ViewPoint Volume 2 Issue 4 Winter Solstice 2016 by VerdenGroup

CONTENTS Volume 2, Issue 4 - WINTER SOLSTICE EDITION 2016

Welcome

Pro Tips

Art of . . .

New here?

Jumping into Collaborations with Payers

Collaboration

Susanne Madden will guide you through this issue's theme and highlight the great content that we've brought together this quarter.

Robert Goff explains how and why physicians & Payers should consider joining forces. Once considered unthinkable, these collaborations can be very rewarding for all.

Our editor reflects on the critical need for like-minded individuals to collaborate like never before as medicine falls under the dark shadow of the incoming administration.

Big Impacts

NCQA Update

Payer News

The Trump Effect on Medicaid

Is PCMH Worth It?

Susanne Madden takes a hard look at how the future of CMMI? as well as the Medicaid expansion? is in imminent jeopardy under a Trump Administration.

The transition to a Patient-Centered Medical Home can be challenging; Tiffany Lauria weighs the hard work necessary to gain recognition against the benefits of PCMH .

Guest writer Lucien Roberts spoke with Anthem's Regional VP (VA) to discuss Payer-Provider collaborations. Read how Anthem is now focusing on solutions. . .

CONTRIBUTORS

Frontlines

THE VIEW POINT TEAM Podcast: Mental Health in Pediatric Practice Susanne speaks with Dr. Christoph Diasio about how they successfully incorporated mental and behavioral health into Sandhills Pediatrics in North Carolina.

Susanne Madden

Julie Wood

Heidi Hallett

Spotlight Tech Trends Forecast for 2017 A year end look at some of the big tech trends we predict will be making an impact in 2017. What you need to know about mHealth, wearables, and more.

Tiffany Lauria

Scott Hodgson

David Magbee

GUEST CONTRIBUTORS

37 Connect Connect with us online. Here you'll find details on the key events and conferences that we'll be attending this Spring. You'll also find handy links to connect with us on all of our media streams.

Robert Goff

Lucien W. Roberts

ViewPoint is a digital publication that looks at perspectives on the business of healthcare and is produced by The Verden Group. ViewPoint is available by free subscription and is distributed seasonally. Print copies are available by request. Please contact us for pricing. The Verden Group is an innovative consulting firm focused on shaping the landscape of advocacy by empowering medical practices to navigate through the increasingly complex business of healthcare, and to advocate on their behalf with insurers and regulators.

Contact Us: The Verden Group 48 Burd Street, Suite 104 Nyack, NY 10960 phone: 877-884-7770 email: inquiry@theverdengroup.com

The Verden Group delivers expert services and advice to meet needs across your practice. We work with individuals and groups of any size from start-ups to super groups. From contract negotiations and management, to social media set-up and administration, and PCMH transition ? we are your Partner In Practice. To learn more about our services visit www.theverdengroup.com Subscribe to ViewPoint to stay on top of all our news and views on the business of health care. Read past issues of the magazine and additional content at: verdenviewpoint.com 3

About the graphics & illustrations in this issue: For this issue we've veered away from our regular pool of photographers to find visual inspiration on collaboration from the ultimate collaborative tool ? the internet. 4

? W ELCOME ? Happy Solstice, Readers! This issue we are examining how collaborations across health care are leading to improved relations, new opportunities and innovation at a pace we've never seen before! Learn how clinically integrated networks are paving the way for better, smarter physician-payer relationships, and to the betterment of all. Read about what Anthem (VA) is doing to foster closer ties to its physicians and actively work on solutions to health care challenges, collectively. Explore how teamwork helps create the biggest payoffs for medical homes, including a fascinating podcast with Dr. Diasio about incorporating pediatric mental health into the medical home. Contemplate how a lack of collaboration with the states on Medicaid is likely to create significant challenges in care delivery and hit the poorest harder than ever. And hear what I have to say about the dark days that lie ahead and how to come together, to join forces, like never before in order to save the best in our culture. . . May good sense and common purpose prevail in 2017.

SUSANNE MADDEN | EDITOR-IN-CHIEF

? PRO TIPS ?

Robert Goff | CEO University Physicians Network

JUMPI NG I NTO COLLABORATI ONS WI TH PAYERS Cr eat ing Oppor t unit ies f or Physicians

The unthinkable is occurring ? physicians collaborating with Payers. Collaborations with the ?dark side.? It is happening and can actually be successful; however, not without stress and not without a concerted effort by both physicians and Payers to understand each other and what they bring to the collaborative effort. More importantly, it needs to be successful for the sake of physicians, their finances, and their patients. It rewards physicians by doing right by their patients clinically; as fiduciaries for the costs of care incurred by their patients; and pragmatically enjoying economic benefits of success (if achieved) in the process. Stimulated by a commitment on the part of the Federal Government to tie physician reimbursement to quality and outcomes, and the potential of Accountable Care Organizations (ACO), commercial Payers have sought to harness, for their benefit, this evolving change in the dynamics of care delivery. The concept is very simple, empower physicians (with and without hospital partners) to design, implement, and operate their own clinically integrated network. If it can be successful in meeting quality and cost measures, the physicians (and their hospital partners) derive an economic upside. To get providers involved, performance results in economic rewards. Historically, the general theme of the physician-payer relationship has been one of friction and conflict. Physicians viewed Payers as nefarious enterprises striving to reduce their income with burdensome bureaucrats that interfere with patient care. As dollars 6

have dominated the conversations, Payer?s view the medical community as, if not completely, then principally economically self-interested with patient well-being considered secondary. Both Payers and physicians approach collaboration with a great deal of cynicism. Both have to cultivate a new understanding of each other and accept the fact that they each need the expertise the other has. Together they can work towards and achieve what both desire. For the Payers, it is lowering the rate of cost increases that only translate into higher premiums for employers and consumers alike. For physicians, it is a financial upside for achieving measures of quality and cost containment. Physicians, who control 85% of medical costs with their prescription pads and treatment plans, will actually benefit from delivering better care faster ? and yes, cheaper.

The key point of understanding what is necessary for Payers is that the vast majority of physicians are truly committed to quality and effective care delivery. Yes, physicians want to be paid, and paid appropriately; and, given the information,

" The concept is ver y sim ple, em power physicians (wit h and wit hout hospit al par t ner s) t o design, im plem ent , and operat e t heir own clinically int egrat ed net wor k." appropriate measures and support of their efforts, they are prepared to earn it through performance. Payers need to also understand that physicians, if engaged, are closest to the needs of the patients and the deficiencies in the system of care delivery and have the greatest potential for improving care quality and cost.

One key point to understanding what is necessary for physicians is to internalize the new world for health plans. Under Health Reform (The Accountable Care Act), health plans must spend 85% (80% for small groups) of premiums on medical care, with 15% (20% on small groups) allowed for administrative costs, including sales, marketing, and also including profit. If a plan spends more than the 85%, they must absorb the loss; however, if they spend less, they have to refund those dollars to whomever pays for the policy. In essence, Payers need the expertise and creativity of physicians just to survive. Years of Payer efforts to mandate utilization controls have clearly failed to stem the rising costs of care delivery.

Commercial Payers are seeking out physicians and providers who are prepared to take on the same responsibility and rewards as are being promoted under the Federal ACO program. Both physicians/hospitals and commercial plans are aggressively seeking out these opportunities to work with each other. There are two factors driving provider engagement with Payers. First, the expectation that currently there is a window of opportunity to begin clinical integrations and shared savings with upside-only benefits early before there is a forced move to risk sharing with its downside consequences. Second, to capture

patient volume within a collective of physicians and hospitals. Can a collective of providers use this ?window?to learn how to work together; to build an infrastructure now, so that when and if risk sharing becomes the norm in physician reimbursement, they will have the potential of success? And, as patient volumes become increasingly changed as increased patient financial responsibilities are motivating a reduction in visits to physicians, can the collective become self-promoting in the aggregate to replace lost volume and capture new volume? In the case of University Physicians Network (UPN) working with NYU Medical Center (NYUMC), the motivation to be early adopters has been in learning how to ride the bicycle now before the training wheels come off. Together a new entity was created, NYUPN Clinically Integrated Network (CIN), tasked with seeking out opportunities for collaboration with Payers, and building and operating an infrastructure to support those efforts. UPN representing the physicians, and NYUMC, the Hospital, share 50/50 ownership and control, with physicians appointed by each party, representing 80% of the Board of Managers. Each Payer has its own worldview in approaching work with our CIN. Some more prepared than others, some more sophisticated to support the effort than others, and some more flexible than others. Now with six ?shared savings?arrangements in place and operational, there are some observations shared as to what is involved and the impact: One of the greatest leaps in understanding is the concept of attribution. Attribution is the methodology that assigns the responsibility for specific patients to the CIN and to the individual physicians. It?s not a perfect science, and each contract with a Payer can calculate attribution differently. A simple explanation is: attribution is a formula that seeks to assign the costs and quality of care delivered by the physician that is most likely to have the greatest contact/influence over a patient?s care. This means that claims data is used to see where patients get their primary care services and then attribute the responsibility of preventive and routine care to that primary care physician. Similarly, claims data is used to attribute the responsibility for ?downstream costs?(costs beyond primary care) resulting from the primary care physician?s referrals or following primary care contact. In other words, ?responsibility?for those costs is attributed to the physicians that was primary, or had the greatest potential to influence downstream costs. The costs and preventive services responsibility is then ?attributed?to that physician for specific patients. For purposes of patients being counted in the agreement, those whose primary care physician is in the CIN?s provider?s network are counted. Payers have some differing nuances as to how they define primary care, or primary responsibility. Some will use pure primary care specialties only such as internal medicine, family practice and pediatrics, while others will include obstructions/gynecologists, and first line internal medicine specialists, such as cardiology, and gastroenterology. Every physician has difficulty with the concept of attribution, for every physician will 8

tell the anecdotal tales of the patients that won?t come in for preventive services, the patients they haven?t seen before who head out to a specialist, or similar tales of why they aren?t responsible or can?t control their patient?s decision. All true and, in point of fact, such patient choices cannot be restricted and often the Payer?s own benefit packages provides for this patient choice. However, the reality is that attribution models are actually fairly accurate in the aggregate in identifying the physician that can most influence and direct the patient?s care experience. Physicians will have to struggle with the issue of ?responsibility?for costs and quality with the lack of the ability to control, or even address, the recalcitrant patient that will not follow their advice and guidance. Again, in actual experience, physicians have more influence over patient decisions than they give themselves credit for. It is the difference between the physician saying, ?You need to see a cardiologist?and the physician saying, ?I would like you to see my colleague, Dr. X, a cardiologist for x.?Additionally, in building the performance measures for quality and costs, the norm of what can be controlled/influenced by physicians is readily identified, and adjusted, in which those physicians that are cavalier in their ownership of this responsibility become readily apparent.

attributed to the CIN. And it is a wealth of data, but it is not yet information. One of the greatest challenges to the CIN is to understand and manipulate this ?big?data to make it usable; to turn it into information. The very clear obligations of the Payers to the CIN for the delivery of data, its timeliness and quality, is essential to this collaborative relationship. It is from this data that the physicians in the CIN are going to know their challenges. What is the health status of the ?attributed lives?? What percentage has not received the expected routine and preventive services? This is the basis of the quality measures on which the CIN will be judged. In addition, the CIN will learn where the dollars have been going for these ?lives.? Are these patients obtaining material levels of care from providers outside of the CIN? If so, is this an opportunity to ?capture? volume? Are these patients receiving care from providers that are not contracted with the health plan? Such care is largely not coordinated with the physicians in the network and much more costly, often hundreds of times more, than services by contracted providers. The challenge then is to ?re-capture?these patients by providing services within the CIN. To do so requires understanding the impediments to internal referral activities. Largely these are issues of access to needed specialists. If a large volume of neurology referrals go outside the CIN, for example, efforts to increase access by increasing supply, or expertise are needed. Out-of-network activity needs to be scrutinized as well because it identifies deficiencies in access within the CIN network. Is it caused by a lack of quality in the CIN providers of those specialties, availability, or perhaps the

With ?lives attributed,?the patients identified for quality and economic responsibility, physicians and their collaborating health plan now have a collective challenge: What do we know about these patients? What do they need and how do we engage with them? This is opening the Pandora?s box of data from the Payers. It is claim data; it is the aggregate of paid and unpaid claims for the patients now 9

continuation of historic referral patterns that are now in need of confrontation and change?

long been pressing, to learn to document and report diagnoses fully and completely. However, now with the CIN in collaboration with Payers, the physicians stand to benefit from accuracy in data and in claims. When it comes to assessing meeting the quality goals, include in your collaborations the provision of having medical record documentation included in any assessment, and not solely relying on claims data. With data becoming information you know what you?re dealing with, where the challenges are, and the opportunities.

A word of advice ? when entering into such collaborations with Payers, put the risk of non-delivery of data (according to the agreed schedule of timeliness and completeness) on the

"As you turn data into information, you will identify non-physician providers that deliver care with vast differences

On one level, there is the challenge of patient engagement. Building a strategy to reach out and motivate patients to come into the physician?s office to obtain preventive services and to keep up with care if chronically ill isn?t easy. There is no one solution to this challenge. The approach must be multi-channel, from making sure offices know to perform or order these services when a patient presents for other reasons, to phone and mail campaigns to patients. Joint efforts at patient engagement should be undertaken using resources from both the CIN and the Payers. For example, Payer mailings to targeted patients that support physician office visits and remind patients of their benefit plans, which often do not have copays or applied deductibles for preventive services. The CIN works with its physicians so that office staff knows that there will be an increased volume of requests for appointments and can plan ahead to accommodate the workload. The CIN can also use the data to provide the practices with lists of patients and their missed preventive services. First, so the practice is prepared to provide the service when the patient makes that appointment, and second, so that the office can report back if the service had already been provided, in the medical record documentation, but not in the billing information.

in cost." Payer. In other words, if the Payer does not deliver, the physicians get specified credit towards meeting the goals and targets. Data turned into information will be an eye opener. As their history of claims activities becomes shared and known to others, information can readily scare the physicians in the CIN. Of course, the data will never be perfect, but it will be telling, and it will be incomplete. Claims data, which is what payers have, suffers because it is not matched with clinical information; it is dependent on the claims submitted by physicians, the quality of which is highly variable. This is why it is so critical for physicians to embrace EHRs and shared clinical data. For example, physicians are notoriously lax about diagnoses being submitted on billings; after all, the only motivation is to enter a code that will get the bill paid. Also, claims data from a Payer represents only what the Payer receives in claims. On review of medical records, often times there are preventive and routines services documented, but whether the services were not billed, or perhaps paid by a different insurance carrier, is not in the claims data of the Payer. The CIN will, for its own sake, now have to press its physician members to do what Payers have 10

Make sure the primary physician knows their patients are being contacted. One example would be reaching out to a patient to schedule their mammography when their physician knows the patient had a double mastectomy. Avoid the embarrassment.

For example, perhaps lower level of readmissions for post-acute care when home care is provided rather than nursing home care, or outpatient cardiac rehabilitation compared to inpatient rehabilitation. Longstanding patterns of treatment, especially if they only add costs and nothing towards improving outcomes, may be appropriate to change. ?Traditional?referral patterns may need to be challenged. Outcomes, when known and compared, need to be shared. Most physicians have no hesitation to change when shown there is a better course of treatment/care available to their patients. But it means sharing data, and reporting comparative information.

The big clinical challenge is to use the data to identify high-risk/high-cost patients; aggressively act to provide care coordination and support to reduce the cost of care by improving interventions. Here you need not only need to consider the traditional nurse case managers it?s time to think outside of the box. Can you team up with a sophisticated home care operation to not just engage post-hospital discharge, but to use their resources and protocols as a tool to avoid hospitalizations? In general, 5% of the population incurs 50% of the medical expenses. You?re not going to deprive necessary care to anyone, but instead work in a coordinating and creative manner to deliver what the patient needs in different ways.

Information now known will also identify those medical practices and physicians that will be most challenging. Tracking the care ordered by practices will identify things that you hope not to find, such as those few physicians that are perhaps gaming the system, or treating their referral activity with what could be considered disregard for cost and appropriateness: for example, the participating physician that funnels all ambulatory surgery to a non-contracted ambulatory surgery center, or the devotion to a non-contracted laboratory. Or perhaps the physician has an interest in the non-contracted physical therapy practice that seems to always get his referrals. Such non-clinically justified ?business?arrangements need to be addressed head on.

As you turn data into information, you will identify non-physician providers that deliver care with vast differences in cost. For example, hospital outpatient services are more costly than independent clinical laboratories; ambulatory surgery centers are less costly than hospital outpatient surgery; and office based surgery is even less costly. The appropriateness of place-of-service substitution is a topic that needs to be explored. Additionally, at times, you will find unexpected differences in outcomes by providers.

Another important value of information is to identify the opportunities for improved revenue by improved diagnosis coding. As noted before,

physicians and their billers who are increasingly good at CPT coding, have relegated diagnosis coding to the back burner. What one code will get this claim paid? After all, physicians are paid on CPTs, so who cares about the diagnosis code? You should. Now you need to care and there is the need for re-education across all physicians and billers in the CIN. Diagnosis coding is critical for the economic success of these collaborations. The economics of shared savings, and soon-to-be-shared risk, are adjusted based on the severity of illness of the patients. The outcry against the old concept of capitation was that if you had a sick patient, your capitation was insufficient. The adjustment needed then and now, is the full and complete documentation of severity of illness of each patient. As documented severity of illness increases, and recognition that sicker patients do cost more, the dollars that Payers will pay towards these reimbursement arrangements goes up. A recent retrospective review was conducted on claims data along with medical record information for some 200 out of over 100,000 patients. This review found that had these physicians documented their billings with the appropriate diagnoses ? diagnoses that the physicians would properly consider when ordering further care ? the added reimbursement to the CIN would have been in excess of $1 million that would have readily paid out to the physicians themselves. Common conditions present such as diabetes, COPD, depression, and obesity are often not coded on the bill and can dramatically impact dollars.

pay and why. Claims data has identified very apparent practices, most often by non-CIN network and even non-contracted providers that bear investigation for fraud and abuse. For example, the non-contracted physical therapist that has an average cost per visit of $5000, or the physician running $30,000 for surgeries for which Medicare pays $800. Here the CIN must challenge the Payer to exercise its fiduciary obligations to confront and investigate such payments. This collaboration with the Payer should include the removal of such abusive costs from the responsibly of the CIN. While these arrangements provide physicians with greater control over their daily world, and hands more responsibility to the physicians individually and collectively for the success of their venture, the Payer cannot sit on the sidelines. They have a vested interest in the venture?s success. Remember, if successful, healthcare costs are constrained thus making their products more competitive in the market, and garnering for them the opportunity for business and financial growth. The Payer?s role dramatically and definitively changes with the CIN and its physicians. They become a data source and, depending on the company, Payers will play a more or less active role in the engagement with patients, as well as supporting clinical, educational, and financial resources towards the infrastructure and operation of the CIN. The degree to which each Payer participates is the negotiation of the shared savings/shared risk arrangements. The journey that NYUPN is undertaking is off to a good start: with 6 contracts in place, and over $12 million in shared savings accrued to the benefit of our CIN by the first quarter of 2017, with half going to the physicians, and quality measures being passed as a prerequisite to the entitlement to economic payment. Four of the contracts are showing positive performance, with

Reviewing paid claims data will identify the costs and services incurred by the attributed patients and produce some surprising insights in to what is being provided to patients. In our experience Payers, especially those that serve as third party administrators to self-insured employers appear less ?diligent?as to whom they 12

the oldest showing costs increases at a rate of half the cost growth compared to the cost growth in the market. Of the remaining, one is too new to measure and the other has structural deficiencies that are restraining the rewards being earned ? so it?s back to that Payer for more collaborative discussions. This performance and these distributions are measures of early and readily achievable impact. The data is becoming information and it?s revealing that more opportunity readily remains to challenge the efforts, and earn the rewards. For both Payer and physician, and their Clinically Integrated Network, the journey is just beginning. Early success is coming from ?low hanging fruit?of opportunities, closing quality gaps, ending referrals to non-contracted physicians, and improving diagnosis coding. The real challenge and opportunity lies ahead and it is going to be data driven. As physician EHRs link up with CINs, marrying clinical claims data, physicians as scientists will begin to challenge themselves to understand and intervene using the patterns of care that identify the better outcomes with the lowest cost. This is where the real opportunity is: how to implement care delivery that can be faster, better, and cheaper. That challenge will dramatically change existing patterns of care and patterns of referral activity. Physicians, working collectively through a CIN, will have to work collaboratively with their Payer collaborators to continue to refine the care needed by their attributed patients to accomplish success.

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? The Ar t of Collab orat ion ? Susanne Madden | Founder & CEO The Verden Group Therefore, I call on every reader to do their part; to collaborate with one another to find ways to get through the anarchy destroying our institutions, the ignorance that will thwart our efforts to improve patient care, the policies that will put our health at risk and lead to the poorest being hit the hardest, the bullying and hatred that our children will have to endure, and war - not just the continuation of the longest war - but the specter of nuclear war if today's asinine tweets by an unhinged President-elect are anything to go by.

As I write on Solstice night, the shortest (therefore darkest) day of the year, it reminds me that no matter how dark the night, the light will return and we will flourish once again. But we cannot flourish as individuals. We can survive, sure, but to truly be successful it takes collaboration, teamwork and moving beyond our egos to see a greater good. That mindset is critical as we contemplate what potentially lies before us - dismantling of Medicaid, privatization of Medicare, the end of social security, of public schools, of the EPA . . . and based on today's tweets, even the specter of coming nuclear war.

In this issue we may be exploring lighter themes like collaboration across the business of health care, but we are deeply concerned for our clients and colleagues, our coworkers, friends and families. Supporting charities and activist organizations are a great way to get involved and find strength in numbers. I encourage you to learn about Doctors for America, an organization of physician-leaders that believe in putting medicine before politics, collaborating and inspiring for the highest good for all.

And so collaborate we must in ways we've never done before if we are to preserve American values and its culture of equality. I, for one, am already sick of hearing how we must come together under the new administration. Unity for all is not a theme that this administration can understand. Rather, it is a pendulum swing so far from the center that we would be fools to blindly follow down a path that has been paved with hatred, violence, intolerance, lies, and more lies, arrogance and ignorance.

Stay safe and stay engaged in 2017. Someone's life will now surely likely depend upon it.

? BIG IMPACTS ?

Susanne Madden | CEO & Founder

THE TRUMP EFFECT ON MEDICAID Uncertainty is increasing among physicians impacted by the Medicaid expansion. If you are a physician in a group practice or hospital located in an impoverished zip code, this expansion may have already increased your patient pool. It may also have increased your ability to provide follow-up to your patients who are noncompliant with medical management or drug treatments for their chronic conditions (e.g., diabetes and hypertension). Meanwhile, CMS?embrace of a value-based payment model (VBPM) affecting both Medicare and Medicaid has promoted a trend by group practices and hospitals toward forming Accountable Care Organizations (ACOs). At the forefront of this shift toward Medicare and Medicaid managed care has been the Center for Medicare and Medicaid Innovation (CMMI)? established under the Affordable Care Act (ACA) to pilot-test healthcare delivery and payment innovations. Under a Trump Administration, the future of CMMI? as well as the Medicaid expansion? is in imminent jeopardy.

CMMI Goal of Replacing Medicaid Fee-for-Service Model The basis for CMS focus on replacing a fee-for-service (FFS) model has been that the duplication of health-related services (e.g., x-rays) and lack of coordination of care has led to the exploding national healthcare cost-burden. According to CMS, the US health expenditure grew to $3.2 T in 2015, of which $545 B (17%) was for Medicaid. (Meanwhile, CMS also reported $646 billion [20%] in 2015 for Medicare.) A total of 3,141,300 people were enrolled in Medicaid/CHIP as of September, 2016, per the Kaiser Family Foundation? of which 9 million are dually enrolled in Medicaid and Medicare. These dual beneficiaries are mostly impoverished seniors or younger people with disabilities, and widely recognized as ?high risk/high need?patients. Therefore, CMMI financial alignment demonstrations projects have been mainly aimed at this group. ?As of June, 2016, over 370,000 beneficiaries who are dually eligible for Medicare and Medicaid were enrolled and receiving services from health plans in nine states with capitated financial alignment demonstrations,?according to the Kaiser Commission on Medicaid and the Uninsured. 16

What is the ?A Better Way?Healthcare Plan?

Attitudes Toward CMMI by Trump?s Cabinet Appointees

House Speaker Paul Ryan voiced his approval at this summer?s Republican National Convention of a specific national health plan developed by some members of Congress (including Tom Price? Trump?s choice for Secretary of the Dept. of Health and Human Services [DHSS]). According to this policy document? A Better Way? ?In the 114th Congress alone, House Republicans introduced more than 400 individual bills that would improve our nation?s healthcare system.?

Along with supporting ACA repeal, President-elect Trump?s proposed cabinet appointees to head CMS (Seema Verma) and DHSS (Tom Price) disapprove of CMMI and its demonstration projects. ?Price has been an outspoken critic of the innovation center,? according to an article on November 30, 2016 in The Atlantic. Meanwhile, Verma was a consultant in the design of Indiana?s Medicaid policy, under the governorship of Mike Pence; this policy requires Medicaid enrollees to pay fees for their coverage, per an article in Fortune Magazine. For beneficiaries unable to pay the required co-pays and monthly fees, some services are not covered; also Medicaid coverage can be discontinued if fees are not paid.

The commonality of these Republican-sponsored bills is that they either limited ACA implementation or repealed it. Overall, the perspective embodied in A Better Way is that ?the federal role should be minimal and set a few broadly shared goals, while state governments determine how best to implement those goals in their own markets.? Furthermore, this document promulgates: ?States have been in the business of regulating health insurance for decades. They should be empowered to make the right trade-offs between consumer protections and individual choice, not regulators in Washington.?

Block Medicaid Grants and Increased State Authority In regard to the Medicaid position advocated by Trump and his appointees? favoring block grants to states or per capita spending limits? a Commonwealth Fund report of November, 2016 states: ?Current proposals for dramatically reducing federal spending on Medicaid would achieve this goal by creating fixed-funding formulas divorced from the actual costs of providing care.? Furthermore, Rosenbaum et al? its

According to the Sargent Shriver National Center on Poverty Law, there are few actual details included in A Better Way. The exception is required spending limits for Medicaid, necessitating ?a drastic cut, leaving tens of millions of low-income people at risk of losing coverage.?

authors? note that this change would create funding gaps for states, resulting in narrowed coverage and/or a reduction in Medicaid enrollees. They also emphasize ?states already vary enormously in the proportion of low-income residents eligible for coverage and in the amount spent per enrollee.?Not mentioned is that physicians and hospitals would also lose out on overall revenue if Medicaid-covered patients are unable to obtain medical care due to loss of their insurance.

initiation of team-based prevention. For example, people living below the poverty level often have inadequate nutrition, and this can lead to a high carbohydrate intake (e.g., potatoes) and subsequent obesity. Around 90% of Type 2 diabetics are obese, according to the American Society for Metabolic and Bariatric Surgery. Therefore, diabetes prevention efforts aimed at encouraging weight loss, healthier diets, and increased exercise can be coordinated by the patient?s healthcare team to reduce the risk of developing Type 2 diabetes and its complications.

Medicaid Supplemental Payments States currently receive supplemental Medicaid payments in the following two separate forms: -

In a September, 2016 report by the Center for Consumer Engagement in Health Innovation, the authors note that, ?the implementation of Medicaid ACOs varies significantly from state to state?, and that ?Medicaid also makes up a significant percentage of state budgets.?

Disproportionate Share Hospital (DSH) payments; Upper Payment Limit (UPL) payments

The purpose of these supplemental payments has been to aid hospitals disproportionately serving Medicaid beneficiaries, and also to compensate providers for low Medicaid payment rates.

Legal Basis for Roll-Back of Medicaid Expansion Thirty-two states (including the District of Columbia) have thus far chosen to expand Medicaid coverage to enrollees earning between 100-138% of the Federal Poverty Level (FPL). However, President Trump?s anticipated action following assumption of the presidency will be to dispense with appeal of the federal court?s decision in May 2016 (in Burwell v. House of Representatives). Since this federal district court?s decision was that the ACA health exchanges? cost-sharing subsidies were illegal? and dropping Obama?s appeal will allow the ruling to stand? that lower court?s decision will likely serve as precedent in undoing the Medicaid expansion.

While these Medicaid supplemental payments were already scheduled for phase-out over 10 years under the ACA due to their incompatibility with VBPMs, they will likely be quickly eliminated as a consequence of the belief in a more limited role for CMS by both Price and Verma.

Why ACOs were Vital to a Value-Based Healthcare Model The assumption underpinning CMS support for ACOs is that patient-centered medical homes (PCMH) enable a better approach to clinical care and prevention of chronic, costly disorders. A related assumption is that a healthier population will help to control US healthcare costs over time. The particular advantage of the PCMH approach is that it can better address lifestyles leading to future chronic disorders through

Meanwhile, states that expanded Medicaid coverage may find that they are no longer able to do so if the federal contribution is lowered. It is likewise probable that the 19 states that did not choose to expand Medicaid? due to the 18

Supreme Court?s decision in 2012 (NFIB v. Sebelius)? will no longer be permitted that option under a Trump presidency.

Consequences of Medicaid Cuts and ACA Repeal In a report in December 2016 for the American Hospital Association and the Federation of American Hospitals, Dobson et al calculated that passage of the healthcare bill in 2015 introduced by Tom Price? H.R. 3762? would have generated a financial loss between 2018-2026, with an ?impact on hospitals of $165.8 billion?. Additionally, this Dobson et al report estimated that? by 2026? the number of uninsured would increase by 22 million if the ACA were repealed. Lack of insurance has been linked to delaying preventive care or necessary medical treatment, and that delay has been well correlated by the CDC to a lowered overall health status and premature death.

CMS and DHHS Policy Implications for Physicians If Medicaid payments are severely curtailed under new CMS and DHHS policies, physicians may find themselves in the ethically untenable position of choosing not to accept new Medicaid patients, or accepting diminished annual revenue. However, for those providing care in low-income communities, the option of NOT accepting new Medicaid patients may not be available. Instead, the consequence may be closure of physician group practices in these communities, which will likely result in support staff job losses as well as difficulties for their patients in acquiring new primary care physicians (PCPs).

Conclusions The ACA price tag may soon appear to be minimal in comparison to the increase in high-cost infectious and/or chronic disorders caused by cutting costs off the backs of the most impoverished and diseased patients. The withholding of treatment to HIV/AIDS patients who were drug addicts in the 1980s should be a clear reminder of the consequences of judgmental and short-sighted health policies aimed at curbing costs, in that an unnecessary expansion of the epidemic occurred requiring billions of dollars to control.

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We shouldn?t have to learn that lesson all over again.

? NCQA UPDATE ?

Tiffany Lauria | Practice Consultant

I S PCMH TRANSI TI ON WORTH THE EFFORT?

If your practice has considered becoming a recognized Patient-Centered Medical Home (PCMH), you no doubt appreciate how challenging the transition process can be, often requiring a full overhaul of process, policy and even practice culture. But beyond the assurance of enhanced patient care and the workload needed to meet and prove that your practice fits a set of national standards, is the question of how much value will this transition bring to my practice? In order to answer that question, we need to look at the status of the market today, where things are headed, and how becoming a PCMH can help your standings.

A Payer Perspective Just for a moment, put yourself in the position of the insurance companies and other healthcare Payers. The Payers are feeling a tremendous amount of pressure to decrease costs while improving patient outcomes. And the source of this pressure might surprise you ? not only are they feeling the weight of their own expenditures and revenue cycles, but more and more often the pressure to do better is coming from employer groups and the patients themselves. Mid to large size employer groups are demanding change, and one way they are facilitating that change is to eliminate the Payers. As of 2015, 83% of covered workers at larger firms are enrolled in plans which are either partially or completely self-funded. It?s as if employers are standing up and saying ?we want quality care for our employees and if you can?t deliver, we will take our business away from you and pay for it ourselves?. 20

And today?s patient is absorbing more of their healthcare costs than ever before. With coinsurance and large deductibles, patients are increasingly becoming a driving force for determining physician selection based on total out-of-pocket cost to them. While this can often provide a cost savings benefit to the Payers, the decisions of today?s pro-active and educated patient can push the insurance company into the role of responder, rather than decision maker. Looking at this from the perspective of the Payer, are you seeing the need to accommodate the demands of the employers, moderate patient impacts, and manage the ever-growing list of Federally mandated programs and requirements? Payers are responding to the direction of the industry, and this changes the way they will interact with your practice.

An Evolving Direction Most of the larger insurance companies now utilize tiered networks, a method of stratifying providers based on the average cost of care they provide and specific quality metrics. If your cost of patient care comes in above average, or even if your patient satisfaction levels do not meet the Payers standards, you will be sorted into a specific tier and patients will be discouraged from seeing you. In a tiered network, patients are still welcome to seek care with providers in any tier, as long as they are willing to pay more for that care in the form of higher coinsurance and deductibles. And if your patient?s employer contracts for narrow networks, you and your practice may even be excluded as an option altogether for a number of patients in your area, negatively impacting your patient rolls. This tiering strata is increasingly being utilized to control costs and prohibit provider choice. In 2015, 17% of employers offering health benefits have high performance or tiered networks in their largest health plan. Ultimately, this means you have to work harder to ?qualify?to see a large amount of these patients. Perhaps the biggest impact to your practice is the use of new payment models by both insurance companies and Medicaid/Medicare Payers. This is a one directional push away from typical fee-for-service and towards payment based on the meeting of quality metrics and pay-for-performance (P4P). These payment models demand that your practice show the value of your care in the form of lowered health costs and less resource utilization, such as the emergency room or frequent high cost radiology tests. These metrics must be proven per patient and practice wide to qualify for performance incentives and per-member-per-month payments. Of greater impact, is the emerging policy of no-payment or negative adjustment penalties for missed 21

With just a quick look at how the Payers are evolving and transitioning, it?s easy to see the long-term impact to your medical practice. How can transforming to a PCMH mitigate these impacts and ensure a valuable return on the efforts it requires to transform?

quality and cost metrics. Not only could your practice miss the mark on receiving incentives, but soon we will see these penalties become a reality in which your practice must pay a percentage of revenue back to the Payers. In addition, the legal structure of your practice dictates how Payers provide reimbursement and referrals. Practices within Clinically Integrated Networks (CINs) and Accountable Care Organizations (ACOs) are preferred by the Payers, as these structures are specifically designed around lower cost and performance metrics. Recognized Patient-Centered Medical Homes are also viewed as bringing value to the Payers, even though these may be independent or associated within smaller organizations.

PCMH and Your Practice Before diving right into the benefits in contracting and payments, it?s important to note that the value of a Patient-Centered Medical Home is quantifiable in multiple areas. The benefits start right in the center with the patient, bringing exceptional added value of improved medical care, increased access and enhanced communication. But moving outwards from this center, the activities that surround the patient

ÂŠ Marvel Studios/ / Paramount Pictures

Source: www.medicaid.gov

and the newly implemented policies and procedures can have a significant financial impact on the practice.

M edical Hom e

For example, the transition to team based care will ensure that all clinical staff are working at the top of their license, performing those functions that require a specific skill set, and not tasks that a lower paid staff member can accomplish. And the majority of tasks performed in clinical and non-clinical areas will have been reviewed, streamlined and implemented into a written protocol, creating efficiencies in staff time and resource use. minimizing calls to the office and staff time. Patient recall reporting can significantly increase the number of patient visits annually, and many EMRs and practice management systems have remote log-in capabilities that allow the provider real-time access to patient records, which may help minimize urgent care visits outside of your practice. Additionally, third party applications like PerfectServe?s Charge Capture now allow the provider to automatically bill for after-hours contacts and phone calls at the time of contact, eliminating the need for time spent in next day documentation. An upfront investment may be required for upgrading the technology in the practice, however this will provide a financial return in the long-term if you do the research before you buy.

Another area where practices see tremendous value is the ability to moderate risk: -

Shared decision-making with the patient and increased communication between team members decreases non-compliance and the potential for safety mistakes or miscommunications. Tracking and follow-up procedures are assigned and routinely completed, ensuring that the provider always has the information needed to properly diagnose and treat. Medical record documentation will be more thoroughly completed and routinely monitored with progress and performance reports. Evidence-based decision support and treatment algorithms, along with treatment care plans will be further integrated into the care of your patients.

Getting Paid The shift to pay-for-performance (P4P) and value based compensation is not just today?s target. These types of reimbursement models are increasingly more evident across all Payers, and the Federal programs are leading the charge to continue this trend in the future. One big example of the trend is MACRA, with its two different payment tracks both being linked to specific metric reporting. Another, the Oncology Care Model (OCM), is now expanding accountable care into Oncology, with payment arrangements

The good news is that malpractice underwriters are catching up with this trend and may soon be offering specific coverage discounts to recognized medical homes. The use of technology in a medical home also brings tremendous value to your practice. Patient portals allow for self-scheduling and the ability for patients to view their own test results, 23

Source: https://qpp.cms.gov/docs/Quality_Payment_Program_Overview_Fact_Sheet.pdf

coordination fees and bonus incentives for performance targets. For example, Humana?s Medical Home Program offers a care coordination payment to practices that meet the reward measures on a quarterly basis, in addition to incentives for HEDIS measures and other shared savings opportunities. And achieving PCMH recognition can automatically align your practice for participation in some of these programs, without the need for contract negotiations. In other programs, such as in the MACRA Merit Based Incentive Payment System (MIPS), your recognition qualifies your practice for specific weighting in certain categories. Transforming your practice to a recognized Patient-Centered Medical Home is financially worth the effort. To secure pay-for performance and quality incentives, your practice must be

that include financial and performance accountability for episodes of care surrounding chemotherapy administration. On the insurance company side, the majority of companies continue to expand programs that link performance to reimbursement. A 2014 survey of Blue Cross and Blue Shield companies revealed that nearly $71 billion in medical claims spending was tied to models that reward quality. Did your practice benefit from this and other quality reimbursement models last year? A recognized Patient-Centered Medical Home is well situated to reap the benefits of these programs. Most of the larger Payers, as well as Medicare and state Medicaid plans, have specific programs that provide enhanced reimbursement in the form of per-member-per-month care 24

able to leverage actual performance and actual quality during contract negotiations. Your PCMH recognition assures Payers at the beginning of negotiations that you have already committed to meeting the standard that is expected. If a Payer program is not already in place, focus negotiations on: -

How your recognized PCMH standing will lower Payer costs for care. Provide data on how your practice stands out in this area, possibly with lower emergency room and urgent care visit numbers or a referral process that encourages patients towards Payer preferred specialists. Special programs that your practice provides. For example, you may already provide excellent asthma education and management through an RN or NP. Take advantage of this and create a written policy for this activity, patient materials, and market this program, highlighting any successes in patient care and cost utilization. How your practice uses your technology to improve care. Recalling your patients for follow-ups and care opportunities isn?t just good for the patient ? the Payers know that a healthier patient means less utilization and lower costs for them.

Outside of negotiations, proving your practice?s value routinely through cost savings on claims data and high patient satisfaction scores will ensure that you place well in Payer physician profiling and tiering stratums. You need the Payers to drive more business to you, and you need to decrease the risk of losing patients when their employers implement tiered networks. The competition is waiting around the corner to pick up any patients that have left your practice, so make your Medical Home a proven quality environment for both the patients and the Payers, and continually look at ways for improvement and how your well-earned PCMH recognition can bring lasting financial and other benefits to your practice.

- ROLL CALLAt The Verden Group, we assist many practices in achieving National Committee for Quality Assurance's Patient Centered Medical Home and Specialty Practice Recognition programs. Congratulations to our clients that have recently achieved NCQA PCMH

Pediatric Care of Rockville

level 3

Friendship Pediatrics

level 3

Hirsch Pediatrics

level 2

Taskinul Haque, M.D.

level 3

Parkside Pediatrics (Five Forks) level 3

? PAYER NEW S ?

Lucien W. Roberts, III | MHA, FACMPE

WHEN PAYER COLLABORATIONS BECOME PROVIDER SOLUTIONS

Our friend and colleague, Lucien Roberts, sat down to speak with John Syer, Anthem Regional Vice President for Provider Solutions, to discuss the state of collaborative efforts between Payers and providers. Mr. Syer?s title?s suffix, Provider Solutions, conveys a new era in Payer/physician relations. He?s no longer ?network management?or ?provider relations?? the role of John and his team is to create and nurture win-win solutions with physicians as their partners. Anthem wants physicians to succeed in this brave new world. Indeed, its success and your success are intertwined as never before. Anthem is developing teams to work with physicians, sharing tools to make care coordination and cost effective care feasible even for smaller groups, and reaching out to help practices succeed.

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In speaking with John and his counterparts at other insurance companies, the move from fee schedules based upon a percent of Medicare?s fee schedule becomes clear. Many contracts will retain a percent of Medicare base calculation, but don?t expect across-the-board increases going forward? commercial Payers are on the same path as Medicare. Groups who demonstrate cost-effectiveness, high quality, and caring healthcare will be rewarded. Those groups who fail to do so will be marginalized, though it?s unclear whether Payers will reduce reimbursements, exclude groups from networks, or take other measures. Cost-Effective, high quality, caring ? physicians must do well in all three measures to thrive, so let?s take a look at Anthem?s take on each. 26

It is problematic to attribute patients to specialists, particularly when a patient sees a multitude of specialists, so specialists will be measured on their own performance. Site-of-service choices will be huge. Using preferred (i.e., low cost, high quality, caring) options for imaging, lab, and therapies will be critical to achieving cost savings and thereby financial rewards. Taking the easy out of sending non-critical patients to the ER will have an adverse impact. To the consternation of some hospitals, Anthem has begun an overt effort to reduce its infusion spend. It still authorizes Remicade and other recurring infusions, but only if these infusions are done in a physician?s office or other outpatient setting. Infusions done in costlier hospital settings are no longer authorized. In markets where other office/outpatient options are not available, Anthem will help physicians find or develop alternatives. As I said at the beginning, Anthem sits on our side of the table quite often these days.

COST EFFECTIVE HEALTHCARE Primary care and specialty care are different beasts and will be graded separately. Primary care providers will be attributed patients who use them as their primary care physician.This sounds straightforward, I know, but many attribution models are far more complicated and far too complicated. Anthem will take a two-year look back at the medical costs of this attributed patient population and use that as the cost basis for improvement. Thus, a primary care group will be measured against a two-year old snapshot of itself rather than against an esoteric target that bears little direct relevance. It?s not where you started so much as where you finish. Outliers ? those patients with unexpected catastrophic healthcare costs ? will be excluded, so as not to penalize a group?s overall performance. Primary care groups will receive a PMPM (per member per month) payment for proactive clinical coordination. This payment compensates providers for the work done outside of the face-to-face patient visit: 24/7/365 availability, active care coordination, and a group?s investment in its own population healthcare management infrastructure. One innovative facet of Anthem?s plan is to give practices access to some of its care management tools. A practice will be able to see notes made by Anthem care management nurses, check if a patient is really filling his prescriptions or getting therapy as recommended, etc. Sounds big brotherish, perhaps, but aligning our efforts with Payers?efforts to keep patients healthy and out of the hospital makes sense.

Formulary selections and use of generics will impact both primary care and specialty physicians. Residual savings will be part of the two-year spending look back. Initially, there is no downside risk. Groups who do not demonstrate cost effective healthcare will not be penalized, but they will not receive increases, either. I anticipate downside risk will be prevalent in most contracts within five years. Groups who do well and desire a greater share of the savings pool will be offered the chance, provided they are willing to take some downside risk, at some point in the near future.

HIGH QUALITY

One caveat: the clinical coordination PMPM must be earned. Practices that do not engage in proactive care coordination will lose these payments, making it harder to achieve cost effective healthcare.

Anthem will measure quality using broadly accepted evidence-based clinical practice guidelines and not arbitrary or market-specific guidelines. This use of ?best practices?,many 27

developed by our professional societies, is an important step, I believe. HEDIS (the Healthcare Effectiveness Data and Information Set), NQF (the National Quality Forum,) and AHRQ (Agency for Healthcare Research and Quality?s National Guideline Clearinghouse) are sites where guidelines used by Anthem and others may be found. Quality will be judged relative to these national guidelines and not to the group?s prior performance. There will be different performance thresholds, with groups performing better on their quality metrics having the potential for greater financial reward. Quality is in the eyes of the beholder, though, and the beholder is increasingly the patient. That is where ?caring?fits into the equation.

CARING The hypothesis is simple: 1. Patients who like their doctors are more likely to be compliant patients; 2. Compliant patients are healthier patients; 3. Healthier patients are less expensive; 4. Less expensive patients are those who like their doctors, so let?s pay these doctors more. Anthem will survey patients using a tool that closely resembles the PQRS-CAHPS (PQRS Consumer Assessment of Healthcare Providers and Systems) patient survey adopted by Medicare. Your practice will be graded by your patients on the caring part of the care they receive. -

Did you listen carefully? I believe listening with your eyes is just as important to patients as listening with your ears. Did you show respect, including respecting a patient?s wishes for sharing their PHI? Did your staff treat your patients with courtesy and respect? Nothing turns a patient off quicker than being greeted rudely or treated like a number and not a person. It has a direct bearing on a patient?s perception of you and the quality of the care you provide. Did you see a patient within fifteen minutes of their appointment time? If not, did you apologize to your patient for being late? Did the patient get an appointment as soon as they needed one? Waiting is the hardest part. Did you discuss with the patient why they might need a procedure or medication as well as why they might not? It?s about engaging the patient in their own healthcare decisions. Did you or your staff discuss the cost of prescriptions with the patient? It?s better to prescribe an alternative the patient can afford than one they cannot and thus will not take. 28

I know it?s hard to get all of this done in a fifteen-minute appointment. Therein lies the challenge and the opportunity. This I know: manners never go out of style. Simple kindness conveys caring as much as anything. Communication with patients ? letting them know what to expect and then meeting these expectations, letting patients know when a provider is running late, calling patients to check in ? is the other primary aspect of conveying caring quality.

meeting cost effectiveness, high quality, and caring targets will be a prerequisite to favorable terms. I asked John about unique, practice-specific bundling options (i.e., a fixed price for a package of a consult, nutritional counseling, and a customized work-out schedule). He acknowledges the merit of such ideas but was upfront in acknowledging the difficulty in making group-specific carve-outs work. Benefits design (how insurance plans are packaged and sold) is not geared toward such bundling innovations at the individual group level? yet. That day may come.

CLOSING THOUGHTS The opportunity for financial reward lies in doing well in all three areas. In this case, the old adage ?Two out of three ain?t bad,?does not apply. Each group must meet baseline targets in all three areas to be eligible for financial reward. ?Group?is an important word in these models. Cost effectiveness, high quality, and caring are measured in aggregate at the group level. A most cost effective group can be brought down by the performance of its own outliers and miscreants. There will be an additional consequence for specialists, as failing to earn designation as ?preferred?will result in fewer referrals. After all, primary care doctors are being incented to use cost effective, high quality, and caring specialists.

The results of Anthem?s beta testing of its model have been impressive on the Cost Savings, High Quality, and Caring fronts. Patients are getting better real care (cost, quality) and better perceived care (caring). What impresses me most, though, has been the reaction of beta sites such as my primary care doctor?s group. They see Anthem as a partner in success rather than an obstacle or enemy. Anthem is an ?open book?if you will, sharing with practices as never before in an effort to produce better care. My own experience has been the same. I am optimistic and believe in John and his team.

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Size still matters, but not as much. Larger groups with a dominant market presence remain in a better position at the negotiating table, but 29

? FRONTLINES ?

CLICK ON THE Susanne Madden| CEO & Founder

MICROPHONE TO LISTEN

A Conver sat ion wit h Chr ist oph Diasio, MD In our latest ViewPoint podcast Susanne speaks with Dr. Christoph Diasio about how they successfully incorporated mental and behavioral health into Sandhills Pediatrics in North Carolina. Read an excerpt from their conversation below or click on the microphone above to listen to the podcast. Madden: Tell us a little bit about why you felt it was important to incorporate this into your practice. Was it a need that wasn't being fulfilled in your community that really was the driver for that, or was it really more along the lines of hey, it?s fun to do and we can do it? Just explain to us a little bit about the thinking behind actually taking that next step to bring it in-house. Diasio: I'm going to answer ?C?, all of the above. Pediatricians do the work that we do because we want our patients to do well. We are clearly not motivated by money unless we were sorely misguided and strange. I think the thing that makes it fun is to see patients that you've had struggle with severe mental illnesses, who have basically just hit the wall of being unable to get care, to then see those patients thrive once they have access to excellent mental health care, that's the part that makes it fun. The business part, those sorts of things were where the challenge was, but as far as being interested in mental health or having a friendliness to it, that's something that goes back into the long history of the practice. One of my senior partners, Bill Stewart, has been somewhat jokingly referred to as the amateur child psychiatrist for our county for the last 30 years. We had a practice that probably had more mental health problems than maybe an average pediatric practice. The other thing I probably should introduce is that we are a practice in a semi-rural part of North Carolina. We're one of the major providers of pediatric care in our county and beyond. And so we already have this pool of patients who we knew were struggling with mental health, and we had doctors here that were just general pediatricians that were just doing the best they could going to continuing 30

Click image to read Dr. Diasio's bio.

education, trying to get them help because there really wasn't very much in our county. We absolutely saw a need that wasn't being filled. Then some of the mental health clinicians who were in town did things that we didn't really quite agree with, but we were ignorant enough about mental health that we couldn't really tell whether it was good or bad or just sort of okay care. Basically, an opportunity presented itself to bring in mental health, and we jumped on it with both feet. It was really that we felt there was a large and unmet need and we were delighted to be in a position that we could help our patients get care that they really need. Madden: Now in thinking about this and saying okay an opportunity presented itself in terms of how to manage these patients better, smarter, more integrated, was there a model that you could follow for this or did you really have to build that from scratch yourselves and figure out your own path? Diasio: Well, we make the path by walking, so yes, we made the path by walking. Basically, we had a child psychiatrist who picked up the phone and called us and said, "I'm moving to town for a job opportunity with my husband. Would you be interested in hiring me?" We said, "When would you like to start? What would you like? We'll do it any way you like." 'Cause we knew what kind of demand there was. If you had come to me five years ago and said, "Hey, Christoph, why don't you integrate mental health?" I would have thought about let's bring in the likes of a clinical social workers. Let's start small. One of my general management approaches is to try to not miss opportunities and to be in a position that if there's an 31

opportunity, you should jump on it. This particular individual did an extraordinary job and was just ... Sometimes it's more about the right person than the degree or licensure, and this person immediately got our culture, understood what we were trying to do and how we were doing it. With that, we very rapidly built up a program from having a child psychiatrist, to adding two psychiatric nurse practitioners in a year's time, to adding a licensed professional counselor, to added a PhD psychologist. We're continuing to expand, so it's been a very rapid launch over the last three years into this program, so no, there was no model that we followed. If you look at most of the work on integrated mental health care, it's all around the practice keeping the simple to moderately severe mental health. We do it the other way around where we keep the moderate to severe because there's more options in our community for pediatric patients with mild mental health problems. We end up taking care of moderate to severely ill kids because there's not a lot of other options for them. In our community, we've done it precisely backwards from what most of the stuff you read talks about doing integrated care. More . . . .

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VIEWPOINT MAGAZINE ONLINE Online at www.VerdenViewpoint.com you'll find expanded content, video, images, tips, interviews and more. Watch for links throughout the magazine or simply click on the link above to explore.

W HA T CA N YOU FIND ONLINE? -

Engaging audio podcasts Video interviews and industry commentary Our Graphic ViewPoint image gallery Popular articles from the Group's blog Susanne's 'Pearls' articles from Physicians Practice magazine Frontlines: Stories from our clients, colleagues and consultants Every issue of ViewPoint released to date

Look for this 'button' throughout the magazine for downloadable PDF versions of articles.

K TO CLI C A D RE K BA C ES I SSU

PODCA STS

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www.ver denviewpoint .com 32

YOU' RE ONLY A CLICK A W A Y FROM GREA T A UDIO CONTENT.

? SPOTLIGHT ?

Heidi Hallett | Communications Director

TECH TRENDS TO WATCH Our 2017 Forecast

The use of cutting edge technology is nothing new in the field of medicine ? last spring we told you about some of the futuristic devices and technologies that are at the forefront of exciting scientific exploration ? and as we wrap up 2016 we?re taking a look forward at some of the tech trends we think will make a big impact in the coming year. You?re likely already familiar with some of this tech, such as telemedicine and wearables, but are you ready for it? If you answered anything but ?yes?, you?ve got some catching up to do; your patients and their families are choosing to use new tools and tech to manage their healthcare needs now more than ever before.

mHealth isn?t the future, it?s now A recent survey of healthcare consumers sites that ?80% of customers who have communicated real-time via a mobile app prefer this method to a traditional office visit.?For millennials and other digital natives, mobile is the preferred methods for communication and if you?re not providing those services they?ll find a provider who will. More and more baby boomers, from busy working parents to over-worked executives are choosing the speed and convenience of text messaging over phone calls. In fact, the development of mobile health apps, or mHealth, has been so prolific that the AMA has implemented a set of policies designed 33

to ?foster the integration of digital health innovations into clinical practice.?The broad-ranging policies state that the technology used must, among other things, support patient-centered delivery of care, establish or strengthen the patient-physician relationship, promote care collaboration and support data portability, as well as ensuring that all services are compliant with state practice laws.

demand for telehealth services increases, more Payers are offering these benefits. Expectations for telemedicine is high and a recent article credits not only consumer demand but also Payer demand and proven clinical effectiveness as some of the major driving factors. Despite the evidence that telemedicine is on the rise there are still strides to be made. In many ways, this new to healthcare is not accessible to those who need it most; the elderly and low-income families, many of whom do not have the skills, or indeed the access, to use the internet. Practices that can provide assistance to seniors in achieving a basic level of internet literacy will be ahead of the pack in terms of making the most of telemedicine for an aging population.

Not all mobile apps are subject to FDA regulations so the playing field is muddy. Without rigorous evaluation before launch, the AMA has raised concerns that many mHealth apps on the market may be cause for concern when it comes to quality and patient safety. The question of the security and safety of mobile apps is said to be one of the reasons not all practices are jumping on the mobile wagon just yet ? but waiting isn?t the answer. As the patient population ages and more and more consumers demand mobile healthcare services, there is a real and present need to address these concerns and get more physicians onboard with mHealth.

Many seniors and their loved ones are already finding comfort and security with the aid of mobile telemedicine devices. While emergency medical response services have been around for decades (who can forget the LifeCall commercial from the 80s?) companies like Eddy Health Alert system are bringing updated tech to these live-saving devices. Available as watch-like wristbands and pendants, the new wearables use the wifi and GPS technology allowing for immediate two-way interaction in a medical emergency. With the push of a button, family or caregivers are notified and medical help will be sent as required.

Telemedicine positioned for explosive growth Secure texting with a patient, teleconferencing with colleagues, and real time video chats between patient and physicians are all forms of telemedicine. Telemedicine is a lot of things but one thing it isn?t is a passing trend. As consumer

responsible for enormous breakthroughs in more industries than we can count, from product manufacturing to aerospace and aviation, environmental sustainability and even the culinary arts. Some of the most exciting and cutting edge technologies to come from 3D printing have been in the world of healthcare. The advancement in prosthetic limbs through 3D printing is nothing short of remarkable. Research and trials on 3D printed prosthetics abound and the rapid growth in this sector is in part due to the portability of 3D printers. Patients no longer need to travel great distances to get fitted for prosthetics when the technology can come to them. Two of the greatest advantages to using 3D printing are affordability and speed of production, making both patients and Payers happy. Students at UCF have developed a 3D prosthetic arm for about $300 ? as compared to the $40,000 cost of traditional prosthetics ? with the ultimate goal being free limbs for any child who needs one:

Wearables 2.0 A quick Google search for Fitbit or Apple watch will tell you sales for fitness and productivity wearables are down. While manufacturers are challenged with finding ways to get repeat customers and brand loyalty, the healthcare industry is taking up the torch and revealing new, smarter, more life changing uses for wearable tech. When experts from the medical field collaborate with the makers of wearable tech, incredible advances happen. Imagine a patch-style wearable that can monitor heart rate, respiration, wheezing and coughing. That?s what the team at New York start-up Health Originals created with their ?intelligent asthma monitoring system?ADAMM, now in clinical trials. Data is sent directly to a smartphone alerting the wearer to changes in bodily symptoms and advising on medication. What if you could treat your chronic pain patients without writing another prescription for pain medication? Quell, a relatively new wearable device has delivered very promising results with clinically proven neurotechnology that stimulates sensory nerves that then carry neural pulses to the brain, triggering the body?s natural response to pain. Currently being marketed primarily as a fitness health-tracker, the technology behind smart earrings has enormous potential in the healthcare arena. The current models already include heart monitoring with Bluetooth connectivity to your smartphone so surely monitoring of other critical symptoms is possible. Wireless hearing aids that can send sounds directly from your smartphone or tablet to the wearer?s ear already exist so how long before that tech gets paired with smart earring tech?

A recent article about how 3D printing is changing the world reported that, ?Of all of the other industries that 3D printing is changing for the better, the most inspiring headlines are coming from its application in the world of medicine and healthcare.?The article shares links to over three dozen articles about amazing advances in medical technology due to 3D printing and one of the most compelling is the story of a 3D printed model heart that helped surgeons in Florida perform a life-saving

3D printing saving lives It?s no secret that 3D printing has been one of the biggest tech advances in recent years: it?s 35

operation on a baby. By using a 3D model before surgery, doctors can practice on an accurate model, vastly increasing chances for success in the operating room.

The quest for tomorrow?s tech continues One of the greatest things about the race to provide better, more efficient, more life-changing tech is that the track never ends. With every new piece of technology that goes from imagination reality, there is another seed of advancement around the corner, taking root. In the near future diabetics will no longer need to prick their skin to test their sugar levels. Researchers in Australia are already working on an implantable device that will automatically read a patient?s levels and release insulin as needed. While some patients may feel uncomfortable with the idea of an implanted device with the ability to ?read?and respond to bodily symptoms as they happen is quickly changing minds. As the concept of internal devices becomes more mainstream, so too does the thinking in terms of the delivery method into the body. Still in its early stages, a new ?smart pill?that acts like a tiny computer in your stomach can send electronic messages to a patch-like sensor on the patients skin. When the digital pill comes into contact with stomach acids it automatically starts sending data to

physicians, caregivers and family members alerting them to when and if a patient is taking their medications. Of course, wherever there is access to personal data, there is also a concern about how that information is going to be used. Insurance companies are (unsurprisingly) very keen to see this type of data as it could help them to target non-compliant patients and potentially move them to a higher-risk category with higher premiums. But for many, concerns about insurers having access to their personal health data is a distant concern when stacked against the life-saving capabilities of this new technology.

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VIEW POINT Edit or -I n-Chief : Susanne Madden | Edit or ial, Design and Pr oduct ion Manager : Heidi Hallet t | Cover Design: Scot t Hodgson Cont r ibut or s: Susanne Madden, Julie Wood, Heidi Hallet t , Tif f any Laur ia, Rober t Gof f , Lucien W. Rober t s ViewPoint is a seasonal publicat ion, dist r ibut ed digit ally ÂŠ The Ver den Gr oup 2016 38