Tampa Bay Medical News December 2015

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PHYSICIAN SPOTLIGHT PAGE 3

Selim Benbadis, MD ON ROUNDS

The Trouble with MACs

Group Seeks Statewide $4.5 Million Appropriation from State Legislature FAFCC Seeks Funds for Free and Charitable Medical Clinics

By DANIEL CASCIATO

FTC Calls Market Competition with PBMs’ Aggressively Low MAC Price Lists “Vigorous”’

As we head into the new year, one legislative priority for the Florida Association of Free and Charitable Clinics (FAFCC), a 501(c)3 tax-exempt organization established in 2013, is a request for a $4.5 million appropriation for free and charitable clinics in the 2016-2017 fiscal year. Last year, the appropriation ended up getting vetoed by Gov. Rick Scott, among a handful of other appropriations in and outside the health sector.

“This reinstates and expands on the statewide appropriation of $4.5 million that was provided to the Florida Association of Free and Charitable Clinics in the 2014-2015 fiscal year,” said Nicholas X. Duran, executive director of the FAFCC. Duran notes this appropriation will enable FAFCC’s 90-member free and charitable clinics and specialty care networks to serve approximately 14,000 additional uninsured Floridians in need of primary and specialty healthcare. When FAFCC clinics received

Controversy continues to swirl over the impact Pharmacy Benefit Managers (PBMs) have on the nation’s new healthcare delivery system ... 6

New Amniotic Allograft Storage Breakthrough Enriches Healing Potential Advanced Stem Cell Preservation is the Key

Each day, physicians discover more about the power of regenerative medicine, a game-changing specialty that uses biologics to regenerate human cells or tissues to help heal damaged organs ... 9

(CONTINUED ON PAGE 4)

WHO’S TENDING OUR DOCTORS?

8 Steps to Improve Revenue Cycle Efficiency

By LyNNE JETER

Editor’s Note: This article is part of a Medical News exclusive series, “Who’s Tending Our Doctors?” to focus on ways the industry can help alleviate physician stress and allow physicians to return to the joy of practicing medicine.

Even though patient care is top priority for doctors, administrative drills remain a nagging worry. To take the pressure off the financial side of a medical practice, the American Medical Association (AMA) recently launched a module on revenue cycle efficiency in the AMA STEP Forward series, aimed at making life easier for (CONTINUED ON PAGE 8)

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PhysicianSpotlight

Advantage USF Epilepsy Program Director, Selim Benbadis, MD, Aces Career and Tennis TAMPA - Perhaps it was odd that a hospital appealed to the senses of a trauma patient, especially one only 13 years old.

But Selim Benbadis spent two months there and he was not just intrigued, he was influenced.

He was enjoying the summer in his Vence, France when “A motorbike accident landed me in the hospital. I was a passenger and was wearing flip-flops.

My foot got caught in the wheel,” Benbadis recalled. His heel was severely injured.

Luckily, the damage was all soft tissue, he said, “but I was on the orthopedic floor and every day the doctors would come by and have a discussion about whether I was going to need a skin graft.”

“The hospital was very clean and everything around me smelled good. There was an orthopedic surgeon I was very impressed with. He always dressed in white and I looked up to him. I thought ‘This is what I am going to do!’ That is when I decided to be a doctor,” said Benbadis, adding that he never required surgery. “It was very traumatic physically and emotionally because I was two months in the hospital, which set me behind from starting school” he said, and it also interrupted his favorite activity, soccer.

Actually, soccer was more than a pastime. By the time he enrolled to study medicine at the University of Nice, Benbadis was playing semiprofessional soccer.

It consumed most of his free time between the ages of 18-25, he said, and it also gave him independent means. “As a student, I made enough money to have a nice life – car, gas, the ability to go out and have fun,” he said.

At the same time, Benbadis also became an accomplished tennis player, parlaying his athleticism into an opportunity that ultimately led to his decision to move to the U.S. and to pursue his medical specialty.

Every summer “I taught tennis at Camp Winnebago in Maine. I was able to improve my English and see America.

It really changed my life,” he said. “One of my boy’s dad was a doctor at the Cleveland Clinic and invited me to interview,” which resulted in Benbadis staying there to complete his internship, his residency in neurology, and fellowships in both epilepsy and sleep medicine. “I owe it all to Camp Winnebago!” he laughed.

Benbadis also owes some of it to one ta m pa b ay m e d i c a l n e w s

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of his mentors, Patrick Sweeney, MD, then the director of the neurology residency program. Benbadis credits Sweeney with “teaching me how to teach. … He showed me how to round with residents and students and make it interesting, and that no matter what kind of patient you see, there is always something to learn and stimulate thinking,” he said.

Sweeney remembers Benbadis because “he seemed to have his head screwed on right. Very practical and down to earth. He cut to the chase very quickly and more so than other residents,” remembered Sweeney, 78, now retired after 41 years at the Cleveland Clinic. Benbadis “is well-published about pseudo-seizures. He has made his mark in this area of neurology,” said Sweeney.

Neurology satisfied multiple interests, Benbadis said. “Initially, I wanted to be a surgeon, then I considered pediatrics. But when I finally chose neurology, I knew subspecializing in epilepsy would mean I

would see a lot of children,” he said.

After he left Cleveland, Benbadis did a two-year stint at the VA hospital in Milwaukee, but the climate did not agree with him. “I am from the south of France.

I needed warmer weather,” he said. So, in 1996, Benbadis accepted a position with the Cleveland Clinic Florida in Fort Lauderdale. “I thought it would be the best of both worlds, but it wasn’t very academic, and that’s the environment I really wanted. It functioned more like a private practice,” he said.

Then he got a call from the University of South Florida College of Medicine in 1999. They needed someone to direct their epilepsy program. The one who found me was Fernando Valle, the neurosurgeon with whom I still work today and who manages the epilepsy surgery program. He’s the surgery part and I’m the neurology part. This is the job I wanted – great academics, great location, a residency program. I’ve been very happy here,” said Benbadis.

“Dr. Vale and I have grown together here. We have really built this together as a team. When I came, there was nothing but an embryonic epilepsy program, and it was not (affiliated with) USF. It was at Tampa General Hospital and run by private neurologists. It was really dismal for a university of this size,” he said.

Now TGH hosts a Level 4 epilepsy

center, one of only four in Florida that are academic centers, which means they have residency and fellowship programs, he explained. The center has done more than 50 resective surgeries per year since 2003 and that sort of volume makes it distinctive as a Level 4 center, he said.

Benbadis said he spends 90 percent of his work week seeing patients. I am in the clinic almost every day, and when I am not, I am in the hospital. Still, he must make time for teaching and research, but “I multi-task very well and I get a lot of things done,” he said.

When he’s not at work, the 55-yearold trades his white coat for tennis whites because he competes on the USTA senior circuit. In Florida he finished number one two years ago, and last year he was number two. “I usually finish somewhere in the national rankings between 13 and 20,” said Benbadis. To stay on top of his game he practices three or four times a week, even in the dead of summer, and every session is preceded by a trip to the gym, he said.

Benbadis prides himself on maintaining balance in his life. “I work every day and I play every day. A lot of people either like to work or play – they work five days a week and play only on the weekend and do not work. I’m not like that. I like to do both on the same day; I work and I play every day.”

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Medical Marijuana Bill Goes Up in Smoke State Legislature Tries to Pass Marijuana Legislation in 2016

By DANIEL CASCIATO

One of the biggest healthcare legislative issues was snuffed out this past year. The 2015 legislative session adjourned in Florida with state legislators failing to pass any comprehensive medical marijuana legislation.

Although Gov. Rick Scott signed into law the strain of marijuana known as Charlotte’s Web a year ago, there have been several blockages in the courts and in the legislature since then.

Charlotte’s Web is cannabis low in euphoria-inducing THC which means users are unable to get high.

Proponents of the bill had hoped to finally get medical marijuana into the hands of patients who desperately need it, notably those with human immunodeficiency virus, epilepsy, amyotrophic lateral sclerosis, autism, multiple sclerosis, Crohn’s disease, Parkinson’s disease, paraplegia, quadriplegia or terminal illness and to alleviate symptoms caused by a treatment for such disease.

The law survived a challenge in the courts but at issue now is distribution.

Originally, a lottery was going to determine which five growers statewide could grow and distribute it. That idea was scrapped and a scorecard system had been proposed.

Attorney Michael Smith of The Health Law Firm, headquartered in Altamonte Springs, and with offices in Orlando and Pensacola, said the legislature is expected to try to pass legislation again in 2016.

“The state has been struggling with this issue Michael for several years now,” Smith Smith said. “While Charlotte’s Web is approved, it has taken a long time to finalize the rules.”

Smith added there had been numerous challenges to the initial rules and several lawsuits were filed. “Numerous appeals were filed. There’s a lot of money on all sides of that issue and everyone is very aggressive in exercising their legal right regarding how that’s to be worked out.”

According to the Marijuana Policy Project, in addition to considering comprehensive medical marijuana legislation, the state legislature was presented with legislation that would have taxed and regulated marijuana like Colorado

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DECEMBER 2015

does. The legislation, introduced by Rep. Randolph Bracy, was not brought up for a vote.

United for Care, the largest organization in Florida fighting for a medical marijuana law, announced that it would collect the necessary signatures to put the issue before voters in November 2016. In November 2014, a similar measure received 58 percent of the vote, just shy of the 60 percent needed for voters to enact a constitutional amendment.

“We collected over a million petitions in 2014 and nearly 3.4 million people voted ‘yes’ for medical mari-

juana. There’s no question in my mind that we’ll get medical marijuana back on the ballot for 2016,“ said Ben Pollara, campaign manager for United for Care, in a statement released by the organization this summer.

John Morgan, chairman of United for Care, added that the legislature had an opportunity to keep this off the ballot by passing a law. “They turned their backs on the patients of Florida - but we can‘t and we won’t,” he emphasized. “We’re going to win this war and help suffering Floridians in 2016. I’ll do whatever it takes to get this done. This is about compassion for hundreds of thousands of very sick people in Florida.”

In November, Sen. Jeff Brandes (RSt. Petersburg) proposed new legislation to allow qualified patients with a range of conditions or symptoms to access medical marijuana if recommended by

their physician. The bill also establishes a robust and free-market regulatory approach to the governance of cultivation, processing, and retail sale of medical marijuana in Florida.

“This legislation recognizes the growing support in Florida for the medicinal use of marijuana as an additional option for physicians in the treatment of their patients,” said Brandes. „We build on the best practices of the 23 other states that have legalized medical marijuana. The bill creates a responsible regulatory framework, offers patients with debilitating conditions access to this course of treatment, and focuses funding on valuable medical research.“ The legislation allows a patient with either a specified medical condition or symptom to use medical marijuana as recommended by their physician. The bill licenses cultivation, processing, and retail facilities and fully replaces the existing Charlotte’s Web licensing system.

The legislation establishes rigorous requirements over the medical marijuana distribution system, including product tracking and independent laboratory testing. All state tax revenues raised from the sale of medical marijuana are designated for medical research focused on the use of marijuana by patients.

Group Seeks Statewide $4.5 Million Appropriation from State Legislature, continued from page 1 the previous appropriation, the clinics served 125,000 uninsured Floridians and provided nearly $300 million worth of care in 2014.

“This appropriation is projected to represent just 10 percent of overall funding of this sector, nearly all of which derives from the private sector,” said Duran. “Similar to the first appropriation, FAFCC will serve as fiscal agent and make grants based on budget Nicholas X. size, community need Duran (based on percentage of uninsured non-elderly adults), and ability to serve additional low-income, uninsured Floridians.”

It’s important to point out, added Duran, that no state dollars will be used

by FAFCC to administer the grant program. Instead, FAFCC will assess grantees a 5 percent management fee, which must be paid out of non-state funds.

“We’ve received a good deal of support of elected officials and community leaders leading into this upcoming session and the Florida Medical Association passed a resolution at its 2015 annual meeting in support of this request for funding,” he said.

Another priority for FAFCC in 2016 is to support legislation and regulations that maintain and update the sovereign immunity protections for free clinics and their individual providers. Florida’s Sovereign Immunity law (section 766.1115), enacted in 1992, is one of the nation’s most robust state statutes offering liability protection to clinics and providers rendering free care to uninsured individuals, noted Duran. “This provides medical volunteers and professionals with protections and allows FAFCC members with the critical ability to recruit physicians and other healthcare professionals to donate their time to care for low-income patients.”

According to Duran, Florida’s sovereign immunity law, which provides robust liability protection for providers and clinics, has often been highlighted as shining example for other states to consider in leveraging existing medical resources. Since 1992, Duran said that workforce changes resulting in some clinicians in free clinics being employed (augmenting the efforts of nearly 8,000 volunteer providers), an increased focus on quality care, and the advent of a first-time state appropriation have altered the conditions under which clinics and networks operate.

“FAFCC is working with legislators

to introduce minor revisions during the upcoming legislative session to the sovereign immunity law and Volunteer Health Care Provider Program rules to protect and promote the interests of clinics and networks in providing access to healthcare for Florida’s uninsured,” said Duran.

Even with the Affordable Care Act in place, Duran said that free and charitable clinics continue to play a critical part of the healthcare safety net. Currently, Florida has chosen not to expand its Medicaid program – or implement an alternative – but in the event the state chose to move forward, a study by the Urban Institute indicated there would still be approximately 1.7 million uninsured residents.

“The need for a strong healthcare safety net in Florida isn’t going away,” he said. “Most free and charitable clinics and networks report an increase in demand for services. FAFCC clinics and specialty networks provide the kind of ongoing care that insured patients would get from a family physician or specialist that uninsured patients might otherwise seek at an urgent care center or hospital emergency room. In doing so, they prevent many of their patients from winding up in hospital emergency rooms, where treatment costs exponentially more.” ta m pa b ay m e d i c a l n e w s

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DECEMBER 2015

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The Trouble with MACs

FTC Calls Market Competition with PBMs’ Aggressively Low MAC Price Lists “Vigorous”’

By LYNNE JETER

Controversy continues to swirl over the impact Pharmacy Benefit Managers (PBMs) have on the nation’s new healthcare delivery system.

Conflicts of interest, opaque pricing, a marketplace the Federal Trade Commission (FTC) said shows “vigorous” competition, and PBMs’ role in driving the Maximum Allowable Cost (MAC) for reimbursement have thrust the pharmaceutical business into a stewing national debate over PBMs’ role in Obamacare.

According to the National Community Pharmacists Association (NCPA), a lack of transparency benefits PBMs, which members say keep two MAC lists for the same prescription drug health plan – one for health plan sponsors, another for pharmacies. The trade association argues that pharmacies are reimbursed at a low rate, based on an aggressively low MAC price list, while plans sponsors see a higher MAC price list, with spread pricing pocketed by the PBM. PBMs, mostly a third-party administrator (TPA) of drug prescription plans but often an integrated health systems service, generate MAC drug lists to determine how retail pharmacies are reim-

bursed for multi-source, generic drugs.

Robert Weinberg, JD, a Polsinelli shareholder representing PBMs, specialty and mail order pharmacies, plan sponsors, and other stakeholders in the pharmacy benefit market, emphasized the tremendous value PBMs bring to the healthcare delivery system.

“Sure, PBMs have been very successful and Robert profitable, but their sucWeinberg cess has always been aligned with the value they create for plan sponsors and their members by making the use of prescription drugs safer and more affordable. PBMs make money when they save their client’s money,” said Weinberg, adding that “a big component of this has always been driving higher utilization of generic drugs through effective clinical programs and lower reimbursement through the use of MAC pricing, which is intended to reflect the average acquisition cost of an efficiently managed pharmacy.”

However, the problem lies in PBMs not communicating real-time with pharmacies about specific drugs on the MAC list or the price of reimbursement.

“PBMs have enjoyed broad discretion to manage drugs on their MAC lists and how they’re reimbursed,” he pointed out, and then quickly added, “but their ability to manage MAC reimbursement in ‘real time,’ through their sophisticated adjudication platforms, results in lower costs being instantly passed through to the consumer at point-of-sale and to plan sponsors.”

Pharmacy chains like Walgreens, the nation’s largest with nearly 8,000 stores, may negotiate guarantees, or average effective rates, such as the Average Wholesale Price (AWP), minus a percentage for all MAC drugs.

“With scale, pharmacies are able to negotiate generic effective rates, or average rates, so they’re able to prospectively negotiate reimbursement levels in the aggregate,” said Weinberg, who spent nearly a decade as an executive and in-house counsel for a significant PBM. Under new laws that have been passed in several states, pharmacies may challenge reimbursement from PBMs on the grounds they cannot acquire a MAC drug list to stock their shelves at a rate allowing them to break even.

“It’s good for the independent retailer, but will likely lead to the unintended conse-

quence of higher drug costs for consumers and plan sponsors,” he said. “Ultimately, these laws negatively impact a lever the PBM has to manage lower reimbursement for its clients, which are typically employer groups.”

PBMs rely on their ability to broadly manage MAC list drugs and pricing to manage their client guarantees.

The wrinkle comes from these new state MAC laws, which affect the administration and reimbursement methods for plan sponsors, including for self-funded plan sponsors.

“These laws do disrupt the PBM business model,” said Weinberg, noting that independent retail pharmacy associations have been more successful lobbying for change at the state versus federal level.

“But that model has always been good business, not only for the PBMs, but for the plan sponsors and members they represent. PBMs focus solely on managing the pharmacy benefit, and have created very focused clinical and adherence programs to manage disease states, improve patient outcomes, in addition to holding down reimbursement levels for prescription drugs through their arrangements with manufac(CONTINUED ON PAGE 9)

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Q&A: Merging Back-Office Operations with Other Medical Practices

By DAVID OGBURN AND RICH LECOMTE

Around the country, more doctors are realizing that it might make sense to merge their back-office operations with other medical practices.

This isn’t really a merger. Instead, it’s a way to cut overhead while building a top-notch operation that can handle everything from billing to scheduling to customer issues.

But if you consider this approach, it’s important to understand the risks involved. With this in mind, here are some questions and answers with David Ogburn and Rich LeComte of USAmeriBank, specialty lenders who advise medical practices on whether it makes sense to join with other practices from a financial perspective.

Q: Are there any changes customers would see if their doctor joins with other medical practices?

A: Probably not. Many small practices are outsourcing their billing tasks anyway.

Medical billing is a very fragmented process, and the billing piece can be confusing, so the advantage of this approach is that it takes the burden away from the clinicians so they can focus on patient care, which is what they want to focus on.

Q: Does this approach help with health insurance issues?

A: Absolutely. According to the American Medical Association National Health Insurer Report Card, the percentage of claims requiring a rework ranges from five to a little over 20 percent. From a revenue management standpoint, you really need to focus on this 5-20 percent.

If the cost can be taken down on chasing

this percentage of reworked claims, that can be significant. In fact, if you want to improve your bottom line, it’s important to improve marginal revenue and decrease marginal costs. The goal is to do both.

Q: How does one of these partnerships get started?

A: In most cases, attorneys or other third parties are leading the way, acting as an agent that can talk to several medical groups and investigate possibilities. Often, a partnership starts because a couple of specialists decide to team up, since they already know each other and think an alliance might make sense.

As you investigate doing this, it’s important to work with a knowledgeable health care attorney, who can make sure the structure is done correctly. This is a must because of all the regulation involved. At the same time, your bank can speak to the pros and cons from a strategic financial standpoint.

Q: What’s the potential downside of doing a partnership like this?

A: If you don’t plan correctly, you could be stuck in a practice that you don’t want to be in. So it’s important that the practices involved match up in terms of work ethic, spending habits and in their overall vision for running a business. Also, if the practice plans to market itself as an entity to the world, it’s critical that there be agreement on how to market and what the budget for that should be.

So if a doctor is thinking about doing this, ask questions. What are the capital requirements for each of the practices involved – do they match up? Are insurance reimbursements different, and if so, how would this affect cash flow? And how should you share profits at the end of

the day? Answers to these questions will tell you quickly whether getting together would make sense.

Q: Do you see many groups that include multiple specialties?

A: We are seeing fewer of those. Insurance companies or hospitals have already absorbed a lot of multi-specialty practices, which reflects the impact of the Affordable Care Act and the growing scale of major health systems.

Q: Is there an optimal number for how many practices should get together?

A: We tend to see the successful ones with at least five practices, and the entity tends to be regional in nature. Once you get out of your own region, the markets look very different. Also, Medicare offices are divided into geographic regions, so those contracts can vary depending on where you are geographically.

Q: What about the employees in your office? Will have you have to reduce staff?

A: Certainly, you may need to redeploy personnel. So you should ask yourself which people are really helping drive

business compared to the people who are doing work that might be more efficiently done in a larger office. It’s important to have employees who can focus on making the practice better, so redeploy your resources with that in mind.

David Ogburn is Senior Vice President – Professional & Executive Banking Division at USAmeriBank. A 27-year banking veteran, Ogburn’s entire career has been in commercial banking in the Tampa Bay market. At USAmeriBank, Ogburn oversees the professional & executive division, which focuses on the unique banking and credit needs – both personal and professional – of owners of such professional services as physician practices, law firms and CPA firms.

Ogburn can be reached at dogburn@ usameribank.com.

Rich LeComte is Senior Vice President – Specialty Lending Manager at USAmeriBank, which has a specialty in helping health care organizations and professionals with their banking needs. LeComte focuses on helping clients on both a local and national basis in such areas as business loans, lines of credit, and financial and business analysis. He works with such clients as hospitals, medical practice groups, senior housing providers and health insurers.

LeComte can be reached at RLeComte@ USAmeriBank.com.

Member FDIC | Equal Housing Lender ©2015 USAmeriBank

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8 Steps to Improve Revenue Cycle Efficiency, continued from page 1 physicians nationwide.

“An efficient revenue management system is critical for your practice’s financial health and sustainability,” said Christine A. Sinsky, MD, FACP, an internist with Medical Associates Clinic, a multispecialty group practice with sites in Iowa, Wisconsin and Illinois, Dr. Christine and the AMA point perA. Sinsky son for STEPS Forward.

“Electronic methods can streamline revenue-related processes, such as eligibility checks, claims submissions and payments, all allowing your practice to maximize the amount of time available for patient care.”

To improve revenue cycle efficiency, doctors may follow eight steps: • Select a practice management system (PMS) that fits your needs.

• Verify insurance eligibility electronically before every patient appointment.

• Reduce prior authorization burdens through electronic transactions.

• Submit claims electronically to save time and money.

• Determine the status of submitted claims.

• Leverage electronic remittance advice (ERA) to simplify processing of payment information.

• Review electronic payment options

and make an informed choice for the practice.

• Maximize collection of patient payments.

“As with any technology selection, the ‘right’ PMS for your practice is the one that will best meet the needs of you and your staff,” said Sinsky. “Whether purchasing your first PMS or changing to a different product, first turn your attention inward to your practice. Soliciting input from all staff who use and interface with a PMS and including them in the selection process will ensure that you pick a vendor and product that matches your practice’s priorities and needs. A thorough analysis of your practice’s revenue cycle process and workflow will provide valuable insight into your system’s requirements. Additionally, this type of analysis will help to identify opportunities for automation through the PMS that will improve the efficiency of your practice.”

Verifying insurance eligibility electronically before every patient appointment is greatly underrated.

“Ideally, this eligibility check should be performed electronically,” said Sinsky.

“Although most health plans allow patient eligibility to be verified over the phone or via a health plan web portal, these methods are often inefficient and may not provide you with all the necessary information.”

Because reducing prior authorization burdens via electronic transactions

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dovetails nicely with the AMA’s belief that prior authorization is overused, the AMA urges health plans to limit the use of these programs to true utilization outliers, instead of broadly applying coverage restrictions to all practices. To reduce the physician’s time spent on prior authorizations, the AMA recommends incorporating a team-based model into the practice routine. (Medical News will cover the teambased model in 2016.)

“Ideally, a physician will be aware of drugs’ prior authorization requirements before sending a prescription to the pharmacy, which minimizes the chances of patient medication nonadherence,” said Sinsky, pointing out that electronic prescribing system vendors are in various stages of implementing electronic prior authorization technology.

To save time and money, submit claims electronically.

“Healthcare claim submission used to require a cumbersome, manual process of completing a paper form, mailing it to a health plan, and waiting – sometimes weeks! – for a response,” said Sinsky. In addition to time and cost savings, “electronic claims submission often speeds heath plan adjudication and payment.”

Determine the status of a submitted claim via the electronic claim status inquiry to confirm receipt of submitted claims, and to garner claim status.

“Health plans are required to support real-time claim status processing,” said Sinsky. “To electronic eligibility inquiries, practices can also send ‘batch’ transmissions to health plans to check the status of multiple claims at the same time. By law, the practice must receive a response by the next business morning, although some practices report receiving these responses much sooner. Rather than waiting two or more weeks before taking action on a submitted but unadjudicated claim, using the electronic claim status request provides the practice with an immediate status report on the claim. The practice can then fix a problem, resubmit the claim and lower the days in accounts.”

Leverage the ERA, an electronic version of a paper explanation of benefits (EOB), to simplify processing payment information.

“Manual reconciliation processes and

sifting through stacks of paper EOBs can be sizable administrative hassles,” said Sinsky. “The standardized ERA offers a way for practices to reduce these burdens, more quickly identify those claims that require reworking, and generally have staff spend more time on higher-value activities.”

When determining electronic payment options, consider the hassle attached to paper checks, a time-consuming activity that’s ripe for fraud.

“Using electronic payment can simplify your practice’s revenue cycle and lead to faster payment from health plans,” said Sinsky, pointing to the industry standard Automated Clearing House electronic funds transfer (ACH EFT). “However, be aware of the benefits and risks of various electronic payment options to make the best choice for your practice.”

For example, even though health plans and their vendors may offer supplemental “value-added” services for an additional, percentage-based fee, all health plans are required to offer basic ACH EFT upon physician request and at no additional cost beyond a nominal, per-transaction banking fee of approximately 34 cents.

“In addition to ACH-EFT payments, health plans frequently use virtual credit cards (VCCs) for physician claims payments,” said Sinsky. “Practices are charged interchange fees of up to 5 percent of their total payment to receive these VCC payments. In some cases, health plans are receiving cash-back incentives of up to 1.75 percent from the credit card merchants for using this payment method.”

Collecting payments at the time of service is the vital first step in any effective patient collections strategy.

“Especially because of the growing prevalence of high-deductible health plans leaving many patients to bear additional financial responsibility for their treatment, doing so will increase your practice’s cash flow, decrease accounts receivable, and reduce billing and back-end collection costs,” said Sinsky.

In summary, “Every workflow that a practice converts from manual to electronic process will save valuable time and resources while also reducing the overall administrative burdens of practicing medicine,” said Sinsky.

How often are physicians talking with patients about weight?

NOT OFTEN ENOUGH. Almost half of people affected by obesity say they have not been advised by a physician about how to achieve a healthy weight.* Learn more about treating obesity seriously. www.ObesityCareWeek.org

* US Center for Public Affairs Research 2012 Report.

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The Trouble with MACs, continued from page 6 turers and retail pharmacies. MAC pricing is only one tool in the PBMs’ belt, but it’s a very effective tool.”

In Medical News markets, state laws and pending legislation to provide clarity on PBMs’ derivations of MAC pricing, and standardization for how drugs are selected for inclusion on MAC lists, run the gamut – greater PBM transparency, length of time between drug list adjustments, more consistent PBM audit practices – with little uniformity. For example, significant MAC legislation hasn’t passed in Missouri, home of St. Louis-based Express Scripts (NASDAQ: ESRX), the nation’s largest PBM with 2013 revenues topping $100 billion.

By contrast, Tennessee has a rather onerous MAC law, mandating among various legal components that PBMs “shall not set the MAC for any multi-source generic drug it places on a MAC list below the amount found in the source used by the PBM to set the cost.”

State law highlights from other Medical News markets: • In Alabama, the law governing MAC statutes establishes minimum and uniform standards and audit criteria of pharmacy records.

• Arkansas has created a Bill of Rights conducting pharmacy audits and requires MAC list updates every seven days.

• Florida’s MAC law governs the timing of audits for pharmacies participating in Medicaid.

• Kentucky requires MAC drug list adjustments every 14 days.

• Louisiana’s MAC law spells out broadly the regulations governing recoupment of assets and an appeals process for pharmacists appealing audits results, while also requiring PBMs to update their MAC drug list “on a timely basis.”

• Mississippi regulates how PBMs interact with the state insurance department and abide by regulatory compliance laws.

These state laws have been drafted broadly enough to cover self-funded plan sponsors. But this “may ultimately be their downfall,” said Weinberg, noting that Maine and the District of Columbia (DC) passed anti-PBM laws in the mid to late 2000s to make PBMs fiduciaries in certain respects.

The Pharmacy Care Management Association (PCMA), a national trade organization that represents PBMs, challenged both laws on ERISA preemption grounds governing self-funded plans. The DC law was struck down; even though Maine’s law was upheld, lawmakers repealed it.

According to the NCPA – established in 1898 as the National Association of Retail Druggists – much more work needs to be done legislatively to address marketplace challenges regarding PBMs. “Pharmacies are required to sign contracts not knowing how they’ll be paid,” said NCPA president Bradley Arthur. “It’s equivalent to agreeing to the services of a home builder, not knowing how you’ll be paid or what materials will be utilized in the home’s construction.”

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New Amniotic Allograft Storage Breakthrough Enriches Healing Potential Advanced Stem Cell Preservation is the Key

By STEVE SPENCER

Each day, physicians discover more about the power of regenerative medicine, a game-changing specialty that uses biologics to regenerate human cells or tissues to help heal damaged organs.

One biologic solution that is effective for wound and tissue healing is an amniotic allograft. In this case, a woman having a C-section can donate her placenta from which the amniotic membrane is derived.

The amniotic membrane is rich in stem cells, proteins, and growth factors that are important to healing.

In order for the amniotic allograft to be most effective, it is important to keep as many cells alive as possible between the time the membrane is harvested and stored until it is used with a patient.

Unfortunately, this has been a challenge. For example, in the most common storage technique, where the amniotic membrane is dried and dehydrated, once the water is removed, the structure of the tissue collapses. And while the healing proteins are retained, the stem cells, which create the proteins, die. This means that there will be no new proteins created.

Some providers have tried to freeze the amniotic allograft for storage, but the results are largely the same as with the dehydrated products.

However, recently Birminghambased Nutech Medical has made a breakthrough in storage technology that appears to boost the allograft’s healing potential.

“Over years of experimentation, we’ve developed a proprietary storage system,” said Howard Walthall, CEO of Nutech. “We store the fresh amniotic membrane in a special solution that maintains the structural integrity and viability for 42 days from the date of processing.

This is longer than ever before possible.”

In this fresh amniotic allograft, which Nutech has named Affinity, most of the stem cells are still alive. According to Walthall, the definition of a stem cell is subject to interpretation. “The most common definition of a stem cell is that it can reproduce itself and differentiate down multiple lineages, meaning that it can be persuaded to become a different cell type.

Many cells in the body can only become the type of cell they are. A stem cell can, in theory, become a muscle cell, a bone cell or other types, depending on the environment. If that’s the definition of stem cells, then many of the cells in amniotic membrane are stem cells.”

And while stem cells are found everywhere in the body, amniotic based cells have some special traits. “They are much younger so their capacity to reproduce

Katie Mowry (left) and Howard Walthall hold Nutech’s storage solution for amniotic allografts.

Wound that had not healed in two years.

The wound is healed after six weeks of Affinity treatment.

themselves is larger and they can also differentiate into a larger variety of cell types.

So they can become almost any cell in the body,” said Katie Mowry, of Research and Development at Nutech.

“Specifically for Affinity,” Walthall said, “these (stem) cells produce proteins in a variety of categories. They produce regenerative proteins, growth factors that play a role in blood vessel formation which is important to bring nutrients to a wound site. They produce anti-inflammatory growth factors and regenerative healing factors. There are many proteins that are produced – probably hundreds. We’ve studied 40 to 50 specifically and we’ve found a large number of growth factors compared to other amniotic products.”

“Growth factors are produced by (stem) cells and usually have an effect on either cell growth or migration,” Mowry said. “For example, a cell in our Affinity Allograft may produce a growth factor that causes the fibroblast cell to do something – maybe to proliferate or move (migrate) to fill in a wound void.

“We haven’t tried to quantify the number of growth factors in Affinity because it’s a tissue product. It’s a whole tissue system. So not only are most of the (stem) cells still alive, but the structure of

the matrix remains intact.”

So far, the Affinity allograft has been used by wound care specialists for hardto-heal wounds as well as by surgeons to close surgical incisions. And orthopedists are using it to heal soft tissue injuries in tendons, ligaments, and cartridge.

“One of the most rewarding experiences with Affinity so far involved a doctor in Pennsylvania who used it on a wound patient,” Walthall said.

“The lady had the wound for two years before she tried Affinity,” Mowry said. “She had been treated before with Debridement, Enzymatic Debridement, and some other graft products. They had also tried using a Wound V.A.C. on it. She was getting close to needing an amputation. She had had osteomyelitis, which is a bone infection, twice because this was such a deep wound. So he started treatment. The physician placed the graft over the wound, and then placed a nonadhesive dressing over the top. He continued this treatment weekly and after six applications, the wound was gone.”

Healing cases like this are becoming more prevalent as advances like the Affinity allograft continue in regenerative medicine.

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GrandRounds Dr. Mackay Vein & Circulation Specialist First in Florida to Use VenaSeal™ Closure System Dr. Mackay Vein & Circulation Specialist announces that Dr. Edward G Mackay is the first in Florida to treat patients with venous reflux disease using the VenaSeal™ closure system. The VenaSeal™ closure system is a new, minimally invasive Dr. Edward G. Mackay procedure that uses an advanced medical adhesive to close the diseased vein in patients with symptomatic venous reflux disease.

The VenaSeal™ procedure is the only procedure to use medical adhesive to collapse and close the vein, with high closure rates across three clinical trials.

Additionally, patients treated with the VenaSeal™ closure system often have minimal to no bruising, and can return quickly to normal activities.

Unlike other heat based treatments, the VenaSeal™ closure system does not require tumescent anesthesia (multiple injections of a dilute local anesthetic), and eliminates the risk of burning or nerve injury associated with thermal based procedures. In some cases, patients also may not need to use compression stockings post procedure.

Hospital Board Elects 20152016 Slate of Officers The Sarasota County Public Hospital Board, which governs Sarasota Memorial Health Care System, elected its new officers for 2015-2016.

Made up of nine citizens elected

by Sarasota County voters to four-year terms, the hospital board meets monthly to oversee the hospital’s finances and quality improvement efforts and to set the strategic direction for the system.

Each November, the board appoints a new slate of officers from its elected members.

Gregory Carter, who represents the southern district, was chosen as chairman of the Board, succeeding Marguerite

Malone, Ed.D, who served the previous two years as chair. First elected to the Hospital Board in 2002, Carter also served as chair in 2009-2010. An employee of AT&T's Engineering Gregory Carter Department for 31 years, Greg served as project manager, coordinating all aspects of construction for the corporation's network facilities for the state of Virginia and working as a liaison between the company and vendors, consultants and project personnel. Currently the owner/operator of a general home repair business, he also served in the U.S. Army Corps of Engineers.

Other board members elected to office for 2015-2016 include: • Alex Miller – First Vice Chair • Marguerite G. Malone, EdD – Second Vice Chair • Joseph DeVirgilio, Jr. – Treasurer • Robert Strasser – Secretary • James Meister – Assistant Secretary • Darryl Henry – Assistant Treasurer The Board recognized Dr. Malone for her outstanding leadership and guidance during the past two years. As board chair, she successfully oversaw a period of many accomplishments and challenges, including leadership transitions, trauma designation, national accreditations, the launch of the hospital’s Medical Residency Program with Florida State University and the opening of our Bee Ridge Urgent Care Center.

Manatee Memorial Hospital Becomes First on Florida’s West Coast wIth New Heart Failure Monitoring Solution Manatee Memorial Hospital is the first facility on Florida’s West Coast to implant a new miniaturized, wireless monitoring sensor to manage heart failure (HF). The CardioMEMS HF System™ is the first and only FDA-approved heart failure monitoring device that has been proven to significantly reduce hospital admissions when used by physicians to manage heart failure.

The CardioMEMS HF System features a sensor that is implanted in the pulmonary artery (PA) during a nonsurgical procedure to directly measure PA pressure. Increased PA pressures appear before weight and blood pressure changes, which are often used as indirect measures of worsening heart failure. The new system allows patients to transmit daily sensor readings from their homes to their health care providers allowing for personalized and proactive management to reduce the likelihood of hospitalization. The sensor is designed to last the lifetime of the patient and doesn’t require batteries.

Once implanted into the pulmonary artery, the wireless sensor sends pressure readings to an external patient electronic system located in the cardiologist’s office. The cardiologist can detect any changes and adjust treatment.

The CardioMEMS HF System, from global medical device manufacturer St. Jude Medical, is approved by the U.S. Food and Drug Administration (FDA) for commercial use in the U.S. For more information, visit http://www.heartfailureanswers.com/.

Three HCA West Florida Hospitals Earn an “A” Patient Safety Score Medical Center of Trinity, Oak Hill Hospital and Regional Medical Center Bayonet Point have again been recognized with an “A” safety score by The Leapfrog Group, an independent nonprofit run by employers and other large purchasers of health benefits. The score was awarded in the latest update to the Hospital Safety ScoreSM, the ABCD or F scores assigned to U.S. hospitals based on preventable medical errors, injuries, accidents, and infections. The Hospital Safety Score was compiled under the guidance of the nation’s leading experts on patients’ safety.

To see the hospitals’ scores as they compare nationally, visit the Hospital Safety Score website at www.HospitalSafetyScore.org.

TGH Earns Highest Designation For Its Senior Care An academic nursing program created to help hospitals improve medical care for older adults has awarded Tampa General Hospital (TGH) its highest designation for comprehensive care of the elderly.

TGH is the only hospital in Hillsborough County – and one of only five in Florida – to earn this designation from the Nurses Improving Care for Healthsystem Elders (NICHE) organization.

NICHE, based at NYU College of Nursing, is the leading nurse-driven program dedicated to helping hospitals improve the care of older adults. The exemplar status awarded to TGH – the highest of four program levels – was granted after a rigorous evaluation of the current and future goals of the hospital’s NICHE program for older patients, defined as those who are 65 years old or older.

A main focus of TGH’s NICHE program is encouraging nurses to become trained Geriatric Resource Nurses Tampa General Hospital is the only hospital in Hillsborough County, and one of only five in the state, (GRN’s) through the NICHE organization. to earn the highest designation possible for its comprehensive care of older adults from the Nurses Nurses who earn the GRN designation have the knowl- Improving Care for Healthsystem Elders (NICHE) organization. Members of Tampa General’s NICHE Steering Committee are Jaclyn Castek, left; Robin Atkins, Cherree Alicea, Horacio Figueroa, edge and experience to care for older patients, said Robin Felice Rogers Evans and Bill Gross.

Atkins, TGH’s NICHE program coordinator. They are able to identify and understand syndromes unique to geriatric patients and share the most current knowledge in caring for older patients with their units’ staff, she said.

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