Rep jan18 by BOC design Inc

vol.26 no.1 â&#x20AC;˘ January 2018

repertoiremag.com

PAMA: Jim Poggi, Tested Insights, LLC

The Stage is Set

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

MACRA Quality Measures— Are Your Customers Ready?

WE UNDERSTAND the current healthcare environment can be complicated and confusing. Let us help your customers realize how our rapid tests and systems can meet some of the MACRA quality measures physicians face today.

Sekisui Diagnostics IS your partner in healthcare. Call your rep today at 800-332-1042. www.sekisuidiagnostics.com MADE IN THE USA

JANUARY 2018 • VOLUME 26 • ISSUE 1

PUBLISHER’S LETTER New Year, Familiar Themes......................................6

PHYSICIAN OFFICE LAB In with the New

Setting expectations and bringing a new lab test into the physician office lab.........................8

DISTRIBUTION South by Southeast

ROi acquires GPO in Orlando......................................... 12

CONTRACTING EXECUTIVE PROFILES

PAMA: The Stage is Set

TRENDS

Sara Henderson

Top Challenges

The Department of Health & Human Services looks at the long road ahead

Future Supply Chain Leaders................................... 14

TRENDS A Head Start on Diabetes

Eating right, staying active, can turn the tide on prediabetes..........................................28

Patient Safety

It’s not only an inpatient issue

page

repertoire magazine (ISSN 1520-7587) is published monthly by Share Moving Media, 1735 N. Brown Rd. Ste. 140, Lawrenceville, GA 30043-8153. Copyright 2017 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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January 2018

JANUARY 2018 • VOLUME 26 • ISSUE 1

QUICKBYTES

TRENDS Looking for Pristine Data?

It starts within your own organization.......................... 42

Technology news

WINDSHIELD

Steve Pollack 3D Printing: What Will it Mean for You?

A revolution in manufacturing may affect the healthcare supply chain.................................... 46

HIDA GOVERNMENT AFFAIRS UPDATE CMS Pursues Medicare Deregulation......... 50

HEALTHY REPS Information to stay healthy................................ 52

SMART SELLING Keep Your Pipeline Full.......................................... 54

REP CORNER

Jeff Marco:

Guest on a Mountain

Automotiverelated news 58 4

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PUBLISHER’S LETTER

New Year, Familiar Themes 2018 is starting out with the same types of change, partnerships, and consolidation

we’ve seen the last five years. Which leads me to believe you will have great opportunities to help your clients improve their businesses by educating them on all the changes happening. One of the big stories this year will be the launch of PAMA, which cuts diagnostic testing reimbursement for Medicare. Many of your clients may still be unaware of the reform, and it can be very scary when they learn about it. In December, I did a two-part podcast on the subject, sponsored by Sekisui. The first part was with Mark Zacur, Vice President and GM at Fisher Healthcare, while the second part was with Repertoire’s newest columnist, Jim Poggi, formerly with McKesson’s lab team. Mark spoke to how PAMA will affect health systems. While Medicare pays $7 billion in Scott Adams lab test reimbursement, he said $2 billion of it is across only five tests. To learn what those five tests are, go to Repertoire’s website and listen to the podcast. There is enough content in the podcast to make you conversational on PAMA with any lab tech. Jim spoke to how PAMA will affect you, as well as how you can use it to your benefit to help your customers. One of the key takeaways from Jim’s comments was the increased focus on molecular. If you want to learn more about molecular testing and how to position it, take a look at the advertisers in this issue, and look up their 2-Minute Drills in RepConnect. These short videos will help you feel comfortable discussing these tests, and hopefully help you sell more lab in 2018. We saw two partnerships at the end of the year that will be fun to watch as well. Midmark and Heine is one, and we conducted a live interview with each company that can be found on the Repertoire website. The second partnership was between Sekisui and Mesa Biotech. It looks like 2018 will be another year of mergers, partnerships, and consolidation. I point out the partnerships and PAMA because it’s where we are today in our industry. Change is constant, and we have to embrace it. As Don Draper said in an episode of Mad Men: “Change is neither good or bad, it simply is. It can be greeted with either terror or joy. A tantrum that says I want it the way it was or a dance that says, look something new.” Amid all the change, there is an opportunity for you to win the day with your customers. Embrace the change in 2018. Dedicated to Distribution, R. Scott Adams

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PHYSICIAN OFFICE LAB

In with the New Setting expectations and bringing a new lab test into the physician office lab

By Jim Poggi I am excited to have the opportunity to share my

thoughts with the distribution community regarding “lab”. It has been my focus throughout my entire career, and I am passionate about it. My objective with this column is to help you and the practices you serve optimize patient care by using lab in the physician office. We will explore lab with facts, fun, fables and foibles. I plan to look at the business of selling lab products as our customers see it, perceive it and ultimately, CARE about it. I hope you will learn a bit, laugh a lot and create outstanding lab solutions for your customers as a result.

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My guiding philosophy is that for you to be relevant to your customers and engage them to actively consider starting or expanding a lab, you need to counter two issues summed up in the famous customer comment: “I don’t know and I don’t care.” Your job, with my help and that of your manufacturers, is to convey information (facts) to help the customer to know, and to also create a bridge between those facts that stimulates the customer to act on them by fitting the facts to their feelings, experiences, emotions and needs (care). To the extent that we are able to successfully perform those two objectives, everybody wins – patients, care givers, you

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PHYSICIAN OFFICE LAB and your suppliers. Ultimately, the health care system will meet two of MACRA’s key objectives: better patient outcomes and better patient satisfaction. So, how does this relate to “bringing a new test into the physician office lab”? In a future article we will provide more detail on test selection. Today, we are looking at the overall process of getting the prospect to KNOW and CARE.

Getting the prospect to know (facts) Know your prospect’s patient mix, needs and practice objectives. Actively ask questions about their daily activities, challenges and work flow. Make clear notes regarding their pain points and keep them in mind as you seek to find problems to solve. Understand their payer mix and any obstacles and opportunities it provides. Many insurance companies cover an annual wellness exam. Is lab covered? Can lab screening tests be performed in the office? Most practices see a classic mix of patient conditions, including infections, diabetes and pre-diabetes, heart and circulatory issues and knowing which diseases they see most frequently can guide your thinking about which screening tests are most appropriate. The basics

Putting in the time to think in terms of getting your customer to know and care makes a difference.

usually include waived tests for urinalysis, pregnancy, respiratory infections, diabetes screening (glucose) and monitoring (glycosylated hemoglobin) present a classis start for the typical primary care practice.

Getting the prospect to care (needs) Share the customer facts with a trusted supplier who you believe covers some of the tests pertinent to the practice and develop a solution together. Propose the solution with your supplier and ask: • How do you see these tests impacting your daily work flow? • How do you see these tests being used in counseling your patients? • To what extent do you believe having these tests available during the patient visit will help you initiate or modify a patient treatment plan?

The payoff (adding value) Ask your customer: “How may we help you implement the new test(s)?” • Staff meeting to introduce the solution • Staff training • Patient brochures and information • Announcement to the patients Every day, great facts meet resistance because they cannot convey the full story – they don’t touch the needs and emotions of the prospect. Putting in the time to think in terms of getting your customer to know and care makes a difference. Offering implementation assistance shows that you care, and makes you a more valuable resource.

Sysmex XW™-100 CLIA-waived CBC analyzer Faster test results, clinical decisions and greater practice efficiency are coming to physicians’ offices with the first CLIA-waived CBC analyzer. Hematology diagnostics leader Sysmex is bringing more lab testing to the point of care. One of the most common blood tests can be conducted reliably and accurately on-site, in as few as three minutes. The device’s ease of use and innovative technology means in-house staff can operate it in just a few easy steps, without lengthy certification and training. The new Sysmex XW-100 will improve health care efficiency and patient care, starting in early 2018. Visit www.waivedcbctesting.com for more information.

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DISTRIBUTION

South by Southeast ROi acquires GPO in Orlando

Resource Optimization & Innovation’s (ROi’s) acquisi-

tion this fall of Orlando-based Healthcare Purchasing Alliance LLC signals its intent to grow its: • Group purchasing program • Regard® private-label line • Custom pack services • Expertise in self-distribution and consolidated service centers Founded in 2002, ROi serves as the supply chain arm of Mercy, a nonprofit health system based in Chesterfield, Missouri, near St. Louis. From its 100,000-square-foot facility in Springfield, Missouri, ROi provides distribution services to Mercy’s 44 acute-care and specialty hospitals, and more than 700 physician practices and outpatient facilities with a fleet of 125 vehicles servicing nearly 2,000 locations daily. In 2011, ROi signed its first partnership agreement with another IDN – Baton Rouge, Louisiana-based Franciscan Missionaries of Our Lady Health System. The agreement gave FMOLHS access to ROI’s contract portfolio, as well as assistance opening

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and operating a central distribution center in Baton Rouge – the FMOLHS Logistics One Supply Distribution Center. More agreements for cost management and supply chain services followed, including: • Spartanburg Regional, in Spartanburg, South Carolina (September 2012). • HPS, a Middleville, Michigan-based GPO servicing acute- and non-acute-care providers in 20 states (January 2017). • Virtua, a New Jersey-based health system (July 2017). The transaction involving HPA is more than a partnership agreement, however. It is an acquisition. Others may follow. HPA, previously owned by Orlando Health and South Lake Hospital, is now a wholly owned subsidiary of ROi, operating as a separate entity to manage HPA’s legacy contract portfolio and provide custom contracting solutions. Through the HPA acquisition, Orlando Health and South Lake Hospital agreed to a seven-year GPO membership term with ROi, while also maintaining membership with HPA.

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“ROi’s GPO will continue to drive a committed sourcing strategy, which has proven to be a competitive advantage that delivers significant cost savings to providers,” says Michael Rivard, interim president and chief operating officer for ROi. “As we work through the integration of HPA and Orlando Health, we are working collaboratively with the healthcare organizations to consolidate their purchases to ROi contracts based on a timeline that is aligned with their goals and needs. As contracts are moved to ROi, the HPA team will transition to supporting ROi’s continued expansion efforts in the non-acute market.”

Expertise in self-distribution The acquisition strengthens ROi’s expertise with consolidated service centers and self-distribution, says Rivard. “ROi brings a unique provider perspective to helping health care systems interested in self-distribution. We have more than a decade of provider experience, developing an integrated supply chain and self-distribution model for our founder and majority owner, Mercy. Orlando Health brings additional experience with a provider-owned Consolidated Services Center (CSC), which they have been operating for years.”

11/30/17 11:27 AM

ROi is expanding the CSC collaboration that started between HPA and Orlando Health through its Regard® product line and Custom Pack Solutions offering, he adds. “With both Orlando Health and Virtua recently becoming members of ROi’s GPO, we now serve four health systems with self-distribution operations,” says Rivard. “ROi is helping to bring these four members (Mercy, FMOLHS, Orlando Health and Virtua) together to share best practices and collaborate further on new opportunities. “This is a very exciting aspect of our clinically integrated supply chain model. We are able to bring solutions all the way from the manufacturing plant to the patient bedside. “ROi will continue to pursue acquisitions that grow or supplement existing service and product lines, or help expand into new service or product offerings,” he says.

“ ROi brings a unique provider perspective to helping health care systems interested in selfdistribution.”

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January 2018

CONTRACTING EXECUTIVE PROFILES

Future Supply Chain Leaders Meet tomorrow’s supply chain leaders. Earlier this year, Repertoire’s

sister publication, the Journal of Healthcare Contracting, asked for nominations of young people with the energy, dedication and courage to shape tomorrow’s healthcare supply chain. As you can see, the supply chain will be in good hands. 14

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Matthew Almeida Manager, SCC warehouse Sentara Healthcare Norfolk, Virginia

Lee Dubois National director, purchase services Tenet Healthcare Corp. Dallas, Texas

Nomination submitted by Robert H. Saunders, Director materials management, logistics administration, Sentara Healthcare:

Nomination submitted by Robert Hines, director of national accounts, Angelica:

Without question, Matt Almeida is a “Future Supply Chain Leader.” In July 2014, he began his Sentara Healthcare career in Supply Chain Customer Service. During that time, Matt demonstrated his leadership skills and was soon promoted to warehouse manager of second shift picking operations. He quickly mastered the Lucas Pick-to-Voice technology, along with the IRMS WMS, and began to drill down on productivity and fill ratios. Under his leadership, fill rates moved well into the 99 percent range. Matt is currently managing our day shift operations and has been instrumental in focusing on receiving accuracies. He also serves as a team member for our DNV ISO9001 accreditation. Matt is the “Future Supply Chain Leader.”

Lee is not only a future supply chain leader; he is going to be an innovator in segments of healthcare that need a refreshing new look/view. He has been tasked with several major contracts and initiatives for Tenet Nationwide. I worked with Lee as a supplier on a specific Tenet initiative regarding consolidation of linen and laundry vendors. Lee worked diligently and quickly through a process that normally takes two to three times longer to complete, with an end result of gaining nationwide savings for all Tenet locations. His industry knowledge and ability to direct the process are a true testament to his abilities now and in what the future will bring.

Sara Henderson Executive director, sourcing and procurement Avera Health Sioux Falls, South Dakota Nomination submitted by Steve Huckabaa, vice president supply chain, Avera Health: Coming to corporate supply chain in May 2014 after 10 years in finance, Sara tackled our item master by leading a virtual rewrite of our new MEDITECH platform, consolidating eight healthcare information systems into one. She persuaded finance and surgery constituents to align 11 reporting modules into our item master, creating a single source of truth. She organized a major shift from our Value Analysis Team to Evidence & Value Committee with physician engagement. She is leading our $13 million systemwide savings initiative. She presented “Patient Charge and Revenue Management within Supply Chain” at the Spring SMI Forum with rave reviews and request for nationwide webinar.

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January 2018

REACHING THE

SUMMIT

DEPENDS ON HAVING

INNOVATIVE TOOLS With challenging ascents, having the most innovative tools to reach the summit is crucial. No matter who you’re outfitting, whether it’s a reference lab, a physician office lab or something in between, we’re always working on new ways to provide the best tools for the way they test. From molecular assays to our trusted rapid diagnostics, we’re providing a broader range of products and services covering respiratory infectious diseases, hospital-acquired infections, women’s health and pregnancy, cancer screening, cardiovascular health, eye health, drug screening and public health. Not to mention every Quidel brand comes equipped with our world-class customer service and technical support teams — ready to answer questions, provide samples, training and additional support to help get you to the summit.

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CONTRACTING EXECUTIVE PROFILES David Forbes Director of contracting Mercy Health Services Baltimore, Maryland

Mercedes Flores System director, International Supply Chain CHRISTUS Health Irving, Texas

Nomination submitted by Jack Medkeff, vice president operations/supply chain, Mercy Health Services:

Nomination submitted by Tony Scanio, MBA, CGBP, director, data management & business intelligence, International Operations;and David Burboa, director, logistics & operations, International Operations, CHRISTUS Health:

As a consultant to Mercy, in 2011, David successfully brought together a disparate group of physicians and administrators, and created a business process that lives to this day. Later, when he became director of contracting for Mercy, he proved to be a quick study, learning the concepts of contract law, and he had the appetite and energy to take on industry giants as well as the various medical specialty vendors. Mercy writes the great majority of its agreements, thus agreement terms must be able to stand the test of the courts. David presently has a stable of about $400 million worth of supply, software, lease, service and consulting agreements in his portfolio. Accumulated savings well exceed $10 million over the past few years. He has been a featured speaker at several regional and national conferences on topics covering contracting principals, the need for accurate supply data, and advanced techniques for maximizing healthcare supply chain information system data collection. He is pursuing his MBA from Loyola University.

Mercedes utilizes her vast, diverse background in a variety of industries to obtain outstanding results in the International Supply Chain for CHRISTUS Health. Never afraid to change the status quo, she is leading positive change throughout the international supply chains of CHRISTUS Health in Chile, Colombia and Mexico, while navigating distinct cultures, regulatory environments, and logistical and purchasing models. In her time with CHRISTUS, this includes significant hard dollar savings, important efficiency improvements, better personnel management, and improved communication and decision-making with clinical staff.

Jessica Campbell Contract coordinator, supply chain BJC HealthCare St. Louis, Mo. Nomination submitted by Kelly Bouckaert, sourcing manager, BJC HealthCare: Jessica has come into our Sourcing group with enthusiasm, energy, and a wonderful work ethic. From day one, she was looking to work hard and have an impact. When I would give her a project or task, she would not only complete it quickly and accurately, she would dig deeper and really learn and understand what she was doing and why. She is extremely analytical, which is valuable in a Sourcing role that supports 15 hospitals. She is able to review and/or create data and see trends, value, and make assessments from this data that are very accurate and concise. She has a good eye for pointing out discrepancies or areas to pay attention to. Jessica works well with everyone, and in her young career, really understands how to work with all levels of management in a respectful and professional manner. She takes constructive feedback well, and learns from it. She learns and understands her portfolios to the best of her ability, allowing her to speak to it precisely, and she is always able to answer questions from senior leadership without hesitation. She shows that she enjoys her job, and her positive attitude and outlook on work is contagious to others around her. Jessica just started the BJC MBA Cohort through Webster University, again demonstrating her drive and willingness to learn and continue developing into a future leader.

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CONTRACTING EXECUTIVE PROFILES Bill Selles Director of supply chain sourcing Spectrum Health Grand Rapids, Michigan

Cody Williams Supply chain director Brookings Health System Brookings, South Dakota

Nomination submitted by Randy Sportel, senior project specialist, Spectrum Health:

Nomination submitted by Christi Wilts, receiving/distribution clerk, Brookings Health System:

Bill has been in his role since February 2017 and has made numerous upgrades within the Sourcing Department. Bill brings supply chain experience from both outside of healthcare (Target) and also from the healthcare insurance industry (Priority Health). Bill has increased staff engagement through a number of process improvement events, including streamlining the contracting/legal process flow, increasing the number of master contracts in development, decreasing non-value add processes, and increasing the education offerings for staff – such as Michigan State negotiation seminars – on the Spectrum Health premises. Bill has also worked with the major spend departments to be more deeply engaged in the budget and contracting processes to effectively align departments with Supply Chain for decreasing costs for our new fiscal year.

Cody has changed the way the hospital operates by implementing an electronic requisitioning program as well as the two bins/ Kanban system. Hospitalwide, staff – especially nurses – have had more time to focus on patient quality of care, knowing all of their needed supplies will be there. Departments know that if they need anything, Cody is approachable and can be depended on to get the task done. Cody has also changed the culture and morale with his outgoing and energetic personality. He is a smart and effective young leader who makes work fun. FYI: Cody just completed the Lean Horse 100 Mile Race Course in Custer, South Dakota.

Eric Tritch Executive director, strategic sourcing, supply chain University of Chicago Medicine Chicago, Illinois Nomination submitted by Kevin Markech, regional client executive, Vizient: Eric shows a consistent progression in an ever-changing healthcare environment. As a leader of one of the most exceptional hospital supply chain teams, Eric leads by example and pushes his team not only for results but to integrate themselves throughout the health system. Eric and his team are well respected by clinical leaders and have gained trust, allowing the clinical teams to focus on patient care while Eric and his team ensure the right products are on contract at the most competitive price and available for the end users. Eric participates in various councils, task forces, and is often sought for his strategic insight. Many hospitals I work with want to know what the University of Chicago Medicine (UCM) is doing and how they are doing it. Eric is always open to knowledgesharing with peers and does so through conferences, phone calls and site tours at UCM. Eric is at the forefront of technology and will make the right investments to bring forth speed and efficiency to their process. He wears many hats and has most recently taken on responsibility to build out a network affiliate program for the UCM Supply Chain. I have been in some of those conversations with other hospitals and they are always impressed with the high level of expertise that Eric and his team display.

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Four building blocks for tomorrow’s leaders What will it take to be a supply chain leader of the future? The Association of Healthcare Resource and Materials Management (AHRMM) and the Strategic Marketplace Initiative (SMI) conducted research, including extensive interviews, to come up with some answers. They identified four key building blocks for tomorrow’s leader: qualifications, competencies, experience, and personal traits. Qualifications Future supply chain leaders must possess qualifications that demonstrate they are capable of leading a supply chain program, according to AHRMM and SMI. Formal academic qualifications are a “must.” • A post-graduate degree is considered a minimal qualification. • Academic concentrations in healthcare administration and/or supply chain will help. • Attainment of an advanced degree, such as an MBA, can prepare the professional to engage in high level and executive duties. Leadership training is desirable. Future supply chain leaders can bolster their qualifications with professional training in such topics as: • Lean principles. • Six Sigma. • Group facilitation. • Quality improvement methods. Attainment of the CMRP designation (Certified Materials & Resource Professional) from the American Hospital Association demonstrates seriousness in healthcare supply chain practices, as well as a level of professionalism.

Competencies • Communication. As supply chain leaders interact with CEOs, physicians, nurses, life science professionals, executives, groups, etc., communication is a key competency. Communication can be by the spoken word, written word, non-verbal and the use of graphs or charts. • Negotiation. Developed through practice, mentoring, or formal training, negotiation competencies reveal an ability to persuade others, strategize, align incentives, protect assets, and achieve positive outcomes for all involved, according to AHRMM and SMI. • Analytics. Supply chain leaders should understand how data is managed, how metric formulas are developed, and how to apply analytics to various business needs. Experience Aspiring supply chain leaders should seek to learn from a variety of experiences, both within and beyond healthcare supply chain. Every experience – whether performing a physical inventory, leading a project team, implementing a new system or technology, working with clinicians, presenting to an audience, or simply managing people – helps to build that body of experience. Personal traits The positive traits of a leader can be seen by others in a person’s actions, attitudes and behaviors. They include: • An ability to see the “big picture” and to ensure that others see it too, by building and sharing their vision. • A strong ethical background. • Intellectual curiosity. • Self-motivation. • Positive thinking. • The ability to be an active listener. • Flexibility. “The Healthcare Supply Chain Leader of the Future” may be downloaded free of charge at www.smisupplychain.com/tools or www.ahrmm.org/ supply-chain-leader-of-the-future

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January 2018

PAMA:

The Stage is Set

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

he Centers for Medicare and Medicaid Services released its final rates for the Clinical Laboratory Fee Schedule in November, as part of the Protecting Access to Medicare Act (PAMA). The new schedule – which was to become effective Jan. 1 – is an attempt to bring the rates that Medicare pays for lab tests closer to the rates paid by private payers. (In other words, down.) If there’s good news, it’s that reimbursement for any test may be cut no more than 10 percent in years 1, 2 and 3, or 15 percent per year for the following three years. Payment rates under the revised Clinical Laboratory Fee Schedule will be updated to reflect market rates paid by private payers every three years for most tests, according to CMS. Repertoire Publisher Scott Adams recently interviewed POL expert Jim Poggi of Tested Insights LLC (and former director of lab business development for McKesson Medical-Surgical), to gauge the impact of the new rates on providers, distributors and manufacturers. Jim Poggi

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* Not available when combined with other oﬀers. Additional analyzers must be purchased separately. Analyzers and kits will be drop shipped to the customer address. Oﬀer good for new and current BD Veritor™ Plus System customers. The value of any rebates, discounts, or incentives provided may constitute a “discount or other reduction in price” under Section 1128B(b)(3)(A) of the Social Security Act (42 U.S.C. Sec. 1320a-7b(b)(3)(A)). Customer shall satisfy any and all requirements imposed on buyers relating to discounts or reductions in price, including, when required by law, to disclose all discounts or other reductions in price received from BD and to accurately report under any state of federal health care program the net cost actually paid by customer. BD, BD Logo, and BD Veritor are trademarks of Becton, Dickinson and Company. ©2017 BD

PAMA: The Stage is Set Don’t panic It’s true the federal government wants to reduce its payments for point-of-care testing, says Poggi. But by law, the maximum reduction in reimbursement for any test is 10 percent in Years 1, 2 and 3. “So folks who are concerned about gross reductions should put aside those concerns. “The most important thing that distributor account managers and suppliers should be thinking about is having

These are things we need to think about very deeply in the next 12 months.” PAMA will bring change. “The intent of PAMA is clear – to take the tests used most frequently and reduce reimbursement enough to get the attention of patients and physicians,” says Poggi. Tests likely to be targeted include vitamin D, PT/INR (which is already moving to coagulation clinics), and comprehensive and basic metabolic panels, particularly in the CLIA-waived space. “Test requests for drug screens and confirmations will continue to garner debate. The opioid use epidemic and patient treatment options balanced against high reimbursement for the tests will continue to be trends.” But the enemy – if there is one – isn’t a reimbursement cut, says Poggi. It’s fear.

“ Keep in mind that physician practices don’t perform labs; they see patients who need laboratory testing.” calm, rational discussions with their clients,” he says. To do so, they need to understand PAMA themselves, and then advise practices on how to deal with the shifting sands of reimbursement as well as the focus on improved outcomes and patient satisfaction. “The patient as consumer is coming into focus. Reps need to find out how their customers feel about this and what it means to them.

One enemy “The new rep – and the established rep who wants to do a better job – have to think about this through a very simple lens. First, they have to keep in mind that physician practices

Cancer profile tests: More on the horizon The U.S. Food and Drug Administration intends to speed up the availability of cancer profile tests, which help healthcare providers discover the genetic mutations present in a particular tumor. Such information may help inform how best to treat the cancer. In November, the agency authorized Memorial Sloan Kettering Cancer Center’s IMPACT (Integrated Mutation Profiling of Actionable Cancer Targets) tumor profiling test (assay). IMPACT is an in vitro diagnostic test that uses next-generation sequencing (NGS) to rapidly identify the presence of mutations in 468 unique genes, as well as other molecular 24

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changes in the genomic makeup of a person’s tumor. In addition, the FDA announced the accreditation of the New York State Department of Health (NYSDOH) as an FDA third-party reviewer of in vitro diagnostics, including tests similar to IMPACT. This means that laboratories whose NGS-based tumor profiling tests have been approved by NYSDOH do not need to submit a separate 510(k) application to the FDA. Other accredited, third-party FDA reviewers also may become eligible to conduct such reviews and make clearance recommendations to the agency.

Along with the its authorization of IMPACT, the FDA is establishing a Class II regulatory pathway for the review of other NGS-based tumor profiling tests for use in patients diagnosed with cancer. Class II designation allows these types of tests to be eligible to use the FDA’s 510(k) clearance process, either by submitting the application to the FDA directly or through an accredited third-party reviewer, like NYSDOH. Approximately 38.5 percent of Americans will be diagnosed with a form of cancer at some point during their lifetime, according to the National Cancer Institute at the National Institutes of Health.

PAMA: The Stage is Set “The patient as consumer is coming into focus. Reps need to find out how their customers feel about this and what it means to them.”

don’t perform labs; they see patients who need laboratory testing. That’s an important way to view the patient/ physician interaction. And second, regardless of practice size, they have to look at the practice as a business.” Reps can help their customers understand how POL testing can improve and speed up their clinical decisions, and how the distributor can help the practice operate more efficiently. Underscoring the changes in POL reimbursement is MACRA, that is, the Medicare Access and CHIP Reauthorization Act of 2015. “MACRA has brought an emphasis on patient satisfaction and improved outcomes, that is, clinical utility,” says Poggi. Tests that are urgently needed to establish or maintain a patient program for treatment will continue to be important to Medicare. All physician groups, regardless of size, will be affected by PAMA, he adds. “Ultimately, it’s less about the size of the group and more about how they truly feel about testing that will make the difference.” Those that tie financial outcomes directly to testing, and make clinical utility a secondary consideration, are likely to experience the most severe changes. But those that clearly link patient satisfaction and patient counseling to testing will probably be least affected. “We are seeing that emphasis from financial outcomes to patient outcomes occur over time.” Specialists who use testing to initiate or manage a patient treatment program – e.g., cardiologists, oncologists, rheumatologists and infertility specialists – as well as those who treat patients with lipid disorders or diabetes, are likely to be less impacted than others, he continues. “In addition, you’ll see an increase in testing around genetic dis-

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orders, particularly pediatrics, oncology and fertility, a technology which is being developed rapidly, and which delivers better patient outcomes.”

Upside

Many of the tests considered for payment increases fall into specific categories: DNA/genetic tests (including DNA probes for Mycoplasma pneumonia); cytopathology; and microbiology/antibiotic susceptibility, says Poggi. “In general, these tests are not high volume in the POL, but they do point to increased acknowledgement of antibiotic stewardship and also the increasing role of molecular tests in lab medicine.” While many respiratory tests (strep, flu, etc.) will see reimbursement cuts, tests for adenoviruses will likely fare better. Some urine tests, including urine albumin and urine screening for bacteria, may be reimbursed more generously than in the past because of PAMA, he adds. Poggi calls molecular testing “one of the greatest revolutions” he has seen in his 20-some years in the lab business. “Molecular testing is another area in which clinical outcomes and improving patient care are being tremendously enabled.” Already some of the big reference labs are trying to specialize in one area of molecular testing, in order to establish themselves as experts in that area. “It’s not just the increase in the number of tests, but in their quality,” he adds. “We’ll see a continuing focus on molecular testing in every specialty group and disease state. We’ll also see it expand into oncology, companion medicine and disease susceptibility testing.

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TRENDS

A Head Start on Diabetes Eating right, staying active, can turn the tide on prediabetes

Eighty-four million people – more than one of three adults in the U.S. –

have prediabetes. Nine out of 10 don’t even know they have it. It’s time to do something about it, says Ann Albright, PhD., RD, director of the Division of Diabetes Translation, National Center for Chronic Disease Prevention and Health Promotion, U.S. Centers for Disease Control and Prevention. The blood glucose levels of people with prediabetes are higher than normal, though not high enough to be diagnosed as type 2 diabetes. The good news is, prediabetes can – with effort – often be reversed. The CDC-led National Diabetes Prevention Program (National DPP) – which Albright helped develop – is designed to help people with prediabetes participate in evidence-based, affordable, and high-quality lifestylechange programs to reduce their risk of type 2 diabetes and improve their overall health.

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Year-long program

Established by the Diabetes Prevention Act of 2009, the year-long program consists of a series of sessions providing information, group support, and offering feedback in stages to optimize behavioral change. Programs are offered in a group setting, online, or other virtual approaches, and are led by lifestyle coaches who are trained to use a CDC-approved curriculum and who have the knowledge and skills to effectively deliver the program. Goals should focus on moderate changes in both diet and physical activity to achieve modest weight loss over the first six months, in the range of 5 percent to 10 percent of baseline body weight. Strategies used to achieve these goals must include a focus on self-monitoring of

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TRENDS food intake and physical activity, building of self-efficacy and social support for maintaining lifestyle changes, and problem-solving strategies for overcoming common challenges to sustaining weight loss. “It is a structured, highly-evidence-based program for preventing or delaying type 2 diabetes,” says Albright. “We have used the evidence from the original randomized trial along with subsequent studies and translated it,

“Diabetes is like a rock in a pond – meaning it increases the risk of other chronic conditions and diabetes complications such as hypertension, hyperlipidemia, sleep apnea, amputation, and kidney failure.”

two states currently provide coverage, two will begin in 2018, and 20 more are working on it.

The long haul

“Type 2 diabetes prevention calls for moderate, long-term lifestyle change, and the need for it is urgent,” says Albright. “Because diabetes is like a rock in a pond – meaning it increases the risk of other chronic conditions and diabetes complications such as hypertension, hyperlipidemia, sleep apnea, amputation, and kidney failure – it’s critical that we achieve type Your risk for prediabetes 2 diabetes prevention. “We have to begin taking lifestyle Type 2 diabetes can be delayed or prevented in people with change seriously. We have to stop prediabetes through effective lifestyle programs, according to the wringing our hands, and we need to Centers for Disease Control and Prevention, which advises people be problem solvers and focus on adto take the following test to determine their risk for prediabetes. dressing the barriers for people getThe more “yes” answers, the greater the risk of prediabetes. ting into the program and sustaining • Do you have a mother, father, sister or brother with diabetes? lifestyle changes. It’s a significant • Have you ever been diagnosed with high blood pressure? undertaking, but over the last four • How old are you? years we have made substantial prog• What race or ethnicity best describes you? ress with all of the stakeholders who • Are you physically active? have joined in to help reduce the • Are you a man or a woman? burden of diabetes in this country.” • Have you ever been diagnosed with gestational diabetes? • How tall are you? In 2015, the American Medical • How much do you weigh? Association and CDC joined forces to launch a multi-year initiative intended Source: DoIHavePrediabetes.Org to reach more Americans with prediahttps://doihaveprediabetes.org/prediabetes-risk-test.html betes and stop the progression to type 2 diabetes. Prevent Diabetes STAT: Screen, Test, Act - Today™, aims to sound an alarm and shine a light on prediabetes as a critical creating an infrastructure that allows the program to be and serious medical condition. delivered at a national level by trained diabetes prevenThe initiative includes tools to help physicians incortion coaches in churches, YMCAs, and community centers porate type 2 diabetes prevention (screening, testing and throughout the country. referring patients) into their practices, and to promote “More than 1,500 organizations currently offer the prediabetes awareness among their patients. intervention, to more than 155,000 people for which we currently have data,” says Albright. The average weight loss is 4.1 percent. “As a nation, we’re striving for 5 perSpreading the word cent average weight loss,” she says. Over 70 commercial CDC continued its work to increase prediabetes awarehealth plans provide some form of coverage for the proness the following year with the launch of the nation’s gram, and starting in April 2018, Medicare will pay for defirst prediabetes awareness campaign. Launched January livery of the program. Insofar as Medicaid is concerned, 2016 in partnership with the Ad Council, the AMA and

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TRENDS the American Diabetes Association, this national effort encouraged people to learn their risk for prediabetes by visiting the campaign website, DoIHavePrediabetes.Org and taking a one-minute risk test. Earlier this year CDC partnered with CBS to launch “Your Health with Joan Lunden and CDC,” a televised and digital mini-series in which CBS host Joan Lunden, Albright and special guests explore diabetes, prediabetes and related topics.

“We have to work on preventing new cases of type 2 diabetes, and improving outcomes for those with diabetes,” says Albright. “There are many pieces to solving this puzzle, but with the National DPP, we are working to make sure this evidence-based lifestyle program is in place and available to the people who need it. As the common defense against health threats for the country, we remain committed to using our available science, surveillance and service to work with stakeholders and reduce the impact of diabetes in the U.S.”

Prediabetes checklist Organizations participating in the CDC-led National Diabetes Prevention Program must use an approved curriculum that meets the CDC requirements for recognition. CDC offers two curriculums in English and Spanish: the 2012 National DPP curriculum and the Prevent T2 curriculum. Organizations may also develop and use their own curriculum, though it must

be submitted, reviewed, and approved by CDC prior to its use. The PreventT2 curriculum is based on the original 2002 DPP trial and follow-up studies. It promotes modest weight loss (5-7 percent) and increased physical activity through a 12-month lifestyle change program, and also reflects new literature on self-efficacy, physical activity and diet. There are 26 modules.

First six months Organizations must present all 16 of the following modules within the first six months. “Introduction to the Program must come first.” Otherwise, there is no required order. However, CDC recommends that organizations present the next six modules in the order listed, since they provide the foundation upon which the rest of the curriculum is based. CDC recommends presenting Stay Motivated to Prevent T2 at the six-month mark. • Program Overview • Introduction to the Program • Get Active to Prevent T2 • Track Your Activity • Track Your Food • Eat Well to Prevent T2 • Get More Active • Burn More Calories Than You Take In • Shop and Cook to Prevent T2

• Manage Stress • Find Time for Fitness • Cope with Triggers • Keep Your Heart Healthy • Take Charge of Your Thoughts • Get Support • Eat Well Away from Home • Stay Motivated to Prevent T2

Second six months Organizations must present at least six of these 10 modules during the last six months. Prevent T2 – for Life! must come last. Otherwise, there is no required order. • When Weight Loss Stalls • Take a Fitness Break • Stay Active to Prevent T2 • Stay Active Away from Home • More About T2

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• More About Carbs • Have Healthy Food You Enjoy • Get Enough Sleep • Get Back on Track • Prevent T2 – for Life!

LISTEN UP! Let yourself get talked into greater success! This year’s speaker line-up has been carefully chosen to noticeably improve performance in your company. Learn what you may have been missing from those who make success their business. Through their insight, humor and personal sharing, you will be inspired to: ■

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Molly Fletcher, Molly Fletcher Co.

Bryan Offutt, Under Armour

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TRENDS Burnout

Patient Safety It’s not only an inpatient issue

More needs to be done to improve patient safety in the outpatient set-

ting, says the American College of Physicians (ACP) in a new policy paper, Patient Safety in the Office-Based Practice Setting. “In recent years, much attention has been focused on improving patient safety in hospitals,” Jack Ende, MD, MACP, president, ACP, was quoted as saying. “We now must extend that focus to include the ambulatory setting. Medical errors that happen outside of the hospital are just as important to prevent.” The paper outlines the following seven principles and recommendations aimed at improving patient care in office-based practices.:

A culture of safety Physicians and healthcare organizations have a responsibility to promote a culture of patient safety within their practices and among colleagues with whom they collaborate. •P atient safety goals must be embedded in the daily activity of the healthcare team and office staff. •M edical error reporting efforts should encourage accuracy, confidentiality, and compliance, and ensure that information is useful, actionable, and non-punitive, and is focused on actual events and near-misses. •A culture of safety can be encouraged by adopting liability protections that protect physicians and the healthcare team from being penalized for reporting errors and working with patients to address safety issues.

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A 2012 survey found that nearly half of U.S. physicians surveyed experience at least one symptom of burnout, and the prevalence of burnout is higher among physicians than other workers. General internal medicine physicians and other front-line physicians were among specialties reporting the highest amounts of burnout. Subsequent surveys indicate that the problem is worsening. Rick factors for burnout among healthcare providers include time pressure, lack of control over work processes, role conflict, and poor relationships between groups and with leadership, combined with personal predisposing factors and the emotional intensity of clinical work. Additional factors include the following: • Health information technology. Concerns have been raised about the association between electronic medical records (EMRs) and higher stress levels, less job satisfaction, and increased time pressure among primary care physicians. • Alert fatigue due to the barrage of information delivered through computerized order entry systems, EMRs, and other avenues may cause clinicians to tune out and become desensitized to information, potentially raising the risk for an adverse event. • Error incident reporting can pose an administrative burden, discouraging clinicians from reporting less severe mistakes. Recommendations to reduce burnout include: • Workflow redesign, such as changing call schedules and assigning certain tasks to nurses or medical assistants.

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TRENDS • Improved communication among clinicians and staff, including teamwork building and monthly clinician meetings to enhance collegiality. • Quality improvement projects directed at clinician concerns, such as more automated prescription phone lines and medication reconciliation projects.

Patient and family education Patient and family education, engagement, and health literacy efforts are needed to educate the public about asking the right questions and providing the necessary information to their physician or other healthcare professional. Materials should reflect the linguistic and cultural characteristics of the audience.

Needed: Patient safety metrics ACP supports the continued research into and development of a comprehensive collection of standardized patient safety metrics and strategies, with particular attention to primary care and other ambulatory settings. Domains could include medication safety, diagnosis, transitions, referrals, and testing issues. ACP recommends expanded patient safety research efforts to better understand ambulatory medical errors and the efficacy of patient safety practices. Most patient safety measures have been focused on the inpatient setting and initiatives, such as value-based purchasing and hospital-acquired-conditions penalties, ACP points out. In fact, of the 22 patient safety measures endorsed by NQF in 2016, only four were related to the ambulatory setting. If ambulatory care patient safety is going to improve, errors will have to be reported and compared with patient safety targets to help understand the epidemiology of errors and spur better outcomes. But developing process and outcomes measures for outpatient safety won’t be easy. Patients are cared for by multiple clinicians in multiple settings, complicating coordination of care assessment, and real-time tracking of outpatient safety events is more difficult to achieve than in the inpatient setting. Also of concern is the issue of proper attribution, to ensure physicians and other healthcare professionals are not blamed for errors outside of their control.

An efficient, interoperable health IT system can facilitate healthcare team communication, efficient workflow, and delivery of educational prompts that improve timeliness and accuracy of diagnoses, and enhance care transitions and referrals. Communication breakdowns between clinicians and patients may threaten patient safety. Use of medical jargon, health illiteracy, and limited understanding of information can increase the risk. Further, patient confusion can lead to medication adherence problems that lead to adverse drug events. Evidence shows that patient engagement is associated with fewer inpatient adverse events and can instigate best practices, such as high hand-washing rates among clinicians. The Institute of Medicine has stressed the importance of patient-clinician engagement in improving diagnosis, points out the ACP. Healthcare professionals and organizations should create an environment that is conducive to patient engagement, making electronic health records and diagnostic testing results accessible to patients, and identifying opportunities to include patients and families in efforts to learn from diagnostic errors and near-misses.

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Patient-centered care Team-based care models, such as the patient-centered medical home, should be encouraged and optimized to improve patient safety and facilitate communication, cooperation, and information-sharing among team members. Evidence suggests that healthcare delivery system models that encourage better communication and collaboration among clinicians may be associated with safety improvements.

Healthcare IT An efficient, interoperable health IT system can facilitate healthcare team communication, efficient workflow, and delivery of educational prompts that improve timeliness

and accuracy of diagnoses, and enhance care transitions and referrals. Health IT can also facilitate patient-clinician communication outside of the office setting in ways that mitigate the potential for errors and improve patient self-management. Computerized provider order entry systems have been shown to reduce medication errors, and have been widely adopted in the hospital and outpatient setting following implementation of the federal HITECH Act and Meaningful Use program. Technologies, such as text-based and pager alerts, computerized decision-support systems, and decision-support algorithms, may help reduce diagnostic errors

A national safety agency A national effort to prevent patient harm across the healthcare sector should be established. A national entity could be charged with coordinating and collaborating with stakeholders, defining the problem, setting national goals, and developing and assisting in the implementation of a patient safety action plan with attention given to the ambulatory setting. In its “Free from Harm” report, the National Patient Safety Foundation calls for the creation of a centralized agency to coordinate patient safety efforts. Such a body would function similar to the Federal Aviation Administration or the Nuclear Regulatory Commission, and would coordinate efforts, facilitate communication among stakeholders, provide direction, ensure accountability and disseminate best practices. ACP believes that establishing a regulatory agency would elevate the issue, broaden the focus from single patient safety initiatives, and help to break down silos that act as a barrier to system-wide patient safety improvement.

Diagnostic errors Diagnostic errors are the most common type of error that occurs in the ambulatory setting, says the American College of Physicians in “Patient Safety in the OfficeBased Practice Setting, American College of Physicians: A Position Paper, 2017.” Although definitions and terminology for diagnostic errors vary, the Institute of Medicine has developed a patient-centered definition of diagnostic error: “the failure to (a) establish an accurate and timely explanation of the patient’s health problem(s) or (b) communicate that explanation to the patient.” According to the IOM, at least 5 percent of all U.S. adults who receive outpatient care each year will experience a diagnostic error, and most people will likely experience a meaningful diagnostic error in their lifetime. A population-based study estimated that the rate of outpatient diagnostic errors is 5.08 percent, or about 12 million U.S. adults every year. The IOM estimated that 10 percent of patient deaths are attributable to diagnostic errors and found that most paid malpractice claims for the outpatient setting were attributable to diagnostic errors. A 2017 study conducted by the Mayo Clinic found that 21 percent of patients who had received a second opinion regarding a diagnosis had their original diagnosis completely changed, and 66 percent of patients saw their original diagnosis better defined or redefined. Only 12 percent of original diagnoses were complete and correct. In a 2006 review of paid malpractice claims for diagnosis errors that resulted in adverse outcomes, 59 percent were associated with a major or significant physical adverse outcome and 30 percent were associated with death. The diagnoses missed were cancer (59 percent, with 24 percent involving breast cancer), infections (5 percent), fractures (4 percent), and myocardial infarctions (4 percent). Eighty-five percent of errors occurred in physicians’ offices. A 2013 study used electronic medical record triggers to detect primary care diagnostic errors and found that pneumonia, decompensated congestive heart failure, and cancer were the most common diagnoses missed.

Source: Patient Safety in the Office-Based Practice Setting, American College of Physicians: A Position Paper, 2017, www.acponline.org/acp_policy/policies/patient_safety_in_the_office_based_practice_setting_2017.pdf

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January 2018

TRENDS

Top Challenges The Department of Health & Human Services looks at the long road ahead

January 2018

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The Department of Health & Human Services is responsible for a $1.1 trillion

portfolio. Thatâ&#x20AC;&#x2122;s a lot of money. And a lot that can go wrong. The Office of Inspector General synthesized its work in oversight, risk analysis, data analytics and cybersecurity to arrive at what it considers to be the top 10 management and performance challenges facing the Department of Health and Human Services.

Challenge No. 1: Ensuring program integrity in Medicare In FY 2016, the Centers for Medicare & Medicaid Services (CMS) reported an improper payment rate of 11 percent, corresponding to $41 billion, for Medicare fee-for-service, i.e., Medicare Parts A and B. Some types of providers and suppliers pose heightened risk to the financial integrity of the program. For instance, OIG and CMS have identified high rates of improper payments for home healthcare, hospice care, and certain hospital services. Additionally, OIG estimates that Medicare improperly paid hundreds of millions of dollars for chiropractor services that did not meet Medicare requirements.

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TRENDS Challenge No. 2: Ensuring program integrity in Medicaid Reducing improper payments to providers is a critical element in protecting the financial integrity of the Medicaid program. In FY 2016, HHS reported an improper payment rate in the Medicaid program of 10.5 percent. OIG audits have identified substantial improper payments to providers across a variety of Medicaid services, including school-based services, non-emergency medical transportation, targeted case management services, and personal care services. OIG has also uncovered improper payments made on behalf of individuals ineligible for Medicaid, deceased beneficiaries, and beneficiaries with multiple Medicaid identification numbers.

have access to and receive high-quality services and are protected from abuse or neglect.

Challenge No. 5: Ensuring integrity in managed care and private insurance Improper billing and fraud by healthcare providers is not limited to Medicare and Medicaid fee-for-service programs. Medicare Advantage (managed care) organizations, Medicare Part D sponsors and Medicaid MCOs also face these risks.

Challenge No. 6: Improving financial management HHS is the largest civilian agency within the federal government. Operating a financial management and administrative infrastructure that employs appropriate safeguards to minimize risk and provide oversight for the protection of resources remains a challenge for HHS.

Improper billing and fraud by healthcare providers is not limited to Medicare and Medicaid fee-for-service programs. Medicare Advantage (managed care) organizations, Medicare Part D sponsors and Medicaid MCOs also face these risks. Challenge No. 3: Curbing the opioid epidemic More than 33,000 people died in 2015 from overdoses involving opioids, both prescription and illicit, an increase from approximately 28,000 deaths in 2014, reports CDC. Yet, only about one-fifth of individuals receive specialty treatment, and even fewer receive medication-assisted treatment.

Challenge No. 4: Improving care for vulnerable populations HHS programs provide health and human services to many vulnerable populations, including individuals who receive nursing home care, group home care, hospice care, or home and community-based services, as well as children from low-income families in foster care. The OIG says that HHS must ensure that these individuals

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Challenge No. 7: Protecting the integrity of grants

In FY 2016, HHS awarded more grants than any other federal entity – more than $100 billion in grants, excluding Medicaid. Recent legislation expands the department’s reach and increases expenditures through new grant programs. In passing the 21st Century Cures Act, Congress authorized (and subsequently appropriated) billions of dollars in new federal spending to address national public health needs. This included $1.8 billion for cancer prevention, diagnosis, and treatment; $1.5 billion for neurological research; $1.4 billion for the Precision Medicine Initiative; and $1 billion in grants to states for opioid prevention and treatment. The Act also authorized funds for smaller grants to address other public health needs. For example, it authorized $200 million over four years for grants for mental and behavioral health education training.

Challenge No. 8: Ensuring the safety of food, drugs and devices FDA’s responsibility to ensure safe, effective, and quality medical products begins long before a product is brought

to market, and continues after FDA approval. FDA oversees more than 13,000 drug facilities and 25,000 medical device facilities. The agency is also responsible for authorizing the use of investigational medical products as well as ensuring the safety and efficacy of all prescription medical products before marketing in the United States. In 2016, FDA approved 22 novel drugs, 73 first-time generic drugs, and 91 novel medical devices.

Did you know? The Department of Health & Human Services is the

Challenge No. 9: Ensuring program integrity for American Indian and Alaska Native populations In FY 2016, HHS administered 45 percent of all federal funds that serve American Indian and Alaska Native (AI/AN) communities – a total of $7 billion. A number of HHS agencies administer programs for AI/ANs throughout the United States. With an annual budget of approximately $6 billion, the Indian Health Service is the largest of these programs and, in partnership with tribes, provides or funds healthcare to approximately 2.2 million AI/ANs who are members of the 567 federally recognized tribes, located in 36 states served by 662 health care facilities.

Challenge No. 10: Meeting cybersecurity threats As HHS works to leverage the power of data, the department will maintain and use expanding amounts of sensitive data. So, too, will individuals and entities – such as states, contractors, providers, grant recipients, and beneficiaries – involved in delivering or receiving benefits from HHS programs. Cybersecurity incidents and breaches pose a significant risk to the confidentiality, integrity, and availability of sensitive data. Source: Top Management and Performance Challenges Facing HHS, 2017, U.S. Department of Health & Human Services, Office of the Inspector General, https:// oig.hhs.g ov/reports-and-publications/ top-challenges/2017/2017-tmc.pdf

largest civilian agency within the federal government. In FY 2016, HHS reported total budgetary resources of approximately $1.1 trillion. With almost 69 million enrolled individuals, Medicaid serves more enrollees than any other federal healthcare program, and represents one-sixth of the national healthcare economy. The Centers for Medicare & Medicaid Services reports that combined federal and state Medicaid expenditures were $574 billion for FY 2016. Medicaid is jointly administered and funded by CMS at the federal level, and by states. In FY 2016, Medicare spent $679 billion and provided health coverage to 56.8 million beneficiaries. The 2017 Annual Report by Medicare’s Board of Trustees projects that spending for Medicare Part B (medical insurance) will grow by almost 7 percent over the next five years, outpacing the U.S. economy, which is projected to grow by 5 percent during that same time. It also estimates that the Trust Fund for Medicare Part A (hospital insurance) will be depleted by 2029. In 2016, the Food and Drug Administration approved 22 novel drugs, 73 first-time generic drugs, and 91 novel medical devices. The FDA oversees more than 13,000 drug facilities and 25,000 medical device facilities. The Indian Health Service – in partnership with tribes – provides or funds healthcare to approximately 2.2 million people in American Indian and Alaska Native communities, who are members of the 567 federally recognized tribes. Source: Top Management and Performance Challenges Facing HHS, 2017, U.S. Department of Health & Human Services, Office of the Inspector General, https://oig.hhs.gov/reports-and-publications/top-challenges/2017/2017-tmc.pdf

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TRENDS

Looking for Pristine Data? By Bruce Stanley

It starts within your own organization As a practitioner and consultant, I find the successful implementations often occur when the organizational leader asks questions like, “What does success look like for us? What can we do in our local site to support the industry initiative?” What often surfaces as an “aha” moment is the realization that organizations can take simple steps to ease the pain. These steps center around how companies create clarity with their own sensible and sustainable internal business rules, processes and financial reporting.

Many of us in healthcare have experienced well-intentioned initiatives

over a generation trying to “fix” the complexity of our healthcare operational systems and the transactional/financial processes. I’ve worked with many technically savvy individuals who tell me, “This looks easy. One more tweak and we’ll be there.” The more candid professionals freely admit that this is actually hard work. Looking back, some of us might remember the EHCR initiative of the late 90s, which was intended to revolutionize and streamline contracting. HINs were the Holy Grail of contract simplification. Today we have new buzzwords, like GLN, GTIN, UDI and so on. So why, after so many years, are we still talking about data and process standardization and alignment? Because no one person, group or company owns the complete data set.

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Simple is better As companies begin their organizational homework, they start to see the workings of their own supply chain

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TRENDS

UDI and direct marking The Food and Drug Administration in November issued final guidance on direct marking of the unique device identifier (UDI) on devices. By law, a device must be directly marked with a UDI when the device is intended to be used more than once and intended to be reprocessed before each use. However, “intended to be used more than once” and “intended to be reprocessed” were not defined in the UDI regulations. The November guidance provides FDA’s interpretation of these terms, clarifies when direct marking of devices with a UDI is required, provides recommendations for how labelers should comply with the UDI direct marking requirements, and clarifies the criteria for exceptions to the direct marking requirement. See the Federal Register, Nov. 17, 2017, https://www.federalregister.gov/ documents/2017/11/17/2017-24992/ unique-device-identification-direct-marking-of-devices-guidance-for-industry-andfood-and-drug

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processes, and they see what amazing things could happen if they modified them, regardless of any industry standard. Taking simple steps to make their own life easier and more manageable are key to getting off on the right foot. Examples include SKU rationalization, price streamlining, contract choice management and selection, feasible direct distribution and value-based data. Astute leaders realize that implementing simplification rules won’t happen by accident or by dictum, but only when they fix and organize their companies with stronger and more understandable internal platforms. They know that in order to understand how an organization actually operates, one needs to “flip it on its edge” and then ask a million questions – many of which aren’t easily answered. They view their organizations from different perspectives, i.e. staff skill sets, business rules, actual practices, exceptions, financial reconciliation and all the rest. Asking the right questions about the organization can be much more valuable than the answers at this point. They might include: • How does our operational and financial data work? • Why do we do this transaction the legacy way? • How is the ownership of all data managed and why? • How could financial reconciliation work? • Who should own what parts of what data? • What other industries would you mirror, if any? • Could we better align timing and terminology?

Add device identifier to claims forms, groups urge CMS Adding a device identifier (part of the unique device identifier, or UDI) to medical claims forms would provide better data on product performance and detect device failures sooner than current methods, according to a number of medical and healthcare organizations. The organizations – including Geisinger, Intermountain Healthcare, Premier, the American College of Cardiology and the American Medical Group Association – made the recommendation in a Nov. 15 letter to Seema Verma, administrator of the Centers for Medicare & Medicaid Services. In November, the Office of the Inspector General reported that the failure and recall of just seven cardiac implants cost CMS $1.5 billion in followup care to patients affected

Fortunately, organizations such as GS1 and the Health Industry Distributors Association are immensely helpful in setting the stage for our industry. This momentum helps our own organizations build the platform with stronger data understanding, so that once and for all we can align and drive towards pristine data in healthcare. Having data accuracy close enough isn’t good enough any longer. Data needs to be – and can be

by the faulty products, and Medicare beneficiaries an additional $140 million in out-ofpocket expenses. “Given the limited scope of the investigation, the costs to both taxpayers and patients is assuredly higher when considering other products, including hip and knee implants,” according to the letter-writers. To address the issue, OIG recommended adding device identifiers to claims to indicate the brand and model of device used. (The device identifier is a fixed portion of a UDI that identifies the labeler and the specific version or model of a device.) “Claims data … could supplement other data sources – such as registries – to provide more robust data on product performance and detect device failures sooner,

“Despite the help of industry standards, the burden remains with each company to make those standards its own.”

which is important to both prevent problems sooner and provide assurances to organizations that participate in alternative payment models that the products they use are high quality,” according to the letter-writers. As a tool for postmarket surveillance, “claims data could provide longitudinal information (such as revision surgery to remove an implant) on patient outcomes from thousands – even millions –of patients in ways that other data sources may not be able to provide,” they write. “Adding the device identifier will provide claims with information on the brand and model of device, so that researchers – including within some of our organizations—can evaluate the quality of specific devices.”

– perfect. When it’s not, nothing works right. Pristine data alignment is in your organization’s control and no one else’s. It all comes down to heavy lifting. It’s always easy and certainly less effective to suggest to someone else to “make your transactions timely or use our technology and follow these standards.” The bottom line is, despite the help of industry standards, the burden remains with each company to make those standards its own.

Bruce Stanley is a supply chain and contracting operations consultant, and an adjunct professor at Endicott College’s MBA program, teaching global supply chain, contracting and healthcare informatics and regulations. In 2011, he co-founded The Stanley East Consulting Group, in Ipswich, Mass., a consulting practice specializing in supply chain, contracting, order fulfillment and project management for small and medium-sized companies, startups, and companies in transition or divestiture. Earlier, he served as senior director, contracting operations, for Becton Dickinson.

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TRENDS

3D Printing: What Will it Mean for You? A revolution in manufacturing may affect the healthcare supply chain

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Did you catch this spring’s announcement that Adi-

das has partnered with 3D printing firm Carbon to unveil the Futurecraft 4D shoe? The midsoles are crafted with light and oxygen using a 3D printing process called digital light synthesis. It’s a safe bet that we will see more – and more complex – 3D-printing applications in the consumer world in the years to come. Already, the technology has affected the development and manufacturing of instrumentation, implants (e.g., cranial plates or hip joints) and external prostheses, such as hands. Some day, 3D printing may be used to create living organs. And when the U.S. Food and Drug Administration issues a draft guidance for the

industry on the subject (as it did in May 2016), you know this thing is for real. It’s too early to tell how 3D printing will affect the medical device industry, but it could change the way in which devices are developed, manufactured and acquired.

What it is 3D printing is a process that creates a three-dimensional object by building successive layers of raw material. Each new layer is attached to the previous one until the object is complete. Objects are produced from a digital 3D file, such as a computer-aided design (CAD) drawing or a Magnetic Resonance Image (MRI). Says the FDA, the flexibility of 3D printing allows designers to make changes easily without the need to set up additional equipment or tools. It also enables manufacturers to create devices matched to a patient’s anatomy (patient-specific devices) or devices with very comSteve Pollack plex internal structures. 3D printing can be used to fabricate complex geometric structures, “allowing the creation of engineered porous structures, tortuous internal channels and internal support structures,” something that isn’t possible – certainly not easily – with traditional, injection-mold manufacturing, says the FDA. Significantly, the technology speeds up the design process. Rather than going through the much-longer and expensive process of design, prototype, machine tools and finally production, manufacturers can go directly from design to production. That means that manufacturers – and perhaps health systems some day – can design or modify devices to satisfy individual provider’s preferences quickly – far more quickly and far less costly than they could with traditional injection molding. Want a new handle for that trocar? Coming right up.

Like a jet printer Here’s how to think about 3D printing, explains Steve Pollack, research scientist, Carbon, Redwood City, California, developer of additive manufacturing processes and materials. Traditional manufacturing calls for the manufacturer to take a chunk of steel or other material and essentially carve away anything that shouldn’t be part of the finished piece or device. “But with additive manufacturing, you start with a liquid or molten solid, maybe even a gas, and only introduce solid material where you want it; and where you don’t want it, you don’t introduce it.” Pollack knows about the medical world. Prior to joining Carbon in 2015, he was director of the Office of Science and Engineering Laboratories (OSEL), part of the U.S. Food and Drug Administration’s Center for Devices and Radiological Health. His early work experience was with American Hospital Supply, for whom he performed analysis of polymeric materials for such American units as American Edwards and American Bentley. 3D printers essentially operate like ink jet printers, continues Pollack. Whereas the ink printer lays down a set of dots of ink which represent a character, then moves to the next one, the 3D printer solidifies a liquid (or powder) in the X-Y (that is, two-dimensional) plane, then lays down a layer on top of that, and another, and another, until the piece is complete. The technology dates back to 1984, when Chuck Hull filed his patent for Stereolithography Apparatus (SLA). Two years later, he founded 3D Systems, said to be the first 3D printer company in the world. The company commercialized the first 3D printer – the SLA-1 Stereolithography (SLA) printer – in 1987. Another pioneer in the field is Scott Crump, founder of Stratasys, who in 1988 invented a process called Fused Deposition Modeling (FDM) by mixing wax and plastic

“Something like a trocar handle, which has internal fluid flow, a camera, complex plumbing, lots of negative space – that’s our sweet spot.”

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January 2018

TRENDS in the family kitchen. 3D printers that run on FDM technology build parts layer-by-layer from the bottom up by heating and extruding thermoplastic filament. Pollack describes the three basic 3D printing technologies today: • Stereolithography. Light is shone onto liquid; a chemical reaction solidifies the liquid. •P owder fusion. Powder is spread in a thin layer, then heated selectively either with a laser or through a chemical “mask” that controls temperature rise, and then solidified. • Fused Deposition Modeling, sometimes called plastic jet printing, in which a strand of solid polymer is heated to melting and solidified in the desired shape, layer upon layer. Carbon’s process – Digital Light Synthesis, or DLS – is a variant of the liquid-to-solid, or stereolithography,

examines the prototype and requests necessary changes, at which point the process starts again. “But with additive manufacturing, you conceive of the part, print iterations of it until you’re satisfied, then start manufacturing it with the same machine,” says Pollack. By removing the intermediate steps, the manufacturer can release new products in weeks. That means if surgeons request a new handle for a trocar – say, one that is more textured – the manufacturer can conceive and produce it fairly quickly, without spending thousands of dollars (sometimes hundreds of thousands of dollars) creating a mold, then a prototype, then a new mold, etc. In some medical centers, 3D printing has been used largely for making models, most notably, for preoperative surgical planning, says Pollack. Based on radiographic images, the surgeon prints a model of the patient’s anatomical feature and, in essence, is able to “practice” on the patient before the actual procedure. “We’ve had a lot of requests for that [application], and I suspect we’ll be in that space,” he says. The challenge for the medical manufacturing community is ensuring that 3D printing can produce devices with: 1) advanced mechanical and physical properties, 2) biocompatibility, and 3) the ability to be sterilized, if necessary.

“ You start with a liquid or molten solid, maybe even a gas, and only introduce solid material where you want it; and where you don’t want it, you don’t introduce it.” process, says Pollack. DLS is driven by Carbon’s CLIP technology, which works by projecting light through an oxygen-permeable window into a reservoir of ultravioletcurable resin. As a sequence of UV images are projected, the part solidifies and the build platform rises. Carbon says the process improves surface quality and creates isotropic mechanical properties (the same in all directions) of the device being printed.

Faster, less expensive Traditional manufacturing finds designers drawing an object, making a model, showing it to others, then making necessary changes, explains Pollack. At that point, engineering goes back to the drawing board to figure out how to turn this model into something that can be manufactured through injection molding. They have to figure out how to make the “negative” of the shape, so it can be molded in the factory. “Mold engineering is a very tedious, complicated process,” he continues. And it’s expensive. After the mold has been engineered, the team

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Sweet spot Chances are, 3D printing won’t have much of an impact on simple consumables, such as syringes, which can be made economically through traditional injection molding, says Pollack. But it could be used before long to produce new cushion materials for hospital beds, wheelchairs, etc., for the prevention of pressure ulcers. “Something like a trocar handle, which has internal fluid flow, a camera, complex plumbing, lots of negative space – that’s our sweet spot,” says Pollack. Already the technology has been used by others on an emergency basis to provide upper airways to babies born without one. But producing implants demands long-term testing, animal testing…and regulatory hurdles. In fact, in May 2016, the FDA issued preliminary recommendations for manufacturers of additive manufactured devices. But the questions remain, Will the agency regulate hospitals as manufacturers of medical devices? And if so, how? “No one knows the answer to that,” says Pollack.

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HIDA GOVERNMENT AFFAIRS UPDATE

CMS Pursues Medicare Deregulation

In its first year, the Trump Administration made several key regulatory changes at

the Centers for Medicare and Medicaid Services (CMS). These include rolling back the previous administration’s bundled payment program, soliciting feedback on current requirements, and taking steps to reduce the regulatory burden on providers.

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

These deregulation efforts are detailed in HIDA’s forthcoming Medicare 360° report. Below are some of the key Medicare insights contained in this year’s edition: Acute Care Market •C MS has launched the Patients Over Paperwork initiative, which calls on providers to offer feedback on regulations, with the aim of reducing the administrative burden on providers. Post-Acute Market •C MS has requested information from these providers on how the agency can streamline requirements and improve efficiency in each of its proposed rules for post-acute care. Physician Market •W hile CMS continues to implement payment changes under the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA), the agency has also taken

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payments to post-acute providers. This measure lays the groundwork for CMS to create a single post-acute payment system. Physician Market •C MS predicts over 500,000 physicians participated in the Merit-Based Incentive Payment System (MIPS) under MACRA in 2017. The agency encouraged all physicians to report data through this program so they would not risk having their Medicare reimbursement cut.

Other key changes CMS has taken several steps that are not connected with deregulation or outcomes measurement, but will have a profound effect on large segments of the healthcare industry. • T he agency has dramatically changed the way it pays for lab services as part of the Protecting Access to Medicare Act of 2014. Specifically, the Clinical Lab Fee Schedule is now based on private payer rates. Under this new system, reimbursements for most lab services will be reduced, and many will receive the maximum 10% cut (CMS cannot cut a test more than 10% in 2018).

steps to ease the law’s burdens in 2018. Several industry groups have already raised concerns about the measures doctors must report to CMS.

CMS continues efforts on quality, outcome measures HIDA expects CMS to continue its efforts to link payments to care quality and outcomes. Here is a look at some of the changes taking effect in 2018: Acute Care Market •C MS has introduced the Meaningful Measures initiative, which makes quality measures focus more on outcomes, such as 30-day mortality rates for certain conditions, and less on process. Post-Acute Market •C ongress has implemented several policies in recent years, including the IMPACT Act, which provide CMS the tools it needs to make value-based

• CMS’s “Emergency Preparedness Requirements For Medicare And Medicaid Participating Providers And Suppliers” aims to ensure adequate planning for disasters and to strengthen coordination between providers and federal agencies. This rule drew particular attention during congressional hearings on 2017 hurricane season response, due to its potential for strengthening emergency preparedness. Distributors can play a key role in helping providers comply with these requirements, which took effect on November 15, 2017. HIDA’s forthcoming Medicare 360 °: 2018 Medicare Reimbursement Analysis and Outlook features payment details and regulatory outlooks for other care settings as well, including ambulatory surgical centers and home health agencies. HIDA also has a number of other resources to keep you and your customers up to date on regulatory and legislative developments. For more information on HIDA reports and resources, email HIDAGovAffairs@HIDA.org.

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January 2018

HEALTHY REPS

Genetic testing and warfarin dosing

Third dose of mumps vaccine?

Blood thinners are often prescribed to help prevent blood clots that can lead to pulmonary embolism, heart attack and stroke. Though effective at preventing these clots, warfarin can cause life-threatening bleeds. Warfarin has led to more emergency room visits for older people over the last decade than any other medication. This is because it can be difficult for doctors to determine the right dose. A team of scientists led by Dr. Brian F. Gage at Washington University in St. Louis investigated whether genetic testing can help predict the best warfarin dose to give a patient. They compared outcomes for patients whose initial doses were based on clinical information alone (e.g., age, weight, etc.) to those whose initial doses were based on their genetic makeup (genotype) along with clinical factors. The researchers collected blood samples from the patients and screened for genetic differences in the genes VKORC1, CYP2C9, and CYP4F2, which are related to blood clotting and warfarin metabolism or sensitivity. Adverse events were tracked for 90 days, including major bleeding, deep vein thrombosis, and pulmonary embolism. There were fewer adverse events in the genotypeguided dosing group: 87 events, or 10.8 percent of the genetic group, versus 116 events, or 14.7 percent of the clinically guided group. No patient died during the study.

With the U.S. facing a growing number of mumps outbreaks, an expert panel that advises the Centers for Disease Control and Prevention recommended that people who are at risk during outbreaks (such as those on college campuses) should receive an additional, third dose of vaccine, reports STAT. The Advisory Committee on Immunization Practices unanimously voted to approve a third dose of mumps-containing vaccine as a tool for outbreak control, despite acknowledging evidence to support the practice is limited. After years of low numbers of mumps cases – fewer than 1,000 cases nationally a year – the disease has made a resurgence in the past decade. There were nearly 7,000 cases nationally in 2006 and more than 6,000 in 2016. As of early October, there were 4,667 cases in 47 states and the District of Columbia in 2017.

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Memories are made of this Using an innovative “NeuroGrid” technology, scientists showed that sleep boosts communication between two brain regions whose connection is critical for the formation of memories. The work, published in Science, was partially funded by the Brain Research through Advancing Innovative Neurotechnologies (BRAIN) Initiative, a project of the National Institutes of Health. A brain structure

called the hippocampus is widely thought to turn new information into permanent memories while we sleep. The study – involving rats – confirmed the presence of ripples in the hippocampus during sleep and found them in an area on the brain’s surface involved in processing complex sensory information. As a result, the researchers theorize that such communication is important for the creation and storage of memories, and they hope to use the NeuroGrid in people undergoing brain surgery to see if the same ripples occur.

How do the biggest losers keep losing?

researchers led by Dr. Bernd Schnabl at the University of California San Diego School of Medicine. The researchers found that mice lacking stomach acid had higher levels of intestinal bacteria as well as imbalances among the microbes. In particular, the mice had increased levels of Enterococcus in their guts. Further experiments suggested that these bacteria can reach the liver, where they can cause liver inflammation and damage. The team looked at whether people taking proton pump inhibitors – heartburn medication – have similar microbiota changes. They collected fecal samples from healthy people before and after PPI treatment. After two weeks, those taking the PPI treatment also had a higher number of Enterococcus.

After years of low numbers of mumps cases – fewer than 1,000 cases nationally a year – the disease has made a resurgence in the past decade.

Researchers have been working to understand which aspects of diet and physical activity are most important for weight control. A team led by Dr. Kevin D. Hall of the National Institutes of Health studied participants in a season of “The Biggest Loser,” a televised weight loss competition. Of 16 competitors enrolled, 14 participated in a follow-up study six years later. Seven participants had maintained an average weight loss of about 25 percent of their starting weight. The other seven returned to a weight that was within 1 percent of their starting weight. The calorie intake of both groups was similarly reduced from before the competition began. The main difference was in levels of physical activity. The weight loss maintainers increased their physical activity by an average of 160 percent from before the competition began, while those who regained their weight had only a 34 percent increase. The scientists calculated that an increase of about 80 minutes per day of moderate physical activity or 35 minutes per day of vigorous activity was necessary to maintain lost weight. These amounts are much greater than current recommendations for daily physical activity.

Heartburn: The lesser of two evils? The recent rise in the use of stomach-acid-suppressing medications might be contributing to an increased incidence of chronic liver disease, according to a team of

Steady as she goes One in four Americans aged 65+ falls each year, resulting in more than 2.8 million injuries treated in emergency departments annually, and more than 27,000 deaths, per the U.S. Centers for Disease Control and Prevention. The National Council on Aging leads the National Falls Prevention Resource Center, which supports awareness and educational efforts about falls, and promotes evidence-based fallsprevention programs (such as exercises). For more information, go to www.ncoa.org/fallsprevention

Vacation deprivation Americans are struggling to use their vacation time, per Expedia.com’s Vacation Deprivation® report. Millennials are the most vacation-deprived age group (62 percent) and receive the least vacation time. They are also the most likely to shorten their trips due to impending workload (53 percent). But it’s not just millennials who are struggling to achieve work/life balance. Around half of workers in the U.S. report feeling somewhat or very vacation-deprived, and were projected to lose approximately 462 million vacation days in 2017. The primary reasons cited for not taking time off are budget (43 percent), the desire to save up vacation days for a longer holiday (30 percent), and not being able to get away from work (22 percent).

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SMART SELLING

DISTRIBUTOR SALES STRATEGIES FROM HIDA

Keep Your Pipeline Full

Wouldn’t it be nice to grow your sales territory to the point where you didn’t need to

By Elizabeth Hilla, Senior Vice President, HIDA

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prospect much? You’d have so many loyal customers buying regularly from you that you could devote most of your time just to keeping those customers happy (and maybe even squeeze in the occasional round of golf). There may have been a time in the past when some experienced distributor reps achieved such an ideal state. Today, however, even your most loyal account could be gone next year or next month. The physician practice that’s been buying from you for 10 years could get acquired by a hospital. Or new management could come in at your best surgery center account and demand a change in purchasing practices. Customer turnover is inevitable, and you should work to minimize it by taking great care of your customers. But that may not be enough if the facility’s ownership changes. That’s why it’s imperative to build and manage your prospect pipeline actively.

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• Experiment with social media (particularly LinkedIn). I’ve found that a short, not-pushy InMail message can often get a positive response that leads to an introductory phone call. My message is often just a single qualifying question: “Hi Jim, does XYZ Manufacturer sell through distributors?” • Actively participate in local provider groups, such as your local or state AHRMM or AHCA chapter. Once you’ve built your pipeline, there are more tools than ever to help you manage prospects – contact management software, email marketing tools, LinkedIn, and many others. But they only work if you actively and regularly use them. You can easily find yourself with an empty pipeline if you’re too focused on taking care of urgent requests from current customers. The best way to avoid this is by setting up regular times on your daily or weekly calendar for prospecting activities. Make sure your plan includes time for: Identifying prospects: Constantly work to expand and update your prospect lists. If you see that a current LinkedIn contact has a new job, for instance, record that change right away.

Building your prospect pipeline Here are a few ideas for building your prospect pipeline, and ultimately growing your account base: •A sk loyal customers for referrals. “Hey Janet, you guys have really benefited from your expanded inoffice lab. Do you know folks at other practices that I should be talking to about this?” •L ook for more of the types of customers that love you the most. For instance, if you have done well with ob/gyn customers, actively search for similar practices in your area.

Calling on prospects: Make sure you’re spending time every day or every week picking up the phone and/or knocking on doors to reach your prospect accounts. Warming up your cold calls with advance contact via email is fine if it works for you, but you won’t win new business until you have live contact with a prospect. Following up on opportunities: When you reach an interested customer, follow up with requested information right away. Then set and follow a timeline for continued follow-up. If you’re not prospecting, your account base will almost certainly shrink because of inevitable customer turnover. Actively managing your prospect pipeline can help you recover from potential losses, as well as continue to grow your accounts and future revenue.

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January 2018

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

Technology news

Are you ready, boots? UnitedHealthcare and Qualcomm Inc. have integrated wearable devices from Samsung Electronics America Inc. (Fit2 Pro and Gear Sport) and Garmin International Inc. (vivosmart® 3) into UnitedHealthcare Motion™, a national wellness program that provides eligible plan participants access to activity trackers and enables them to earn more than $1,000 per year by meeting certain daily walking goals. UnitedHealth says that Motion participants have collectively walked 130 billion steps, earning more than $19 million in incentives since the program began. The program enables employees to earn up to $4 per day in financial incentives based on achieving F.I.T. goals: 1) Frequency: complete 500

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steps within seven minutes six times per day, at least an hour apart; 2) Intensity: complete 3,000 steps within 30 minutes; and 3) Tenacity: complete 10,000 total steps each day.

For those long, long rides Naztech (www.naztech.com) introduced the Xtra Drive Mini, a thumb-sized, high-speed Micro SD card reader capable of up to 256GB of extra storage for iOS devices including the iPhone 8, iPhone 8 Plus and the iPhone X, as well as the iPad and iPod. It has a capacity of up to 170,000 photos, 74,000 songs, or 72 hours of video. Shows can be watched directly from the drive without using any of the Apple device’s own memory.

Weekend deals

Research presented at the American Heart Association meeting in Anaheim claims that, when paired with the right machine-learning algorithms, the Apple Watch’s heart-rate sensor and step counter can make a fair prediction of whether a person has high blood pressure or sleep apnea.

Apple is offering a feature to the App Store called “This Weekend Only,” which lists deals that can be found inside apps, as opposed to discounts on downloads of apps themselves, according to TechCrunch. Every Thursday, users will find on the Apps tab an app labeled “This Weekend Only,” with promotions valid through Sunday.

Startups to watch Some startups that could make your life easier and your business run smoother, per the Chicago Tribune: 1) Foodietrip (matches people looking for food tours with hosts for tastings); 2) Gadget Flow (shopping site for cutting edge products, including those from Kickstarter, Etsy, Amazon and IndieGoGo); 3) COSIGN (lets you click on objects, such as clothing, on a friend’s social media page and tells you where you can buy it); 4) globalVcard (could become the premier provider in digital payment); 5) Pindrop (neutralizes phone calls that are trying to steal someone’s identity); 6) Nowait (partners with Yelp to let you virtually stand in line at a restaurant); and 7) Bellhops (active in 50 cities, hooks you up with college kids who are willing to move your stuff).

Do it yourself

Your personal physician The Apple watch doesn’t have a sphygmomanometer or polysomnographic equipment found in a sleep lab – but thanks to machine learning, it might be able to help with their work, reports Wired. Research presented at the American Heart Association meeting in Anaheim claims that, when paired with the right machine-learning algorithms, the Apple Watch’s heart-rate sensor and step counter can make a fair prediction of whether a person has high blood pressure or sleep apnea. The new study adds to evidence that the right algorithms might transform the Apple Watch from personal trainer to personal physician.

BITalino is a set of hardware and software ingredients that allow just about anyone to build their own body monitoring devices, reports Madgadget. The folks behind BITalino have made it easier to collect data from different body sensors, to process it, and to share it. The software, which previously required stand-alone computers to run, is now available in a cloud-based version. It makes it easy to go from assembling a kit to using the gathered data, as there’s no software to install or a computer to manage. Moreover, BITalino is beginning to provide plugins for the software that are designed to process specific kinds of data in a proper way. One of the first releases is a heart rate variability package that implements guidelines from the Task Force of the European Society of Cardiology and the North American Society of Pacing Electrophysiology. All the gathered and processed data can be stored on Dropbox, Google Drive and other online cloud storage systems. There’s also an Android app that can be used to gather data, and work is underway to allow memory cards to be used to acquire the data.

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January 2018

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

Tesla Semi

Car dealer of the future From Automotive News: The year is 2030, and the 10,000-square-foot showrooms of the past are relics. So are many of the staffers who once worked in them. Those who remain need new skills to mirror the new realities of automotive retailing. Now, a few models of autonomous vehicles sit in the center of a tidy, tasteful and tiny showroom, available for purchase or subscription ride-hailing services. The vehicles are framed by just four desks where the transportation consultants – formerly called salespeople – work. Whether a customer buys an autonomous vehicle, or signs up for a subscription ride-hailing service, most transactions happen digitally, including

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virtual in-home test drives. On rare occasions, some customers visit the micro dealerships to touch the cars and work with a transportation consultant on a personalized subscription plan. The product presenters or transportation consultants understand the car, present its features online, arrange financing or payments, and deliver it if needed – tasks that go beyond today's "Genius" staffers at BMW dealerships.

I want one of these You probably won’t need one of these to get around in your town, but it is cool thinking about it. The Tesla Semi is a full-size electric truck that can go from 0 to 60 mph

towing 80,000 lbs., its max tow load, in 20 seconds, according to Tech Crunch. It can go 500 miles at highway speed, and it requires no shifting of gears (as is normal for most electric vehicles), with regenerative braking, which provides “basically infinite” brake life per Tesla. One 30-minute charge will get you 400 miles. The driver is centered in the cab, with touchscreens on either side of him or her, offering navigation information, blind spot monitoring and trip data logging applications. Take advantage of the million-dollar warranty. And take pride in parking this beautiful vehicle in your driveway … or the nearest rest stop.

Self-driving shuttle buses Despite this fall’s fender bender involving a small driverless shuttle in Las Vegas, autonomous shuttles could become viable tools of mass transit, according to Wired magazine. They could be used on college campuses, in retirement communities, or to supplement public transportation in the suburbs. “Most transit authorities are looking for opportunities to answer the first-mile, last-mile question,” bridging the distance between transit hubs and people’s final destinations, Maurice Bell, Keolis North America’s head of mobility, was quoted as saying. By the way, here’s how the fender bender in November occurred: The shuttle encountered a semi-truck backing out of an alleyway and stopped. It couldn’t back up, because there was a vehicle directly behind it. So it just sat there as the truck slowly backed into it. (The shuttle could have honked, a Keolis representative said, but didn’t because the truck’s trailer moved in a way that the autonomous system did not anticipate.)

Flying cars on demand Uber announced it wants to launch at least a few flying “cars” in Las Angeles in 2020, with a real commercial service to follow a few years later, reports Wired. Uber is reportedly working with aerospace partners at Embraer, Bell Helicopter, Pipistrel, Aurora Flight Sciences, and Mooney Aviation, to develop a drone. Don't expect the program to look like Uber's ground service, at least not for a while. It’s likely the first flights will have to follow agreed-upon routes, such as above freeway corridors.

On-demand test drives A mobile used-car dealership in Nova Scotia is offering the opportunity for car buyers to inspect, test drive

and purchase their next used-car from the comfort of their driveways. The service, Clutch, is only available to residents in the Halifax metro area. How it works: Clutch captures high definition photographs of its used cars at their headquarters. Once listed on their website, anyone with a computer or smartphone can browse, book an at-home inspection or test-drive and even get financing on Clutch's proprietary buying platform. www.clutchcanada.com

How much longer? Customers at automotive body repair shops can get a realtime update of the repair process via Carbeat™, a software application introduced by AkzoNobel’s Vehicle Refinishes business. The application is deployed on a large touch-screen monitor, and provides a comprehensive overview of the work in production. The company says Carbeat “enhances the quality and granularity of captured cycle time data, which enables deeper insight into ways to improve efficiency and eliminate waste.”

Cool dashcam Car and Driver magazine introduced a new dashcam – the MinioPro – featuring 1080P video capture, auto recording, a microSD drive with up to 64GB card capacity and a GPS antenna. While dashcams are often used to document time spent on the track, they also are increasingly essential as electronic evidence resolving disputes stemming from road incidents, according to the magazine. The MinioPro features a built-in motion sensor, which detects abrupt changes in vehicle speed and automatically captures a still image and locks in the five seconds prior to and subsequent to an incident. It is available at Best Buy with a suggested retail price of $200.

Formula E The first thing you notice about electric car racing is that it’s relatively quiet, according to the author of an article by the Consumer Technology Association. There is a high-pitched whining sound, but not nearly the eardrumshattering blasts one gets at NASCAR races or from Indy cars. Formula E racing takes place in the world’s largest cities, right in the heart of the city. Hong Kong, Mexico City, Paris, Montreal, Marrakech and New York were on the calendar this year; Santiago, Rome and Sao Paolo are lining up for future races.

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Jeff Marco: Guest on a Mountain Jeff Marco climbed Mt. Whitney in

March 2012 and got about 350 feet from the top before he had to turn back. One year later, he tried again. This time he made it. That Marco – account manager for McKesson Medical-Surgical – attempted and then achieved the summit of Mt. Whitney, the highest mountain peak in the lower 48 states, is notable. The fact that he did it a decade after being diagnosed with multiple sclerosis makes it remarkable. The ascents up Mt. Whitney taught him a couple of lessons, not just about mountaineering, but about how to live a full life with a debilitating disease. And they carry lessons from which others – even those without MS – might benefit.

Family farm

Jeff and Wendy Marco at the top of Mt. Grandfather — his first 100-mile, 10,000+-ft. elevation gain road race following the two times on Mt. Whitney

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Born in San Antonio, Texas, Marco and his family moved to rural Culpeper County, Virginia – about 70 miles southwest of Washington, D.C. He recalls mucking horse stalls each day, spending countless hours in the fields baling hay and performing other chores on the family farm. After graduating from high school, Marco took a year off to travel with Up With People, a performing arts and social-awareness group for young people. For a year he traveled with the group throughout the United States, Mexico and Australia. “We

would arrive and meet our host family; do a community service event, and then perform.” Those community service events might involve painting or rehabbing structures, working with special needs groups, visiting the sick in hospitals, etc. On Day Three, it was on to the next town. The year with Up With People was an eye-opener for an 18-year-old kid who was used to going to school, wrestling, playing soccer and working on the farm. “To this day, I still reflect on that experience, traveling around the world with a group of people between 18 and 26, who themselves were from all over the world – Japan, New Zealand, Germany. It shapes your worldview, being exposed to so many different cultures, not just in an immediate sense of the cast, who you’re with 24 hours a day for 365 days. But expand that to all the host families we stayed with.” After his year off, Marco began working on a college degree. “I didn’t follow the traditional educational path – high school to university then professional job,” he says. “Working and paying cash meant it took me quite a bit longer to finish my degree.” In fact, his college years were action-packed: He was a member of the crew team. He worked as a bartender to earn tuition money. He met his wife-to-be, Wendy; the two got married and had their first child, Cierra. Then, in June 2001, as he was finishing work on his biology degree, he was diagnosed with MS.

“Symptoms had begun appearing several years prior – trigeminal neuralgia, facial spasms, slurred speech, numbness and tingling sensations in legs, fatigue not helped by coffee or sleep,” he says. MS – like many other neurological diseases – isn’t a one-test diagnosis, he points out. Neurologists rely on numerous tests including MRI, evoked potential (a test to measure the electrical activity of the brain in response to stimulation of sensory nerve pathways), analysis of central nervous system fluid and other tests to eventually conclude whether or not the symptoms are caused by multiple sclerosis. Despite the diagnosis, Marco had some career decisions to make. “I had a family and a mortgage while still in school. My wife, Wendy, was building a business as a hockey skating coach. All this was making me rethink my career aspirations. A friend mentioned medical sales, and I began in 2002. Fifteen years later, here I am, a McKesson account manager.”

“When you’re above tree line, you have to bring everything to survive, because there’s nothing there for you. I love it. I absolutely love it.”

Diagnosis MS is a chronic autoimmune disease that is the result of the body destroying the protective casing (myelin) surrounding the nerves, explains Marco. As the myelin is destroyed, signals from the brain become interrupted and normal function is degraded over time. A host of issues can develop, from cognitive decline and depression to chronic fatigue, blindness, ambulatory issues that range from trouble walking to the inability to walk at all, and other physical and psychological challenges.

A decade-long secret For a decade, Marco refused to share his diagnosis with anyone outside the family, including those with whom he worked. It wasn’t always easy. “For the first decade of my life with MS, most of my pain was the result of the interferons I had been injecting

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corner for a few days – avoiding people and generally feeling sorry for myself.” After several days, he decided to take action – in a big way: Climb Mt. Kilimanjaro in Tanzania. Then, deciding that wasn’t enough of a challenge, he decided to tackle Whitney. “I trained like a maniac,” he says. Wendy wasn’t keen on the idea. “She was terrified at the prospect of me climbing a big mountain – in the winter – with crampons strapped to my boots – an ice axe in hand – a 60-pound pack on my back – in freezing temps and high winds. “I had some very significant issues both times on the mountain,” he says. Dehydration – a common occurrence among mountaineers – can affect those with MS more severely. “The first time, I failed to summit – got to about 350 feet from the top and had to turn back. That’s a harrowing story.” But he and Wendy raised more than $35,000 for the Multiple Sclerosis Society. “It’s hard to explain the emotional devastation that I felt – coming down and not having made the summit,” he recalls. “But on the way down, I vowed I would be back the following year.” On the second attempt a year later, he reached the summit but had an even more significant issue once reaching the top. “That is quite a story. It took me eight hours to descend about 2,000 feet back to upper camp at 12,500 feet. Once I made it back to camp the real fun began – it was a long night.” That second climb was his last attempt at mountaineering. But he doesn’t regret a moment. “I love being in the mountains, being in an environment where it’s ridiculously challenging – below-zero temperatures, high winds, steep pitches. When you’re above tree line, you have to bring everything to survive, because there’s nothing there for you. I love it. I absolutely love it.” Wendy Marco is the owner of ColdRush, a company that provides ice hockey And climbing Mt. Whitney taught skating instruction. him some valuable lessons.

into my body, either every other day or once a week, depending on the therapy I was on. It was miserable. “Interferons are proteins designed to activate the immune system and re-direct a subset of T-cells (white blood cells) away from their destructive behavior on nerve tissue,” he explains. “My immune system would hyper-respond. Injecting the medicine was like injecting the flu virus. I spent nearly every day of that first decade with significant flu symptoms – fever, body aches, chills…virtually mimicking the flu sans the nausea. I survived on buckets of coffee and entirely too much ibuprofen.” Then, five years ago, Marco found that he couldn’t hide his MS any longer. “I went for a trail run, and it didn’t go well,” he recalls. “A half-mile in, my right leg started failing. I fell numerous times and had to cut my run short after two miles. I limped home with the gut-wrenching realization that the degradation had finally begun. I was depressed

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Can’t fight a mountain “I believe my failure the first time on the mountain was, in part, due to my arrogance…or maybe ‘ignorance’ is a better way to put it. I trained hard. My goal was to be the strongest person on that mountain at that time. I knew I had to overcome limitations, so I overcompensated. But you’re a guest on a mountain. I made some mistakes; I didn’t hydrate well enough. “It didn’t even occur to me that not making the summit was an option,” he continues. “Things went wrong and I didn’t make it. I hadn’t partnered with the mountain. Instead, my approach was to conquer it. Well, mountains can’t be conquered. They allow you to visit, maybe summit sometimes, but they have their own rules – something I didn’t understand or respect.” The same could be said for MS. “There is no cure for MS, though there are therapies designed to slow its progression,” he says. “However, I am certain that my high activity level has helped almost as much as the medication. I take a very proactive approach to this disease. I exercise a lot. I can no longer run at all, but in my training for mountaineering, I discovered cycling, and have been an avid cyclist for several years now.” He sometimes rides in sponsored MS 100-mile rides to raise money. Every day, he cycles or works out on an indoor rowing machine. “I feel like we can have amazing lives, even with chronic diseases, if we don’t allow them to stop us from doing something … anything … as long as we try.” His family seems to be on the same wavelength. Wendy is the owner of ColdRush, a company in suburban Washington, D.C.,

“Mountains can’t be conquered. They allow you to visit, maybe summit sometimes, but they have their own rules.”

that provides ice hockey skating instruction. She works with children up to NHL players. She has a communications degree from Texas A&M University with a minor in theatre, and was a television news reporter before she started ColdRush. She grew up on the ice and was a competitive figure skater for over 10 years. Their older daughter, Cierra, is in Boston studying musical theatre at the Boston Conservatory at Berklee, while younger daughter Kylie is a competitive dancer and will likely follow her sister into the performing arts as a musical theatre artist. “With MS, you have to be physically stronger and emotionally tougher than others just to live a normal life,” he says. “And if you want to go beyond normal, outside your comfort zone, you need to work even harder to make that happen. “But you may just discover you’re capable of far more than you realize.”

Sales training from behind the bar Everybody should work in a restaurant, says Jeff Marco, account manager for McKesson Medical-Surgical. He speaks from experience, having tended bar for several years while working his way through college and helping support a young family. And that advice might be especially helpful for would-be sales reps. “Working in a restaurant, you encounter so many different types of people,” he says. “You’re dealing with the public – lots of different personalities. “What I learned was, no matter who I was dealing with, I was dealing with whatever was going on in their head at the moment. That was especially helpful to keep in mind when they weren’t being very nice. I learned that it’s more about what’s going on in their life than it is about you. “You learn how to navigate different situations and personalities. You learn when to back off. You learn that service is absolutely critical. You learn to take care of the people who you are charged with supporting – whether that customer is at a bar or at a surgery center.”

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Jeff’s Climb By Wendy Marco

Wendy Marco wrote this essay a few weeks before her husband, Jeff Marco, attempted his first climb of Mt. Whitney in March 2012. It was a chilly sunny day in early March 2011. We had left our toddler, Cierra, with my mom and headed to the mountain for a day of snowboarding. We were on the chair lift when my husband turned to me and said, “The left side of my lips are burning really badly. Do they look chapped?” They weren’t chapped, but the burning got worse and less than a week later, when Jeff was reading Cierra a bedtime story, he sounded as if he was drunk, slurring and stumbling over the simple words of “Good Night Moon.” Within a day he was unable to get his lips to form the shapes necessary to speak at all.

A trip to a neurologist followed – the second time he had been. Two years prior, after a bout of serious fatigue and facial paralysis, he had been told he just needed rest. This time they administered a myriad of tests, and by the time the trees had their spring leaves, he had a diagnosis: multiple sclerosis. MS, I learned, is a progressive

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debilitating disease that over time strips its victims of physical function. There is no cure. I remember the moment it hit me. I was driving to work and I had to pull over, because the tears that swallowed my eyes made it impossible to see the road. I just kept thinking about the life we had planned and the things we most loved to do together – snowboard, rock climb, hike, water ski. Now I was wondering if in 20 years he would be in a wheelchair, unable to walk our daughter down the aisle on her wedding day. What I don’t remember is the moment it hit him. I grieved, he didn’t. He didn’t tell anyone, not his family, not his best friends. Some might call it denial. I actually think he was just plain mad. He finds pity objectionable, and he certainly didn’t want anyone feeling any for him. If he was fearful, the fear was far overshadowed by the anger he had for even having to entertain that emotion. I wanted to “fix” it, so a few months after his diagnosis I participated in the MS walk. The deal we made was that I would reach out to my friends and acquaintances, but not to his or our shared friends. The support of the hockey community was overwhelming. Players and their families showed up and walked with me and helped raised money for the MS Society. Right after that, however, Jeff completely retreated. He didn’t want to meet or see anyone that knew he had MS. He avoided everyone associated with my world,

and I learned that his disease was not something I could talk about with anyone anymore. So, for the next 10 years, until just a few weeks ago, I did whatever I had to do to help keep his secret. Once the slurred speech of that first exacerbation subsided, it was easy for Jeff to hide his disease. For almost a decade, as far as anyone could tell, he looked like everyone else. No one but those of us inside the walls of our home were aware of the severe pain in his legs, head, neck and back. Others didn’t realize that when he walked, his right leg was numb, nor could they see the welts on his body from the drug injections he gave himself daily to keep the MS exacerbations at bay. They didn’t know that he suffered from a disrupted sleep cycle, typical of MS, and that insomnia made it impossible for him to sleep through the night. He would regularly pace at 2 a.m., or I’d find him asleep, face first on the floor of his office most evenings, as he tried but failed to work through extreme fatigue. Jeff didn’t just hide MS from others; he was stubborn about admitting the changes to himself. No matter how bad it got, and how obvious it was to the kids and I that what he was going through was a result of his disease, the majority of the time he just flat refused to accept that MS had any impact on him whatsoever. The pain, fatigue, tingling, mood swings, weaknesses… all of it he would attribute to something else. Since he was diagnosed so soon after we were married, I’m not actually sure if it’s just who he is or who he became, but Jeff never rests. He is always busy getting things accomplished. Despite the challenges of his disease, he’s built a successful career with a large medical company. We had our second daughter, Kylie, just after he was diagnosed, and he is an active dad who gets both girls off to school each morning while I teach. He often volunteers at their schools, and he coached both of their soccer teams. Multiple sclerosis symptoms are much worse in heat, and patients are advised to avoid hot conditions. Coaching soccer in the very hot and humid D.C. summers triggered many MS symptoms. The team parents had no idea that Jeff was self-conscious about his short runs on and off the field, deeply embarrassed by what he thought

were clumsy warm-up kicks to the goalies, or that he would be in pain and physically and mentally drained for several days after coaching through hot weekend summer tournaments. The reality of MS had begun to set in, but it would be a short jog through the woods this past summer that would be the turning point – the exact moment Jeff would no longer be able to hide his disease from anyone, most importantly, himself. Our neighbor, and Jeff’s very good friend, Brent, invited Jeff to do a “Spartan Race” with him. One of Jeff’s favorite activities has always been trail running. So, with obstacles, mud, and other craziness thrown in, Jeff jumped at the chance and signed up right away. It had been a while since he had gone for a run. He didn’t realize that in the time that lapsed, lesions in his brain and spinal cord had grown, and his MS had progressed to a point where his light run would bring on a personal low that would alter the course of his life. Jeff was less than one mile into his planned five-mile run when his right leg began to drag. His foot and leg swung as if he were a wooden puppet with his only control at the hinges of the knee and hip. It felt like his leg was asleep. He simply couldn’t run. He hobbled home. When he came through the door he didn’t speak. He didn’t have to. I knew. A few days later he tried again. He returned home muddy and bloody. He had fallen multiple times. This time he spoke, but the words he used to describe himself were so crude and demeaning that I just can’t bring myself to put them on this page. It had been more than 10 years since his diagnosis but it had finally hit him: He had multiple sclerosis, a progressive, debilitating disease for which there is no cure and whose cause is unknown. It wasn’t just that he couldn’t run anymore that was so hard. It was the realization that MS was now taking away function, his body was beginning to succumb to the disease and his future was unsure. In his own way, Jeff finally grieved. Jeff called the people running the race and asked them to withdraw his registration and donate his registration fee to a charity. Then he called his friend Brent and told him he wouldn’t be able to run the race with him. He then told his good friend

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corner of five years the truth – that he had MS and that he was no longer able to run. Making this phone call was excruciating, a difficult blow to a man as proud, athletic, and self-reliant as my husband. For the next three weeks Jeff was miserable to be around. The kids and I had lived through the waves of severe depression his drugs had caused before, but this time was different. Before, he had been short-tempered and angry; this time he

was emotionally absent. When he was home, he disappeared into his office and wouldn’t eat with the family. Then one day I came home from work and found him on the family computer looking up Mt Kilimanjaro. I hadn’t seen my husband smile in weeks, but there it was, a smile on his face when he looked up at me and announced, “I’m going to Africa and I’m going to climb Mt. Kilimanjaro.” Any spouse who lives with a person who has MS has challenges, and while I can’t say I’ve been perfect every day, I have always tried to be supportive. But this time I found myself saying out loud the first thing that popped into my head, the least supportive thing a wife in this situation could

possibly say: “What the hell?! You can’t even run through the backyard!” There’s no excuse for my reaction, but there is a reason; I knew all too well that determined look in his eyes, and this new approach of his to “beat” MS terrified me. After a little more research, Jeff decided that Mt. Kilimanjaro – while challenging due to the altitude – was “just a hike.” He wanted to do something harder, a more technical climb that would allow him to push his physical limits, so he set his sights on an alpine climb of Mt. Whitney in California, the highest mountain in the lower 48. This is no small feat. The summit of Mt. Whitney stands 14,505 feet above sea level, and then there is the snow, ice, and cold to contend with. I begged him to try climbing something smaller first, to test his abilities and then climb Mt. Whitney a year later, but he said “I want to climb it while I still can and I might not be able to a year from now.” His last MRI showed new lesions, two in particularly worrisome spots on his brainstem and spinal cord. He’s right; his future is uncertain, and there was simply no changing his mind. Among the things Jeff loves to do but can’t anymore is run, and it does bother him, but that loss lit a fire in my husband. Now that he’s striving toward this ambitious goal with a new training regimen, Jeff is genuinely happier than I’ve seen him in over a decade. It took 11 years, but Jeff is no longer embarrassed to admit that he has multiple sclerosis. He is proud and happy to share his story. He is hoping that his quest for the summit of Mt. Whitney will inspire others with MS or other challenges to look for the things they CAN do, to find joy in setting goals and striving to achieve them.

Editor’s note: Jeff Marco came within 350 ft. of the summit of Mt. Whitney in 2012, but reached the summit on his second attempt one year later. Wendy Marco is the owner of ColdRush, a company in suburban Washington, D.C., that provides ice hockey skating instruction. She works with children up to NHL players. She has a communications degree from Texas A&M University with a minor in Theatre, and was a television news reporter before she started ColdRush. She grew up on the ice and was a competitive figure skater for over 10 years.

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the perfect partnership Midmark and HEINE, a world leader in diagnostic instruments, have come together to offer you the latest in exam room technology. Now you can complete the exam space with best-in-class, German-engineered diagnostic instruments and a painless sales and delivery experience.

What makes our diagnostic instruments different? Exclusive Technologies LEDHQ The exceptional color-rendering properties of halogen with the lifelong capabilities of LED. Aspherical Optical System (AOS) Redirects corneal reflections away from the examinerâ&#x20AC;&#x2122;s path of sight, eliminating glare. 4.2x Magnification Higher magnification and a large field of view bring even the finest details to light.

Contact your Midmark rep or visit: midmark.com/sibREPjan

seeing is believing MKT-00154

optimal illumination + superior optics + quality design

MightySat Rx Fingertip Pulse Oximeter ™

Featuring Masimo SET Measure-through Motion and Low Perfusion Pulse Oximetry ®

™

Measurements

SpO2 PR

Pulse Rate

Pi PVi

Oxygen Saturation

Perfusion Index

Free Downloadable Masimo Professional Health App*

Pleth Variability Index

> View, trend, and share up to 12 hours of data iPhone not included

Designed for Performance > High-resolution display

> Plethysmographic waveform

> Durable and lightweight > Enhanced comfort

© 2017 Masimo. All rights reserved. Apple is a registered trademark of Apple Inc. registered in the U.S. and other countries. *The Masimo Professional Health app is downloadable from the App storeSM for iOS devices or Google Play™ store for select Android devices. For an up-to-date list of compatible smart devices, see: www.masimoprofessionalhealth.com. Only available for Bluetooth® LE enabled models.

PLLT-10018D

Caution: Federal (USA) law restricts this device to sale by or on the order of a physician. See instructions for use for full prescribing information, including indications, contraindications, warnings, and precautions.

PLCO-001425/PLMM-10697A-1117