ViewPoint Volume 2 Issue 3 Autumnal Equinox 2016 by VerdenGroup

CONTENTS Volume 2, Issue 3 - AUTUMNAL EQUINOX EDITION 2016

Welcome

Big Impacts

Art of . . .

One Nut At A Time

Clinical Integration

Building

During the busy Fall we look to the clever & industrious squirrel for motivation For him and for us, this season is about planning, hard work, and building for the future.

Some say Clinical Intergration is a radically different approach, but Robert Goff explains why the focus should be on the opportunity for a bigger payoff in the future.

Susanne talks about why and how we build. From indie start-ups and Super-Groups, to growing your practice and your community, this issue is your bluepring to building big.

Legal Notes

Connect

Pro Tips

Super Group Formation

Connect with us online.

Building Out New Lines Of Business

Super-Groups are a great way to stay competitive. Guest columnists Daniel Frier and Julia E. Cassidy explain the benefits and 3 key phases of formation.

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

Susanne Madden asks you to take a good look around. You might be surprised at how many ways to expand your practice are already within your reach.

ay York State Thruw Photo Credit : New

Authorit y

22 TEAM AND CONTRI BUTORS

Industry News Medicare & Hospital Outpatient Prospective Payment Systems How Does it Affect Your Practice? Tiffany Lauria explores the possible impacts of parity payments on hospital-owned practices and what your next steps should be. Susanne Madden

Julie Wood

Heidi Hallett

Spotlight Urgent Care Everywhere Urgent Care is no longer a trend & the accelerated growth shows no signs of slowing. Tiffany Lauria talks about how UC's have changed and why they may not be a bad thing after all.

Ahmed Nawaz

Tiffany Lauria

Scott Hodgson

Robert Goff

Julia E. Cassidy

Daniel Frier

30 Check Up NCQA In Your Community Tiffany Lauria explains why integrating a multi-level system of patient interventions enhances total delivery of care, and how to build out services for your community and tap into community programs.

ViewPoint is a seasonal publication produced by The Verden Group and distributed digitally. Print copies available by request. Please contact us for pricing.

36 Payer News

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.

Health Insurance Company Mega Mergers (& Freezes!) What's at issue with the proposed mergers? What does it mean for your practice? Heidi Hallett & Susanne Madden unpack the concerns and the likely impacts on contracts, billing & revenues.

The Verden Group delivers expert services and advice to meet needs across your practice. From contract management to social media management, start ups to super groups, PMCH to research studies, we are your Partner In Practice.

Frontlines Successful Practice Acquisition Susanne Madden talks to Dr. Bonnie Feola about practice acquisition and how she successfully transitioned a practice with a great history into one with an even greater future.

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.

NCQA Update

Read past issues of the magazine and additional content at: verdenviewpoint.com

Roll Call, Updates from NCQA & More Take a look at the most recent Practices to achieve NCQA Patient Centred Medical Home recognition, and read the latest updates from NCQA. Plus: NCQA's take on MACRA. 3

? W ELCOME ? I don?t know what it is like for you but Autumn always seems to be the busiest time of year for me and the team. It may be that with passing of the long, hot days of summer, the cool fall air energizes us and puts some urgency on preparing for the long, cold season ahead. At times, that sense of urgency can feel overwhelming so I have a saying for those extra busy times: ?be like a squirrel and tackle one nut at a time.? Whether your goal is building stores or building out new lines of service at your practice, the important pieces are the same: know your environment, have a solid plan in place to get the storing/building done, and always keep growing, even if its incrementally. To help us illustrate the building theme in this issue, we drew on some local inspiration - Nyack (our HQ) and New York City. Right outside our door here at The Verden Group office is the massive project of building the New NY Bridge to replace the Tappan Zee Bridge. The good folks at the NY State Thruway Authority gave us permission to use their photos for the cover and table of contents so that we could share this with you. Next, we asked our good friend and exceptional photographer, Andy Conrad, to help us out with the rest. Andy is based in Nova Scotia, Canada, and takes an annual pilgrimage to NY every September to see what his lens can find. We are delighted to feature the talents of our tea-drinking (never coffee!) friend. You can learn more about him and how to view his other work (which includes illustration, design and photography) on page 11.

SUSANNE MADDEN | EDITOR-IN-CHIEF 4

? BIG IMPACTS ?

Robert Goff | CEO University Physicians Network

CLI NI CAL I NTEGRATI ON The Oppor t unit y, The, Challenge and The Alt er nat ive (Econom ic Er osion)

Despite some positive slowdown in health care costs year over year, costs continue to defy gravity as they are still increasing at double the pace of overall inflation. The projected nightmare scenario is that by 2045, on the Federal Government level alone, health care and social services will consume 100% of the current tax revenues of the country, leaving the coffers empty for any other services supplied by the Federal Government. With fee-for-service reimbursement fully discredited, and blamed for nearly all the evils of healthcare, from fragmented care, unnecessary services, poor quality, government and commercial payers continue to seek models that will ?bend the cost curve?downward. They believe that there is sufficient money going into the healthcare system, but that those investments are inefficiently utilized. Both government and commercials payers have tried to bring healthcare spending under control through such schemes as utilization management, prior authorizations, retrospective reviews, and rate freezes. It hasn?t worked. Intrusive administrative approaches have become expensive hassles to medical providers, added barriers to needed care, and added costs without meaningfully demonstrating cost savings or improving quality of care. So a new ? some would say radically different ? approach is being tried next. Clinical integration (CI), with care provided through such entities as the Accountable Care Organization, is where the next big 5

push is. Clinically Integrated Networks utilize payment bundles and performance based metrics, placing the problems of cost and quality on the medical providers, physicians and hospitals. The thinking is: let the provider community organize to deliver care under a financial model that puts them at risk for the cost of care and the quality of the care provided. After all, providers are closest to the source of the issues, and surely can adapt and impact change better from the ?inside?than continued failed interventions by outsiders?

The providers that organize themselves will have a wide range of flexibility in how they operate and, provided that the goals of meeting quality measures and cost targets are met, economic rewards will flow. The motivation of both government and commercial payers is of course to shrink the cost in the volume based fee-for-service world and they believe that if providers are at risk for costs and quality then they, being closest to the actual delivery of care, can produce better outcomes in quality and cost.

The Opportunity

The commitment by both government and commercial payers to contract on a value based purchasing (VBP) model is real and aggressive. Medicare has already committed to moving the majority of its ?distribution of dollars?to payment models that are based on value, and a coalition of the major national commercial plans have likewise committed to move in the same direction.

It may sound tough, but it is an opportunity for the providers to take control of their future and design a delivery program that works, that they themselves control, and if successful, also enjoy an economic upside while delivering care in a more cost sustainable manner and of a higher quality. The mantra adopted is the Triple Aim: improve care for the individual, improve population health, and reduce per capita costs.

In other words, Payers are seeking to move contracting to provider groups that are prepared to accept responsibility for costs and quality (which is how value is being defined). Provider groups wishing to pursue such contracts are going to have to become clinically integrated in order to be successful.

There is a lot in the Triple Aim that harkens back to the days of capitation, global capitation of physician groups. Here is an economic target: if you meet it, you economically benefit. It is the same general concept here, with the addition of quality measures.

The Challenge Success in clinical integration is a challenge. The dynamics to get the rewards and the money to replace the erosion of fee-for-service payments needs to change dramatically. It is no longer the physician as Lone Ranger. What you do and how you do it impacts the entire ?team?which includes ALL of the physicians in the clinically integrated network (CIN). Individual performance will matter to you and to the entire group as your participation is assessed since ?one bad apple can spoil the barrel?. In simple terms, clinical integration models share a common structure of providing medically necessary care at an aggregate cost. Those costs attributable to the patients in the ?panel?are generally growing at a rate less than the market against which the CIN is competing. Successfully pass the quality gates ? a series of proxies for delivering quality care, such as the traditional HEDIS measure of things such as levels of vaccinated children, A1C levels, mammography screenings, etc. ? and what is available for economic reward is based on the aggregate performance of the entire physician and/or hospital performance of those in the CIN. If the collective is not successful, then no one earns any additional dollars. If there are ?earned?rewards, the CIN then determines how to distribute the dollars to those in the network. Achieving the twin goals of cost and quality can be complicated; especially if the physicians that have joined together cannot become enlightened that this is in their self-interest. Also, if those in leadership roles are unable, or unprepared, to confront physician practices that are damaging to the whole, then the model cannot produce effective results. Cost is a function of utilization and volume. It is also a function of where care is delivered and by whom. The first place that any CIN needs to look to impact costs is the use of non-contracted providers by the physicians of the CIN. For example, who is referring to non-contracted laboratories, where costs can easily run 1000% more than the same testing by contracted in-network providers? The same is true with the referral practices to specialists. Are referrals being made because of historic referral patterns, or perhaps something more nefarious? (I.e. kickbacks). Or do such referrals identify a deficiency in quality or availability of the needed among those in the CIN? Such non-par utilization did not matter much to physicians in the past, as long as their patients did not complain that such non-par referrals resulted in higher out of pocket costs. (After all, many non-par providers have been willing to waive the patient financial responsibility in return for the referral and being paid high out-of-network rates). Then there is the question of where care is being provided. Is the care delivered in the least restrictive, least costly setting? For example, hospital outpatient services are far costlier than the same service in private physician offices, or in freestanding centers. Under fee-for-service such decisions had no impact on the physician making the decision but now there is an economic dimension to decision making. 7

And then comes the hard part, the actual utilization patterns of the physicians in the CIN. This is where it really gets hard. Physician leadership is required to understand the treatment patterns of the physicians and to look for those patterns that provide the acceptable quality outcomes, with the least use of resources (costs). For example, leadership will have to address that ENT who does all of his procedures in the hospital outpatient setting, while his colleagues perform most of their procedures in less costly offices or free standing centers, or understand and address the use of multiple MRIs by certain orthopedists before surgery, while others use only one. For years, government and commercial Payers have tried, and failed, to stem costs by introducing invasive controls (prior auths, restrictions on care). It is the balance of cost and medical necessity, but now in a CIN it is the providers who are making the determination, based on their clinical judgment, and bearing the economic consequences of that decision, rather than arbitrary Payer administrative policies setting barriers.

Accomplishing all this requires extensive and effective leadership. For example, who should be the primary care physician of the chronically ill patient? Their general internist? The nephrologist, or the cardiologist? And at what point in the patient?s care should such care be transferred? Or how best can it be shared or co-managed? Similarly, a CIN will have to press for physicians to work ?at the top of their license?. That is, care should flow to the resources that can provide it in the most cost effective manner. Perhaps that patient?s care can be followed by a primary care physician, or provided by a physician extender, with follow up managed by a nurse? Determining who and how is at the heart of managing costs and care. The creation of a CIN also opens up a whole range of patient engagement, across the lifespan of the patient. Not only must the CIN take on ? either directly or through their provider network ? the outreach to engage patients for preventive care services, but they must also move away from seeing patients as dependents engaging health care providers only when sick or injured, to seeing patients as partners in care. The economics of the VBP reward the efforts associated to improve the health status of patients. That is, instead of being paid for acute, episodic care, the goal is to keep patients healthy and managed and therefore get paid for care management instead. Health plans and government have long been stymied in addressing utilization pattern differences, as they have long been afraid of the argument that ?quality?will suffer. The HMO?s have long been attacked for challenging the necessity of

It is well understood that 5% of the population accounts for 50% of health spending. To confront the high-cost patients, CINs need to build mechanisms for care management and coordination. That is identifying the high cost patient ? and with the right data, those identified as at-risk of becoming high cost ? and engaging them with the right specialists in an effort to provide needed care, while also trying to reduce the cost by such things as maintaining the health of the chronically ill, and avoiding duplication with an acute episode. 8

services, with the accusation of ?profit over people.? Now, we are swiftly moving away from Payers ?managing dollars?to providers ?managing care?and that responsibility and the consequences for practice patterns rests with the CIN collectively.

greater upside opportunity for all in the CIN. Data analytics are critical to understanding the structure of care delivery, to measure performance, and to delve deep into aberrations. As the CIN comes to understand the pattern of care delivery of its participating physicians and other providers through the use of data, it will have to confront deficiencies in the system of care delivery and, to be successful, it will have to adapt and change. For example, physicians whose patients are high utilizers of emergency room services will necessitate a deeper analysis to determine how to avoid ER use. Is it patient preference, or is it the lack of readily available physician services as an alternative? Plans to reduce these expenses could consist of working with physicians to increase hours, expand services and hours with the addition of associates, or perhaps collectively open and operate an urgent care center where needed. Out-of-network referrals on a specialty basis may identify issues with access due to capacity, or even poor scheduling practices.

The reality is that there is little to no new money being made available to fee-for-service reimbursement. Fee-for-service rates are now capped or being cut. The Role of Data To meet the challenges placed on a CIN, data is critically necessary and it has to be converted to information; timely and accurate clinical and financial information that helps to identify areas of opportunity for improvement. For example, data that will identify ?gaps in care?? those patients in need of preventive and routine services ? in order for outreach to hit the best ?targets?. It is data that will compare the treatment practices of physicians by diagnosis to identify the best practices for delivering care in the most effective and efficient manner. To obtain data, the CIN will have to engage with its physicians to obtain clinical information from the practice?s electronic medical records and with the Payers to obtain the claims histories. With the development of a database for the CIN, everything in the provision of care becomes known across the entire entity. This can be very unnerving for physicians, as their pattern of care will be exposed, and many of the knee-jerk defenses used in the past with Payers won?t stand up to the scrutiny of their colleagues. The reality is that this is how best practices for cost and quality improvement are identified and then disseminated to the specialty, with the result of a

The Alternative If a CIN can be successfully created, the opportunity that is available is to capture the revenue stream from an increasingly willing set of Payers: employers, commercial plans and Medicare and Medicaid, that are seeking organizations of providers to take responsibility for care and the quality of that care for a patient base. Those that control the patient base, control the revenue stream, and being in on its design and operation, they will be able to influence their future. Those that end up on the outside looking in, will be trying to get by on what the CIN offers. For the individual physician, being part of a CIN means being actively engaged ? engaged in working with colleagues in understanding the information gleaned from the data, and helping 9

design the best practices and protocols that evolve over time. It also means knowing that to the extent that the CIN is successful, more of the physicians?income will come from that source, and that how the CIN?s economic success is distributed, and individual physician efforts are recognized, is now in the hands of the CIN leadership. As CINs become more proficient, their performance becomes their market plan. If the CIN can demonstrate success in cost increase curtailment, and quality, payers are very interested in engaging in discussions of what you, the CIN, can do for them. And CINs as a provider response, for the first time, has empirical data to show how both quality and costs are being managed. Historically, healthcare providers have argued that they provide quality care, and perhaps they are more cost effective than others, and in reality had no data to support such statements. Now with data, successful CINs will be able to show their ?value? to Payers, and seek out new opportunities to capture increasingly larger patient panels.

of other?s efforts to shift dollars from you, don?t you think?

The efforts today to create and operate a CIN are efforts focused on the future, with the biggest payoff in the future. Currently fee-for-service remains the dominant model of payment but, the writing is on the wall ? fee for service is dying (or dead). The question is, which physicians and/or hospitals are going to seize the opportunities now, and learn how to be successful with these VBP arrangements now, while the risks are low?

The physician who remains wholly dependent on fee-for-service reimbursement will see his income rapidly erode. It will erode for two reasons: first, the lack of increases in fee-for-service rates, and secondly, physicians organizing into clinically integrated entities will be seeking to capture the patients and retain them in their organization. If you don?t want to be part of clinical integration, you will shortly find yourself on the outside, wishing you were in. As payments move from the traditional fee-for service to value-based payment model, physicians need to understand this new reality and how to get paid well in this opportunity-producing model.

Clinical integration is a game changer ? done right, it is an organization that is comprised of health care providers that are prepared to operate with a high degree of enlightened self-interest, putting the needs of the collective that is the organization ahead of personal maximization of income and control of the patient. The singular, possessive of ?my patient?, has to give way to ?our patient?. Physicians are becoming engaged in various clinically integrated entities because that?s where the money is moving and that?s where larger organizations are focusing. The reality is that there is little to no new money being made available to fee-for-service reimbursement. Fee-for-service rates are now capped or being cut. With those rates flat-lining or declining, these dollars will become an increasingly large and important portion of the physician?s compensation.

Knowing that curtailing the growth of healthcare costs ultimately means that the revenue of individual providers is going to be impacted, resistance is to be expected as the creation of the CIN can and will bring a material disruption to existing providers of care. It is much better to be part of the solution, and be in a position to know and adapt, than to be on the receiving end

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About t he im ages in t his issue: Throughout the pages of ViewPoint, you normally find pictures of nature taken by our team and our clients. For this issue, we are showcasing the photography or Andr ew Conrad, focusing on New York's architecture and buildings. You can see more of Andrew's work at www.conradt hedesigner .com . If you'd like to see more of the photography that inspires us, please visit the Graphic Viewpoint section of our website.

The Ar t of Build ing Susanne Madden | Founder & CEO The Verden Group

The nature of our work here at the Group is primarily to build things ? with clients, for clients, and building new companies for ourselves ? we are in a perpetual cycle of building and improving something. From helping new independent practices to start up, building Super-Groups, and helping our clients to grow their businesses, much of our work is building. In this issue, we asked the legal experts at Frier & Levitt to lay out the steps required to legally and thoughtfully form a Super-Group. We also turned to our colleague and frequent contributor, Robert Goff, to explain why you need to pay attention to clinical integration and how to start building the components you'll need for tomorrow, today. We also explore how to go beyond PCMH and the many benefits of building a medical home 'community'. Our team of researchers and writers also take a closer look at the market and what is happening with Medicare parity site-of-service payments, and how the insurance industry giants attempts at building new mega-companies impacts us all. Of course, with all this talk of building we had to share our tips for developing new lines of service within your primary care practice,? I believe that in order to grow you must thrive. We've also put a spotlight on the rapid expansion of Urgent Care, and talked to one savvy Pediatrician about the smart way to buy a practice. We hope this issue will give you plenty to think about and will inspire you to tackle some building projects of your own! 12

? LEGAL NOTES ?

Daniel B. Frier, Esq. Frier & Levitt, LLC

Julia E. Cassidy, Esq. Frier & Levitt, LLC.

WHAT YOU NEED TO KNOW ABOUT FORMI NG A SUPER-GROUP

The increased emphasis on cost, quality and compliance in the delivery of healthcare has simultaneously promised to save our healthcare system, while adding immense complexity to the private practice of medicine. The advent of MACRA and all of the intricate payment methodologies proposed by CMS will inevitably trickle down to commercial payers, providing opportunities for well-prepared physicians, but leaving most small, unsophisticated medical practices ill-equipped to survive in the new data-driven environment. As hospitals have scrambled to form captive practices, co-management relationships, ACOs and CINs in an almost scattershot attempt to garner market share, small medical practices will likely be faced with take-it-or-leave-it payer contracts that virtually guarantee a smaller piece of the overall reimbursement pie. These market forces have caused physicians to increasingly see the need to become part of larger networks of physicians which are able to engage as a group in alternative payment arrangement with CMS, commercial insurers, self-insured employer plans and hospital organizations. These networks must be sufficiently integrated to avoid federal and state antitrust violations, and be able to monitor and enforce compliance among its physician participants in order to enter into meaningful fee arrangements with payers. The gold standard for integration is a clinically and economically integrated group practice operating under a single Taxpayer Identification Number (T.I.N.). Commonly referred to as ?Super-Groups,? 13

these practices have proliferated over the past several years because, if formed properly, they provide many advantages over traditional practice structures in the face of the paradigm shift that is occurring in the delivery of healthcare.

Structure Super-Groups are commonly formed as limited liability companies (LLC) owned exclusively by qualified physicians licensed in the state where the Super-Group is located, with each physician owning one membership unit of the LLC. In general, all of the partners/owners of the practices joining the Super-Group will become members, and all associate physicians will become associate physicians (non-members) of the practice, and be required to enter into associate employment agreements directly with the practice. Although a Super-Group is a single group practice operating under one T.I.N, one of the frequently used methods to organize the Super-Group involves using separate ?Care Centers,?each of which constitutes a separate ?satellite?office location or group operated by those physician members of the Super-Group who are affiliated with that particular Care Center. Each formerly independent medical practice will cease to practice medicine as a separate company, and the physicians will comprise their own separate and distinct Care Center of the Super-Group. In general, a Care Center?s professional collections will be distributed to the Care Center, after subtracting its direct expenses (e.g., rent, payroll, insurance), and the Care Center?s allocable share of common overhead. This Care Center model allows the former groups to retain a great deal of autonomy while still enjoying the benefits of the Super-Group.

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Benefits of Super-Groups The basic theory behind the formation of a Super-Group is that physicians will generally be in 14

a better position to face the ever-changing and complex healthcare environment if they are part of a larger group of like-minded practitioners. Super-Groups hold a number of advantages over smaller practices, and the following list provide some examples of the advantages of Super-Groups. -

Super-Groups are in a better position to implement alternative fee structures such as bundled payments, episodes of care and shared savings because of their size, access to more sophisticated information technology and level of clinical integration. As a Super-Group, physician members may be in a better position to implement quality and efficiency initiatives that will enable it to negotiate with third-party payers than would a much smaller practice. For instance, Super-Groups have the opportunity to accumulate substantial data that may be used to implement quality and cost-saving measures that, because of the increased number of physicians in the practice, can result in substantial absolute dollar savings that can be used as a tool in pro-competitive negotiations with insurance carriers. Such programs are already in place through larger payers and ACO projects. A Super-Group may be able to invest in ancillary services (e.g., lab services) and treatment modalities without violating the federal prohibition against self-referrals (Stark). A Super-Group may have increased leverage to negotiate lower medical malpractice premiums and other costs typically incurred by medical practices. This ?group buying power?may also enable the Super-Group to negotiate more favorable deals for products and services such as bank financing, EMR and Practice Management software and medical supplies and equipment. Time consuming practice management functions, such as billing, accounts payable, credentialing, negotiating with vendors, pension administration and human resources administration, will be performed by a management company, allowing the Care Centers to focus on patient care and practice building; The Care Centers will have the ability to share coding and billing practices in ÂŠ Marvel Studios/ / Paramount Pictures order to optimize collections. Depending upon the geographic scope of the practice, the formation of a Super-Group may provide the practice with the ability to negotiate more effectively with local hospitals.

Formation Forming a Super-Group usually involves three phases of steps. The steps do not necessarily have to be followed in the exact order listed below, but these are generally the steps which a group must follow to properly and fully form the group. When practices are ready to form a super-group, the practices should engage the services of an attorney who is familiar with the Super-Group formation and who understands the various legal restrictions and requirements which must be met. He or she will be able to help you walk through these steps listed below. 15

Phase One -

Initial meetings to discuss short-term, medium-term and long-term goals and compile list of potential members; Draft a letter of intent and confidentiality agreement by and among prospective members; and Form Limited Liability Company, obtain federal tax identification number and state employer identification number.

Phase Two -

Form an Implementation Committee; Establish a meeting schedule for the Implementation Committee and other members; Implement a due diligence process through the collection and analysis of critical financial and legal information from prospective owners; Prepare an Operating Agreement and other organizational documents, which detail, among other issues, management structure, compensation formulas, committee structures, officer responsibilities, etc.; and Evaluate legal issues including Federal Stark, Anti-Kickback, antitrust issues and state law issues.

Phase Three -

Work with the attorney to draft ?care center?agreements; Establish board of directors based upon mechanism described in Operating Agreement; Select officers and form committees (e.g., credentialing, Benefits, Information Technology); Create policies and procedures to ensure legal compliance (e.g., billing compliance, HIPAA compliance); Review and negotiate vendor contracts (e.g., practice management systems, EHR contracts); Review and negotiate banking agreements (e.g., line of credit, term loan); and Legal review of managed care contracts.

While it may seem like a big change from a small practice, becoming a member of a Super-Group can bring many advantages to a practice and its physicians. It can provide a great deal of leverage in contracting and allow the physician members to participate in a number of endeavors they would not have otherwise been able to do. Super-Groups can be an excellent way to stay competitive within the ever-changing landscape of healthcare.

Frier Levitt is a national boutique healthcare law firm located in Pine Brook, New Jersey. Its 25 attorneys bring collective experience and backgrounds in pharmacy, hospital administration, professional licensing, Attorney General actions, clinical practice, and medical billing. They provide comprehensive legal services to healthcare providers, including physician groups, laboratories, surgery and imaging centers, Compounding and Specialty Pharmacies, Outsourcing Facilities, chemical manufacturers, repackagers, wholesalers, group purchasing organizations, buying groups, and other healthcare related businesses. Frier Levitt is uniquely positioned to serve as a creative and thoughtful guide to healthcare providers, offering a broad and deep understanding of federal and state healthcare laws and regulations and the industry as a whole. For additional information, visit: www.FrierLevitt.com. 16

? CONNECT ? JOI N US AT THESE EVENTS. CLI CK ON EVENT TI TLES BELOW FOR MORE I NFO.

AAP NATI ONAL CONFERENCE

UNUSUAL I NTERSECTI ONS

- HOW TO START A NEW PEDIATRIC PRACTICE IN 5 EASY STEPS with Susanne Madden & Chip Hart - VISIT THE TEAM AT THE PATIENT CENTERED SOLUTIONS BOOTH #1738 - Oct 22-25, San Francisco, CA

A 1 DAY GATHERING OF UNLIKELY MINDS TO BREAK DOWN SILOS AND INSPIRE INNOVATIVE PROBLEMS ACROSS DIVERSE INDUSTRIES. October 2, Vienna, VA

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? PRO TIPS ?

Susanne Madden| CEO & Founder

BUILDING OUT NEW LINES OF BUSINESS FOR YOUR PRIMARY CARE PRACTICE

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Are you delivering the same services day in and day out? It?s easy to stay stuck in the routine of ?sick and well?particularly if your practice is busy and financially healthy. Most of us like routine. We like to know what to expect from our days, and frankly, ?fixing what isn?t broken?doesn?t land very high on anyone?s priority list. I?d like you to reconsider. I?m asking you to take a good look at what is going on in the market around you. We have moved into ?value based care?where the emphasis is on creating better outcomes and a producing higher quality at less cost. It?s the era of convenient care, where better patient experiences are the focus and both patients and employers are looking for more; and you, dear doctors, are the ones tasked with providing it. I?m not suggesting that you let them squeeze you until you have nothing left to give ? I am talking about opportunity. From my perspective, with ?patient centeredness? comes real opportunity for you to EXPAND your services. Building out your practice?s services is about offering more to your patients while at the same time strengthening your practice through additional income streams, increased patient loyalty and retention, as well as attracting new patients.

Don?t just do it for your patients. If you want your practice to thrive, you have to grow and out-compete the market forces around you. If you think your 18

fellow specialists and hospitals are your competition, you are not seeing the forest for the trees and it?s time to take a closer look at the big picture. Retail based clinics are expanding services; urgent care companies are a growing trend and significant threat to your ?sick care?business. Add to that innovative healthcare disruptors springing up all over the country, utilizing everything from virtual visits to telemedicine and mid-level home visits to bring better services to patients. Adult primary care and pediatric practices are being tasked with becoming medical homes: practices that are able to coordinate care better, manage patient care plans, educate and encourage the patient to ?self-manage?their own care, and generally be as available as possible to patients when and how they need them. Easy, right? Of course it isn?t. It takes a lot of work and a significant investment of time, energy, resources and money to transition to that type of model. But once that transition is made, we find that our clients rarely stop there.

Bringing New Services Into The Medical Home The ?no brainer?move is to bring those services that commonly get referred out back inside the practice instead. It?s not as hard or as risky as you may think. First, look to see what services can easily be expanded. Create ?clinics? within your practice to meet your patients?needs. For pediatrics practices, that might simply mean developing areas of medicine that are already being tackled daily, such as asthma, obesity and teen issues. By developing defined programs for these areas, you can better allocate resources and create defined ?services?for those patients that need them. Examples of clinics includes:

Asthma clinics: (pediatrics and internal medicine) Develop existing staff by training them to become Certified Asthma Educators that can assist with: -

Treatment, education and management of asthma including medication monitoring and compliance. Asthma control and action planning. Spirometry and nebulizer treatments. Patient centered goals and objectives related to control of the disease. 19

Nutrition clinics: (pediatrics and internal medicine) You don?t have to hire a nutritionist in order to bring these services in-house. Provide on-site nutritional health evaluation by an independently contracted counselor instead. They can assist with: -

Treatment and counseling services for individuals, families and groups. Tie in with community based weigh-ins and ?weight watcher?program at the local YMCA. Scheduling alongside follow up visits for patient convenience.

Adolescent clinics: (pediatrics) You can do so much more to address your teenage populations by creating a more ?teenage-friendly?environment for them. Here are just a few ways in which you can make your teenaged patients feel more comfortable: -

"To thrive, you have to grow and out-compete the market forces around you."

Set aside specific hours for teens (certain days & hours) Change up exam rooms to create dĂŠcor geared towards teens (not ?kiddie?) During special teen hours, show teen-specific programming on the TV in the waiting room and put out teen magazines and toys (puzzles and games, not necessarily screens) that appeal to their demographic. Develop a program around teen screenings and additional services.

Once you?ve established programs that are a natural extension of your practice, and can see the profitability and benefit of providing them, you might consider building out entirely new areas of your practice. New business lines may include:

Lactation/ Breastfeeding Center (pediatrics) The Center can reside within your pediatric practice or in a separate location altogether. Some practices designate exam rooms as special nursing rooms, fitting them with a baby scales, changing tables, rocking chairs and recliners and even soft lighting and relaxing music or nature sounds. Breastfeeding consults are scheduled in conjunction with the newborn visit for patient convenience. You can utilize a trained employee or contract with an independent agent to provide these special services. It?s a great practice builder and new Moms love the newborn/nursing rooms! 20

Behavioral Health Center (adult medicine and pediatrics)

For some small practices in your community, your ability to provide after-hours care to their patients can help reduce their call burden; and certainly you will become their preferred choice to refer their patients to when they are closed (rather than a corporate urgent care facility). Make sure to provide excellent follow-up and pass back their patients and you should be able to enjoy on-going business from them for a long time to come. Not only will you be making better use of your space (you are paying for it 24/7 after all!) but you?ll also be competing directly with retail-based clinics allowing you to retain your patients in your practice as well as attracting new ones. Many Payers offer separate contracts for Urgent Care and often pay a set amount for an urgent care code. Note: higher copays for patients are likely! Patients prefer that you, their trusted & familiar practice, provide these services and better access to them. Why would they go elsewhere when they can get what the extended care and programs they need all in one place? Don?t just take my word for it: ask your patients what they want and need! You have a captive audience of hundreds of patients coming through your practice doors ? ask for their feedback by inviting them to share their opinion in a short survey! Keep it short and simple and poll them often. Surveys of no more than 3 questions have proven to be very successful. Your patients will be happy that you asked and you won?t be sorry for asking, either.

Use the space you already have or if you have none to spare, consider expanding to a site close by for patient convenience. If your practice population supports it, you can staff it with an employed behavioral health psychiatrist or social. If you don?t have someone in-house, you can contract independently or lease some of your space to a therapist or social worker that is looking to build their practice. This allows you to operate under defined hours with your practice staff managing the schedule and setting up appointments. Your patients will appreciate the convenience, more immediate access, improved coordination and follow-up as well as the reassurance of familiarity that comes with in-practice services and programs. You don?t need to launch a full behavioral health program ? even starting with an ADHD program and a qualified/trained nurse is enough to get things started.

Urgent Care/ After Hours (pediatrics and internal medicine) This business is typically located in a separate space, adjacent to or co-located with your practice, with a dedicated entrance in order to differentiate it from your practice (often a requirement under Payer contracts). Existing providers and staff operate the After Hours & Urgent Care Clinic ? when you close your regular practice at 5pm, you simply shift the team and all after hours care over to the clinic.

Happy building!

? INDUSTRY NEW S ?

Tiffany Lauria| Practice Consultant

MEDICARE & HOSPITAL OUTPATIENT PROSPECTIVE PAYMENT SYSTEMS How Does it Affect Your Practice?

In a proposed rule released this past July, Medicare put forward prospective regulations designed to update the payment policies and payment rates for services furnished to Medicare beneficiaries in hospital outpatient departments (HOPDs) and ambulatory surgical centers (ASCs) beginning January 1, 2017. Among these included proposals, is the intent that the majority of items and services furnished by non-excepted off campus provider based departments (PBDs) will now be paid with the Medicare Physician Fee Schedule and that physicians performing these services would be paid based on professional claims, and at a non-facility rate. This is referenced as a site-neutral payment system, bringing payments for these outpatient hospital departments in line with typical medical practice billing for Medicare patients. CMS states that this proposed payment system will be a transitional system for 2017 only while they ?continue to explore operational changes that would allow a non-excepted off-campus PBD to bill Medicare under an applicable payment system, which, in the majority of cases, we expect will be the MPFS.? In the interim, there are certain HOPDs that can continue to bill using the Outpatient Prospective Payment System (OPPS) if they 22

were already billing under this system prior to November 2, 2015. If these departments continue to offer the same services and bill from the same physical address as they did on Nov. 2, 2015, they may be excepted from the site-neutral payment provisions. Not surprisingly, CMS is requesting comments on this exception. This proposal will impact practices across the United States, and possibly your practice.

or $1.44 billion, in one year. With significant decreases in reimbursement rates coming in, providers in these non-excepted practices will likely experience lower incomes while still averaging the same number of patients. With this in mind, practices that are considered off-campus provider-based departments must look at their billing structure and consider what arrangements need to be made for seeking reimbursement in 2017. For example, if you are currently operating under a joint-billing model with a hospital, this proposed rule may now necessitate a new compensation arrangement, splitting your billing to a single model. The door is not closed, however, to investigating how to continue receiving payments under OPPS. CMS makes specific mention that if an off-campus HOPD meets all the requirements, it may enroll as a different provider or supplier type (such as an ASC or group practice), and become eligible to bill under the applicable payment system. With the effective date of January 1, 2017 looming, practices better evaluate options. Fast.

Impacts of the Proposed Rule ? Current Campus Practices The American Hospital Association was quick to release a statement detailing their disappointment in the proposed rule, ?We are extremely dismayed by the short-sighted policies in today?s proposed rule,?stated Tom Nickels, Executive Vice President of Government Relations and Public Policy, ?the agency is actually proposing to provide no funding support for outpatient departments for the services they provide to patients? In addition, CMS?s refusal to continue current reimbursement to hospitals that need to relocate or rebuild their outpatient facilities in order to provide needed updates and ensure patient access is unreasonable and troubling. Taken together, it appears that CMS is aiming to freeze the progress of hospital-based health care in its tracks.?

Impacting the Non-Hospital Practices But what if your practice is not affiliated and on-campus of a hospital? You possibly may be feeling a sense of relief, or at least a touch of eagerness to see where this proposal will land in the next few months. James Madera, Executive Vice President of the American Medical Association, laid out the AMAs position in a 12-page document addressing all of the proposed regulations in this CMS release. Specifically addressing the issue of HOPDs and payment equity, Mr. Madera states, ?the AMA believes that by creating more equitable payments between sites of service, this proposal will help offset some of the pressures that are driving small, independent physician practices to be acquired by hospitals. In recent years, there has been an increase in the number of physician practices that have been acquired by and

Is your practice currently part of a hospital system and located outside the proposed 250 yards from the hospital campus that would allow it to retain its billing status under OPPs? Many practices are, and we would expect this to especially impact specialty providers, such as Gastroenterologists and Cardiologists, who frequently work in conjunction with hospitals but may likely fall outside the proposed perimeter. The loss of the ability to bill at facility rates is significant; the Medicare Payment Advisory Commission (MedPAC) estimates that this would cut hospital outpatient payments by 2.7 percent, 23

integrated into hospitals. We believe that preserving the existence of independent physician practices is vital to our health care system.?As on off-campus practice, the smaller, independent provider offices have been swimming against the tide of hospital acquisitions, fighting to retain their independence, but to a large degree, unable to do so because of the consolidations and disparity in equity, reimbursement and access to the resources that hospital systems can provide. Will this shift in payment systems truly increase the practice's ability to remain independent? Possibly, but weighing the potential would take a much longer article, one based not only around the upcoming proposed CMS changes, but also around Payers, quality and performance incentives and a whole slew of other factors. It is possible that without a preferential payment system in place, hospitals may be less concerned about keeping their patients ?on-campus?,thus leading to the opportunity for enhanced patient flow into your practice. However, the likelihood is that in order to try and off-set the possible upcoming reimbursement loss, these patients may actually be even more tightly controlled as hospitals?desire to retain at least as much of the MPFS for themselves.

Next Steps Much of the outcome of this proposed rule will not begin to be felt until a little later into 2017; however, practices ? especially newly defined off-campus practices that fall outside the 250 yard range ? must begin to evaluate their potential for reimbursement now, and determine the steps that their practices will take in order to increase reimbursement through other means and incentives, as well as new contracting models.

Supporting Independent Practices For your pract ice t o st ay independent , you need access t o: - Medical supply pricing that larger practices & organizations demand - Vaccine purchases with the lowest prices & highest rebate program - A suite of expert services & products to best support your practice - Contract Management, HR, Compliance, Grant Sourcing and more

Wemanageyour costsand services. You manageyour patients. Find out how you can join here: www.IPMSO.org

? SPOTLIGHT ?

Tiffany Lauria | Practice Consultant

URGENT CARE EVERYWHERE?

Urgent Care Centers are now popping up everywhere. The most recent numbers (from 2014) show that 87% of existing UC Center companies acquired or built at least one new location, indicating that there is enough of a demand to sustain continued growth in this area for some time to come. From its humble beginnings in the 1970s, when forward thinking physicians rode out the label of ?doc-in-a-box?,to the explosion of growth that we have seen up to today, Urgent Care is no longer considered a trend. The Urgent Care Association of America (UCAOA) has identified 7,100 full-service Urgent Care Centers (defined as those centers offering x-ray, lab and extended hours) across the United States. In fact, this number may actually be as high as 9,000 by some estimates, if you also factor in retail based clinics. And urgent care is not only for adults? growth in the Pediatrics has been so accelerated that a Society for Pediatric Urgent Care was formed in 2014 to specifically address the needs of this population. But why has this field undergone such expansion over just the last few years? We consider it to be a matter of coverage, cost and convenience.

Coverage The Affordable Care Act may have helped to play a role. By fostering greater access to healthcare coverage, the numbers of consumers with coverage by February 2015 had grown to 16.9 million Americans. Simultaneously, the strains on limited numbers of primary care physicians helped to create a backlog of patient requiring services. With newly covered consumers trying to navigate their healthcare coverage, the convenience and access of walk-in clinics made these services an easy ?sell?.Even with high deductibles, coverage gives patients access to lower, discounted rates than if they had no coverage at all, and even with out of pocket costs, Urgent Care is affordable care.

Cost

The Associat ion of American Colleges is project ing a short fall of primary care physicians in t he range of 12,000-31,000 physicians t hrough year 2025.

A second reason for this rapid growth can be laid at the feet of the insurance companies. Not only is urgent care less expensive than emergency care (as evidenced by the 2012 Benchmarking Study by the Urgent Care Association of America), recent conversations with Anthem, Optima, and Tricare, to name a few, confirmed that facilities bill the same codes whether under their professional provider or urgent care contracts but the patient co-payment is less than that for ER care. An average co-payment for urgent care can run a patient anywhere from $25 to $75. Meanwhile a visit to the emergency room often requires a co-payment of $100 or higher. But that?s not all; insurers deliberately assisted in the support of these businesses by credentialing and contracting these businesses as in-network entities and promoting the lower-than-ER-cost care to Employers and patients alike.

Source: www.aamc.org

disruption to care continuity, it was also noted that these centers do not appear to emphasize care coordination and that the respondents had little to no role in connecting patients to follow-up care. So what role then does the Urgent Care Center play in today?s environment of patient-centered medical homes? Given the prevalence of Urgent Care Centers, and the increasing utilization of these centers by patients across the United States, the impetus lies on both the Urgent Care Provider and the Primary Care Provider to ensure that communication and care transitions are implemented and followed through for the good of the patient. At the national level, we see this need being recognized through the National Committee on Quality Assurance?s Patient Centered Connected Care Recognition Program, which helps ancillary providers become part of the medical neighborhood. Ideally, the Urgent Care Center will view itself as an extension of the primary care environment, and as another positive addition to the neighborhood. Dr. Mohammed Arsiwala, founder of Michigan Urgent Care, states that his business model is to support primary care physicians and not to directly compete with them? an attitude we can hope all Urgent Care Physicians share.

Convenience And then there is the matter of convenience, which is no small issue in today?s world of ?on-demand?services. Everyone needs healthcare, and when they do, they want it now. It?s no wonder that 89% of Urgent Care centers surveyed in 2014 saw an increase in the number of patient visits. And 84% of these centers reported that their patients spent an average of only 60 minutes, from walk-in to walk-out. Fitting healthcare needs into busy lives has never been easier. But quality of care remains an issue. In a 2013 Research brief by the Center for Studying Health System Change, it was noted that, ?Overall, respondents perceived that urgent care centers improve access to certain services for privately insured people without significantly disrupting care continuity. But respondents were uncertain about UCCs?impact on costs.? While respondents felt that there was no significant

New Role for Urgent Care Centers? In its 2011 statement paper titled The Case for Urgent Care, the Urgent Care Association of 27

America floats a very interesting prospect for the role of Urgent Care Centers in the future as key sites for non-emergency treatment in a disaster. They posit that these centers can effectively become overflow facilities for the non-critical victims, and with their experience in handling unscheduled walk-in patients, they may be well positioned to take up this function with some additional training. With the Zika virus hitting the southern United States, historic flooding in many states that seems to grow worse each year, and a series of natural disasters that appears to keep escalating, add in one really bad flu season and one can see the merit of such claims. Whatever role that Urgent Care Centers take on in the future, it is apparent that this expansion in recent years has been born out of some necessity to meet the needs of an ever demanding, and ever sicker population, all the while providing a profitable business model to a vast array of owners and investors. It is vital then that providers of all types recognize the current role that these centers play in their patients' lives and in the healthcare field, and make plans accordingly to incorporate these centers into their own practices' procedures and communication policies moving forward. W an t t o k n o w m o r e ab o u t Ur g en t Car e? Fo l l o w t h i s l i n k t o a p r esen t at i o n ab o u t h o w t o d ev el o p an d b u i l d y o u r o w n Ur g en t Car e cen t er . 28

SEARCH MEDICAL POLICIES ANYTIME, INSTANTLY. BE INFORMED ABOUT HIGH IMPACT POLICY CHANGES, AUTOMATICALLY. Here at The Policy Authority, we make it our business to know health care insurance company policies inside and out. We track changes and advise our clients on the impacts to their revenues, operations and physicians so that you don't have to.

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? CHECK UP ?

Tiffany Lauria | Practice Consultant

NCQA IN THE COMMUNITY Going From Medical Home to Medical Home Community

The continued growth of the National Committee of Quality Assurance?s Patient Centered Medical Home (PCMH) Recognition Program since 2008 has been a transforming force in fostering the focus of healthcare around the patient. With this increased focus comes the awareness of the need for providing more than just the standard well and sick care inherent in most primary care practices. Innovation is being called for around how to build infrastructure to support and extend the ?medical home?to encompass the many needs of the patient, not just the few. But can, and should, this infrastructure be positioned in the primary care office, structurally and financially? For many the answer may be ?yes?.Forward-thinking primary care practices have been busy adding services, and even entirely new businesses, to their existing practices in order to meet demand. Far from taxing the ?little guys?to stretch further, the opportunity to control more of the patient?s care from the primary core is a boon for those that are able to see the possibilities. With research and effort, building ?home-grown? programs not only improves care to existing patients and increases patient satisfaction, doing so increases the opportunity to care for more patients and in new ways too. Some of the best programs that we have seen include incorporating already available offerings and resources in community that may be more cost efficient than what the 30

practice can provide. Often, expanding the medical home means combining specialized, practice-tailored programs with community and outside resources. What most medical homes are looking to do is to provide a network of services that allows for total care across the spectrum of patient needs. This can be accomplished as follows: Individual-level interventions: involve one-to-one interactions between a patient and a provider. Clinical services can also extend to most proximal large systems (e.g., the family), and are well suited for addressing the health needs of the individual and the family. Social, family and community network interventions: are oriented to close social groups and primarily target behavior change and social support. These mostly occur in community settings including "YMCAs", workplaces, schools, places of worship, and other venues. Community-level interventions: influence living and working conditions and can include interventions that target specific communities defined by geography, race, ethnicity, gender, illness, or other health conditions. To the small primary care practice, integrating a multi-level system of patient interventions might seem like a daunting task. Let?s look at a few ways to implement this in practice.

Building Within Your Practice Walls As primary care providers, no one knows your patients better than you do. Yearly, monthly, and sometimes weekly, you are seeing the same patients repeatedly, and their families. Perhaps you have identified a few gaps in services that you would like to be able to fill in-house? If there is an area of need that you know your patients and their families would benefit from, consider developing a new line of business right within your practice. A simple example is taking care of asthmatics or diabetics. Education is a key component of excellent care, and can be met by either having an existing staff resource train up to coach and educate patients or by hiring a new resource to perform the work and being able to bill out those services appropriately. Here are some tips on how best to research which services may work well for your practice: 31

Utilize your technology to evaluate your population: age, diagnoses, most utilized procedures, and so on. Do you have a percentage of patients that all work in the same occupation? Same place of employment? Then go beyond the typical data: This is where really knowing your patients comes into play. Are many of them on the local football or other sports teams? Do you live in an area where alternative medicine is preferred, such as herbal remedies or acupuncture? Is the local teen hang out a fast food joint? Are the older ones in your population lacking sufficient mental engagement activities? Determine which service lines make the most sense to offer. In pediatrics, for example, some of these services include: ADHD Support, Obesity/Nutrition Programs, Lactation Consulting, Asthma Education, Sports Medicine, Behavioral Health, and Travel Clinics. For Internal Medicine medical homes, you might consider employing a part or full time behavioral health specialist or an occupational therapist, offering integrative services in-house, a travel clinic, or a weight loss program. Defining the needs of your patients first helps to guide where the best opportunities lie. After determining which services to add, research how best to document, code and bill for those services and contact your Payers to ask if there are any restrictions to billing certain services from a primary care office (such as mental health), and highlight the savings that the Payer will also benefit from by keeping services within your practice (rather than patients being referred out to higher priced specialty offices). In addition, for many of these services there will be opportunities for the patient to pay the practice directly. Many practices hesitate to do this, but with the added value and time savings that you are delivering, some patients will welcome the convenience and participate in a direct pay situation.

Adding a new business line to your practice requires work and buy-in from all members of the practice? providers, administrators, nurses, front desk and billing staff. Everyone must know their role. With careful planning and execution, these service lines enhance your ability to provide the total, patient-centric care that fits your medical home model, while simultaneously bolstering your business model.

Building Your Community Beyond Your Walls When contemplating the next levels of intervention? social, family and community? take a look around to see what is already available to you and your patients This may be a good project for a care coordinator or nurse supervisor to take the lead on and develop. Cataloging resources in a number of different areas and making them easily accessible to all will help to keep the list dynamic and relevant to patient needs. Posting up these resources on your website, in the waiting room, and keeping handouts available in exam rooms goes a long way to helping to share the information with patients. Look for: -

Condition specific education programs, nurse or educator visiting services, support groups and so on for various illnesses Information about prescription discount programs Wellness and fitness programs and addiction cessation hotlines and classes Farmers markets and locally owned supermarkets and produce centers, meals on wheels and neighborhood food pantries Literacy programs, day cares, parenting classes, Office of the Aged programs and veteran centers Cultural and heritage centers Disaster management seminars, local fire houses and shelters, Even lists of local state and city representatives for the more pro-active patients! 33

Looking for National Resources? Here is a list to get you started. Click on each website name to learn more about these services. 211.org - a free service to locate local resources for housing, health, disasters, abuse, victims, convict re-entry into society, and more. RxAssist.org - a directory of patient assistance programs run by the pharmaceutical companies to help patients afford their medication. Eldercare.gov - a program of the US Administration on Aging to aid in connecting older adults to appropriate services. PatientAdvocate.org - a non-profit provider of patient services such as medication & arbitration, negotiation of medical debt, and a list of multiple resources.

Once you?ve identified community programs, don?t just refer out. Invite some into your space too! The benefits of creating these community connections can have a direct impact on your patient?s health. This looks different in each practice, but perhaps in yours it means a local yoga teacher uses your waiting room to offer classes to senior citizens, opening up your practice doors to potential new patients and complimenting your weight loss program offering. It can be as simple as informing every new mother that the firehouse on Main St. conducts car seat

inspections every Wednesday from 3-5pm, or as comprehensive as arranging for the community hospital liaison to visit your 9 year old asthmatic patient every 8 weeks. Perhaps you have a patient whose parents do not speak the local language or a low literacy rate even in their own language? consider having a translator available during certain hours. By providing culturally competent care and appropriate resources - both components of the NCQA PCMH recognition program, by the way ? you?ll benefit both your community and your practice. To truly branch out into the community, however, we need to be inclusive of all of our neighbors, and that means engaging insurers too.

patients into three different risk levels, varying the amount of contact and education that the patient may require. Utilizing this and other payer programs can lessen the practice burden while assisting some of your patients who would not otherwise benefit from care management activities. Don?t hesitate to let your patients know that they may be able to receive ?extra? benefits from their insurers too. Some offer free community fitness and cooking classes, and free apps to help patients connect to wellness advice and even other community members. Coach by Cigna is one example, offering access to personal health coaches and two week challenge programs, such as adding more vegetables into your diet. These are good resources, but the key for your practice is knowing what is available and presenting these options when needed.

Partnering With the Payers Do a quick inventory of some of the insurance company websites and you?ll likely discover a number of useful tools, for both you and your patients. For example, say you want to expand by hiring a Behavioral Health Provider in-house, Aetna provides a good deal of transparency on their website, detailing the billing guidelines, reimbursement and required coding, as well as an eight point checklist for integrating behavioral health into the primary care setting. Billing just five patients per week with code 99242 could earn your practice $27,079.00 annually, and allowing for an experienced Licensed Clinical Social Worker at $31.00 for ten hours per week to net the practice a $10,959.00 profit. Many Payers have created useful programs for care management. As part of your NCQA Recognition, you have already demonstrated a level of care management for a sub-set of your patients, however, providing these management activities for your entire panel of patients may exhaust your resources. Consider keeping your most chronically ill patient?s care management with your in-house team and refer others to their respective Payers. For example, Humana?s Condition Care program stratifies referred

Your Community For your practice to provide care that goes beyond the basics and truly embrace the medical home concept, your practice should begin to encompass the many different and unique challenges that your patients are facing. As we?ve just discussed, this means expanding your medical home boundaries through the creation of practice-grown service lines, developing community alliances and utilizing Payer resources. Such expansion is possible; you just need to look for the opportunities, and follow through on the efforts required to make your medical home a full and interactive medical home ?community?.

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.

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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

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-PAYER NEW S -

Susanne Madden | CEO & Founder

Heidi Hallett | Director of Communications

HEALTH I NSURANCE COMPANY MEGA MERGERS (& FREEZES!) What The Likely I m pact s Will Be On Your Pract ice

The proposed mergers of Aetna-Humana and Anthem-Cigna could significantly change the business of healthcare insurance, as we know it. While the Department of Justice and the behemoths hash it out, there may be significant ramifications to your practice during and after the proceedings.

What Are The Issues? In a letter to the US Department of Justice dated Nov 11, 2015, the AMA respectfully urged the DOJ to block the AETNA and Humana mergers, stating that market concentration in the insurance industry is an important issue of public policy and that, ?the anticompetitive effects of insurers?exercise of market power pose a substantial risk of harm to consumers.?The letter goes on to provide an analyses of the proposed health insurance mergers, revealing considerable concerns regarding the impact on patients in terms of access to, and the quality and affordability of health care. In summarizing their concerns and urging the Department of Justice to block the

proposed mergers, the AMA pointed to several areas of concern: -

Collapse of competition, likely permanent, in markets where the merger is being proposed; Consolidation leading to price increases, not greater efficiencies or lower costs; Degradation of the quality and quantity of physician services. A merger could result in reduced reimbursements for physicians, which in turn could mean shorter patient visits and/or reduced services; Despite the insurer?s claims, there is no evidence to support that the mergers would lead to greater efficiencies, innovative payment and care management programs; Competition is good for consumers. Competition benefits consumers through ?lower prices, better quality, and greater choice.?

The association has done the legwork to back up its position. Through participation in Congressional hearings on both Anthem?s proposed acquisition of Cigna and Aetna?s proposed acquisition of Humana, and utilization of data compiled annually by the AMA, it has the research and stats to back up the claims that competition, not consolidation, will ?lower premiums, force insurers to enhance customer service, pay bills accurately and on time, and develop and implement innovative ways to improve quality while lowering costs.? The claims make a lot of sense. How would a small or start up insurer (like OSCAR) be able to enter such a market? Large insurance companies are already notorious for inefficient practices and processes ? how does getting bigger solve the problem inherent in getting bigger? And so on. It comes as no surprise that the insurers don?t agree with the AMA. In an email to the Huffington Post,

Aetna spokeswoman Cynthia Michener wrote, ?We believe the combination of Aetna and Humana will improve the health care system and offer consumers more choices and greater access to higher quality, more affordable care.?And Anthem?s spokeswoman Jill Becher took it a step further by publicly suggesting that if costs increase, physicians are partly to blame, ?Some AMA members may fear that a combined Anthem-Cigna will be able to negotiate lower rates for their services ? even though that could translate to

"A lack of competition in health insurer marketsisnot in the best interestsof patientsor physicians. If a health insurer merger islikely to erode competition, employersand patientsmay be charged higher than competitive premiums, and physiciansmay be pressured to accept unfair termsthat undermine their role as patient advocatesand their ability to provide high-quality care.? - AMA President Steven J. Stack, M.D.

lower prices for consumers,?she continued. ?Providers play a critical role in our health care system, and they share responsibility for keeping health care affordable.? While we don't doubt that there is 'fat' yet to come off the bone in terms of trimming healthcare costs, putting continuing downward pressure on physician rates while for-profit insurers make record profits is quite audacious. California Insurance Commissioner Dave Jones, put it simply when he said, ?The Aetna and Humana merger has anticompetitive impacts that will likely result in increased prices, decreased availability of health insurance products, and decreased quality and 37

access to healthcare.? While Jones ? a known consumer advocate ? does not have the authority to block the mega-merger, he does hold substantial influence with the DOJ, which ultimately has the final say. For their part, the Insurers talk a lot about ?greater efficiencies? and ?value for our customers and provider partners,? but they have yet to provide any substantive evidence to support these claims. A recent article in the Connecticut Mirror points to Medical and Consumer groups who fiercely oppose the merger, saying they have ?flooded the states? insurance commissioners with letters opposing the mergers.? For consumer groups, the main concern is with premiums going up and quality of care going down. Medical groups share the concerns of the consumer group and also worry they?ll have less leverage when negotiating fees from Insurers. We agree. In addition, there is the impact to physicians?practices that should also be considered.

How The Mergers ? During and After ? Can Impact Your Practice Contracting and Billing Blues If Aetna and Coventry?s recent merger is anything to go by, we can expect credentialing and contracting ?freezes?as the companies bring together processes and contracts. Of particular concern for physicians should be moving employment or opening new practices; those freezes can mean that tax identification number and demographic updates are frozen too and patients cannot be seen by you at your new practice. Loss of revenue for physicians The merger could result in lower payment rates, particularly when one company pays network participants less than the other company. Often merged companies require that participants in one line of business have to also participate in the other, and that can cause a practice to take on lower-paying business. Over time a company may decide to ?blend?rates, which reduces the higher rates too. All this will have some physicians asking if they should refuse terms of, or even terminate a relationship with, an insurer. But if the insurer is now the biggest game in town, that can mean cutting your practice volume in half, or moving to a concierge model altogether, which is really only possible if you have the right demographics to support that type of business. Mega-mergers cost big bucks At the end of the day, the Insurers want to make money from this deal. Who will absorb the costs incurred by the merger itself? Insurers make their profits from holding on to as much of the premiums as possible, so either consumer costs go up and/or physician payments go down. In other words, we all end up ?paying? for this in the end. Except the insurers. A merger between Aetna and Humana would have far reaching effects outside of those respective organizations. As the players in the healthcare arena keep changing, physicians and physician organizations must be proactive in keeping abreast of these changes and in leveraging their collective voices to protect their practices and their patients. If allowed to go unopposed, there is no doubt that insurers would continue to implement changes landing them right where they want to be? at the top of the profit chain. 38

? FRONTLINES ?

Susanne Madden| CEO & Founder

A Conver sat ion wit h Bonnie Feola, MD

Susanne Madden: We're delighted to have an opportunity to chat with Dr. Bonnie Feola of Busy Bee Pediatrics this morning. Bonnie, thank you so much for joining us today at Verden ViewPoint and for taking the time to speak with us about your recently acquired pediatric practice. Dr. Bonnie Feola: I?m happy to chat with you! Susanne Madden: The first thing that I really want to know is what inspired you to consider buying an already established practice? We often have clients that want to start their own practice to do it their own way but you went the route of acquisition. Was it just an opportunity that arose, or were you specifically looking to buy a practice?

Want more stori es l i k e th i s? To read more stori es f rom th e Frontl i nes cl i ck h ere.

Dr. Bonnie Feola: Actually it was an opportunity that arose. I had always thought it would be wonderful to have my own practice but I really never thought that I had the time to devote to starting a practice from scratch. Being a pediatrician, being a parent and all the things that go into learning about medicine ... earlier in my career I didn?t think it was an option in terms of my business experience and just not having enough time. Now I have 39

WHA T YOU NEED TO K NOW Key Points for Successful Practice Acquisition Look behind the curtain: nothing beats having an ?insider view?by working at the practice before acquisition

Slow and steady wins the race: roll out changes over time, being sensitive to both staff and patients

Meet patients?'tech' expectations: don?t underestimate the need for web-friendly access through your website and social media channels

Make tech work for you: choose a specialized and customizable EMR and take advantage of education and technical support

It?s a group effort: work collectively with staff to implement change so they can take ownership in the improvements

Know what you don?t know: know when to ask questions and get expert advice

Network with other physicians: get peer support and benefit from the exchange of knowledge and experience from members of a group like SOAPM

Find the balance: adjust your schedule to allow for business management hours, and, most importantly, don't lose a healthy work/life balance

much more experience and with my kids going off to college, the opportunity arose and by this time I had a few years of administrative experience and management experience. I thought, "You know what? This could be a great opportunity for me" because I really felt that to start up a brand new practice ? with all that?s involved in that ? it could be overwhelming. When the opportunity came up to take over from a retiring physician at an up-and-running practice that I already worked in, I thought "This is a practice that I feel very comfortable in." I quickly found that the staff and the retiring doctor felt the same way, so we really felt that it was a well-suited match. So it?s been wonderful and challenging acquiring the practice. It was already up and running, we had a panel of patients, had an established location and staff with experienced nurse practitioners that already worked there. Everybody wanted to stay and transition with me to the new ownership.

Susanne Madden: I think what's really nice about that is the fact that you were actually working at the practice so you already knew everybody there and had a sense of how the practice was running, There is nothing like that ?insider view?of the organization. You truly knew what it was that you were buying. Dr. Bonnie Feola: I have to say it was wonderful. The retiring pediatrician was very open in allowing me to ?look behind the curtain?in terms of seeing his financials and all the details about what was going on with the practice. He basically said, ?you have open entrĂŠe to talk to the staff. They can give you any information that you want.?It was wonderful to have that experience and that sense of confidence, knowing that he felt comfortable opening everything up to me even before we signed the papers was great. Susanne Madden: It's great that you had a lot of things in place but I wonder: were there some hurdles or any significant issues around things that you did want to change? And what were the things that you 40

ultimately did change at the practice once you owned it?

to Busy Bee Pediatrics, but everything else really remained the same. We had the same staff. We had the same location, same phone numbers.

Dr. Bonnie Feola: The practice was very well established in the community, and had a great reputation. The name of the practice was actually the name of the pediatrician that owned the practice. One of the first things that everybody asked me was, "Are you going to change the name of the practice to your name?" I really was not comfortable doing that at first. Partly because I was the newcomer and also the practice was already established under that name. I wanted to honor what they had already established and what the practice already meant to the community.

Altering the vision of the practice was also challenging. As I mentioned, I was sensitive to respect the ?history?of the practice in the community and I wanted to honor what they had established. Some of the staff had been there 20 to 30+ years and we have generations of families that come to the office. We were already seeing children of former patients. The challenge was to maintain that sense of familiarity but at the same time acknowledge our new identity. Susanne Madden: I love the story about the name and I think what you did was so fair, to really acknowledge, "Hey, if I put my name on it, what about everybody else who has built this practice over time??

But then one night I was sitting at home, going over piles of papers and doing my due diligence. My husband came home and saw me at the table with all these files and stacks of papers and he jokingly said to me "So how's my busy bee?" It was like a light went on. I just said "Oh my gosh. That is a great name for a pediatric practice!" He just started laughing and said, "You know, that's kind of a cute name." It ends up that the state of Utah ? our practice is in Bountiful ? is known as the beehive state. Also, my initials from my first name and my maiden name are BB, which are the same for busy bee. It all just seemed to fit perfectly.

I wonder too if the changing of the name also led to the changing of the vision. It?s a cultural shift to go from a practice that is named after the owner to one like Busy Bee Pediatrics. Dr. Bonnie Feola: Right. Patients and families liked the fact that it felt the same but at the same time ...

To co n t i n u e r ead i n g t h i s i n t er v i ew cl i ck h er e.

So, that probably was the biggest hurdle, changing our identity from Dr. So-and-So's office

"If youbelievebusinessis built onrelationships,make buildingthemyour business." - Scott Stratten 42

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

Williamsburg Pediatrics,

Level 3

Olitsa Roth, MD

Level 3

Gentle Medicine

Level 3

Sandhill Pediatrics

Level 3

Skylands Medical Group

Level 3

Kindercare Pediatrics

Level 3 43

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 , Daniel Fr ier , Julia E. Cassidy Phot ography : Andr ew Conrad 44Ver den Gr oup 2016 www.Ver denViewPoint .com ViewPoint is a seasonal publicat ion, dist r ibut ed digit ally ÂŠ The