Round-up Magazine, February 2016 by Maricopa County Medical Society (MCMS)

ROUND-UP

PROVIDING NEWS AND INFORMATION FOR THE MEDICAL COMMUNITY SINCE 1955 February 2016 | Volume 63

Committed to Shaping Health Policy, One Initiative at a Time

Raju Thiagarajan, MD, MPH

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ROUND-UP

PUBLISHED MONTHLY BY THE MARICOPA COUNTY MEDICAL SOCIETY

February 2016 | Volume 62

3 5 7 11 17

What’s Inside President’s Page Health Policy

Public Health Update

Zika Virus Update from Maricopa County Department of Public Health By Rebecca Sunenshine, MD

Member Profile

Raju Thiagarajan MD, MPH Committed to Shaping Health Policy, One Initiative at a Time

Nursing Scope of Practice Expansion Proposal By Ross F. Goldberg, MD, FACS

Physicians Need to Push to Fix or Bury the Stark Law

By Robert J. Milligan

24 26

MCMS Board Meeting Minutes The Dollars and Sense of MACRA

By Michael Mills, MD, MPH

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February 2016 | Volume 63 Round-up (USPS 020-150) is published 12 times per year by the Maricopa County Medical Society, 326 E. Coronado, Phoenix, AZ 85004.

Round-up is a publication of the Maricopa County Medical Society (MCMS). Submissions, including advertisements, are welcome for review and approval by our editorial staff at roundup@mcmsonline.com. All solicited and unsolicited written materials and photos submitted to Round-up will be treated as unconditionally and irrevocably assigned to and the property of MCMS and may be used at MCMS’ sole discretion for publication and copyright purposes and use in any publication, website or brochure. MCMS accepts no responsibility for the loss of or damage to material submitted, including photographs or artwork. Submissions will not be returned. The opinions expressed in Round-up are those of the individual authors and not necessarily of MCMS. Round-up reserves the right to refuse certain submissions and advertising and is not liable for the authors’ or advertisers’ claims and/or errors. Round-up considers its sources reliable and verifies as much data as possible, but is not responsible for inaccuracies or content. Readers rely on this information at their own risk and are advised to seek independent legal, financial or other independent advice regarding the content of any submission. No part of this magazine may be reproduced or transmitted in any form or by any means without written permission by the publisher. All rights are reserved.

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February 2016

What’s Inside

It’s that time of year where the State Capitol is abuzz with lawmakers, lobbyists, and policy advocates. If you happen to venture down to 17th Avenue and Washington Street the first few months of the year, you’ll see a constant flow of traffic between the House, the Senate, and the Capitol, as stakeholders and lawmakers dance to the alltoo-familiar tune of making the sausage. It’s a race to the finish each year, as Arizona lawmakers spend roughly three months taking hundreds, if not thousands, of bills under consideration. Many die on the vine, many get pushed through with ease, and many get carved up and watered down. This year, a number of important policy issues that stand to impact the practice of medicine are being pushed front and center. At the annual State of the State address in January, Gov. Ducey called on lawmakers to mandate physician use of the Arizona Controlled Substances Prescription Monitoring Program (CSPMP) prior to writing prescriptions for controlled substances. As a result, it’s highly anticipated that a bill will be introduced around this concept, and physician advocacy groups statewide are sure to weigh in on how such a bill could impact access to care. Another issue gaining momentum is the concept of centralizing all health regulatory boards under a single umbrella, such that physicians, nurses, chiropractors, and all other healthcare providers will all be licensed via a centralized office, and regulated by the Arizona Department of Health Services (ADHS).

Jay Conyers, PhD EXECUTIVE DIRECTOR

jconyers@msmsonline.com 602.251.2361

Perhaps the biggest issue brewing at the Capitol this session, however, is the proposed expansion of what nurse’s can do clinically. A broad request has been submitted that aims to provide advanced practice registered nurses (APRNs) more autonomy and prescribing authority. Many are already lining up to weigh in on the proposed bill, and it’s sure to be a back and forth throughout the legislative session. This month in Round-up, we bring you a number of articles that focus on front-page policy topics that should garner consideration this year, either locally or nationally. Local healthcare lawyer and Round-up contributing writer, Bob Milligan, JD, writes about the Stark Law and how the bill’s own author agrees that the time to move from this outdated law on is now. Former MCMS President Michael Mills, MD, provides an excellent summary of MACRA and how it stands to impact how you practice medicine. We also bring you an overview of the pending nursing scope of practice debate brewing at the State Capitol, with an article from MCMS Board member Ross Goldberg, MD. Arizona House Health Committee Chairperson, Rep Heather Carter, offers a tip for how physicians can get involved in policy making, either directly or indirectly. And lastly, this issue includes an assessment of the Zika outbreak, authored by Rebecca Sunenshine, MD, from the Maricopa County Department of Public Health. It’s a lot to read, so enjoy! Next month we bring you our Quality issue, and how quality has become more front and center than anyone could have ever imagined. We profile Hamed Abbaszadegan, MD, MBA, Chief Health Informatics Officer at the Phoenix VA Health Care System. Dr. Abbaszadegan leads numerous initiatives focusing on the quality and safety of healthcare, and shares with Round-up his thoughts on how quality has quickly become the most talked about word in healthcare. We also have planned a number of great articles on how quality is being implemented in healthcare, and how it is impacting patients and physicians alike. Until then, make it a point to track at least one piece of healthcare legislation session this year. The Arizona Legislature is in full swing now, and you can track any bill of interest by signing onto the Arizona Legislative online portal for bill status tracking. To do so, go to https://apps.azleg.gov and sign up for an account if you don’t have one already.

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Health Policy

e doctors spend most of our careers caring for patients, blissfully unaware of the regulatory and policy framework in which we operate. Until it sneaks up and bites us. Or our patients. Last month I saw a patient who suffered stent thrombosis and a large myocardial infarction after having his clopidogrel stopped only a few weeks after having a coronary stent placed. So far as he knew, he was unable to follow up with his cardiologist without first obtaining a referral from his primary care physician. So his first appointment after being discharged from the hospital, instead of with his cardiologist, was with his primary care physician, who, unaware of the recent hospital admission and stent, told the patient to stop his clopidogrel when the patient mentioned a small amount of blood he had noticed on the paper after a bowel movement. This unfortunate event occurred because the healthcare system in which we practice allows insurance companies to interfere in the care of patients. Or at least allows insurance companies to so obfuscate the rules that patients are scared by the prospect of denied coverage causing personal financial ruin into inappropriate and dangerous decisions. The focus of this month’s Round-up is therefore on health policy. At the federal level, most of us are aware of the Affordable Care Act and of MACRA (Medicare Access & CHIP Reauthorization Act of 2015), more commonly known as the solution to the SGR “doc fix.” Most of the time we simply watch, bewildered, as politicians and competing interest groups define the parameters of federal legislation. We throw up our hands and figure we’ll just do the best we can. And when bad outcomes occur, we take little comfort thinking “I told you so,” believing there was nothing we could have done; that it was out of our control. I encourage you to keep a tally of these “bad outcomes” that we all experience. I was surprised to know that most of the legislators responsible for the legal framework in which we practice have no experience whatsoever in the healthcare arena and simply rely on either the research provided by their staffers or by lobbyists. Often they are very interested in the unfiltered anecdotes and opinions of “real” doctors engaged in full time practice. We

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President’s Page can begin here at home by letting our Arizona members of congress know our opinions, so they can better understand the unintended consequences of some of their decisions. This can range from meeting personally with your congress member to sending an email or leaving a phone message. Another even simpler way to have your voice heard is to simply answer one of our own email surveys from the Maricopa County Medical Society, thereby helping to illustrate the opinions of our membership on a variety of issues. At the local level there are issues pending right now before the Arizona legislature which affect all of us, including the ability for outpatient laboratories to offer direct to patient testing, scope of practice issues regarding the independent practice of non-physician allied health professionals, proposed mandatory use of a PDMP (Prescription Drug Monitoring Progam) to control opioid prescribing, and the proposed consolidation of all statewide licensing boards under a single state entity. A myriad of other local issues are also worthy of our attention including but not limited to vaccinations, gun safety, human trafficking, air pollution, e-cigarettes, and concussions in young athletes. The Arizona Medical Association offers a unique way to meet and interact with the Arizona legislature, called the “Doctor of The Day” program. This requires one half day during which you would be the designated “Doctor of The Day” at the state legislature. You would observe the legislative session that day and meet several senators and representatives. You don’t need any prior legal or legislative experience, and I guarantee you will be surprised by how little the legislators know about health care. The program is open to all members of the Arizona Medical Association. (For more information please contact either the Arizona Medical Association or the Maricopa County Medical Society.)

We can begin here at home by letting our Arizona members of congress know our opinions, so they can better understand the unintended consequences of some of their decisions.

Adam Brodsky, MD, MM MCMS PRESIDENT 2016 abrodsky@msmsonline.com 602.307.0070

There are many other non-physician entities fully engaged in healthcare policy at the local, state, and federal levels, spending much more money, time and resources on their lobbying efforts than are we physicians. We are routinely outflanked by hospitals, insurance companies, non-physician allied health professionals, drug and device manufacturers, even food and beverage companies. Despite the fact that we indeed are all stake-holders and deserve a voice in public debates, there is only one group who routinely has to stare patients in the eye and personally and continually care for them one decision at a time – and that is us. Dr. Brodsky specializes in Interventional Cardiology He joined MCMS in 2005. Contact Information: Heart & Vascular Center of Arizona 1331 N. 7th Street Suite 375 Phoenix, AZ 85006 http://heartcenteraz.com

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P U B LI C HE A LT H U PDAT E

Zika Virus Update from Maricopa County Department of Public Health BY REBECCA SUNENSHINE, MD

hat is Zika virus and where did it come from? Zika is a single-stranded RNA virus in the Flaviviridae family that is closely related to other flaviviruses such as West Nile, St. Louis encephalitis, dengue and yellow fever viruses. It was first identified in the Zika forest (hence, its name) among Ugandan rhesus monkeys in 1947, so it’s been around for a while. It made the headlines next when it caused the first outbreak of about 50 confirmed cases in Yap, Micronesia. There were no hospitalizations or deaths reported and it is thought that 73% of the population of Yap > 3 years of age had been infected with the virus. This outbreak and a 2014 outbreak in French Polynesia are how we know most of what we know about the virus and its transmission. Zika was first detected in the Americas in Brazil during May 2015. Toward the end of 2015, an increase in microcephaly was noted in the areas of Zika transmission. The virus was subsequently detected in the amniotic fluid of two pregnant women and during the second half of 2015 alone, >4700 suspected cases of microcephaly were reported to the Brazilian Ministry of Health (CDC MMWR/ February 19, 2016 / 65(06);159–160). Zika virus has continued to spread throughout South America, up through Central America, parts of Mexico and the Caribbean, including Puerto Rico, the US Virgin Islands and American Samoa. Due to the increase in neurological disorders in neonates temporally associated with Zika virus, on February 1, 2016, the World Health Organization convened an Emergency Committee on Zika virus. They recommended standardized enhanced surveillance for Zika virus infection, research to develop new diagnostics and treatments, and risk communication to those living in or travelling to areas with Zika transmission. So, what do we know about this disease? Zika virus is transmitted to humans primarily through the bite of an infected Aedes species mosquito, which is the same mosquito that can spread dengue and chikungunya. The mosquito vectors, which are found in Maricopa County, typically breed in domestic water-holding containers; they are aggressive daytime biters and feed both indoors and outdoors

near dwellings. Although mosquitoes are the primary mode of transmission, perinatal, in utero, sexual and transfusion transmission events have also been reported. RNA has been identified in asymptomatic blood donors during an ongoing outbreak. Nonhuman and human primates are likely the main reservoirs of the virus. Zika is thought to have an incubation period of approximately 2–7 days. Symptoms include fever, rash, joint pain, non-purulent conjunctivitis and headache, however only 20% of those infected develop symptoms. Most disease is mild and individuals typically recover within a few days to one week; severe complications of Zika are thought to be rare. However, increases in numbers of reported cases of microcephaly and Guillian Barre Syndrome have been reported and are being investigated. Zika virus usually remains in the blood of an infected person for about a week but it can be found longer in some individuals and likely persists in the semen, although it is not known how long. Regarding sexual transmission of Zika virus, two cases of sexual transmission from symptomatic males to females have been confirmed (one in Dallas, TX) and others are under investigation. Thus far, no sexual transmission from females to males has been reported. Zika RNA has been identified in the semen of one male infected with Zika virus 62 days after symptom onset but it is unknown if an individual is infectious this far out. So what is the risk of Zika virus spreading to the continental United States? Of note, only one case of Zika has been documented in the continental US (mentioned above) and it is likely due to sexual transmission from someone who travelled to a Zikaaffected area. Importantly, no cases of Zika virus have been identified in Arizona at the time this article is being written. Perhaps more importantly, Maricopa County Department of Public Health (MCDPH) and Maricopa County Environmental Services have been collaborating to perform enhanced mosquito and arboviral disease surveillance since West Nile virus first hit the County. Due to the increased circulation of dengue and chikungunya in Mexico during 2014 and 2015, vector surveillance was further expanded mcmsonline.com/round-up

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to include Aedes aegypti mosquitoes and a comprehensive plan to identify arboviral disease cases early, employ vector control strategies and isolate the case patient was implemented. We have had multiple travel-associated chikungunya and dengue cases, giving us ample opportunity to exercise our response plan. Interestingly, despite the increased number of cases of both diseases in Sonora, Mexico, which borders Arizona, we never identified a single case of endemic transmission of either disease. Why? We’re not sure, but we suspect it has to do with the fact that so many of us have air conditioning and tend to keep our windows closed. But we aren’t letting our guard down and we are closely monitoring disease spread in Mexico, especially in Sonora, which has thus far not reported a single case of Zika.

So what about pregnant women who have travelled to an area with Zika transmission? If they are symptomatic, call MCDPH right away to facilitate testing. Although we have limited information about antibody testing of asymptomatic patients, data from related viruses suggest that testing may be useful when the time frame of exposure is known. Interpretation of testing results can be challenging and complex. A negative IgM test result obtained 2 to 12 weeks after travel suggests that a recent infection did not occur. As with symptomatic patients, if the IgM is positive, it could be Zika or any other flavivirus. It’s important to discuss the risks and benefits of testing and contact MCDPH if you wish to obtain diagnostic testing. Consult CDC’s guidelines for evaluation and testing of pregnant women if you’re not sure what to do.

So, what do Maricopa County physicians need to know about this disease to manage their patients? First, despite all the media hype, we need stay focused on those who are likely to have the highest risk of complications from Zika – pregnant women and their unborn children. The Centers for Disease Control and Prevention (CDC) recommends that pregnant women in any trimester as well as women trying to become pregnant consider postponing travel to any area where Zika transmission has been documented (http://www.cdc.gov/zika/geo/index.html). For pregnant women who live in areas with documented Zika transmission or those who must travel there, they recommend using an EPA registered insect repellant and wearing long sleeves, pants and socks when outdoors. For updated travel recommendations please visit http://wwwnc.cdc.gov/travel/page/ zika-information.

For all other persons with travel to an endemic area, especially men with sexual partners that are or may become pregnant, testing will be considered on a case by case basis through your local health department. The Arizona Department of Health Services also has a great web page with these and other resources for healthcare providers. http://www.azdhs. gov/preparedness/epidemiology-disease-control/ mosquito-borne/index.php#zika-info-for-providers.

What about Zika laboratory testing for your patients who have travelled to areas with Zika virus transmission? Anyone who develops two or more symptoms of Zika virus within 14 days of travel to an area with Zika transmission is eligible for Zika laboratory testing through MCDPH (or your local health department if you’re in another county). Importantly, since Zika symptoms are very similar to those of dengue and chikungunya, testing should be considered for all three diseases concurrently. At this time, CDC is performing all Zika testing but the Arizona State Laboratory can perform dengue and chikungunya testing and will be obtaining the capacity to test for Zika soon. For symptomatic patients with an appropriate travel history, getting a serum specimen within 7 days of symptom onset is ideal as there is a reliable RT-PCR test available. After 7 days, we rely on IgM serology, which is known to cross react with other flaviviruses. A negative IgM test result in a symptomatic patient suggests that a recent infection did not occur. If the IgM is positive, it could be Zika or any other flavivirus. Therein lies the problem.

Since treatment for Zika infection is supportive care only, preventing disease transmission is paramount. No vaccine is available at this time, but hopefully, research will get us there soon. Finally, know that MCDPH is working closely with Environmental Services, the State Health Department and CDC to continue vector and human surveillance and ensure healthcare providers have access to all available information about this emerging pathogen. Note: many of the facts regarding Zika virus were taken directly from CDC materials were not paraphrased by the author. REBECCA SUNENSHINE MD Dr. Rebecca Sunenshine is the Medical Director and Division Administrator for the Disease Control Division at Maricopa County Health Department. As a CDC Career Epidemiology Field Officer assigned to Arizona since July 2006, she has served at the Arizona Department of Health Services for 4 years and Maricopa County Department of Public Health for 5 years. She is a Captain in the US Public Health Service, trained in internal medicine and infectious diseases at Oregon Health &Science University, and completed her CDC Epidemic Intelligence Service Fellowship in 2006 with the Division of Healthcare Quality Promotion. Her research and publications focus on infectious disease epidemiology, coccidioidomycosis, infection control, and multidrug resistant organisms.

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MEMBER PROFILE

Dr. Thiagarajan in conference with current ASU students.

Raju Thiagarajan MD, MPH Committed to Shaping Health Policy, One Initiative at a Time For our physician profile this month, Round-up took a different approach and sat down with Raju Thiagarajan, MD, MPD, a rising star in health policy. Dr. Thiagarajan works with our own Dr. Bob England at the Maricopa County Department of Public Health, serving as its Health Policy Analyst. With such an abundance of impactful healthcare legislation being considered by our state legislature this year, Round-up took a moment to talk to Dr. Thiagarajan about his journey to a career in health policy.

What is your current role with the health department?

Currently, I work for Maricopa County Department of Public Health as a Health Policy Analyst working specifically in the healthcare sector. A big part of my role is to consult with internal stakeholders and community partners to assist in the development of strategies and policies that lead to improved health outcomes for our community.

What are some of the initiatives you are focusing on?

One of our larger initiatives Iâ&#x20AC;&#x2122;m working on right now is helping to develop and implement our Prescription Drug Misuse and Abuse strategy in Maricopa County. This includes raising awareness and utilization of the Controlled Substances Prescription Monitoring Program among physicians in Maricopa County. I also work with our Office of Tobacco and Chronic Disease Prevention team in the areas of Community Health Workers and tobacco-free initiatives.

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Dr. Thiagarajan participating in a panel discussion at the Virginia G. Piper Charitable Trust.

Are there any particular challenges you are poised to take on this year?

What led you to policy as opposed to clinical medicine?

These are just a fraction of the many public health programs and services that MCDPH provides for the county. The men and women at MCDPH work tirelessly behind the scenes to make Maricopa County as healthy as it can be, and I’m continually amazed every day by their level of dedication.

In your opinion, why are most physicians disinterested in policy and fail to get involved?

I’m especially excited about our Community Health Worker (CHW) project. We are working with Central Arizona College to develop an online CHW certificate program. CHW’s play an important role in reducing barriers to care for vulnerable populations and this is a way to increase the workforce. I also work with our Healthcare Innovation team on how public health can play a role in addressing mental illness in Maricopa County, especially among the incarcerated population.

Do you have any academic involvement in Maricopa County? Yes. I’m adjunct faculty at the University of Arizona Mel and Enid Zuckerman College of Public Health, and I’m excited to be teaching Health Service Administration in their new online track. 12

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Although I had taken some public health classes in medical school, it wasn’t until residency where I became acutely aware of how the social determinants of health impacted a person’s health. After seeing patients who were admitted for social issues, re-admitted for poor care coordination, non-compliant with treatment plans because of lack of resources, etc., I realized that much of medical care was outside the physician’s control. In reality, social and economic factors, physical environment, and health behaviors contribute to 80% of a person’s health.

It’s understandable that many physicians don’t have an interest in health policy. It’s not why most get into medicine. I think it’s also more of time constraints that prevent physicians from getting involved with policy. Many physicians are mainly focused on their clinical responsibilities caring for their patients. Health policy was never emphasized in my training, so exploring this area for some may be an intimidating endeavor.

Also, there may be a component of feeling helpless to really affect change. Or, if they want to get involved, they may not know where to begin.

MEMBER PROFILE

What, in your opinion, are the major policy issues facing physicians today?

One of the major issues facing physicians is payment reform - transitioning from a fee for service to a value-based payment model. Practicing physicians have had to adapt to the constant changes to the healthcare marketplace. Because of its complexity, many physicians don’t have a thorough understanding of how this new system impacts their practice and their relationship with their patients.

In the coming years, what policy issues do you foresee impacting healthcare? I hope more policies will focus on mental illness, especially around mental health coverage. Although the Mental Health Parity and Addiction Equity Act of 2008 attempted to address insurance coverage for mental illness, there are still many gaps and inadequate coverage for those suffering from Serious Mental Illness (SMI), when compared with medical/surgical benefits.

How can public health entities such as the county health department help impact policy?

MCDPH and other public health entities can impact policies by raising awareness for issues surrounding the social determinants of health. Examples include doing Health Impact Assessments for city planning projects, Community Health Needs Assessments for local hospitals, and promoting the Accountable Health Community model to incorporate social services as a vital component of clinical care. Health literacy continues to lag here in the US, and many speculate that it contributes to our overburdened EDs, clinics, etc. Do you see a role for physicians or organizations like ours in promoting health literacy throughout the community so that patients make better choices about their health? I think it is critical for physicians and organizations like MCDPH and MCMS to take an active role in not only promoting health literacy, but also developing health literacy tools and materials. We know that poor health literacy leads to negative health outcomes, especially

in the elderly, minority, and low SES and education populations. Although health literacy is a complex issue, there are four things I think we should always consider: 1) be aware of how cultural differences impact how people understand health information and access healthcare, 2) we must find ways to empower vulnerable populations and make healthcare less intimidating so they can make healthy choices, 3) understand how people consume information in the digital age, especially the youth, and 4) understand that how we frame health information is critical to health literacy. It has to be correct, consistent, and understandable. A recent example of this is the ongoing “debate” over immunizations.

If a physician were interested in becoming more involved in health policy, what would you recommend they do?

Physicians should get involved in policy issues as much as they can. The House and Senate propose many bills each session that relate to healthcare in some form or fashion and it’s important that every physician be aware of what’s being proposed. The Arizona Public Health Association has a legislative tracking committee and would definitely appreciate involvement from community physicians. I also think it’s important for physicians to take part in coalitions that relate to the areas of medicine they practice. I would recommend taking a policy course or even a certificate program, especially now that many schools have online offerings.

Some local medical schools have recently formed their own student advocacy groups. How can these groups be an asset to the physician community?

It’s great that medical students are taking the initiative to form their own advocacy groups. Students bring with them their fresh perspectives, unique experiences, and most importantly, enthusiasm, to highlight issues within healthcare. This could be a great asset to the physician community, especially if these efforts could help bring further awareness to the underlying social determinants that influence health and quality of life. It is also important for students to gain the experience and comfort level to speak with legislators at an early stage in their careers on issues that will ultimately affect them and the patients they serve. mcmsonline.com/round-up

Dr. Thiagarajanâ&#x20AC;&#x2122;s juggling talent comes in handy, especially when you throw light-sabers into the mix! TOP RIGHT: The Thiagarajan family enjoys the time they get to spend together.

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MEMBER PROFILE

Raju Thiagarajan MD, MPH | On the Personal Side Describe yourself in one word. Curious

What is your favorite food, and favorite restaurant in the Valley?

I love trying all types of food and have many favorites, but I’ll never say no to Sushi. I really like Shimogamo in Chandler.

What career would you be doing if you weren’t a physician?

I would probably be a photographer. I got my first DSLR after my first child, Anand, was born and have been infatuated with photography since. It’s the only hobby I can think of which allows uncreative people like me to be somewhat creative.

What’s a hidden talent that you have that most wouldn’t know about you?

I’m not sure if you’d call this a talent but the kids love the fact that I can juggle.

Best movie you’ve seen in the past ten years?

The one movie that I always get sucked into watching if it’s on TV is The Dark Knight.

Favorite Arizona sports team (college or pro)?

This is a tough one. I’m still loyal to my Houston sports teams and my alma mater, Texas A&M University. Once a Texan, always a Texan.

Favorite activity outside of medicine?

Family road trips around Arizona and to neighboring states have become a yearly tradition for us. They are especially fun now that the kids are getting older. We’ve made trips to southern and northern California and New Mexico. I especially enjoy our trips to the San Diego Comic-Con. We love exploring Arizona and some of our favorite destinations here are Payson, Prescott, Sedona, and Flagstaff. I also love hiking and photography. I’ve hiked down the Grand Canyon (down the South Kaibab Trail and up Bright Angel trail) three times and its allowed me to test my photographic skills in some of the most beautiful and challenging backdrops. I’m also a proud board member of the Kyrene Schools Community Foundation. We partner with local businesses and non-profit organizations to support teachers and students with various grants and scholarships. We also support outreach services, prevention initiatives, and social support services like medical, dental, food, clothing, and family crisis assistance for anyone in the Kyrene school district.

Family?

I’ve been married to my wonderful wife Geetha for 11 years. She’s a pediatric hospitalist for IPC in the East Valley. We have three kids, Anand (8), Jothi (6), and Nayan (2).

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Nursing Scope of Practice Expansion Proposal BY ROSS F. GOLDBERG, MD, FACS

On December 7th, the Arizona Legislature Health Committee of Reference (COR) met to consider a major scope of practice expansion (sunrise application) for four advanced practice nursing categories: Nurse Practitioners (NPs), Certified Nurse Midwives (CNMs), Certified Nurse Specialists (CNSs) and Certified Registered Nurse Anesthetists (CRNAs). This was proposed by the Arizona Nurses Association (AzNA) and affiliate nursing associations. For the NPs and CNMs, who already have independent practice authority in Arizona, the requested changes focused on removing the statutory word â&#x20AC;&#x153;collaboration,â&#x20AC;? stating that they feel that this requirement is causing them problems with payers and health systems and causing confusion based on vague language. Certified Nurse Specialists are requesting they be granted an independent scope of practice and prescriptive authority the same as Nurse Practitioners have, despite the disparity between the education and clinical experience of CNSs when compared to NPs.

Finally, the proposal regarding CRNAs asks for a substantial expansion of their current scope of practice, which was put into statue in 2011 after intense negotiations between the Arizona Nursing Board, Arizona Society of Anesthesiology, Arizona Medical Association (ArMA) and the Arizona Association of Nurse Anesthetists. The key element to this change is to remove the current statutory language that requires a CRNA to provide their services under the direction and in the presence of a physician or surgeon, giving CRNAs complete prescriptive authority and the ability to receive patient referrals directly from any licensed health provider. This also includes the desire to have trained CRNAs provide chronic pain management services independently. At the December 7th meeting the COR had two possible options, either vote the application down or recommend it, as is, going forward through the normal legislative process for consideration as a change to existing law. After 5 hours of debate the COR voted 5 to 4 to recommend the application go forward. mcmsonline.com/round-up

The following legislators voted against the Nursing Associations’ sunrise application:

patient safety was paramount and an ongoing theme throughout the entire opposition testimony period.

• Representative Heather Carter (Committee Co-Chair) • Representative Jay Lawrence • Senator Kelli Ward, DO (now retired from the Senate) • Senator Kimberly Yee

This vote for the sunrise application merely was a first step in the process, allowing this issue to be brought to the legislature. Now it must be presented to both House and Senate committees, language crafted and debated, then presented to both House and Senate separately, which require passing votes, and finally to the Governor for approval or veto. At the time of writing this article, those committee assignments have not been made.

The five legislators who agreed to move the nurses’ sunrise application forward were: • • • • •

Senator Nancy Barto (Committee Co-Chair) Senator David Bradley Senator Lynne Pancrazi Representative Regina Cobb, DDS Representative Randy Friese, MD, FACS

The sunrise application was strongly opposed by ArMA, along with the Arizona Osteopathic Medical Association (AOMA) and every major medical society in Arizona. The overall concern was the over-arching concept common to all parts of the application, the request to separate APRNs from physicians as part of the medical team. The testimony was led by ArMA’s veteran lobbyist Steve Barclay along with four expert witnesses: Dr. Raymond Woosley, Dr. William Thompson, Dr. Ross F. Goldberg and Dr. Jane Fitch. Dr. Woosley focused on the rigors of medical education and pharmacology; Dr. Thompson, a pain specialist, discussed the concerns of the already existing issues regarding opioid use and the dangers that allowing more people the ability to prescribe them could cause; Dr. Goldberg discussed the viewpoints from the Arizona Chapter of the American College of Surgeons, focusing on concern for losing the overall ability to direct the care of the patient while under the surgeons’ care; Dr. Fitch, speaking as the PastPresident of the American Society of Anesthesiologists and as a former CRNA herself, comparing the training and education of CRNAs with that of anesthesiologists. The opposing testimony led by ArMA focused on the fact that physicians, who are required to complete rigorous extended education, followed by a mandated residency in order to become competent, independent practitioners, are more fully qualified at their completion of their training when compared to APRNs. That, in the end, the physician is ultimately held responsible for a patient’s well-being and outcome. Nurses are essential in the delivery of high quality and effective health care to patients and they are part of the entire medical team delivering care. Concerns were articulated by each physician speaker as to the implication that with less training and no mandated post-graduate training, they can function at the same level as their physician counterparts and can “break apart” this medical team. The concern for 18

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Interestingly, 8 of the 9 committee members stated, on the record, that they agreed with many of the serious medical concerns raised during the opposition testimony, and stated that they wanted to see those concerns addressed. It is unfortunate that a majority of the committee allowed an overreaching and unsafe sunrise application to move forward despite their acknowledged concerns, perhaps in the mistaken belief that a compromise will be struck. The result of this committee hearing demonstrates the need for all Arizona physicians to be fully engaged and vocal with the Legislature. Direct physician involvement is being coordinated by ArMA and the Arizona Society of Anesthesiologists (AzSA) and is essential to make it clear that physicians will not compromise quality of care, despite a practice environment that is already making it difficult on a daily basis to prioritize patient needs above administrative and business burdens. ArMA, AzSA, the Maricopa County Medical Society, the Policy Committee, as well as the Board of Directors, are working diligently to make sure you remain informed and can provide guidance on how you can get involved and make your voice be heard. ROSS GOLDBERG, MD, FACS Dr. Goldberg attended the New York Medical College and received his medical degree in 2003. He completed General Surgery residencies at St. Vincent’s Catholic Medical Center in 2008 and at Thomas Jefferson University Hospital in 2010. A fellowship in general surgery at the Mayo Clinic Jacksonville was completed in 2012. He currently serves as the Chief of Surgery, Maricopa Integrated Health System; Assistant Professor, University of Arizona College of Medicine – Phoenix; and Director, Minimally Invasive and Hepatic Surgery, Maricopa Medical Center, Phoenix, AZ. He joined the Society in 2014 and immediately expressed interest in serving on the MCMS Board.

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Round-up

It’s an il wind, which blows no good:

Physicians Need to Push to Fix or Bury the Stark Law BY ROBERT J. MILLIGAN

Introduction

A Round-up edition devoted to the importance of physician participation in policy seems an appropriate place to ask a policy question that requires prompt and serious attention: When are we going to fix or bury the so-called Stark Law? The law, which started as an attempt to establish “bright line” rules governing physician referrals for certain “designated health services” has deteriorated into a regulatory morass that is so complex, counter-intuitive and dysfunctional that even the architect of the law, former United States Representative H. Fortney Stark has called for its repeal. While Representative Stark feels strongly enough about the problems with his namesake law to express his opinion publicly, national physician and hospital associations have been curiously silent on the subject. This silence has continued through years in which enforcement agencies and private plaintiffs (and their attorneys) have used the Stark law to extract hundreds of millions of dollars from physicians and other providers, often based on conduct that most people would characterize as honest mistakes. Perhaps these organizations fear that if they speak up for changes to or elimination of the law, they will

be cast as proponents of “fraud and abuse,” the tactically brilliant name that proponents of Stark and other laws have created to encompass conduct ranging from intentional crimes to honest and understandable mistakes regarding compliance with the horribly complex rules governing whether, how and when providers can bill for medically necessary services. In any event, it is time for physicians to stop being silent. This article provides a brief history of the law, from its reasonably well-intentioned origins through years of regulatory tinkering, to its current form. It also summarizes the basic features and flaws of the law, and the penalties associated with violations (including innocent violations of the law). Following a brief discussion of the enforcement environment, we offer a few suggestions for change, and a request for physicians to take the lead in pushing for change.

A Brief History

Frustrated with the need to prove intent to establish a violation of the federal Anti-Kickback Act, one of Representative Stark’s staffers proposed the idea of a statute that would establish a bright line test for regulating financial incentives relating to physician mcmsonline.com/round-up

referrals. The staffer was an attorney and physician (a bit of irony) whom Stark later characterized as “the worst kind of staffer.” That suggestion led in 1989 to the passage of “Stark I,” which regulated physician referrals to laboratories owned by the physicians. Physician ownership of labs was targeted initially because of evidence that physicians who owned labs ordered 45% more lab services than physicians who did not have ownership. In the years following the adoption of Stark I, multiple studies demonstrated an association between ownership and increased utilization for a variety of other types of ancillary services. Concerns prompted by those studies led to the passage in 1993 of “Stark II,” which expanded the application of the law to ten “designated health services” (“DHS”), including imaging, therapy, outpatient drugs, hospital services and other services. In addition to these statutory changes, regulations adopted under the law were proposed, modified, implemented, modified again, and “clarified” on what seemed like an annual basis since the 1990s.2 These efforts, which consumed more than 850 pages of federal publications (by way of comparison, Anna Karenina weighs in at 864 pages), reflected the challenge of reconciling a bright line test with the complex and continuously changing reality of health care. In some cases, these changes worked what can only be characterized as an injustice. For example, one group of physicians paid a six figure penalty because of an arrangement that was perfectly legal when it was structured, but became perfectly illegal as a result of a change in the law. The bright line has become an impenetrable maze.

The Current State of Affairs

As currently embodied, the law prohibits a physician; from making a referral; of a Medicare or Medicaid patient; to an entity; with which the physician; or an immediate family member; has a financial relationship; if the referral involves designated health services; unless an exception applies. Each of the underlined terms is defined, clarified or otherwise expounded upon in the federal publications referenced above. For example, there currently are thirty five exceptions to this bright line rule, and the definitions and commentary on many of these exceptions occupy many pages of text in documents issued over the years. Few of the exceptions are simple and straightforward; some are impenetrable and counter-intuitive. The “byzantine” complexity of the law was one of the reasons reported for Representative Stark’s criticism of his namesake in 2007. According to an article on the Forbes blog that year, (“Stark Regrets: I shouldn’t Have Written That Law”): 22

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While the law’s intent was good, the law banning these businesses might have done more harm than good, [Stark] says now: “It gave every shyster and promoter a loophole.” A whole industry of Stark-compliant businesses was born – not unlike the sector devoted to tax avoidance. Stark had to rewrite and clarify the laws in 1995, and there’s still debate about it... “We now have to keep rewriting the laws like the tax code,” Stark says. Stark says that today he’d go back and strip [out] the original fuzzy language so the law simply forbids kickbacks. “I think we would have stopped more of the shenanigans that way,” he says. He concedes that he created a whole cottage industry of entrepreneurs and Stark law firms that create and sign off on convoluted legal arrangements between doctors and their vendors. Representative Stark called for a repeal of the law, as it currently exists, in a 2013 article in Modern Healthcare. com. Neither his former legislative colleagues nor health care associations have expressed much interest in making an effort to pursue that suggestion. To compound problems that arise because of the complexity of the law, the penalties are downright confiscatory. For starters, the entity to which a prohibited referral is made (e.g., a physician practice that provides DHS and does not fit within the applicable exception) is prohibited from submitting a claim for the service, regardless of whether the service is medically necessary and otherwise appropriate. For the referring physicians, sanctions include civil monetary penalties of up to $15,000 per prohibited referral and possible exclusion from Medicare and Medicaid. That’s just for starters. Government agencies and private qui tam relators routinely and successfully take the position that by submitting a claim arising out of an arrangement that violates the Stark law, the entity also has violated False Claims Act. A violation of the False Claims Act in turn carries potential penalties of between $5,500 and $11,000 per claim. To provide a sense of how quickly those penalties can add up to real money, consider United States v Krizek. In that case, a psychiatrist who was charged with FCA violations (not involving Stark) relating to claims totaling $245,392 faced a possible damage award of $80,750,000. We are not done yet. If a physician practice learns that claims submitted and paid previously were not billable because of the Stark law, and fails to promptly report and repay those claims, the practice can be exposed to additional False Claims Act liability and criminal prosecution.

The Enforcement Environment

Enforcement activities relating to the full spectrum

of health care laws have been an extremely lucrative “business.” For example, the March, 2015 joint DOJ/OIG press release reported that enforcement activities generated $3.3 billion dollars in recoveries. This amounted to a return on investment of nearly $8:$1, and the ROI has at approximately that level for several years. The fiscal year 2012 report by the DHHS Health Care Fraud and Abuse Program stated that enforcement activities had generated $23 billion in recoveries since 1997. Given that return, it is not surprising that the federal budget has included hefty investments in enforcement activities. For example, the Affordable Care Act included $10 million in additional funding for the Health Care Fraud and Abuse Control Account, $250 million per year in additional funding for the Medicare Integrity Program and $75 million per year in additional funding for the Medicaid Integrity Program. In addition to federal initiatives, private parties and their attorneys are very active pursuing False Claims Act “whistle-blower” cases, alleging that arrangements that violated the Stark law give rise to False Claims Act violations. These private whistle-blowers, known as qui tam relators, bring suit on behalf of the government, and they are entitled to between fifteen and thirty percent of any recovery. A January 8, 2016 Google search for “health care whistleblower attorneys” yielded 870,000 hits. It seems very unlikely that the public or private appetite for these cases will diminish any time soon. The low point, to date, in Stark-related enforcement activities is almost certainly US ex rel Kunz v Halifax. In that case, a hospital employed several medical oncologists, and it established a compensation system that included bonuses from a profit pool that averaged approximately $250,000 per year. This pool yielded average bonus compensation of about $40,000 per physician per year. The lawsuit filed by the qui tam relator took the position that the mechanism for funding the pool violated the Stark law. Many health care attorneys disagree with this position. Unfortunately, the trial judge agreed with the relator and entered an order setting the hospital on course for a trial in which the hospital faced a $1 billion damage award if it lost the case. Ultimately, the hospital settled the case for $85,000,000, plus an additional $10,000,000 for the relator’s attorneys’ fees, on top of $23,400,000 in legal fees spent to defend itself. That is a lot of money that will not be available for patient care.

Possible Solutions

The most appealing solution would be to abolish the law, and to rely on the Anti-Kickback Act to regulate financial incentives relating to referrals. Admittedly, that seems unlikely. A combination of other less

dramatic goals might effect a significant improvement over the status quo, however. For example, the potential sanctions for Stark violations might be lessened dramatically, so that the sanctions are at least somewhat proportionate to the seriousness of the transgression. Also, the law might be changed to require a showing that the referring physician knowingly (or recklessly, etc.) made a prohibited referral. Taking a slightly different tack, the law could be amended to provide an exception to the Stark prohibition for providers who disclose the existence of an otherwise prohibited financial relationship to the patient and the payor; that type of “free market” approach would allow patients and payors to scrutinize carefully any referral decisions that might be influenced by financial considerations. Alternatively, an exception might be created for situations in which whatever compensation the physician received as a result of a financial relationship with an entity is fair market value for the services the physician provided to, or the investment the physician made in, the entity.

Conclusion

It will not be an easy task to persuade Congress to change a fundamental part of a regulatory scheme that raises billions of dollars a year. The fact that it will not be easy does not mean it cannot be done, or that the effort should not be made. No one else is going to make the effort. If physicians and their national associations fail to take action, things will continue to get worse, and they may never get better. With apologies to Wm. Shakespeare. There have been a total of 32 proposed and final changes, clarifications, etc. since 1992, including nine in the last ten years, as follows: 1992 (proposed rule), 1995 (final rule), 1998 (proposed rule), 2001 (phase 1 final rule), 2004 (phase II final rule), 2005 (proposed and final rules), 2006 (proposed and final rules), 2007 (proposed and final rules, phase III final rule), 2008 (proposed and final rules), 2009 (proposed and final rules), 2010 (proposed and final rules), 2011 (proposed and final rules), 2013 (final rule), 2014 (final rule), 2015 (final rule).

ROBERT J. MILLIGAN Bob Milligan is a shareholder in Milligan Lawless and specializes in healthcare law. He limits his practice to the representation of individuals and companies in the healthcare and life sciences industry. In addition to his law practice, he has received an LLM degree in Biotechnology and Genomics. In that capacity, he completed coursework and independent study in: FDA regulation; pharmacogenomics; biotechnology science; law and policy; clinical research ethics; reimbursement; technology transfer; and technology licensing. He received his J.D. from DePaul University, where he was a Dean’s Scholar, and his B.S. from Northern Illinois University. Contact him at 602-792-3501 or Bob@MilliganLawless.com

mcmsonline.com/round-up

MARICOPA COUNTY MEDICAL SOCIETY

MEDICAL SOCIETY BUSINESS SERVICES

MCMS Board of Directors Meeting Minutes January 19, 2016 | 6 pm

Board Members

Adam Brodsky, Ross Goldberg, May Mohty, John Couvaras, Ryan Stratford, Jay Crutchfield, Tanja Gunsberger, Kelly Hsu, Lee Ann Kelley, Mac Lato, Richard Manch, John Middaugh, Tabitha Moe, Steve Perlmutter, Pamela McCloskey, and Kimberly Weidenbach were present.

Staff

Jay Conyers was present.

Passing of the Gavel

Dr. Stratford thanked the Board for their support last year, and passed the gavel to Dr. Brodsky.

Old Business

Dr. Brodsky asked Jay to review the old business items on the agenda. Jay reminded the Board about the February 1st legislative reception at ArMA and the February 4th Beers with Peers mentorship event at the Society. He also noted that the nursing scope of practice was still being discussed amongst various stakeholders and that early indications were suggesting a single bill with all four enlargement requests.

Consent Agenda

A motion was made to approve the consent agenda, comprising December Board minutes and the membership & dues collection report. The motion carried.

Committee Charges

Dr. Brodsky walked the Board through the committee charges for the year, referencing the Strategic Plan document that was approved by the Board in December. For the membership committee, Drs. Gunsberger and Daley were designated as Board participants. The committee was charged with developing strategies to engage practice managers, checklists new member welcome packets, recruitment approaches for students and residents, and enhanced referral line metrics and feedback. Additionally, the committee will 24

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consider how social media can be better utilized to recruit and retain members, and explore the value of co-branding with other specialty societies. For the mentorship committee, Drs. Crutchfield and McCloskey were designated as Board participants. The committee was charged with how best to utilize an anchor mentorship event to develop a mentorship program matching our education members with active physician members. The committee will also explore the value of engaging the retired physician base to form a mentorship network for medical students, and will consider a â&#x20AC;&#x2DC;share seriesâ&#x20AC;&#x2122; for Round-up to help medical students and residents understand the steps to entering private practice. For the publications committee, Drs. Moe and Brodsky were designated as Board participants. The committee was charged with how to encourage members to submit content for Round-up and how to incorporate peer-reviewed content in the magazine. The committee will also consider the most appropriate template for ensuring monthly content consistency and relevance. It was suggested that the magazine include research being performed by students and/or residents, if possible. For the finance committee, Drs. Mohty and Moschonas were designated as Board participants. The committee was charged with presenting quarterly financials to the Board, and evaluating new business initiatives throughout the year. The committee will consider the financial commitments required for a community clinic, what capital investments are on the horizon for the Society and Business Services, and additional financial metrics to present to the Board. For the education & quality committee, Drs. Lato and Perlmutter and Ms. Weidenbach were designated as Board participants. The committee was charged with evaluating the possibility of the Society going through the registration/certification process for organizing and hosting CME events. The committee will evaluate the various CME opportunities available locally, and consider which ones the Society should pursue, if at all. The committee will also discuss how the Society was educating members on various federal quality metrics and how we partner with the local medical schools and hospitals on education initiatives. It was

Board Minutes suggested that since CME is not mandatory here locally, it may be difficult to utilize CME as a strong membership incentive. Consideration was given to local and/or emerging topics as CME opportunities, such as opioid prescribing, Valley Fever, and human trafficking. The Board suggested that the Society develop a survey on CME topics and ask the membership which would be of most interest.

Society partner with other local non-profits on healthcare initiatives, examples being the Asian Pacific Community in Action and the Arizona Foundation for Women. Dr. Middaugh, as committee chair, presented a comprehensive list of topics the committee would consider this year, and weighed the value in working more closely with ArMAâ&#x20AC;&#x2122;s public health committee, which he also serves on.

For the philanthropy committee, Drs. Hsu and Kelley were designated as Board participants. The committee was charged with considering the annual event to have a philanthropic theme, developing a comprehensive list of health fairs and clinics that have volunteer opportunities for Society members, and forging philanthropic partnerships with local hospitals. The committee will also determine the theme and speakers for our annual philanthropy event, and discuss how a community clinic could enhance philanthropic activities for the Society.

Each committee was encouraged to recruit at least two new members from the membership, and to have its first meeting of 2016 before the next schedule Board meeting in February.

For the policy committee, Drs. Murcko, Goldberg, and Couvaras were designated as Board participants. The committee was charged with how best to encourage members to participate in policy activities, how to structure monthly surveys on hot topics, and how best to utilize the results, such as Round-up articles. The committee will also consider if the Society should take formal positions on certain hot topics, and how to communicate such positions to the community. Lastly, the committee will help organize a policy forum for the fall. Several survey topics were suggested â&#x20AC;&#x201C; maintenance of certification, proposed legislation for nursing scope of expansion and the pharmacy database mandate, etc. â&#x20AC;&#x201C; and it was agreed that the policy committee would prioritize a list for upcoming surveys. For the public health committee, Drs. Middaugh and Manch were designated as Board participants. The committee was charged with strengthening ties with county and state health departments and fostering relationships with local schools of public health and school districts, especially those in underserved areas. The committee will also consider supporting a comprehensive immunization program, rebranding the Honor Roll program, and developing a list of article topics for Round-up. It was suggested that the

New Business

Dr. Brodsky reminded the Board of the MACRA workshop scheduled for February 6th, organized and sponsored by the Arizona Osteopathic Medical Association. Jay summarized for the Board a draft bill that would transfer authority of all health-related boards to the Arizona Department of Health Services (ADHS). The Board reviewed the bill language and discussed various concerns with the proposed legislation. Jay also summarized for the Board a draft bill that would mandate physician use of the Controlled Substance Prescription Monitoring Program (CSPMP). The Board discussed the issues with the reliability of the current pharmacy database, and agreed that a survey on the topic would be informative for the membership. Dr. Goldberg provided a brief summary of the nursing scope of practice enlargement bill and what could be expected during committee hearings.

Adjournment

The meeting was adjourned at 7:13 pm.

mcmsonline.com/round-up

The Dollars and Sense of MACRA Better Play…or you’re gonna pay! BY MICHAEL MILLS, MD, MPH

Goodbye SGR!

For more than a decade we had to make 11th hour pleas to our congressional leaders to avert payment cuts from the flawed Medicare Sustained Growth Rate (SGR) formula. Concocted in the Balanced Budget Act of 1997 in a futile attempt to control health care costs, the SGR formula tied Medicare Part B physician payment updates to the growth of the economy (per-capita GDP). Each time the formula resulted in planned reductions Congress overrode the scheduled cuts, actually 17 times since 2002 at an estimated cost of $154 billion with temporary patches that only pushed the cuts down the road. Planned cuts had risen to 21% in 2015, and something had to change. We got our “wish” for SGR repeal – along with much more with the enactment of the Medicare Access and CHIP Reauthorization Act (MACRA) of 2015.

Round-up

Political stars align

Based on significant bipartisan and bicameral support in 2014 of a comprehensive bill for SGR repeal / Medicare physician payment improvement that failed to pass Congress due to problems over how to pay for it, Speaker Boehner and Minority Leader Pelosi were able to craft a new bill with agreement on budget offsets, entitlement reforms, and support of other programs. MACRA (H.R. 2) passed in the 114th Congress by overwhelming margins – 392 to 37 in the House of Representatives on March 26 and 92 to 8 in the Senate on April 14 – being signed into law on April 16th by the President. This legislation was publicly supported by over 750 national, state, local and specialty physician membership organizations. (1,2)

Summary Highlights of the MACRA legislation 1. Repeal SGR immediately and scheduled cuts of 21% for 2015. 2. Stabilize Medicare base fee schedule with: a. 0.5% increase June 2015 and 0.5% annual increases through year 2019 (total 2.5%) b. Base rate is frozen 2020 - 2025 c. 2026 and beyond: 0.75% increase annually for participants in qualified Alternative Payment Models (APM), and 0.25% increase annually for MIPS participants. 3. Consolidate current quality and reporting program into MIPS (2019). 4. Sun-setting of penalties under separate programs, merging into one program (2019). 5. Encourage physician participation in APM’s with an extra 5% bonus payment each year from 2019 2024 for qualified, at-risk plans. In addition to permanently repealing the Medicare SGR formula, the law implements a transformative Merit-Based Incentive Payment System (MIPS), and reauthorized the Children’s Health Insurance Program (CHIP), the National Health Service Corps, community and teaching health centers. You can read the entire 95 page law, committee summary, and CBO estimates at https://www.congress.gov/bill/114th-congress/ house-bill/2. By the way, Arizona is the only state in the nation that stopped participating in the federally-funded CHIP program which takes care of kids who do not qualify for Medicaid.

What’s your “value”?

You probably noticed that the bulk of MACRA legislation begins in 2019. Don’t be fooled as a new “value-based” payment system has already started! In an effort to transform Medicare from a passive payer to a value purchaser, the Affordable Care Act (section 3007) required CMS to apply a Value-Based Payment Modifier (VBPM) to all physician payments. All physicians have been automatically enrolled -- you do not have a choice to participate or not! This program does a “look back” of your last 2 years and compares your quality and costs with peers across the nation, assigning groups into low, average and high quality and cost categories, termed “qualitytiering” (see graph table below). While replaced by MACRA in 2019, this is the foundational pathway for payment transformation. Low Quality

Average Quality

High Quality

Low Cost

Largest bonus

Average Cost

—

Largest penalty

—

High Cost

How is quality and cost being measured?

The Value Modifier amount is based on quality-tiering from two metrics: the Quality Composite score (currently being measured by PQRS), and the Cost Composite score. The 6 quality domains are equally weighted, align with the National Quality Strategy, and include (1) clinical process/effectiveness, (2) patient and family engagement, (3) population / public health, (4) patient safety, (5) care coordination, and (6) efficient use of health care resources. The Cost Composite score is based on two equally weighted domains related to Medicare Spending Per Beneficiary (MSPB): per capita costs for all attributed beneficiaries, and for those with specific conditions (CHF, COPD, CAD, DM). Patient attribution occurs irrespective of practice type if the patient only saw one physician over the last 12 months, while specialist assignment occurs when there is plurality of services. Be sure to check your group’s Quality and Resource Use Report (QRUR) with CMS which provides detailed information regarding patient attribution, physician performance used to calculate their Value Modifier, and to confirm you are meeting the minimum number of patients per category. VBMP has already impacted large groups of 100 or more eligible professionals (EPs = doctors, PA, NP, CRNA), and started this January 1st for medium groups of 10-99 EPs with all solo/2-9 EPs groups going live next January. In CMS’ first published experience from 1010 large groups subjected to VBPM for 2015, there was sufficient data for only 106, with 288 of the groups not even registering for PQRS GPRO in 2013 (resulting in a -1% penalty). 14 of the 106 groups had upward payment adjustments based on “high quality” and “low costs” while 11 groups had a downward adjustment. (3) This is not very encouraging. In 2017 a solo/2-9 EPs group participating in PQRS will have a +2% bonus or no change, and a 10+ EPs group will have a +4% increase, -4% decrease, or no change based on VBPM scores. If you are not participating in PQRS, you will automatically have a penalty of -2% or -4%, respectively for these groups. mcmsonline.com/round-up

Now for the MACRA and CHEESE!!!

Picture yourself positioned in the “high quality / low cost” category for VBPM, with a stable base rate and bonuses. Today, you have to start the process of deciding between two new payment systems that will start in 2019. One track keeps the base fee for service (FFS) with the addition of the Merit-Based Incentive Payment System (MIPS), and the other track rewards financial risk taking through Alternative Payment Models (APMs).

Track 1 Fee for Service + MIPS

Track 2 Qualified APM

No bonus outside of MIPS program

5% annual bonus (2019 - 2024)

Flat FFS schedule (2019 - 2025)

Annual increase 0.25% 2026 and +

Annual increase 0.75% 2026 and +

MIPS Assessment on measures: 1. quality 2. resource use 3. EHR/meaningful use 4. Clinical practice improvement activities

Not involved with MIPS

Performance-based payment adjustments: -2019 = + / - 4% -2020 = + / - 5% -2021 = + / - 7% -2022 and beyond = + / - 9%

Eligible physicians must be in Qualified APMs (ACO with MSSP, CMMI, or a Health Care Quality Demonstration Program) that requires: 1. pay based on quality component 2. use certified EHR 3. have a significant share of payments through the APM that is risk-bearing (or is a Medicarerecognized medical home)

Track 1 = trying to minimize penalties

MIPS consolidates the existing quality and cost programs into a single program with four categories of variable weighting, some of which were developed during VBPM: (1) Quality, (2) Resource Use, (3) EHR meaningful use (MU3), and (4) Clinical Practice Improvement Activities (CPIA). Resource Use for care episodes and patient condition groups will be 28

Round-up

assigned to physicians based on 5 defined categories of patient relationships: (1) primary responsibility, extended length of time, (2) lead physician furnishing services and coordinating care, acute episode, (3) physician providing supportive continued care, acute episode, (4) consultant, and (5) provide services as ordered by another physician. Clinical Practice Improvement Activities (CPIA) is a new performance category to promote the following areas: (1) expanded practice access (urgent same day appointments, after hours clinical advice), (2) population management, (3) care coordination (timely communication, information exchange, telehealth, remote monitoring), (4) beneficiary engagement (shared decision making, care plans, training), and (5) patient safety and practice assessment. MIPS scores will be generated on a quarterly basis, with payment adjustments made annually. The lowest 25th percentile performers participating in MIPS will receive a negative adjustment of -4% in 2019, escalating each year up to -9% in 2022 and beyond. With budget neutrality (+$ to winners = -$ from losers), adjustments are situated on a “sliding scale” allowing a proportional positive or negative results in a linear fashion based on the provider’s MIPS score. For those in the top 25th percentile, the Secretary of CMS is allowed to adjust the scale up 3X resulting in a smaller number of winners, with a bonus cap of +12% in 2019, all the way up to +27% in 2022 (versus +4% and +9% without a scale adjustment). In addition, there is a MIPS payment adjustment award totaling $500 million for exceptional performance that is not part of budget neutrality, to be distributed annually to those in the top 25th percentile, with a maximum bonus of 10% per individual. Physicians in the MIPS program will get a 0.25% annual update in base fee schedule in 2026 and beyond.

Track 2 = maximizing quality care low costs

This track encourages physicians to move towards a qualifying Alternative Payment Model (APM) by providing an extra annual bonus of 5% between 2019 and 2024 irrespective of performance, triple the annual base fee schedule increase (0.75%) starting in 2026, and no requirement to participate in MIPS. Physicians interested in the APM track for 2019 will need to start planning out their eligibility now. All non-APM eligible physicians to be automatically enrolled in MIPS with no phase-in. To qualify, a professional must (1) participate in an “eligible alternative payment entity”, and (2) earn a significant share of Part B Medicare revenue through that entity. To satisfy this first component, the entity can be an ACO under the Medicare Shared Savings Program, a Center for Medicare & Medicaid Innovation (CMMI) model, or a Health Care Quality Demonstration Program. The entity must require the use of a certified

EHR, pay providers based on performance and quality measures (such as in MIPS), and the physician must bear “more than a nominal” risk for financial losses (unless Patient Centered Medical Home under CMMI). For the first two years, 25% of your Medicare Part B payments must come through the organization, increasing to 50% in 2021-2022 and 75% in 2023 and beyond. There is an alternative “all-payer threshold” option of 50% all payer payments (including 25% Medicare Part B) in 2021-2022, and 75% all-payer payments (including 25% Medicare Part B) 2023 and beyond. A new Technical Advisory Committee (TAC) will provide feedback to CMS and develop physician-focused APMs, including those for specialist.

With every end there is a new beginning

The flawed Medicare SGR formula had to go. We now have MACRA, with VBPM as a payment transition. With overwhelming bicameral, bipartisan and nationwide physician backing, the responsibility of transforming our health care system from a costly, fragmented one with variable quality into one that rewards the highest quality at the lowest cost (high value) is squarely back on our shoulders. Intrinsically, we know that we can do better through collaboration, accountability, communication and comparing outcomes. This is our chance to positively impact the quality and cost of healthcare in the United States for our patients.

adjustment as a low quality and high cost provider? Check out your QRUR at the CMS site today! The decision for becoming eligible for the APM track is right around the corner, and if you don’t qualify, you will be in the MIPS program by default, so start preparing for those metrics. Lastly, CMS has been clear that it is their objective for all payers, including commercial plans, to adopt MIPS/APM - like strategies. While one can avoid MACRA by opting out of Medicare, we are entering the era of “value purchasing” of health care that is based on the principles of rewarding high quality and low cost.

References: 1. http://www.ama-assn.org/ama/pub/advocacy/topics/medicare-physician-paymentreform.page 2. https://www.acponline.org/advocacy/advocacy_in_action/state_of_the_nations_ healthcare/assets/2015/SGR.pdf 3. https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment PhysicianFeedbackProgram/Downloads/2015-VM-Program-Experience-Rpt.pdf

Don’t delay!!! You need to start reviewing your position today. If you dragged your feet with involvement in PQRS, MU3, or electronic health records, reassess not only the penalties ahead, but also being excluded from the health care delivery community. Soon, you will get your VBPM score. Will you receive a negative

MICHAEL MILLS MD, MPH Is a Gastroenterologist with Arizona Digestive Health (www.azdigestivehealth. com) in Phoenix. He has been a MCMS member since 1999, serving on the Board of Directors from 1999 – 2003, and was President in 2012.

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www.mica-insurance.com Dividends declared for a given policy year reflect the Company’s financial performance during that year.