Highway Safety shows.

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

DOOGEE TT smartphone

Technology news Trio-tracking golf simulator BallFlight™ from OptiShot Golf is said to be the industry’s first “trio-tracking” simulator, offering detailed data on ball spin, ball and club speed, and launch angle. The $5,995 BallFlight package includes game software, driving range, full video data display, free software upgrades, carrying case, USB connection cable, one-year warranty and customer care.

glass, according to DOOGEE. No circuit or component is visible while the user is able to proceed with operation by touching both the front and rear screen. Once the liquid crystal molecules inside the transparent touchscreen are stimulated by electric current, they are rearranged to form text, icons and images. The whole view of the background can protect users from tripping and falling on unseen obstacles while walking.

See-through smartphone

World’s smartest toothbrush

DOOGEE TT is said to be an eye-catching smartphone in a see-through body. It looks like a piece of transparent

The world’s “first truly hygienic toothbrush” collects data providing feedback for better technique and connects

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users to their dentists, according to United Kingdombased Dentii. A smartphone app connects to the electric toothbrush and maps the geometry of a patient’s mouth, noting the brushing paths and pressure. Via the app, the data is sent to the user’s dental professional for analysis and then, if necessary, they will inform the patient on how to improve their dental routine. Dentii is being developed as the world’s first toothbrush that can prompt an individual to go to the dentist at early signs of problems, such as oral cancer. But all this is in the future. The company launched on Kickstarter in February.

also offers various sleep tech gadgets and three varied tension hybrid cool-gel mattresses, which are designed to keep the sleeper cooler and thus enabling deeper, longer and more regenerative sleep.

Dictation software with style Dictation software that transforms spoken words into text formatted with different type styles, subheads and alignments is readily available, reports The New York Times. With some programs, you can even

Hands-free smartphone mount As smartphones have become society’s primary way of taking and storing pictures, things can get tricky when someone wants to take a family photo or a solo shot that requires them to put the camera down or find someone else to take the picture, according to Fromm Works. Selfie Stick-It™ is a hands-free smartphone mount with Bluetooth remote that can stick anywhere. The remote works with both iOS and Android platforms. Selfie Stick-It™ fits any smartphone even when in a case, can be used in portrait or landscape mode, is fully reusable (washable gel can be used over and over again), and works on almost any sealed or painted surface, including wood, glass and marble, according to the firm. Weighing less than 1 ounce, the product is said to have a strong yet temporary hold that won’t damage the attached surface when mounted properly.

World’s smartest pillow ZEEQ is a smart pillow that can stream music to help users fall asleep, monitor and react to snoring, analyze sleep and intelligently wake the user up, according to the manufacturer, REM-Fit. The UK-based company

ZEEQ is a smart pillow

ZEEQ is a smart pillow that can stream music to help users fall asleep, monitor and react to snoring, analyze sleep and intelligently wake the user up, according to the manufacturer, REM-Fit.

add bullet lists, adjust line spacing and apply highlight colors to text, all through spoken commands. In fact, you may find that programs you already use can handle basic formatting by dictation – as long as you use the right commands. For example, when used with the Chrome browser and Google’s system of “voice typing,” Google Docs can add quite a bit of text formatting when you tell the program what to do. To compose and edit text this way, you need a microphone connected to your computer; headset microphones from a smartphone may work if the connector is compatible.

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June 2018

HIDA GOVERNMENT AFFAIRS UPDATE

MedPAC Recommends Key Reimbursement Changes The Medicare Payment Advisory Commission (MedPAC) has released its 2018 report

By Linda Rouse O’Neill, Vice President, Government Affairs, HIDA

to Congress. This year, the report calls for a number of cuts to Medicare fee-for-service payments, mainly to post-acute care providers. Additionally, MedPAC has called for the elimination of the Merit-Based Incentive Payment System (MIPS), which is the newly implemented payment system for physicians. Congress is not obliged to follow these recommendations, and, in light of upcoming midterm elections, it is highly unlikely that lawmakers will undertake any significant payment reform. Legislative change always remains a possibility, however, and these recommendations may inform future reform efforts. Here is a look at some key highlights from this year’s report.

Post-Acute Providers Skilled Nursing Facilities. MedPAC recommends eliminating the market basket update for skilled nursing facilities for fiscal years (FYs) 2019 and 2020. The agency also calls for implementing a redesigned prospective payment system (PPS) in 2019 for these providers. The aim of this redesigned system is to shift payments to medically complex patient stays. Home Health and Hospice. The agency recommends Congress cut Medicare payments to home health agencies by 5% in CY 2019 and rebase this payment system beginning in CY 2020. As part of this rebasing, MedPAC also recommends Congress direct HHS to revise the home health agency PPS to eliminate the use of therapy visits as a factor in payment determinations.

Physicians Merit-Based Incentive Payment Program. As noted earlier, MedPAC has called for the elimination of MIPS in its current form and recommends a new voluntary program be established. Under this program, providers could elect to be measured as part of a voluntary group. Clinicians in these voluntary groups could qualify for a value payment based on their group’s performance on a set of population-based measures. This announcement comes after many providers reported confusion and difficulty when preparing for the new payment system, which required physicians to start reporting in January 2017 to impact their payment in

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2019. Efforts to comply with the law drove provider interest in software and regulatory consulting services, and the Centers for Medicare and Medicaid Services has taken steps to help physicians prepare. It is unlikely Congress will take steps to eliminate MIPS as it passed with overwhelming bipartisan support. However, reducing regulatory burdens and compliance costs for providers remains a key priority for the Trump Administration.

Acute Care Inpatient And Outpatient. MedPAC recommends that for 2019, Congress should update the 2018 Medicare base payment rates (inpatient and outpatient) for acute care hospitals by the amount determined under current law. This means these payers would receive a small payment increase. MedPAC also highlighted that hospitals’ aggregate Medicare margin were − 9.6% in 2016. However, MedPAC also says the average Medicare payment is lower than average costs, but higher than the variable costs of treating a Medicare patient. Ambulatory Surgical Centers (ASCs). MedPAC recommends that Congress eliminate the CY 2019 update to Medicare payment rates for ASCs. It also repeated a previous recommendation that the HHS Secretary require ASCs to report cost data. If you would like to learn more about the MedPAC report, or how it may affect your customers, please contact us at HIDAGovAffairs@HIDA.org.

PEOPLE

Marv Stevens: The man to see Want to know how to sell? It’s easy:

• Be honest • Be prepared • Practice your presentation skills • Strive for clarity in your speaking • Throw in a little showmanship • Make the customer feel good about the selling experience •M ake that customer your friend

and a quasi-consultant to a lot of distributors. He was extremely loyal, too.” Says Terry Stevens, “Marvin was my parent, mentor, someone I could trust. I met just about all the sales managers who came to Los Angeles to work with Dad from the time I was 10 years old until I left for college. I always thought I would finish college, then go to work for Marvin Stevens Associates. And I did just that.” Stevens was the type of person not easily forgotten, according to those who knew him. Always tanned and

Well, maybe not so easy after all. But that’s how manufacturers rep Marvin Stevens did it, says his son Terry Stevens, an independent rep in Northern California. The elder Stevens died in March after a 50-year career as an independent rep. Born in Chicago in 1928, Marv moved to Southern California in the early 1950s to work with his father-in-law in a beer/liquor business. In 1953 he began working for Burton, the medical lighting company, covering the western United States, Hawaii and Alaska. He started Marv Stevens & Associates in 1959, which eventually grew to a firm with 15 or so associates. Stevens represented Midmark when that company was still IE Industries, says John Lee, a veteran of med/surg distribution, now retired. Terry and Marv Stevens He gave the company a strong foothold in the West, representing many other firms as well, including Graham-Field, orthopedic company Frank Stubbs and Monoject (now Cardinal Health). Stevens also represented Medical Products Development Inc. (now Bovie Medical), – John Lee which at the time made disposable penlights for the medical industry. He worked actively until well-dressed, he preferred not to wear socks. He might 2008, after which he did some small consulting gigs. show up at a meeting with shirt, tie and shorts. He was Stevens is said to have been the consummate salesperson. pleasing to be around, and he owned the relationship with “When Marv walked into a room, everybody recogjust about everybody in the supply chain, at least those on nized him, acknowledged him,” says Lee. “He was a very the West Coast. outgoing person on the surface, but actually, shy. “Marv became a great business associate as well as a “When Marv started selling your product, he became good friend to all he dealt with,” says Lee. part of your business. He was a mentor to many sales reps

“ When Marv started selling your product, he became part of your business.”

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June 2018

PEOPLE

Marvin Caligor: School was always in session If you worked for Marvin Caligor, every day was a business lesson. And it

was a lesson you weren’t likely to forget. “Marvin’s greatest strength was knowing how to deal with people properly,” says Sam Zambardino, account manager for Henry Schein Medical, who went to work for Caligor in 1980. “I mimic and copy him to this day.” Caligor – who took over the drugstore and surgical supply house that his father, Sam, had started in 1921 – died in March.

A company built on respect Marvin learned how to deal with people from Sam, who emigrated to the United States in the early 1900s. Speaking with Repertoire in 2005, Caligor said of his father, “He built his business on people and respect. He always called doctors ‘Doctor,’ and they called him ‘Sam.’” He even

“Marvin taught me how to treat a customer.” – Sam Zambardino

treated late-paying customers with respect, Caligor added. Sam Caligor died in 1959. Originally established as a pharmacy, Caligor expanded into medical sales. That’s not Marvin Caligor surprising, given that the company was situated within two or three miles of some of the country’s biggest hospitals, such as Lenox Hill, Mount Sinai, the Hospital for Special Surgery, Beth Israel and others. Over time, the company built a strong hospital and physician trade while maintaining a viable walk-in pharmacy.

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In 1969, Caligor sold the business to Eckmar Corp. (later renamed Health Chem Corp.), but the sale did relatively little to change the way the company operated. Caligor continued to operate the pharmacy and distributorship much as he always had. The company rented warehouse space in Long Island City from Health Chem, from which Caligor shipped bulk items to local hospitals. Still, Caligor was shipping more than $2 million of goods annually from the storefront at 83rd and Lexington at the time the company was sold to Micro Bio-Medics in 1982. After the sale to Micro BioMedics, Caligor’s physician office business took off. Whereas just a handful of sales reps personally called on physicians prior to the sale, ultimately, approximately 200 were doing so. What’s more, Caligor finally got its own warehouse – a 40,000-square-foot facility in Mount Vernon. Even after that, however, Marvin Caligor spent most of his time in the store, nurturing his relationships with customers. Henry Schein acquired Micro Bio-Medics in 1997.

Led by example In 1980, Zambardino was a college grad, working as a carpenter while trying to land a job as a pharmaceutical rep. Lacking a science background or sales experience, he

struck out many times. “One day my dad showed me an ad in the Yellow Pages for Caligor Physicians and Hospital Supply Corp., so I mailed them a resume.” He received a handwritten note inviting him to come in for an interview. “I walked from the subway at 86th to 83rd, in a three-piece suit,” he recalls. “When I got there, the old canopy was ragged and I thought, ‘This must be their warehouse.’” But when he got inside, he could see that half was a retail pharmacy and half was a medical supply business being run out of 150 square feet or so. “People were on the phones, doctors were buying stuff over the counter,” recalls Zambardino. Working for a small pharmacy and medical distributor wasn’t what Zambardino had in mind, but Caligor offered him a job. Zambardino stalled a couple of weeks, until Caligor told him he needed an honest answer from the young man. “That was my first lesson from him: You had to tell him the truth. He could see through everything else.” After a couple of months with the small company, Zambardino decided he would never leave. “I was mesmerized by Marvin as he openly worked to teach me everything he knew about his company,” says Zambardino. “And I soaked it up like a sponge. Marvin

immediately made me feel welcome and gave me the utmost impression I had a long career ahead of me if I chose to. Well, here we are in 2018, still at it. “Marvin taught me how to treat a customer,” he continues. “He led by example, as I would watch him interact with customers on a daily basis. Either on the phone or in the store at 1226 Lexington, Marvin would stop what he was doing and either tell or correct me when I did it wrong. “But he always did it in such a way that you were always eager to learn more.”

83rd and Lexington and a milk shake Just as products were often staged on the sidewalk in front of the Caligor pharmacy, so too was the deal that would make Caligor Physicians and Hospital Supply Corp. part of Micro Bio-Medics in 1982. “I was called by an investment banker, who told me this company was for sale,” recalled Bruce Haber, who was CEO of Micro Bio-Medics, speaking with Repertoire in 2005. At the time, Micro Bio-Medics was a $2 million company

focusing on the school health marketplace. “So we went to meet Marvin. “It was a retail store on Lexington Ave., which wasn’t what I was expecting of a company doing $8 or $9 million of business. There was no place to meet, so we stood on the corner talking. It was winter; we were freezing. Finally, someone got the idea to go to the candy store next door and talk about this over a milk shake. So we started the deal standing on the corner of 83rd and Lexington.”

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June 2018

Industry news Keith Boivin joins Repertoire board Keith Boivin, general manager of IMCO Home Care (IHC), has agreed to serve on the Repertoire editorial advisory board. He joined IMCO with over 20 years of experience in the medical device and medical distribution industry. He has held leadership positions in both sectors managing the national accounts, distribution channels, and GPO contracts for some of the largest vendors in their respective markets. Boivin is currently serving on three medical industry boards and resides in Keller, Texas, just north of Fort Worth, with his wife of 15 years, Kim, and their three children – Lila, 13; Wesley, 11; and Delaney, 10.

McKesson to acquire Medical Specialties Distributors for $800M McKesson Corporation signed a definitive agreement to acquire Medical Specialties Distributors (MSD), a national distributor of infusion and medical-surgical supplies as well as biomedical services to alternate site and home health providers, for $800 million. MSD’s established offering to providers in the home infusion market, as well as technology and services to support customers and patients using these products, will allow McKesson to provide incremental services to other customer segments. The transaction is expected to close in the first half of fiscal 2019, subject to customary closing conditions, including necessary regulatory clearances.

Henry Schein to spin off animal health business Henry Schein Inc (Melville, NY) and Vets First Choice (Portland, MN) announced that Henry Schein will spin off Henry Schein Animal Health (HSAH) and merge it with Vets First Choice. The new company, Vets First Corp will be headquartered in Portland, Maine. Immediately

June 2018

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following a spin-off from Henry Schein, HSAH will combine with Vets First Choice to form a new publicly traded company. Ben Shaw, the CEO of Vets First Choice, will become CEO of Vets First Corp. David Shaw, chairman of the board and co-founder of Vets First Choice, as well as founder of IDEXX Laboratories Inc, will be chairman of Vets First Corp. The current management of HSAH and Vets First Choice will have senior roles in Vets First Corp. “Following the spin-off of HSAH as an independent company, Henry Schein will focus on our market-leading dental and medical businesses as we make continued investments for future growth,” said Stanley Bergman, CEO of Henry Schein. Henry Schein shareholders and Henry Schein Animal Health-related parties will own approximately 63% of Vets First Corp. common stock immediately following the transaction, while Vets First Choice investors will own approximately 37% of such stock. Henry Schein expects to receive between $1.0 billion and $1.25 billion in cash on a tax-free basis as part of the transaction. The transaction is expected to close by the end of 2018, subject to customary closing conditions, including customary regulatory approvals.

Hill-Rom names John Groetelaars as president, CEO Hill-Rom Holdings Inc (Chicago, IL) named John P. Groetelaars as president and CEO of the company, effective May 14, 2018. He succeeds John J. Greisch, who previously announced his intention to retire. Groetelaars will also join Hill-Rom’s board of directors. Groetelaars most recently was EVP and president of the Interventional Segment at BD (Becton, Dickinson and Company), which he joined in December 2017 following its acquisition of C.R. Bard Inc.

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