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

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Erosion of the Doctor-Patient Relationship

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June 2016 | Volume 62 | Number 6 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.

ROUND-UP

PUBLISHED MONTHLY BY THE MARICOPA COUNTY MEDICAL SOCIETY

June 2016 | Volume 62 | Number 6

4 6 8 10 12 14 16 20

What’s Inside

President’s Page

An Interview with MD24 Founder Lin Nguyen, MD By Dominique Perkins

The Erosion of the Doctor-Patient Relationship

Erosion of the Doctor-Patient Relationship By Robert Kravetz, MD

Doctor, Please Look at Me!

Preserving the Doctor-Patient Relationship through Dictation and Transcription By Kamal Irani

What Your Office Space Says About Your Practice

By Kathleen Morgan, CCIM

Spending More Time with Patients

By Derek A. Haas, Yudit C. Krosner, Nirvan Mukerji, MD, and Robert S. Kaplan

A Promise to Physicians:

A sit-down with long time Society Partner MICA By Round-up Staff

5 Ways To Engage Patients By Sachin H. Jain

Bringing the Doctor to the Patient:

How Do Physicians Feel About Medical and Recreational Marijuana? By Round-up Staff

32 34

Health Care’s Top Priority: Fast and Easy Appointments By Jonathan Bush

Bringing the Customer’s Voice into Medicine

By Danielle Cass

Doctors Seek Probe of UA Medical School Leaders’ Exodus

By Ken Alltucker, The Republic | azcentral.com

39 41 43

New Members In Memoriam Marketplace

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What’s Inside June 2016

his month we focus on the doctor-patient relationship. Or, as many like to refer to it, the erosion of the doctor-patient relationship. Is it really eroding, and if so, why has it? In my three short years with the Society, I’ve heard countless concerns from our more esteemed physician members who are now on the other side of the exam table. No longer in practice and now in need of more medical care thanks to Father Time, many retired physicians are dismayed at how younger docs treat them. Below is a far too common account of what I hear.

After I checked in, they took me into some cold exam room and didn’t bother to ask me if I was comfortable or needed anything. The room was freezing. They said the doc would be right in, but I

waited for nearly an hour before someone checked on me. When the door finally opened, this young doc rushed in, didn’t look at me, and went straight for the computer. The doc muttered a few questions that I could not hear, so I asked him to speak up. Rather than turn around and speak to me, he simply raised his voice a bit so that I could hear him. He asked me a few more questions, and then a nurse came in to check my vitals. She didn’t acknowledge or speak to me; instead, she grabbed the computerized blood pressure cup, wrapped it tightly around my arm, never asking if it was too tight, and then hit a button. I watched the doc and nurse for the next 30 seconds, as their eyes were transfixed to the digital readout. Not on me. No comment on whether my BP was high or low, but thankfully my thirty-year career

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as a physician told me the answer my doc should have communicated to me. Within minutes, he was out the door. I recall thinking that I didn’t even get his name, or that of his nurse. Ten minutes later, someone popped their head in the door and directed me to the check out desk, and instructed me to pick up my script there. In total, I spent nearly three hours at the office, despite having an appointment, and my time with the doc was less than ten minutes. He never asked me how I felt, what my name was, or if I had any concerns. Neither the doc nor the nurse put their hands on me. Hell, they probably didn’t even know how to use an old-fashioned sphygmomanometer and thus had to rely on the digital readout. On my way out, there was a sign encouraging me to ‘rate my doc’ on a website. I thought to myself, “If the doc didn’t even make eye contact me with, or ask me how I feel, how can I ‘rate’ my experience with him?“ This is not how my generation practiced medicine. I can assure you of that. Has medicine really come to this; to the point where physicians don’t interact with their patients? Surely not. But this perception is not something new. In 2008, the New York Times published a provocative article on the subject, suggesting that doctors and their patients are now, seemingly, at odds. Many reasons were offered as explanations to the breakdown in communication, and many studies have since been carried out to better elucidate the reasons behind relationship erosion. When you ask physicians about the cause of erosion, many point the finger at insurance companies and growing government regulations. Diminishing reimburse-

ments mean less time for patients (if you still want to make a decent living). Quality reporting metrics mean less time for patients. Working within an EMR means less time for patients. What patients don’t seem to understand is that physicians would prefer to spend more time with them, listening to them. Most seem oblivious to the insurmountable regulatory pressures physicians face, and the ever-declining reimbursement rates that physicians receive for services they render. At every chance I get, I tell these stories and try to convince my friends, family, and colleagues that they should walk a day in the shoes of a physician before they declare that physicians don’t prioritize their patients. I often ask people, “Would you continue doing the same job if your pay for that job declined year after year?” Of course the answer is almost always, “No.”

Jay Conyers, PhD EXECUTIVE DIRECTOR

jconyers@msmsonline.com 602.251.2361

This month, we focus on this topic, and bring you some great articles that address this paradigm shift in a physician’s place on the trust totem pole. With the Society as your advocate, we aim to help you regain that trust. For our physician profile, we highlight the work of Dr. Linh Nguyen, a medical entrepreneur who has built a thriving house call operation in West Valley. He’s truly committed to his patients (as are all of you!), and hopes to bring more care to them, just as physicians did back in the day. We hope you enjoy this issue. Look for Round-up next month, as we focus on education and profile Dr. Linda Lau, Director of Midwestern University’s family practice residency program at Mountain Vista Medical Center. Until then, I ask you to think about this great quote by Perry Cohen: “The missing ingredient in the development of new therapies is the voice of the patient.”

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President’s Page T

he focus of this month’s issue is the unfortunate erosion of the doctor-patient relationship. This erosion is not new - It has been felt, lamented, and written about for at least the past 20 years. Recently, however, new systems have been developed by which the doctor-patient relationship is being further eroded. The first of these are the large networks of providers known as Accountable Care Organizations (ACOs). The large groups were initiated by Medicare several years ago in order to save money by transferring some of the risk associated with healthcare insurance onto the provider organization. If the ACO saves Medicare money, then it stands to share in some of the savings. While one can debate whether or not ACOs save money (some have, most have not), or whether or not they are even capable of saving money (the ultimate “responsible party” - the patient - has no knowledge

Round-up June 2016

of or stake in any particular ACO), what is abundantly clear is that the doctor-patient relationship is suffering under this scheme. Primary care physicians are being forced to choose one ACO with which to “align” themselves. While specialist physicians initially were allowed to join more than one ACO, there is a movement to force specialists to “declare their allegiance” to only one specific ACO. Why does this matter? Because the patients have no such allegiances and are entirely left out of the equation. Because many markets, such as Phoenix, have more than one ACO competing in the same marketplace, there are instances all over the Valley where competing hospitals or outpatient offices are located a few blocks away from each other, similar to the way in which one often finds McDonalds and Burger King or Lowe’s and Home Depot right across the street from each other, competing in the same markets. If I am a physician in a

certain area, and my patient is admitted to a certain hospital nearby, would it not make sense for me to be able to see my own patient there? By what logic does is make sense for me to limit my practice to only “Lowe’s” but not “Home Depot” when they are across the street from each other? While such restriction and consolidation may benefit the financial and market strategy of the large ACO, how exactly does it benefit the patient, who is now forced to see a new doctor every time they wander into a different ACOs “territory?” The second recent development which is contributing to the eroding of the doctor patient relationship is the proliferation of so-called narrow networks. As if the ACO issue weren’t bad enough, if I am lucky enough to see my own patient in my “own” ACO, the next obstacle I may find is that the patient’s insurance company has changed to a narrow network by choosing the lowest cost providers and has decided to exclude me from the network. This can happen at any time without warning. I personally have several patients unable to see me in the office after a heart failure admission due to insurance narrow network issues. Instead, the patients ended up being readmitted for heart failure again. I have other patients with whom I have built up over many office visits a trusting relationship which is finally starting to pay off as the patients finally begin to agree to lifestyle changes and medication changes to dramatically reduce their risk of future cardiovascular events, when suddenly the insurance company notifies them that they have to start seeing a different physician in the narrow network. In some instances the patient’s wife, in a different health plan, can continue to see me, however the husband cannot. By what logic is this helping the patient? One final example of a new phenomena originally intended to improve qual-

ity but which has had the unintended consequence of further fraying the doctor-patient relationship is the growth of the hospitalist movement. Originally intended to improve acute inpatient care, the hospitalist movement has indeed achieved that goal. However, it has completely jeopardized continuity of care, to the point of causing an entirely new branch of medicine to arise - transitional medicine. Can you imagine an entire cadre of doctors and allied health professionals whose only job is to “ease the transition” back to the patient’s primary care physician - the one who is ostensibly in charge of the totality of the patient’s care but who is left utterly out of the loop, having no clue as to what went on in the recent hospitalization? Ironically, it is often the specialists who have the most continuity of care, as for the time being some of them are able to maintain both an office-based practice and still round on their own inpatients.

Adam Brodsky, MD, MM

MCMS PRESIDENT 2016 abrodsky@msmsonline.com 602.307.0070

While I admit that healthcare in the Unites States is too expensive, and I realize that in our market-based economy, market-based principles are an obvious mechanism by which to effect changes in health care, there must be some attempt to not throw out the baby with the bathwater. If we lower the cost of care but completely disrupt the personal relationship between patient and physician, then I am not sure we have truly accomplished our goal.

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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Erosion of the Doctor-Patient Relationship BY ROBERT KRAVETZ, MD

y medical school education, training, and practice took place during what I and many of my fellow contemporaries considered the “golden age” of medicine. During the past fifty years there have been spectacular advances in the basic sciences, clinical diagnoses, and treatment; it was a time when we could not only cure diseases, but also heal and comfort our patients because there was an intimate physician-patient bond.

In recent years, this has all but disappeared. Families and patients are keenly aware of this. We hear comments such as, “the doctor is always in a hurry, he did not listen, or he did not really seem interested in me or my loved one. I was never asked how I felt, all I was told that there would be more tests,” etc. So often tests are ordered without any explanation of their relevance or benefit and no mention is made about the actual procedure or any discomfort or inconvenience that the individual might experience. Doctors routinely order a newer test and still perform the older less accurate one resulting in duplication of information and additional cost.

That was a time when there was a harmonious blending of technology and humanistic medicine; when patients were treated as a person and not as an object with a disease process. It enabled me to always see my patients as unique individuals with a disease to which each one of them responded in a very specific physical and emotional way. The disappearing art of medicine needed to be much more widely disseminated to the current generation of practicing physicians and the young physicians in training.

I have witnessed the slow dissolution of the physician-patient bond and have seen it virtually disappear in recent years. With every new advance in technology, particularly with the advent of managed (or should I say mismanaged) care, another nail is driven into the coffin of caring. Physician selection is no longer a matter of free choice, but rather it is dictated by health plans, insurance companies, and employers. It is not uncommon for a patient to be shifted from physician to physician each year, resulting in a lack of continuity

“One of the essential qualities of the clinician is interest in humanity, for the secret of the care of the patient is in caring for the patient.” – Francis W. Peabody 1

Round-up June 2016

of care and no chance at all for developing that bond.

records, just to mention the most common ones.

With each advance in technology we further distance ourselves from our patients (the new terms being “consumers” and “customers). Robotics is now becoming a more integral part of medicine. A physician in the adjacent room or even in a distant city can perform surgery. I predict that this will become common practice and there certainly are benefits to this advancement. It is not unrealistic to visualize the day when patients will not have to be talked to or even examined by a physician; it will all be done with technology and algorithms and results measured by physician performance.

Practicing physicians today will rightly say that pressure and a lack of time they can spend with patients prevents them from forming a close physician-patient relationship. I certainly understand and empathize with this. The questions is, “how can the art be resurrected”? I would be happy to hear any suggestions in this regard or other comments regarding this issue.

This is not to imply that the advances in technology have not enabled us to diagnose more effectively, as well as treat and cure more, often adding years to patients’ lives, but in many cases quantity of years does not equate to a better quality of life. I support and cheer the new advances and the benefits of technology, however, this has come with a price: namely the disappearance of the humanistic aspect of medicine. Another major problem and concern is “physician burnout,” which has become much more common in recent years. I frequently hear physicians comment to their colleagues that they would readily hang up their stethoscope at a moment’s notice; they would leave medicine if they were able to do so financially. Some valid reasons for this increase are managed care, loss of autonomy, reduced reimbursement, and electronic

Notes:

1. Peabody, Francis W: Doctor and Patient, New York: The Macmillan Company, 1930.

ROBERT KRAVETZ, MD Robert Kravetz, MD, one of the first Gastroenterologists in Phoenix, practiced for 35 years. He is presently on the faculty of the University of Arizona College of Medicine — Phoenix with dual appointments as a clinical professor in the departments of Internal Medicine and Bioethics. Medical Humanism is his area of main interest.

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Doctor, Please Look at Me! Preserving the Doctor-Patient Relationship through Dictation and Transcription BY KAMAL IRANI

octors and Healthcare providers are an integral part of everybodyâ&#x20AC;&#x2122;s life; they ensure the health of a community. Unfortunately, there is growing dissatisfaction with the patient/doctor relationship. 10

Round-up June 2016

While most doctors entered their profession because they want to help patients, they find that they are spending less time with patients and more time dealing with government regulations, entering electronic

records, meeting private payer requirements, and the day-to-day difficulties of trying to a run a business. These factors have resulted in a compromised patient experience. I have been hearing complaints about the lack of eye contact during a consultation more than any other reason for a less than satisfactory doctors’ visit. Patients are frustrated that doctors are spending less time with them and do not give them their full attention during the time that they do spend with them. My own mother, who is used to a personal and caring experience when visiting her doctor, is a prime example of this. She feels like her doctor focuses more on his computer than on her! The other day she remarked that her doctor actually talked more to “that machine” than he listened to her. The general feeling nowadays is that doctors are so focused on their computer (to make sure they are documenting correctly and meeting compliances), that patients feel cheated out of their attention, and feel like they are competing with the computer screen. With emerging technologies the need for medical documentation is more important than ever. Service providers need to make sure the ICD code of the initial diagnosis matches the code on all the medical paperwork like service receipts, doctor’s receipts, and the EOB (explanation of benefits). Accurate documentation is critical to the best possible care a patient will receive. How do physicians then balance this need for accurate documentation and the very basic necessity to make eye contact and connect with their patients? Some physicians have begun using voice recognition software to aid them in their recording process, and there are certainly several available on the market. However, some dictation errors simply cannot be caught by voice recognition software. The role of human intelligence cannot always be replaced by voice recognition and electronic medical records/electronic health records (EMR/EHR) technologies. Surprisingly, sometimes only a human being can identify the correct word to be used for “sound alike.” Physicians nowadays feel that dictation and transcription is a thing of the past because of EMRs and EHRs. This is not so. Transcription is still the most effective form of recording a doctor-patient visit. It frees up the doctor to stay focused on his patient, and provide a meaningful and fulfilling experience for the patient. Dictating a note can provide a more descriptive narrative of the patient’s condition than just entering a code. With the new technologies that are evolving and readily available, medical transcription can be used to automatically populate the transcribed notes into the appropriate fields of the EMR. Dictation is the most intuitive and least time-consuming means of documenting a patient encounter. Many physicians are familiar with it and it does not require them to make a drastic change in their workflow. It lets physicians dictate as usual, while medical transcriptionists remotely

chart directly into an EMR system. It provides for more efficient use of the clinician’s time since a trained transcriptionist can create extremely accurate, high-quality documentation and also identify possible errors in the dictation. When clinicians use point-and-click and EMR note entry to enter data directly into the EMR, it takes them significantly longer to document the patient encounter. Using medical transcription to document the notes can also free up the physician’s time to see an increased number of patients. Adding dictation and transcription is easier than many physicians realize since virtually every EHR is capable of incorporating transcription into the patient note via the interface. With all the new technologies available medical transcription can be used seamlessly along with EMRs to increase the efficiency and accuracy of clinical documentation and provide physicians the flexibility of spending more time with their patients while maintaining revenues. Partial dictation allows physicians to use EHR templates in documenting certain sections, while using dictation for other portions. The partial dictation can then be sent for transcription, and integrated seamlessly into the patient’s electronic chart. EHR templates found in electronic record systems greatly reduce the amount of audio requiring transcription, effectively reducing transcription costs. At the same time, physicians have the option to dictate critical aspects of any patient encounter, allowing for timely and greater detail. Partial dictation offers efficiency and cost reduction, a rarity in the healthcare system. Integrating and importing medical transcriptions into any EMR/EHR software system creates a complete and unified, electronic patient health records system that improves patient care, billing processes, insurance claims, practice-wide communications and feedback to referring physicians. It also results in operational efficiencies and profitability. While accurate and quality reporting are valuable tools for a physician’s practice, face-to-face interaction and trust between doctor and patient remain the most valuable tools for quality and efficiency of care. Protecting that relationship is worth it.

KAMAL IRANI Kamal Irani has owned and operated STAT Transcription since 2000. She is certified in Management of Clinic Information Technology, and previously had a 16-year career as a Software Engineer in the Medical Device industry. “My passion is forming a partnership with my clients and designing a personalized plan that fits the individual transcription needs of our diverse client base.”

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What Your Office Space Says About Your Practice BY KATHLEEN MORGAN, CCIM

medical practiceâ&#x20AC;&#x2122;s physical office space says a lot about the practice, its environment and the message they want to express to their patients. Even as hospitals continue to purchase independent medical practices, each practiceâ&#x20AC;&#x2122;s space says something

Round-up June 2016

unique about them. First impressions are lasting impressions. What do you want to convey when a patient first walks into the lobby and waiting room? The look, size and colors of the waiting room typically sets the tone. In this article, I will explore how different practic-

es use layout and finishes to convey a specific character to their patients. A pediatric group or family practice is focused on making families and young children feel comfortable, with a waiting room hosting a lot of chairs for seating (oftentimes divided by newborns, sick and healthy groupings). The check-in and check-out areas are typically well marked, and designed for numerous patients. The area will typically have a “homey” feel, with pictures of children, maybe even a mural or two, in the lobby. Some toys are available for busy fingers, and the available magazines will cater to children, from coloring books to publications about family life. The clinical space in a pediatric group or family practice is directed toward function and patient flow. Physicians, while providing patient care, also want to maximizing space and patient movement. While the layout can change, depending on the number of physicians and physician’s assistants working together, typically the layout is in a pod form. This allows the physician or physician’s assistant to utilize three to four exam rooms close together to easily move from one patient to another. An OB/GYN practice requires a different layout, and often uses higher-end finishes than a pediatric or family practice space. An OB/GYN practice will contain plenty of seating, but the space will feel larger and less cluttered, and will offer a soothing atmosphere. Characteristically the space will have a relaxed feel and pictures will focus on the happy outcome of smiling families and newborns. Appointments are not clustered together, so the waiting room will not be continually full with patients. Many OB/GYN practices also offer cosmetic services such as cool sculpting or Botox, and oftentimes the waiting room provides a combination of a clinical waiting room with the feel of a luxurious spa. The exam rooms are also typically located in a pod format to facilitate patient flow. A key difference, however, from a pediatrician or family medical space is the need for plenty of bathrooms in the OB/GYN space. A high-end cosmetic dental practice offers a step above in atmosphere and finishings, with an expensive look and feel. Most patients at these exslusive dental practices pay cash for services, as opposed to submitting the visit to an insurance carrier. The practice will appeal to patients by conveying confidence and luxury, so the patient will feel assured in the outcome and good about paying for the services. The waiting rooms are open and airy, furnished with larger chairs or couches. Patients are seen by appointment, and are rarely children, so the waiting room is typically less busy and has a relaxed atmosphere. The finishes will be high end, from the flooring and lighting to the countertops and cabinets. The dental operatory will be roomy, with high end counter tops and finishes focusing on functionality, or-

First impressions are lasting ones. What do you want to convey when a patient first walks into the lobby and waiting room? The look, size and colors of the waiting room typically sets the tone.

ganization and confidence building (generally the appearance of expensive furnishings conveys confidence). Like the other practices mentioned above, a dentist will typically display photos of patients or models with their big, perfect smiles. Any awards the dentist has received are openly showcased. Most successful physicians and physician groups also highlight unique attributes of their staff. Hobbies and healthy activities are often promoted and displayed with themed photos or murals that feature the physician’s passions and personality. This approach can put the patient at ease and make the physician more relatable. Physicians with families and children may display family photos, which provides a focal point for patients as they wait and often become conversation pieces. Specifically, it’s important to have fun with the space; whatever the specialty or ownership, the look and feel of the practice says a lot to a patient, without saying a word!

KATHLEEN M. MORGAN Kathleen M. Morgan, CCIM, is a managing director in the Phoenix office of Newmark Grubb Knight Frank specializing in medical office sales and leasing. A creative, diligent, and 19-year industry veteran, Ms. Morgan’s thorough knowledge of Phoenix healthcare providers and the city’s commercial real estate market ensures a successful and mutually beneficial transaction for all. Her career in commercial real estate is defined by long-lasting relationships with tenants and landlords, buyers and sellers. The duration and success of these relationships derive from her honesty, intelligence and ethical ways of doing business.

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Spending More Time with Patients 14

Round-up June 2016

BY DEREK A. HAAS, YUDIT C. KROSNER, NIRVAN MUKERJI, MD, AND ROBERT S. KAPLAN

ressuring physicians to maximize the number of patients they see and minimizing the time they spend with each is one of five counterproductive mistakes that health care providers often make in trying to reduce costs - the subject of a recent article in Harvard Business Review. Overworked physicians rarely have the time for these difficult conversations, especially when they are restricted to 20- to 30-minute appointments, with much of the front end spent updating a patient’s medical record. When physicians spend an inadequate amount of time with their patients, the patients may not fully understand the importance of complying with all aspects of their recommended treatments, which eventually leads to deteriorating health and higher treatment costs. Approximately 50% of patients with chronic conditions do not take their medications as prescribed. To illustrate the problem, consider our research on the cost of treating patients when their kidneys begin to lose their ability to filter blood. Should the kidneys of a patient with such a chronic disease completely fail when a transplant is not immediately available, the person needs dialysis several times a week to filter and clean the blood. How the patient starts on dialysis has enormous health and cost implications. The vast majority of patients should do peritoneal dialysis at home or start with hemodialysis at a dialysis center. Both approaches require a vascular surgeon to create a fistula or a graft to connect an artery and a vein in the forearm. The surgery must be performed well before dialysis starts since a fistula can take about three months and a graft several weeks to “mature,” or be ready to be used for dialysis. If dialysis is required and a matured graft or fistula is not available, the patient must start with a catheter inserted into a vein in the neck or chest, a process that leads to a much higher risk of infection, blood clotting and death.

When physicians spend an inadequate amount of time with their patients, the patients may not fully understand the importance of complying with all aspects of their recommended treatments, which eventually leads to deteriorating health and higher treatment costs. There are many other examples of how primary care doctors treating chronic diseases, such as diabetes and congestive heart failure, could offer better advice and achieve better treatment compliance if they had more time to spend with their patients. The costs of such extra time would be repaid many times over, often by orders of magnitude, through fewer future complications.

Despite the large health benefits from an optimal dialysis start, more than 50% of patients nationwide begin dialysis via a catheter. Some of these occur because primary care physicians wait too long to refer their patients to nephrologists. Once referred, many patients are in denial that they will need dialysis or that they will need it as soon as actually occurs. Such patients may not adequately prepare for this eventuality despite a timely recommendation by their nephrologist.

DEREK A. HAAS

To understand these issues better, we formed a project team to study patients that started on dialysis in 2011 and 2012. It analyzed historical data of 167 patients insured by Kaiser Permanente in the Georgia region, and used time-driven activity-based costing to assess the costs of care received one year prior to the start of dialysis and also the charges incurred for one year after starting dialysis. We learned that health complications in the year following a sub-optimal start of dialysis led to nearly $20,000 in extra treatment costs per patient.

Dr. Nirvan Mukerji, MD, is a practicing nephrologist and the chief of nephrology in the Southeast Permanente Medical Group in metropolitan Atlanta.

Derek A. Haas is a project director and fellow at Harvard Business School and a founder of Avant-garde Health.

YUDIT C. KROSNER Yudit C. Krosner is director of specialty-care strategy and practice management at the Southeast Permanente Medical Group in metropolitan Atlanta.

DR. NIRVAN MUKERJI, MD

ROBERT S. KAPLAN Robert S. Kaplan is a senior fellow and the Marvin Bower Professor of Leadership Development, Emeritus, at Harvard Business School. © 2015 Harvard Business School Publishing Corp. Distributed by The New York Times Syndicate

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A Promise to Physicians: A sit-down with longtime Society partner, The Mutual Insurance Company of Arizona

Round-up June 2016

BY ROUND-UP STAFF

What is the history or background of MICA, and why did you start it? MICA was founded forty years ago when Arizona’s largest medical professional liability (MPL) insurance carrier announced it was no longer writing MPL insurance coverage. Over the course of six months, Jack Brooks, MD and a dedicated board of trustees created MICA. We issued our first policy April 1, 1976. MICA was and is a physician-owned and physician-directed mutual insurance company. Our policyholders are our beneficial owners. In the years since our founding we have striven to provide exemplary service, stable pricing, prudent underwriting, outstanding risk management programs and an experienced claim staff. Today we provide medical professional liability insurance to physicians, health professionals and medical/ surgical facilities in Arizona, Colorado, Nevada and Utah. We are the market leader in Arizona.

What would you say your biggest influences come from? From the needs of our members: our decisions are based on their interests. As a mutual company our beneficial owners are our insured members. We have no split loyalties between our owners, our capital providers, our managers, and our members.

Our commitment to our members is exemplified by our history providing dividends to our members when warranted. Since our founding we have returned more than one-half billion dollars.

What is a little known secret about this business that physicians wouldn’t know? Resolving formal claims and law suits is a complex process that requires substantial resources. Quality defense counsel working with highly qualified and invested claims personnel coupled with the close support and involvement of our insured proves that the promise of a vigorous defense really does matter.

Are there any tips that you could tell physicians that would improve their experience when they visit? When our policyholders log-in to the MICA website they have quick links that will take them directly to online CME programs with over 80 courses available 24/7, our archive of Risk Management Hot Topics, Lunch & Learn Webinars, and our Lunch & Law Webinars. They can also view an invoice, pay a premium, print a certificate or claim verification, as well as download consent forms, other products, and risk mitigation resources.

How would you like to be remembered? As still here serving the needs of our members. MICA is more than just an insurance company providing medical professional liability insurance. Since our founding, MICA’s commitment has been to the physicians, to the other medical professionals and health related entities we insure, to the patients they serve and to the community.

What makes this business different from other businesses like it? MICA was formed by physicians, directed by physicians and managed by insurance professionals under physician leadership; MICA retains the values of a profession that puts the needs of the patient foremost. We are owned by and work for our member policyholders, and we measure our success by the value we bring, not by the revenue we generate.

If you were to tell a potential customer why they should come here, what would you say? An insurance policy is a promise to pay and the financial strength of a company determines its ability to fulfill that promise to policyholders now and well into the future. MICA’s financial strength rating of A (Excellent) by A.M. Best, the country’s best-known insurance rating agency, affirms our success in balancing our long-term commitment to our members with the needs of the company. Article photos by Denny Collins Photography. www.dennycollins.com • (602) 448-2437

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Dr. James Carland, MICA President and Chief Executive Officer, with Ronald E. Malpiedi, Vice President & Chief Operating Officer

But if they would prefer to talk to a real person, we have Customer Services Representatives available specifically to help them.

If we were sitting here a year from now celebrating what a great year itâ&#x20AC;&#x2122;s been for you and for MICA, what did you achieve? MICA has available multiple educational programs to help our members reduce the potential for their being accused of malpractice. A great year would see those programs result in fewer, less severe claims and as a direct consequence, lower premiums for our members.

Do you have an anecdote about the business that summarizes what you are all about? Physicians and others who provide medical care are professionals dedicated to the health, safety and well-being of their patients. They are also fallible human beings. Medicine is both science and art that require varying degrees of skill, judgment and insight. As professionals, they hold themselves accountable for their errors. In MICA they have developed the means to fairly compensate those truly injured by medical error and the resources to determine if an unsatisfactory outcome is really the result of their actions or inactions.

WANT TO REACH 10,000 PHYSICIANS EACH MONTH? If so, advertise with us in Round-up, the monthly magazine published by the Society and read by more than 10,000 Maricopa County physicians each month. Become a Preferred Partner with the Society today.

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5 20

Ways to Engage Patients

Round-up June 2016

BY SACHIN H. JAIN

There are, of course, limitations, one of which is self-selection bias. People participating in an online community around their disease are already more engaged, more informed and more tech savvy than many others. So while leaders in the health care system integrate the (undeniably valuable) insights from these communities into decision-making processes, we have to account for these patients’ above-average sophistication and its implications for their treatment choices.

edical science has enabled our health care system to deliver outcomes that would have been impossible a generation ago, and advances in fields such as genomics and stem-cell therapy offer immense promise to further accelerate medical innovation. As extraordinary as insights from the laboratory often are, better understanding the experiences of patients and health care providers can provide a roadmap for the critical last mile of medical care, where all policies, procedures and practice converge into action. Below, I offer some approaches drawn from my experiences working in health-care-delivery organizations, government and industry. (The principles I propose are my own and do not reflect official policies of any organizations with which I am affiliated.)

2 3

We must strive to move beyond our own experiences. Those of us who work in health care inevitably refer to our own experiences with the health care system when making decisions about strategy and program design. Even at high levels of policy or strategy discussions, it is common to hear, “when I was at the doctor,” or “when my mom was sick.” And while we can gain insights from these personal encounters, it’s critical to remember that our expertise inside the field strongly informs our experience.

4 5

Remember the other influences of patient health. As impactful as the increasing focus on patient voice can be, it’s critical for organizations to consider the other influencers of a patient’s health that the patient himself might take for granted. Family members, cultural traditions, stress levels, sleep habits and numerous other lifestyle factors impact health but are often considered “just how things are.” Overcome the risks - they’re usually worth the benefits. Because protecting patient privacy is so important in health care, integrating the patient voice is not as simple as one might expect. Meeting the regulatory needs of any health care organization takes planning, flexibility and cooperation across teams.

All leaders in health care have a level of access, familiarity and comfort with medical care that vastly exceeds that of the average patient. Consequently, as health care providers, we have to ask ourselves this question: What stories are we not hearing? If we don’t keep ourselves honest and consider the voice of the patient not in the room, we overlook opportunities to improve care for a substantial number of people.

Through engaging the patient voice, we have a powerful tool to inspire and shape new solutions in health care, and there is real value in working through the associated challenges. As the health care system takes a more collaborative approach to helping patients and as patients become active participants, everyone wins.

Get authentic patient voices in the room. To lead change in health care, organizations must get in the room the voices of real patients — people whose lives are touched by our products and services.

Dr. Sachin H. Jain is chief medical information and innovation officer at Merck, an attending physician at the Boston VA Medical Center and a lecturer in health care policy at Harvard Medical School.

DR. SACHIN H. JAIN

Embrace online communities, but know their limitations. Online communities are a powerful, emerging avenue for insight into patient sentiment about a disease or therapy. Many communities are focused on particular diseases and focus groups, offering a locus of conversation on specific topics.

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after 90 days of billing. Industry statistics show the value of accounts receivable declines sharply after 90 days to around 15 -20% of their original value.When considering the costs of resources necessary to continue billing and subsequent follow up expended on unpaid accounts, your practice may get better return putting those resources into current billing. Assigning delinquent accounts to an agency prioritizes your unpaid bills for earlier resolution.

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Round-up June 2016

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Bringing the doctor to the patient: An interview with MD24 founder

Lin Nguyen, MD Article photos by Denny Collins Photography. www.dennycollins.com • (602) 448-2437

BY DOMINIQUE PERKINS

here may have been a time when Dr. Lin Nguyen could hardly believe he could ever grow up to be a doctor, let alone the founder and CEO of one of the most fast-growing house call med services today.

Nguyen was born in Vietnam, but escaped by boat with his family when he was only 14 years old. He started his working career as a waiter with only a quarter in his pocket. Given the opportunity to study and research biomedicine, Nguyen said it didn’t take him long to find his inspiration in healthcare. “I quickly found out I wanted to be a general doctor, and be a helping hand to patients in need,” he said. mcmsonline.com/round-up

He completed his residency and board certification in family medicine, and then joined the Air Force and became first an Urgent Care physician and then subsequently the Infectious disease Chairman for Sheppard Air Force Base. Nguyen says this was instrumental in forming his passion for practice management and health information technology, and he finds that his career path flowed very naturally from his experience. It was also during his time practicing medicine with the armed services that planted the seeds for his current business model. After leaving the Air Force, Nguyen completed his fellowship in medical management and innovations through the American Academy of Physician Leaders, and the University of Southern California. It was also during his time practicing medicine in the armed forces that the seeds for his current business model were planted. Nguyen said there have been many storms along the way, and that he more than once thought of giving up the whole enterprise. “Because of the endless and unconditional support from my wife and children, I am currently leading an unique innovative successful company of 200+ employees globally from United States to Vietnam,” he said. Nguyen said that when faced with challenges in oppo24

Round-up June 2016

sition of your goals and dreams, he would share three pieces of wisdom from his own journey: 1. Believe in your vision and lead straight on if it’s the right thing to do for the community. 2. In life’s storms, those that stay side by side with you are your family members and leaders. Continuously provide your support to these right, loyal, talented people with your heart. Don’t give up on what you do if it’s the right thing. 3. Constantly learn and improve. The world is flat. Therefore, be an “intrapreneur” or an entrepreneur. When Nguyen left the Air Force, he did so to help a friend turn his business around. But after a while, he needed to focus on his own dreams. He brought his vision to Arizona in 2006, and hasn’t looked back. Nguyen is the CEO and Founder of MD24 House Call. “What drives me every day is the innovations via smartphone and wearable devices, and the ability to bring more value to my elderly patients every day,” he said. Our vision is to establish the most effective global network of health information technology engineers and healthcare providers which will help bring great values

MEMBER PROFILE

and services to patients via innovative wearable technologies at the most effective costs possible,” he said. The idea for MD24 House Call came about while Nguyen was a physician with the Air Force. He was selected to travel to Germany to treat traumatic brain injury for soldiers who had been injured in IED explosions from various locations around the world. At Landstuhl Regional Medical Center in Germany, Nguyen participated and also observed physician’s ability to provide consults and care to wounded soldiers via telemedicine. The lightbulb came on immediately, and Nguyen felt this had far-reaching implications for the future of care. “Although I was still using a Blackberry handheld at that time, I already had a vision of telemedicine via Smart Phone, iWatch, google Glass, and other wearable devices,” he said. Particularly valuable to patients who are High Risk Homebound, telemedicine has the potential to save tremendous costs from unnecessary hospitalizations, readmissions, ER visits, and over-utilized tests. Even though some thought his vision crazy, he was determined not to give up. Today House Calls are the core of his business. Nguyen expects that within the next 3 years, MD24 will staff more than 400 employees and extend their care model to other states and to Asia. Nguyen feels that the healthcare professionals who have joined in his vision truly want to make a difference in the world, and make up a company that truly embodies the motto of putting patient values first and foremost. “MD24 is no longer the vision of an individual,” he said. Huge differences are being made in the lives of high risk homebound elderly patients in both assisted and independent living situations, in group and private homes. Ensuring these patients have access to every single specialty is not an easy task, Nguyen said. The process and procedures are extremely complex. The actual telemedicine technology must be user-friendly for the provider at the patient’s bedside, and the wearable device must also be equipped with intelligence software that can change the patient’s behavior. MD24 partnered with a robust network of home health, hospice agencies, and the independent physician association to bring a multi-specialty approach to their telemedicine service: cardiology, pain management, psychiatry, psychology, wound care, dermatology, and others. “We believe every elderly patient is desperately in need of consistent high quality care,” he said.

Although I was still using a Blackberry handheld at that time, I already had a vision of telemedicine via Smart Phone, iWatch, google Glass, and other wearable devices. As this care model has spread to cover more and more of Arizona, Nguyen is sure they will be able to integrate more independent physicians in new specialties, who see this as an opportunity to accomplish their primary goal: medicine that meets the patient’s needs first. Their “white label” technologies are available to participating physicians who want to integrate a house call telemedicine approach with their existing patients. Nguyen believes that physicians can learn to be leaders for those around them as they face the challenges of accomplishing this goal. The biggest way MD24 works to put patient’s needs first is by recognizing the simple truth that sometimes it is hard for the patients to come to the doctor. Illness, mobility, transportation, finance, and mental and emotional clarity can all play a role in keeping patients from the help they need. This difficulty is compacted by the demands and restrictions placed on the physician during an actual visit. Shortened visit times, increased documentation requirements, and lack of patient preparedness can make it seem impossible to deliver the kind of care and develop the kind of relationship that physicians would consider ideal. Nguyen believes that it will take a different kind of care model, and physicians who are willing to problem solve and lead the way with new solutions, to change the current patterns of patient visits. “Unless there is a unique, successful, physician-centric process model with a ‘You Own You’ mentality providing complete support to the independent physicians, it is extremely hard mcmsonline.com/round-up

Unless there is a unique, successful, physiciancentric process model with a ‘You Own You’ mentality providing complete support to the independent physicians, it is extremely hard to have the physicians fully focus their medicine talents for patients,” he said. “In a broken healthcare system, I truly believe in rising models among physician entrepreneurs who will help partially solve today’s healthcare system challenges.

Some of the options and services available through these partnerships include the MD24 Back Office Xystem, integrations of telemedicine and Chronic Care Management services with both electronic health records and AZ state health information exchange systems, night-call services, and transitional care and follow-ups. “We believe in working together synergistically with PCP’s and physician specialists,” Nguyen said. While technology has been championed as a tool that will provide more efficiency in medicine and actually free up time for the physician to focus on the patient, some feel it is doing just the opposite. Many argue that technology is in fact contributing to the erosion of the doctor-patient relationship, as physicians are more glued to the laptop and EHR during a patient visit and less focused on seeing, touching, and listening to the patient themselves. Nguyen has felt this challenge himself with the MD24 care model, as do most all independent physicians. Improved onboarding procedures and structure help, he says, as does careful follow-through. While current technology may pose its own unique set of challenges, Nguyen believes they were definitely designed with the intention to improve, not to impede. “EHR Technology were designed carefully by many great healthcare information technologists, but still require great attention from physician leaders to help the team with operational processes, especially both notes and CPOE templates,” he said. Some technologies do indeed improve physician’s ability to care for their patients by expanding reach, mobility, communication options, and information convenience. Nguyen encourages physicians to think beyond the HER to differentiate their practices from others by utilizing business solutions, management systems, and telemedicine. “Our country is reaching the tipping point for greatness, leading the globe in healthcare innovations,” he said.

to have the physicians fully focus their medicine talents for patients,” he said. “In a broken healthcare system, I truly believe in rising models among physician entrepreneurs who will help partially solve today’s healthcare system challenges.” Since many of the patients that MD24 deals with are home bound, physicians who wish to take advantage of the telemedicine partnerships could benefit from a great benefit in the care of their patients. “By partnering with PCPs and specialty clinics via paid “timeshared” and telemedicine at no additional cost for HRHB patients, not only do we will help the primary care physicians (PCP) to increase their efficiency and revenue for younger chronically ill patients, but also reduce healthcare costs via reducing readmissions and overutilization of resources,” Nguyen said. 26

Round-up June 2016

DOMINIQUE PERKINS Dominique joined Maricopa County Medical Society’s staff in 2014, and is currently serving as the Communications Coordinator. She has a bachelor’s degree in Communications and Journalism, and over 6 years’ experience as a writer, editor, and social media strategist. Dominique also enjoys helping with Society events. Be sure to look for her the next time you attend! Dominique can be reached at dperkins@mcmsonline.com.

MEMBER PROFILE

Dr. Nguyen | On the Personal Side Describe yourself in one word. Passion

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

“Great Wall”, corner of 35th Ave and Camelback

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

An entrepreneur in technology and globalization. I also humbly extend my believe to you that “The World is Flat” and opportunities in “Healthcare Without Walls” are unlimited for every physician globally.

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

Favorite activities outside of medicine?

Best movie you’ve seen in the last ten years? Star Wars

Favorite Arizona sports team (college or pro)?

Cardinals. Still love pro tennis and Texas Ranger at Surprise Stadium with friends and my daughters.

Family?

An incredible wife and two children who are extremely understanding. I cannot speak enough of how great and tolerant they are. I have spent so much time in MD24 House Call and lost so much time for my children and wife. Without their understanding and support, I would never be able to deliver this “healthcare without walls” model to our elderly patients. They are truly the heroes of all time in my heart.

Traveling Asia and hiking

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How Do Physicians Feel About Medical and Recreational Marijuana? 28

Round-up June 2016

arlier this month, the Society surveyed its members on the topic of marijuana, not only on issues pertaining to medical use, but also the growing push to legalize recreational consumption. So why were we interested, and what were the results of the survey?

In 2010, Arizona citizens voted to approve a medical marijuana program, becoming the 15th state to approve such a program. Today, the number totals 25, with Ohio and Pennsylvania joining the list this year. Of these, three – Colorado, Oregon, and Washington – also allow for adult recreational use. Despite the rash of states now legalizing medical and recreational use, the Drug Enforcement Agency (DEA) still classifies marijuana as a schedule 1 drug, essentially designating the plant as having no clear medical use and limiting its use in clinical research. Yet just last month, the House of Representatives voted to strike down the Department of Veterans Affairs policy of disallowing VA physicians from considering medical marijuana as a viable treatment option for veterans. The bipartisan Veterans Equal Access Amendment is attached to the military appropriations bill, and mirrors language included in a recent Senate spending bill. The proposed legislation still awaits reconciliation and signature from the President. If the amendments remain intact, VA doctors will have another option for veterans in those states with medical marijuana programs, beginning next year. Despite both branches of Congress agreeing that veterans should have the same access to medical marijuana as private citizens in states with active programs, the DEA is still undecided on whether the plant should be reclassified. Many speculate that as early as this summer, the DEA may remove the schedule 1 designation and reclassify marijuana as schedule 2, the same as highly addictive and overly prescribed opioids. Such a measure would open the doors for researchers to scientifically investigate the medicinal efficacy of marijuana. While many speculate that it can serve as a safe alternative to opiate painkillers, little research exists to support such a claim. So how do our physicians feel about this hotly debated topic? Should MCMS take a position on recreational use of marijuana? Of those physicians who took the survey, nearly half – 47% - felt the Society should oppose the legalization of recreational use. Only 21% agreed with the notion that the Society should support such an initiative, while nearly 28% were in agreement that the Society should remain neutral. The remaining 4% said they were unsure as to what position, if any, the Society should take. If Arizona were to legalize recreational use, to what extent should drifting marijuana smoke be considered a legitimate health concern and treat-

ed similarly to tobacco? Not surprisingly, no physicians responding to the survey felt that fewer restrictions should exist for marijuana. In fact, 48% of those who responded agreed that restrictions should mirror those for tobacco, while 49% supported more stringent regulation. The remaining respondents were not sure. Should Arizona ensure that a reliable field-sobriety test first be validated before our state legalizes recreational marijuana use? Overwhelmingly, physicians agreed – 64%, in fact – that a reliable sobriety test should precede recreational legalization. Nearly 19% agreed that the test could follow legalization, whereas 9% did not feel there a need for such a test. Another 8% were unsure. Since many valley pediatricians and ED physicians are reporting alarming instances of children consuming medical marijuana products, should ADHS develop education programs that properly explain the risks of the drug? With respect to education programs, responding physicians agreed almost unanimously (87%) that education programs should be available to both schools and communities, with a handful of respondents – 3% – who felt programs were only necessary for schools, while 4% were unsure, and another 3% did not feel that education programs were necessary.

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Which of the following concern you about medical marijuana use? Here, we asked physicians to select from a list of concerns, not limited to only one reply. Nearly 51% of respondents agreed that the need for individuals to ‘self titrate’ was a concern, and 49% worried about the implications of marijuana being a gateway drug. The option that garnered the strongest response was the concern over insufficient scientific data, with 57% of responding physicians agreeing that enough research has yet to be done. Many commented that the lack of scientific data was a direct result of little funding available for clinical studies, with 51% of physicians agreeing that no money for research was a concern. Roughly 8% of those who took the survey had no concerns at all. Should Arizona physicians who participate in the state’s medical marijuana program be required to take CME to demonstrate knowledge of marijuana’s 30

Round-up June 2016

benefits and hazards? More than 75% of physicians agreed that CME should be a requirement for those physicians who recommend medical marijuana for their patients. Nearly 15% agreed that CME should be recommended but not required, whereas 8% did not feel that CME was necessary. Another 1% of physicians were unsure. When should VA doctors begin prescribing medical marijuana to veterans? Most physicians agreed that a simple law change should not give VA doctors the green light to start prescribing. Whereas only 26% agreed that the only barrier is federal legislation, 14% agreed that DEA reclassification of the drug was also necessary. The largest percentage – 54% – agreed that VA physicians should hold off on prescribing marijuana until federal legislation is passed, the DEA reclassifies the drug, and clinical efficacy studies are completed. The remaining 5% of physicians were unsure.

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Health Careâ&#x20AC;&#x2122;s Top Priority: Fast and Easy Appointments 30

Round-up June 2016

BY JONATHAN BUSH

go to a lot of health care conferences, and of late there’s a seemingly obligatory slide that crops up in nearly every PowerPoint. It’s a now-iconic image of a triangle divided in equal parts and labeled as follows: “improve the patient experience,” “improve the health of populations” and “reduce the per capita cost of care.” This is health care’s “Triple Aim,” and it is definitely trending. I must confess that I’m not a fan of the Triple Aim. It’s not that I don’t believe those three outcomes are vitally important. I just don’t believe it’s possible to aim at three things at once. As a manifesto or creed, it’s inspiring. As a roadmap, it’s a bit hard to follow. A more effective approach to change, I’d argue, is the one taken by Paul O’Neill back in 1987 when he was first appointed CEO of the aluminum giant Alcoa. As New York Times reporter and author Charles Duhigg recounts in his bestseller, “The Power of Habit”, accidents were commonplace at Alcoa, as they would be at any company in the business of handling molten metal on a regular basis. But the company’s safety figures weren’t bad - in fact, they were better than that of their competitors. Nevertheless, O’Neill stood up in front of his investors that year and declared that the company would focus its entire strategy on bringing workplace injuries to zero. “If you want to understand how Alcoa is doing, you need to look at our workplace safety figures,” he argued. No talk of profits, opening new markets, or any of the usual crowd pleasers. Everyone thought he was nuts. By the time O’Neill left Alcoa in 2000 to become Treasury secretary, the company’s market cap had increased by $27 billion and by 2010 not a single employee day was lost to workplace injury at 82% of Alcoa locations. So what happened at Alcoa? O’Neill had located and had the discipline to focus on what Duhigg calls a “keystone habit,” a deep organizational vein that, once tapped, has the power to drive other downstream improvements as it reverberates through an organization. In the case of Alcoa, once employees were asked to suggest ideas for safety improvement they began to surface other issues that had been buried. The rising tide of a more open, problem-solving culture helped raise all of Alcoa’s boats and profits.

What should health care providers focus on as their keystone habit? For my money it’s patient access.

workforce stability - over 17 years, we’ve found that our success depends on focusing first on managing voluntary turnover, ahead of all other traditional performance measures (including the ones our investors care about). Any spike in voluntary turnover is a canary in our coal mine and raises an alert that we take very seriously. So, what should health care providers focus on as their keystone habit? For my money it’s patient access - making it as easy, quick and worry-free to get an appointment with a provider as possible. When provider organizations make a habit of opening their schedules and committing to same-week-orsooner appointments, other good things can happen. Appointment types can be simplified and streamlined, driving other opportunities for process improvement and efficiency. Care is more likely to be directed as appropriate to lower-cost providers and nurse practitioners or even to virtual consults, cutting costs and eliminating unnecessary care. And, most important, physicians can be freed up to see the sickest patients when they need to be seen.

JONATHAN BUSH Jonathan Bush is the CEO and president of Athenahealth and the author of “Where Does it Hurt? An Entrepreneur’s Guide to Fixing Healthcare.” © 2015 Harvard Business School Publishing Corp. Distributed by The New York Times Syndicate.

At my company, Athenahealth, we are big believers in focusing ourselves and our clients on keystone habits and corresponding “sentinel” metrics. Our corporate scorecard, for example, is a waterfall that begins with mcmsonline.com/round-up

Bringing the Customerâ&#x20AC;&#x2122;s Voice into Medicine 34

Round-up June 2016

BY DANIELLE CASS

ealth care providers in the U.S. have 10 million newly insured patients to serve this year. That’s 10 million customers they don’t know much about, which makes innovation all the more important. We’re already experiencing a first, technology-driven wave of transformation — electronic health records, mobile phones, sensors and telemedicine robots are making care more effective and efficient. Now it’s time for a second wave, one that’s propelled by customer needs. Health care organizations must turn to patients, and the people who care for them, for help envisioning the future. What do grandmothers recovering from breast cancer, busy medical office receptionists and frontline nurses and doctors know about defining that vision? Quite a bit. To better understand how health care is experienced by people wherever they are – at home, at work, out and about, or in a facility – we’ve created a scenario-based tool at Kaiser Permanente. It allows physicians, nurses, employees and patients to walk in the virtual shoes (through interactive videos) of customers who are new to the health care system or need care in settings other than hospitals or clinics. We’re using the tool to gather data on patients’ preferences, and to get stakeholders thinking creatively and empathically about how care might be delivered. We’re also capturing their thinking online and through surveys, workshops, events and focus groups. The goal is to weave care more naturally into people’s lives by designing buildings that promote both wellness and efficiency. The project team has shadowed providers and met with members in their homes and communities to understand their values and beliefs. As a result of their input, the back office will be largely open and transparent to facilitate casual staff interaction and collaboration, and to allow patients to see workers and feel connected to them.

We’re already experiencing a first, technology-driven wave of transformation — electronic health records, mobile phones, sensors and telemedicine robots are making care more effective and efficient. Now it’s time for a second wave, one that’s propelled by customer needs. Health care organizations must turn to patients, and the people who care for them, for help envisioning the future.

Health care leaders who have successfully enlisted customers and other stakeholders as partners in strategy and innovation say you need three things to get started: 1. A tangible experience. Engage people physically, emotionally and verbally, suggests Wendy Lee, who leads KP’s consumer digital health strategy. 2. A personal connection. “Our interactions don’t need to be high-tech,” says Bellin Health CEO George Kerwin. “The strongest ideas most often result from collaboration and a multitude of experiences and perspectives.” 3. A commitment to empathy. “Patient advisory councils are usually just asked to bless something created by someone else,” says M. Bridget Duffy, the chief medical officer at Vocera. Instead of simply seeking approval, engage patients in the design process, map what really matters most to them, and use that insight to inform any technology or process

improvements you do. Duffy advises, “You might begin by asking: ‘What one moment most touched your heart?’ or ‘What could we have done differently to ease your burden of illness instead of adding to it?’ Through this approach, we have the opportunity to restore humanity back to health care.”

DANIELLE CASS Danielle Cass is an innovation evangelist in Kaiser Permanente’s Innovation & Advanced Technology Group. © 2014 Harvard Business School Publishing Corp. Distributed by The New York Times Syndicate

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Doctors seek probe of UA medical school leadersâ&#x20AC;&#x2122; exodus 36

Round-up June 2016

KEN ALLTUCKER, THE REPUBLIC | AZCENTRAL.COM

half-dozen top leaders at the University of Arizona's medical school in Phoenix have resigned to take out-of-state posts, and an Arizona doctors group wants the state to conduct an investigation to find out why they left. The Arizona Medical Association has asked the state Board of Regents, which oversees public universities, to conduct an independent investigation of the University of Arizona College of Medicine-Phoenix's leadership churn. Former Dean Stuart Flynn and most of the school's senior leaders have resigned in recent weeks. Flynn's eight-year stint as the Phoenix medical school's dean ended in April when he was recruited to head a new Fort Worth, Texas, medical school formed by Texas Christian University and the University of North Texas Health Science Center. Over the past few weeks, several senior leaders of the Phoenix medical school have announced their plans to resign and join Flynn's leadership team in Texas. The most recent to depart, Dr. Jacqueline Chadwick, had served as vice dean of academic affairs and was perhaps the Phoenix school's longest-tenured leader. Others who announced plans to leave for posts at the Fort Worth school include Drs. Jennifer Allie, Tara Cunningham and Karen Restifo. Matthew Lester, the Phoenix school's deputy dean of administration, finance and operations, will take a new position at Case Western Reserve University's medical school. Dr. Joan Shapiro, the Phoenix medical school's associate dean of research, previously announced plans to retire. The Phoenix medical school’s leadership exodus prompted the Arizona Medical Association’s voting body to pass a resolution asking the Arizona Board of Regents to “immediately have an independent investigation into the departure of the senior leadership team from the UofA College of Medicine.” The Arizona Medical Association, which represents about 4,000 medical doctors, osteopaths and other members, asked the regents to “examine the events and issues that led to the departures of the senior leadership team” and investigate “any UofA organizational impediments of policies that contributed” to the leaders’ departure. The doctors group’s resolution, which was sent to Regents President Eileen Klein, states that the group has no confidence in the UA’s leadership and oversight of the Phoenix medical school. The group asks the university-oversight board to “take corrective action based on the independent investigation” to ensure operations and medical education thrive. Regents Chair Jay Heiler said in a statement that the

The Arizona Medical Association, which represents about 4,000 medical doctors, osteopaths and other members, asked the regents to “examine the events and issues that led to the departures of the senior leadership team” and investigate “any UofA organizational impediments of policies that contributed” to the leaders’ departure.

board wants to hear more from the medical association about its concerns. He added that UA President Ann Weaver Hart and her team will continue to review operating challenges and the structure of the Phoenix medical school. Dr. Joe “Skip” Garcia, UA’s senior vice president of health sciences, oversees UA’s medical-school campuses in Phoenix and Tucson as well as the schools of nursing, pharmacy and public health. He said in a statement that he was surprised by the call for an investigation because he had not heard directly from the doctors group. Garcia said that along with the interim dean, Dr. Kenneth Ramos, he is addressing concerns of medical-school stakeholders and assuring them “that we have clear plans for the future growth and success of the college.” mcmsonline.com/round-up

Garcia added in his statement that medical-school leaders who pursue new posts often offer positions to former colleagues.

cerns after an accrediting body warned that the med school could face probation or loss of accreditation without certain fixes.

“This is normal in academic medicine and a compliment to the talents of the people who work here,” Garcia said in a statement.

Despite the warning, the Liaison Committee on Medical Education approved the UA’s proposed fixes and advanced the Phoenix medical school to “provisional” accreditation.

Ramos said he already has promoted Phoenix medical-school staffers to fill the positions of two senior leaders who took positions in Fort Worth. Ramos added that the leadership changes will come before classes start in July for the upcoming academic year. “We can use the summer months to regroup,” Ramos said. “One of the things we are doing pretty well is messaging, making sure all stakeholders are aware of the changes ... to make them relaxed.” Last year, the Arizona Medical Association raised con38

Round-up June 2016

KEN ALLTUCKER Ken Alltucker is a Watchdog News reporter who covers everything about health care from a consumer’s perspective — doctors, hospitals, insurance, policy, prescription drugs and those seemingly ever-increasing bills. He helps consumers navigate the complex world of health care and serves as a watchdog of government-funded health care. © 2016 Distributed with permission from The Arizona Republic | www.azcentral.com.

New Members Chandrashekar Kalmat Active Member

Douglas L. Cunningham Active Member

Active Members Chandrashekar Kalmat, MD

Anesthesiology • Pain Management Medical School: MI State Univ Coll Human Med Residency: Jackson Memorial Hospital Fellowship: Henry Ford Health System Practice: Zona Spine and Pain Practice Address: 750 N. Estrella Parkway, Suite 60, Goodyear, AZ 85338 Phone: (623) 321-5079 Website: zonaspine.com

Douglas L. Cunningham, DO

Family Medicine Medical School: University of Health Sciences Residency: Phoenix General Healthcare Systems Practice: Pueblo Family Physicians Practice Address: 4350 N 19th Ave, Suite 6, Phoenix, AZ 85015 Phone: (602) 264-9191

Satyaprakash R. Atmakuri, MD

Internal Medicine • Cardiology Medical School: Emory University School of Medicine Residency: Emory University School of Medicine Fellowship: Baylor College of Medicine Fellowship 2: New York Presbyterian Hospital Practice: Tri-City Cardiology Consultants, PC Practice Address: 6750 E Baywood Ave, #301, Mesa, AZ 85206 Phone: (480) 835-6100 Website: www.tricitycardiology.com

Jacob Green, MD

Internal Medicine • Cardiology Medical School: University of Arizona College of Medicine Residency: Emory University Affiliated Hospitals Fellowship: Emory University School of Medicine Fellowship 2: Emory University Practice: Tri-City Cardiology Consultants, PC Practice Address: 6750 E Baywood Ave, #301, Mesa, AZ 85206 Phone: (480) 835-6100 Website: www.tricitycardiology.com

Kai-Chun Sung, MD

Practice: Tri-City Cardiology Consultants, PC Practice Address: 6750 E Baywood Ave, #301, Mesa, AZ 85206 Phone: (480) 835-6100 Website: www.tricitycardiology.com

Amit M. Patel, MD

Pain Medicine • Anesthesiology Medical School: University of Oklahoma Residency: Johns Hopkins Fellowship: Mayo Clinic Practice: Integrity Pain and Wellness Practice Address: 9377 E Bell Road, Suite 131, Scottsdale, AZ 85260 Phone: (480) 494-3550 Website: www.integritypainaz.com

mcmsonline.com/round-up

New Members Derik Kentworthy

Education Member

Shuhaib S. Ali

Education Member

Nicholas Flores, MD

Radiation Oncology Medical School: University of Buffalo, SUNY School of Medicine Residency: Strong Memorial Hospital Practice: Arizona Skin and Laser Therapy Institute, LTD Practice Address: 2224 W Northern Avenue, Suite D-300, Phoenix, AZ 85021 Phone: (602) 277-1449

Glenn Zellman, MD

Dermatology Medical School: Duke University School of Medicine Residency: Baylor College of Medicine Practice: Arizona Skin and Laser Therapy Institute, LTD Practice Address: 2224 W Northern Avenue, Suite D-300, Phoenix, AZ 85021 Phone: (602) 277-1449

Education Members A.T. Still University School of Osteopathic Medicine in Arizona Samantha Ho Harleen K. Sethi Rachel McCain Blessen George Omar Nagy James du Pont Derik Kentworthy Suneun Kim Sireesha N. Mudunuri 40

Round-up June 2016

Deborah L. Enns

Education Member

Nathan Carl Goff

Education Member

Karla Sanchez Christopher Yih

Midwestern University Arizona College of Osteopathic Medicine Katherine Johnson Jeneeca C. Bruce Tyler J. Hinkel Kaila A. Pomeranz Daniel A. Stegman Aditya Varambally Anthony Willm Meng-Chen Vanessa Lin Shuhaib S. Ali Gustavo Anton Deborah L. Enns

University of Arizona College of Medicine, Phoenix Nathan Carl Goff Mounica Y. Rao

In Memoriam Dine, Max MD, FACP

Max Dine, MD, FACP passed away at age 76. Max was born in Cambridge, in 1939, MA to Sylvia and Felix Dine. Max graduated from Lawrence Academy, Tufts University and Tufts Medical School where he was elected to Alpha Omega Alpha honor medical society. He had a successful Oncology practice in California before retiring to Arizona. A brilliant doctor and lobbyist for mental health, he co-founded Visions of Hope and was a Hon Kachina recipient in 2005. Max improved the lives of many by raising awareness and helping to eradicate stigma for those suffering from mental illness by lobbying the State Legislature and passing the “2 little words” bill. The “2 little words” were “and mental” which were added to Arizona’s ADA law prohibiting discrimination in employment. Max is survived by the love of his life, Sharon, daughter Lori (Craig), son Stephen (Michele), stepsons Paul (Karen), and Lynn (Heather), sister Elaine (Mike), nephew Alex and grandchildren Kara, Matthew, Jonathan, and of course Tami. We would like to thank his loving caregivers, Simona and the entire Todor family.

Peterson, Rexford Allan

REXFORD ALLAN PETERSON, M.D., F.A.C.S. May 31, 1922 - April 1, 2016 Rex was gifted with intelligence, integrity, curiosity, creativity, generosity and compassion. Rex was born, the youngest of three sons, to John Peterson and Elta McNeil Peterson in Chama, New Mexico. His father moved his family to Durango, Colorado when Rex was 2 years old so he could provide his sons with a better education. His dad was engineer on the Durango-Chama-Durango railroad route and Rex developed a life-long love for trains. In 1942, Rex was student body President at Western State College in Gunnison, CO. At a dance, he met Dorothea Dell McCrory, during her “Senior Sneak Day”

visit, and immediately said, “I’m going to marry that girl.” They were wed in 1945. During WWII, Rex served as a flight instructor in the Army Air Corps, and after the war, he and Dell returned to Western State College where Rex received the education that set him on a path of achievement as a Plastic and Reconstructive Surgeon in Phoenix, AZ. He gained an international reputation as an innovative surgeon whose scientific presentations to his peers told the truth about the benefits of new procedures, as well as possible complications. He reached the pinnacle of his field when he was elected President of The American Society of Plastic and Reconstructive Surgeons and The American Society for Aesthetic Plastic Surgery. An exceptional teacher, he founded and directed an accredited residency program that gave significantly more direct surgical involvement than programs offered by many very prestigious universities and clinics. Fifty-six plastic surgeons were graduated from Rex’s program and they went on to practice in 13 states and three foreign countries. Other highlights of Rex’s career include the establishment of an Arizona burn unit that is now the 2nd largest burn center in North America, and setting up clinics to repair cleft palates/lips on Native American Reservations in AZ and NM. His volunteer work, spanning 30 years, allowed 1,000’s of children to live without disfigurement. In his personal life, Rex was a creative man full of ideas. He enjoyed designing and building two homes. He enlarged the caves on his NM property. He re-forested the Petrified Forest Ranch by planting hundreds of trees. He built a stairway into the rocks. And he purchased a pair of cabooses, converting them into cherry-paneled guesthouses complete with Victorian furnishings, providing guests with a true one of a kind experience. The Arts were Rex’s passion. While serving on the board of the Heard Museum, he was an early champion of artists Charles Loloma, Fritz Scholder, and Allan Houser before they became famous. He also admired and supported the works of artists Paul Dyck and James Turrell. He was a wonderful chef who enjoyed perfecting recipes, in particular his signature hot fudge sauce. mcmsonline.com/round-up

In Memoriam He took his appreciation for wine and food to another level, serving as Cellarer, then Presiding Officer of the International Wine and Food Society of Phoenix.

Dr. Joe’s wife, Joan, died after a lengthy battle with breast cancer.

He loved being with his family and he delighted in all the family dogs: Chi-Chi, Tiy, Dolly, and Aria. He enjoyed flying, hiking, fishing, hunting, skiing, tennis, and travel and was an ardent fan of Arizona State University and University of Colorado football teams.

During his retirement, Joe and Joyce enjoyed traveling the world together and spending time entertaining their friends and families. Dr. Jo spent his time four wheeling, watching Husker football or Cardinals baseball, playing bridge and cribbage, filling in for doctors while they were out on vacation and working at nearby methadone clinic. He also spend countless hours perfecting the art of drinking a good gin martini.

In late 1997, Rex and Dell retired to Santa Fe County where the door was always open for family and friends to visit, and “The Ranch” became the site of many unforgettable celebrations including Rex’s legendary 4th of July fireworks displays. He is survived by his wife of 71 years, his three daughters, Tia Peterson, Marta Peterson, and Lisa FitzGerald, and his son-in-law, Dan FitzGerald, who loved him and will miss him forever.

Saults, Charles Joseph, MD

On the morning of May 17, 2016, Dr. Charles Joseph Saults (Dr. Joe) passed away peacefully at Hospice of the Valley in Phoenix, Arizona, with his wife and daughter at his side. He was 88 years old. Joe was born in Nebraska, on Feb. 28, 1928. He was the second child of three, and only son to Winfield and Florence Saults. Joe grew up on a ranch south of Merriman in Cherry County, Nebraska, and went to county grade school near the ranch, later graduating from Curtis High School. He attended the University of Nebraska Medical School and graduated in 1954, completing his internship at St, Joseph’s Hospital in Phoenix, Arizona, in July of 1955. Dr. Joe was married to Joan Hertzler on August 11, 1952, in Torrington, Wyoming, and the adopted their two children in 1957, Lynne and Keith. Dr. Joe was an officer in the U.S. Army from 1957 to 1959, during which time he served as a doctor in Korea. As soon as he finished his time in the Armey, he, his wife, and two kids moved to Mullen, Nebraska, where he continued his practice until December of 1998, when he retired. In May of 1979, 42

Round-up June 2016

Joe Saults remarried on Oct. 27, 1983, To Joyce Christensen, at Machu Picchu, Peru.

Dr. Joe was preceded in death by his parents, Win and Florence, his stepfather, Orville Conner, his first wife, Joan, and his sister, Zane Krasomil. Dr. Joe is survived by his wife, Joyce, his two children, Lynne and Keith, his sister, Cameon Ravenscroft, his grandchildren, great-grand-children, nieces and nephews and a lot of dear friends.

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Round-up June 2016

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