Viewpoint Volume 3 Issue 2 Summer Solstice 2017 by VerdenGroup

CONTENTS Volume 2, Issue 4 - WINTER SOLSTICE EDITION 2016

Welcome

Big Impacts

Pro Tips

New voices, new website!

Trumpcare: The Biggest Threat to America's Health?

Disney's Psychology: Employee Engagement

Let's talk about what's new - this issue has new voices and we've rolled out a new site making navigation a breeze,downloading articles easier and sharing a snap!

Susanne Madden spells out the proposals in 'Trumpcare' and the devastating effects it will have on the average citizen and mental health coverage . . . if it passes.

Whitney Smith writes an account of what she learned at Disney and shares tips and tricks to incorporate the principle of 'intentionality' into any practice.

Frontlines

NCQA Update

Payer News

Patient Debt, The Peril of the Independent Physician

NCQA Unveils the Redesigned 'PCMH 2017'

Depression Screening Policies

In a move designed to make PCMH more adoptable, NCQA overhauls its standards and gets more involved with practices. Amanda Ciadella tells us what we need to know about the new program.

Anna Ialynytchev compares the commercial policies of four of the largest insurers to see how depression screening is covered. If you think there is little variation in policy , read on . . .

Our friend, colleague and now author, Robert Goff, shares insights from his new book 'The Patient, the Doctor and the Bill Collector'.

26 Industry News

CONTRIBUTORS

Wold Health Care Congress 2017 Susanne attended the WHCC2017 in Washington, DC. Trump, opioid addiction and mental health dominated. Read about the more notable keynotes here.

Susanne Madden

Whitney Smith

Amanda Ciadella

Robert Goff

Anna Ialynytchev

Revisit Podcast: Mental Health in Pediatric Practice From Volume 1, Issue 4, Susanne speaks with Dr. Christoph Diasio about how his practice successfully incorporated mental and behavioral health into Sandhills Pediatrics in North Carolina.

Tiffany Lauria

Scott Hodgson

David Magbee

Spotlight Kenneth Fenchel, CEO of IPMSO Earlier this year, Susanne Madden and Kenneth Fenchel launched Independent Practice MSO in an effort to further support independent practices. Tiffany Lauria sat down with Ken to find out what its all about.

40 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.

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. 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

? WELCOME ? Midsummer once again and the living is easy . . . for some. For others, the current state of political unrest in health care is causing concern, anxiety and downright depression! So, for this issue, our focus had to be on behavioral health. But first: we are delighted to announce a new home for ViewPoint! We've rolled out a new website that makes finding content easier, has greatly improved mobilized viewing, and added the ability to 'press' any article into downloadable PDFs (rather than making only some content available that way), plus sharing content in a variety of ways is now a breeze. We hope you'll love it. We've also added some new voices to this issue, bringing the perspective of our collective team from across Verden's suite of companies: Anna Ialynytchev, Senior Health Policy and Data Analytics Specialist at The Verden Group takes a look at how four major Payers' policies stack up in covering depression screening in primary care; Amanda Ciadella, Senior Consultant at Patient Centered Solutions shares the latest on NCQA's newly released and completely redesigned 'PCMH 2017' program which includes a greater emphasis on behavioral health, and Whitney Smith, Client Services Manager at Independent Practice MSO, takes us on a journey into the psychology of Disney - how it brings that to bear on employee engagement and what you can do to incorporate the same principles into your practice. May we all take some time to recharge our (mental) health this summer. . .

SUSANNE MADDEN | EDITOR-IN-CHIEF 4

NEW VIEWPOINT WEBSITE

Check out our new websit e at www.VerdenViewpoint .com! You'l l f ind expanded cont ent , video, images, t ips, int erviews and more. Wat ch f or l inks t hroughout t he magazine or simpl y cl ick on t he l ink above t o expl ore.

Browse t hrough past issues onl ine K TO CLI C A D RE K BA C ES I SSU

Read sel ect ed art icl es and l ist en t o podcast s.

'Press' any art icl e int o a downl oadabl e PDF and share t o mul t ipl e pl at f orms easil y.

Browse cont ent by t opic

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www.verdenviewpoint .com 5

? BIG IMPACTS ? SUSANNE MADDEN, MBA, CCE CEO / CoFounder / Editor

TRUMPCARE: THE GREATEST THREAT TO AMERI CA'S HEALTH? Cartoon Credit: Bors at thenib.com

The US Senate was presented with a reconfigured House of Representatives?health plan? H.R. 1628? on June 22, 2017. Crafted in closed-door, Republican-led Committee meetings, no public discussion was enabled prior to its receipt by senators for a vote. Meanwhile, A New Foundation for American Greatness? President Trump?s budget plan for 2018? was released on May 23, 2017.

responsibilities of government will be shifted to clinical providers (e.g., physicians), hospital and medical practice administrators, and community-based charity organizations. Comparison of Senate ACA-Replacement Plan to House Plan The Senate health plan bill? entitled Better Care Reconciliation Act of 2017? includes steeper cuts to Medicaid than the original House bill passed on May 4, 2017, while increasing allowable tax credits for IRS 1040 filers earning enough to itemize deductions. In this way, low-income earners are doubly penalized.

Tax cuts for the highest-earning citizens are prioritized in both the Republican-crafted H.R. 1628 and Trump?s budget proposal, with a likely impact of weakening national public health infrastructure.

Meanwhile, older adults under 65 years of age can be charged five times more for health insurance than young adults (and it is well-known that ?Baby Boomers?as a population are already deficient in retirement savings). Furthermore, the elderly demographic is rapidly growing in the US, and nursing homes are reliant on Medicaid to cover costs when their patients have outlived their financial resources.

A vote on H.R. 1628 probably will have occurred prior to your reading this article. However, regardless of whether H.R. 1628 is passed, or not, the Trump Administration will not cease attempting to limit spending on ?safety net?programs in order to pay for its priority issues (such as constructing a barrier wall along the Mexican border). Winners and Losers: Republican-Conceived ACA-Replacement Plans

While insurers cannot explicitly refuse to cover pre-existing conditions under the Senate-proposed ACA-replacement health plan, this version offers an obvious loophole to insurers.

Low-income families, seniors, disabled individuals, and pregnant women stand to lose the most if Congressional conservatives? under the direction of the Trump Administration? prevail in determining how the Affordable Care Act (ACA) will be replaced or altered.

The loophole mechanism is that insurers can avoid covering pre-existing conditions through federal elimination of required Essential Health Benefits (EHB), as presented in a comparison chart published on June 22, 2017 by National Public Radio.

Moreover, if their healthcare-targeted policies are enacted, all Americans will pay the price; societal 6

Congressional Budget Office (CBO) Reports for Two House AHCA Plans House passage of the first American Health Care Act (AHCA) version failed in March 2017, despite President Trump?s strong support for it. One reason was the CBO?s determination that 24 million people would lose their health insurance within one decade of its passage. However, the primary reason was utter opposition from the House Freedom Caucus, which perceived this bill as not completely eliminating all federal involvement in the US healthcare delivery system. Only in May did the second AHCA version finally achieve passage in the House, and by a 217-213 vote. Some minor changes in this AHCA version were made to garner support from more moderate Republican members; one was a federal aid allotment of an additional $8 B to states for gap coverage of individuals with preexisting health conditions. This enabled enough buy-in from moderate House Republicans to enable the Senate Majority Leader (Mitch McConnell) to forward the process to the Republican-dominated Senate? even though the $8 B is not actually considered realistic for actual coverage of pre-existing conditions. Despite the changes in the second AHCA version, the CBO report of May 24, 2017 still predicted 23 million uninsured people within 10 years (and 51 million uninsured by 2026). The CBO also reported on June 26, 2017 that H.R. 1628 would result in 22 million uninsured people. There is little doubt that elimination of the EHB requirement is likely to make comprehensive coverage less available and/or affordable to a large swath of the US population. Lessons of the Great Depression: Why Safety Nets are Necesssary The financial hardships endured under the Republican tenure of President Hoover led President Roosevelt to promote his ?New Deal?? including establishment of Social Security? to aid the nation during the 1930s. Widespread collapse of unregulated banks had left people destitute and hopeless, and it is well-known that hopelessness can lead to mental health disorders, drug abuse, and increased criminal activities. If approved by the U.S. Senate, the Trump budget alone would accomplish the following: -

Decrease funding for Medicaid by $1.4 T over the next decade. Allow states to curtail enrollment in the Supplemental Nutrition Assistance Program (SNAP), and decrease funding to remaining recipients.Decrease funding for employment training programs targeting the impoverished unemployed. Eliminate much of the federal dollar support to poor mothers with young children. President Trump?s budget seeks specifically to decrease federal funding for SNAP by $190 B, as well as the Temporary Assistance for Needy Families (TANF) block grants to states? plus Native Americans living on reservations? by $15.6 B.

?Deepening poverty is inextricably linked with rising levels of homelessness and food insecurity/hunger for many Americans, and children are particularly affected by these conditions,? according to the American Psychological Association. Disability and Productivity ? Likely Impact on Economy Smoking cessation programs, diabetes self-management, cancer screenings, and prenatal care are all embraced by public health prevention advocates. The EHB provision under the ACA has required health plans to cover a variety of prevention measures; this prevention inclusion was in recognition that health economics research consistently has shown prevention as less nationally expensive than medical treatment.

President Trump?s budget reduces funding by $222 M for public health prevention programs. Meanwhile, mental health and substance abuse coverage is costly to insurance companies, and removal of the EHB requirement means that plans inclusive of such treatment could also entail exorbitant deductibles to reduce the likelihood of their utilization, and/or high premiums to discourage their selection.

Increasing Inequality Will Be the Legacy of the Trump Presidency The Washington Post on May 23, 2017 included an article entitled How Trump?s Budget Helps the Rich at the Expense of the Poor. It describes Trump White House policies related to tax cuts in relation to draconian funding cuts aimed at the poorest individuals (including those with long-term disabilities). While tax relief is desired by wealthy individuals, the transfer of financial assistance through Trump?s budget? if enacted? markedly shifts assistance away from already impoverished individuals. This would disproportionately affect African-Americans. Indeed, 9% of Caucasians in the U.S. live below the Federal Poverty Level (FPL) as compared to 24% of African-Americans, according to the Kaiser Family Foundation.

Adults who are disabled are generally unable to be as productive in the workforce as healthy individuals. The U.S. Bureau of Labor Statistics reported in 2016 that the employment-population ratio for Americans with a disability was 17.5%,as compared to 65% for those without a disability. Furthermore, a lack of adequate prenatal and/or maternal care will assuredly result in a nationwide increase in birth defects, and a future drain on the economy due to these children?s ongoing healthcare needs.

There is no human being who cannot develop a health disorder such as cancer, and this type of life-changing diagnosis can drain the financial resources of even higher income middle-class families. For example, when a spouse succumbs to a life-threatening illness, the remaining spouse often has utilized retirement savings for caregiving. This is especially the case where inoperable cancer or another long-term illness is the cause of death. The result is that the surviving spouse often has diminished financial resources to meet their own future basic needs. That individual may also be the only wage-earner to support the children, or that wife or husband may have left the workforce to care for the terminally-ill spouse.

Medical and Healthcare Organizations Opposing H.R. 1628 The following are just some of the healthcare associations and organizations opposed to the Senate ACA-replacement bill (as well as both versions of the AHCA): -

American Medical Association (AMA) American Hospital Association (AHA) Association of American Medical Colleges (AAMC) American Academy of Pediatrics (AAP) Federation of American Hospitals (FAH)

If President Trump?s policies prevail and any version of the AHCA becomes law, it may become only a matter of luck as to whether someone loses all financial security by mid-life. Even an ill individual making a high salary may lose everything if unable to cover the cost of a high monthly premium or deductible (or if expensive daily medications are required).

Middle-Aged Population are a Prime Target of TrumpCare The demographic in the ?cross-hairs?of Trump?s healthcare policy and the AHCA are adults who are between 50-65 years old, according to an analysis by the Commonwealth Fund. Individuals in this age group? who are not yet eligible for Medicare? are more likely to have chronic conditions and consequently become laid-off from employment than younger workers.

Diverted Tax Dollars: How Trump?s Budget Weakens Medical Research The federal government requires tax revenues to fund federal grants for scientific research of all types. Academic medical centers are dependent on federal grants to perform basic science research (such as

The diverse budget cuts and policies with specific implications for older individuals suggests especially rough times ahead for middle-aged adults.

enabled mapping of the genome), conduction of clinical trials to ensure future patient safety, and to cover the salaries of their postdoctoral fellows. Meanwhile, pharmaceutical and biotech companies are dependent upon medical research centers to support their R& D efforts.

mental health care as a ?non-essential?benefit, meaning that states, employers, and / or insurers will decide if the 1 in 5 Americans who struggle with mental illness will be covered at all, if Trumpcare passes. In fact, according to NAMI , the House bill allows states to let health plans:

The tax cuts in the Trump Administration budget are aimed at providing relief to the wealthiest individuals and corporations; it thereby reduces potential annual federal revenues regardless of reduced funding for Medicaid. Even without the increased expenditure proposed in the Trump budget for the military and the Dept. of Justice?s expanded INS efforts, federal revenue has not matched required payments (i.e., annual amounts budgeted toward paying off the national debt).

Hospitals and Physicians Left Standing in Quicksand

Drop coverage of mental health and substance use (one of the essential health benefits under the ACA today). Charge people higher premiums if they have a pre-existing condition, like depression or anxiety. Create high-risk pools, which are another way of charging people with mental illness more money and providing less coverage.

Apply that to this one simple statement concerning mental health: the World Health Organization determined that depression is presently the leading cause of disability worldwide, and is a major contributor to the overall global burden of disease and you begin to understand the magnitude of what we are facing with repeal. . .

Physicians and hospital administrators in the Trump Era are left to shoulder the burden of caring for people who cannot afford healthcare. Since conservatives in Congress? as well as the Trump White House? view the federal government as not having a role in healthcare delivery, their ACA replacement goal includes elimination of any requirement that individuals in the US have health insurance. This required coverage of nearly all Americans was a central tenet of the ACA, as insurers need healthy enrollees to off-set costs incurred by those who do utilize insurance coverage. Without that fundamental ACA requirement, there is every reason for insurance companies to become anxious about their potential net worth, and raise premiums (and deductibles) to avoid potential future bankruptcy.

The fact that the U.S. healthcare system is dysfunctional is well-recognized. Cruel and mean-spirited policies that target the most vulnerable populations do not bode well for upholding democratic ideals or for a stable economy. As antibiotic-resistant infections are emerging and spreading, it is imperative that enough funding for research and treatment exists to preserve the nation?s health. Therefore, it is vital that Trump?s policies become an aberration, and that compassion towards low-income and disadvantaged Americans prevail in the form of health and social service safety nets.

Mental Health Coverage Takes a Huge Step Backward

There is no crystal ball for anyone to know with certainty that a safety net will be unnecessary at some point. This is why these safety nets exist, and our public health depends upon their continuation.

The Affordable Care Act successfully integrated mental health and physical health, which had been covered separately. Trumpcare does the opposite, classifying

- PRO TIPS WHI TNEY SMI TH Client Services Manager (IPMSO)

ENHANCI NG CUSTOMER SERVI CE THE DI SNEY WAY: THE PSYCHOLOGY OF I NTENTI ON

We can all agree that when it comes to customer service, Disney has mastered the art of delivery. It has a diverse staff that is very well trained to ensure that every interaction its ?guests?have is nothing short of ?magical?! They accomplish this through an intentional commitment to ?employee engagement?,that is, the extent to which employees commit to the values and vision of its company. Whether or not you are Disney, when employees commit it creates a company ?culture?. And company culture is a value that isn?t limited to Disney.

How Does Disney Do It? This past month I went to Disney school to see what I could learn that would be relevant to medical practices. So many of our clients in the medical professions struggle to deliver on good (let alone excellent) customer service in their practices. And while the Customer Service course looked fascinating, it was clear to me that unless a practice can develop a strong mission and engage employees around it, there is only so far good customer skills can carry you. Therefore, I trained on Employee Engagement for five (very fun) days at the Disney Institute, and was impressed by the attention to detail that occurs in every aspect of their process. Starting with how Disney selects its staff to the quality of its extensive (and intensive) training programs, down through its communication with employees and the public, the best word to describe how Disney engages its resources is this: intentionally. 10

Disney?s philosophy is based on each individual?s ability to direct things rather than letting things direct you. You can probably think of a number of different areas within your practice that tend to direct the staff into typical behavior, rather than anyone choosing intentionally to indulge in that behavior. For example, your medical receptionists may be conditioned to react to an aggressive patient, instead of actively directing the conversation to a happier resolution. Or your partners may be resistant to change, despite patient satisfaction surveys that indicate a change may be needed in the ways your practice communicates to patients. Intentionality incorporates a) having a purpose and sharing it across stakeholders (patients and staff ) and b) paying extraordinary attention to detail. And in this way, it creates a two-fold win for delivering excellent customer service.

Let?s learn from Disney There are 5 main areas in which Disney is intentional with their business and that can be translated into your medical practice:

1. Be Intentional with Your Practice?s Culture

Disney?s way: Disney focuses on specific areas across the continuum of service in order to sustain / improve its business results. It calls this approach the Chain of Excellence. The chain starts with a focus on the customer and on the staff, led by excellent leaders that understand the focus on customer service. These leaders align the entire organization around a set of values and vision, making sure the entire company understands two core concepts: ?who we are?and ?where we are going?. These leaders are tasked with overseeing and sustaining the company?s culture and vision, its employee training programs, and on-going engagement of their staff. And together, that leadership and the employees create a working environment that allows for high quality service and customer satisfaction. Does that mean that without a strong office manager or administrator, these principles are out of reach? Not at all! You can be the leader . . .

How to Incorporate These Principles Into Your Practice: To bring intentionality into your practice, you first need to be clear about your own practice?s culture. Spend the time to determine what your practice?s mission is really about and you will be able to clearly communicate to employees and your patients what qualities, behaviors, and ideas your vision of patient care is embodying. (If you need some help in working through that process, go here: Awesome Podcast: Why I Need A Charter) Your practice culture is not just a motto, a mission statement, or a set of job descriptions. Your practice?s culture is a set of behaviors and ideas that will be used to direct decisions made by all members of the practice.

Here?s how Disney instills those values. Whether you are the owner or the manager, the front desk receptionist or the back-office biller, we can all relate to heritage and traditions, shared values, language and symbols, and traits and behaviors. Any company that evolves from a tradition can tell the story that engages others to connect with it. -

are representative of the practice?s values reminds employees (as well as signals to patients) the values and culture they are expected to communicate in every aspect of their working hours. Defining the behaviors that exemplify the traits that the practice wishes their employees to have allows for the development of a set of uniform standards; and these can be called upon when hiring and training employees as well as by employees who can fall back on those expectations in the carrying out of their own responsibilities.

Rather than being a pleasant statement that is crafted once and then filed away, your mission and your culture is developed on a day to day basis through the actions of all staff members, and can easily be altered unintentionally if careful attention is not paid to staying the course.

Discussion of heritage and tradition helps build pride in employees that choose to work with an organization that has a story that resonates with their own, and sharing the history of the practice?s founding and early days helps to remind employees of what the company represents. Shared values lets every employee know what the practice represents, what it does not embody, and sets the tone for how employees are expected to represent those values. Using consistent, defined language and symbols that

A sensibly designed, intentional culture creates an environment in which every employee has the ability to be fully engaged in the business, empowered to act upon circumstance to show off that culture, and therefore best represent you and your practice while feeling fulfilled in the delivery of their tasks every day. Make your culture the foundation for every employee to reflect in every aspect of your practice, and it will become easier and easier for them to base their actions to reflect this vision. 11

Be clear with those that you interview that your practice is about its culture and that everyone?s expectation is to deliver on that culture (it doesn?t matter if that is true today or not, if you don?t start hiring for that today then you can?t end up there tomorrow).

2. Be Intentional During the Selection Process Disney?s way: Disney focuses on hiring for attitude and training for aptitude. Its managers recognize and fully understand that they need to find a balance in behaviors and skills when hiring, but do not worry about skills until they are sure that the behaviors of the potential employee or ?cast member?align with the culture and vision of the company. Disney understands that employees that are the right fit for the company culture are those who become engaged employees.

Use specific questions and wording throughout the interview that portrays your practice?s culture ? it will help both you and the interviewee decide if you are a proper fit together. It is better for a potential employee to ?self-select out?during the interview process rather than go through the entire interview and hiring process only to realize that they are not a good fit for the company two weeks into the job. Employees that do not embody your practice?s culture can weaken that culture, alter the engagement of other employees, and provide poor service to your patients; all of which do not align with your goals and values, as well as create an inevitable lost investment in that hire.

Of course Disney has a strong mission and value statement, making it easy to spot those candidates that are not the right fit and would quickly become disengaged and not add value (in fact, they are likely to tarnish the image that Disney is in the business to portray). The same can be said for specific positions: you can hire the right person but if you put them in the wrong role, they are not likely to shine. During Disney?s selection process, recruiters ask intentional, specific questions that make it apparent to both themselves and to the potential cast members whether they should continue with the process or be passed over during the selection process. Disney?s success lies in recognizing that improper hires can damage their culture and brand.

3. Be Intentional in Training Disney?s way: At Disney, a new cast member?s first stop is to a class called Traditions. This class - taught by highly respected and carefully selected trainers - begins with discussions about new cast members? experiences with Disney and what makes the Disney

How to Incorporate These Principles Into Your Practice: Be intentional when looking for new hires! Once you?ve taken the steps necessary to communicate and maintain your practice?s culture, values, and vision, it is vital to make sure that you are selecting the right people for every position, whether this means selecting from within to promote or hiring externally to fill gaps in the team, that can effectively reflect that culture. When evaluating a potential new hire, remember that you can teach skills, but you can?t train a person in values or change their personality. There are some positions within the practice (e.g. RN, CMA) that require certain skills sets. But you already know that just because someone is trained as a nurse, it does not mean that they are the right fit as a nurse within your practice and your culture.

brand so magical for them. This discussion instills a sense of pride in the new cast member and reminds them that their job is to now bring that magic to life for Disney guests. This respect for ?the magic?and emotional connection with the brand is the basis for the continued engagement of their cast members. The Traditions class is taken by all cast members together and allows for new hires to connect with cast members from other lines of business. The training is then broken off into more specialized training sessions and then to on-the-job training side by side with carefully selected cast members who embody the company?s culture and do their jobs in an outstanding way. Disney cast members recognize that becoming a trainer is a position of great merit and pride, and therefore apply and interview for the coveted position.

papers on his already cluttered desk to the side and asks you to wait a minute while they answer the phone because they are short staffed that day. What message was sent in the first five minutes about the practice and what they value? Do they value organization? Preparation? Are you and your future with the company valued? If the practice is not prepared to give you a foundation for your current position, how are you expected to grow within the company? So, take a step back and evaluate your training processes. Develop a program that starts all employees off with a well-organized training program,led by a specified trainer who has been carefully selected based on their embodiment of the culture and required skills. If this is your office manager, make sure that you convey that you understand that other areas of the practice will not be attended to while training is occurring (a person can only do so many things at once and not freeing them up to focus on training invokes the scenario mentioned above).

Disney makes sure to rotate its training staff so that everyone has the opportunity to be recognized and to eliminate trainer burn out. Training material is carefully vetted to ensure that proper information is being presented to new cast members. There is nothing worse than a game of telephone - where the end process resulted in inaccurate and improper information being shared with your newest staff! On the other hand, inadequate training will frustrate cast members and create space for improvisation, which can create considerable risk, such as communicating inaccurate information to customers, decreasing customer satisfaction, and creating inconsistencies in the brand.

Then, continually update your training program to ensure the accuracy of the information being presented and that it has not deviated from the practice culture or mission statement. Consider starting your new hire training process with a lesson on the history and heritage of the company. This will allow your new employee to see that they are a part of something bigger and gain a sense of pride in your practice. Don?t be afraid to ask a new employee to come in before or after the practice opens or closes to do that initial introduction ? it may provide the best opportunity to introduce them effectively when there are no distractions from patients and other staff. Helping an employee to see where they fit into the success of the practice is a major step in the right direction when it comes to engaging your employees, and taking the time to do it right helps to retain employees for the long term.

How to Incorporate These Principles Into Your Practice: The training process speaks volumes to new employees about practice values. Imagine being a new employee and showing up for your first day of training. A typical scenario goes something like this: you are introduced to your manager and quickly handed off to a co-worker, who is just now finding out that they will be training you today. The co-worker shoves all the 13

4. Be Intentional with Your Communication Disney?s way: Disney has realized that high-quality communication can actively reinforce culture, while low-quality communication undermines it. They are just as intentional about communicating with their cast members as they are with customer communications, realizing that keeping their cast members knowledgeable about the company and company ?happenings?fosters engagement. Disney utilizes many forms of communication with their cast members such as web-based platforms for up-to-date news and information about the parks and resorts, as well as postings for continuing education opportunities for staff. A quarterly magazine keeps employees informed on the more fun or casual aspects of the company and the achievements of their co-workers.

5. Be Intentional When Showing Care Disney?s way: Disney believes that the extent to which it genuinely cares for its cast members is the same extent to which its cast members show care for their customers. It uses care to strengthen the emotional connection between their cast members and their company, which in turn strengthens engagement. Every aspect of the business revolves around the culture of care it has created.

These added forms of communication keep the cast members engaged with the company, certainly, but also with their co-workers, reinforcing their company culture continuously. How to Incorporate These Principles Into Your Practice:

Without Disney?s cast members, its business and vision of creating the most wonderful place on earth cannot be a reality. Because it realizes the importance of its employees, it make special efforts to appreciate its employees any way they can, and as often as they can. It promotes from within whenever possible, making sure to further its cast members? education when there is interest, and make it a point to say ?thank you?and acknowledge proper behaviors. Disney also empowers its leadership with the ability to appreciate cast members in ways that fit the specific cast member?s personality type, rather than having a uniform method for appreciation across the board.

During employee selection and training, your practice?s culture is continually reinforced. Now that they are hired, you must provide continued, on-going communication to ensure willing adherence to company goals, especially in customer service. Communication with your employees, patients and the community reinforces your values in a positive way. Be careful to select communication methods that reinforce your message. For example, if your practice cultivates a family oriented or team atmosphere, pushing hastily drafted memos to communicate important information time and again does little to reinforce teamwork. A more engaging form of communication would be a daily huddle or frequent in-person team meetings to discuss changes within the company, allowing time for questions and feedback. Being intentional in your wording, in your method of communication, and even in the venue of meetings, can have very important impacts on your employees?engagement.

How to Incorporate These Principles Into Your Practice: Care is the aspect of employee engagement that has less to do with your practice and more to do with your employees themselves. As Maslow points out in his Hierarchy of Needs theory, helping humans to meet their full potential involves meeting specific needs,and meeting these needs in the workplace can 14

only benefit your practice in the long-term. Physiological needs and safety needs are met in almost all employment environments, but the next two levels in the hierarchy, belongingness/love needs and esteem needs (such as feelings of accomplishment), are the two that can be positively addressed when being intentional in showing your staff that you care. Helping to fulfill these needs leads to more engaged employees, which leads to their ownership of excellent customer service. In your practice, showing care can be accomplished in many ways such as: showing genuine interest in your employees?personal lives, interests, and their goals for the future (while facilitating advancement when possible), which in turn develops a culture of care that is shared between leadership and co-workers. This is the most underutilized factor of employee engagement in today?s workforce. And with the growing focus on behavioral health in health care, it only makes sense to show the value of behavioral health to your employees by establishing a culture of care within your practice. . .

Closing Thoughts: It all started with a mouse . . . While this may seem like a monumental undertaking at your practice, remember, Disney was not created in a day . . . so pull on your mouse ears and tackle this one step at a time:

2. From there, you can begin to evaluate your selection process, training programs, and communications in relation to that culture, making sure that the culture you have intentionally created is being communicated through all aspects of business. 3. Last, but certainly not least, be intentional in showing care for your employees - this may bring the most immediate improvement in employee engagement. 4. Acknowledge great service when it is seen, and show a genuine interest in your employees and their goals. You may not always have ?magical? experiences or interactions in your practice, but a few small changes can get your practice moving in the right direction for meeting your employee engagement and customer service goals.

Want To Learn More? Join us in Charl est on, Sout h Carol ina on

January 18, 2018 at

Cannon Green for an evening of education, good food and new friends and learn about

Enhancing Cust omer Service t he Disney Way: Though Empl oyee Engagement Visit www.ipmso.org/2018-IPMSO-Charleston for more information and to reserve your seat - it's free!

1. Defining the current culture for your practice is a great first step, and something that you can begin immediately. Ask yourself and your staff what the practice stands for and what behaviors are valued there. This conversation will enlighten you on whether the culture you envision for your practice is in fact present in your practice.

Part of Pediat ric Management Inst it ut e?s Annual Practice Management Conference Register here

? FRONTLINES?

ROBERT E. GOFF Author & Consultant

PATI ENT DEBT: THE PERI L OF THE I NDEPENDENT PHYSI CI AN (First published in MiraMed) The great and continuing debate over Obamacare and plans for its replacement tends to focus on the consequences for the patient and their ability, or lack thereof, to pay for the costs of their care. That debate has brought together the strange bedfellows of the American Hospital Association and The American Medical Association, two organizations that rarely see eye-to-eye. They share a common concern: the impact of patient medical debt on their constituencies because that debt represents a loss of income to hospitals and physician practices. Hospitals have long had distinct advantages when it comes to addressing the loss of income from medical debt. Not-for-profit organizations are often monopolies or at least oligarchies in their communities; maintaining licenses as ?community benefit organizations?they have been the beneficiaries of numerous governmental programs to help them with the costs of uncompensated care and operating losses. Bad debt and charity pools, add-ons to reimbursement rates, as well as negotiating the ability to raise rates paid by commercial insurers to cover costs, have provided relief from uncollectible patient accounts. Moreover, as not-for-profit enterprises, they have the availability to plead for and receive philanthropy from the community they serve. Not So For the Physician Physicians do not operate as not-for-profit enterprises, but, rather, small businesses. They must earn enough to cover the costs of their practice, as well as what they wish to take home to provide for their families. 16

Even large medical groups rarely have geographic market clout comparable to hospitals that can effectively negotiate payment rates with insurers to include the cost of the losses from uncollectible patient accounts. Nor is the individual physician the object of political concern should medical debt cause losses, even if it were to lead to personal bankruptcy.

Physicians also suffer from what we, as a society, want most from them: understanding. They minister to the needs of their patients while taking on the economic consequences of their work. Highly valued patient-physician relationships cost physicians emotionally and frequently cost them revenue. Compared to hospitals, few physicians aggressively pursue patients for unpaid account balances.

Obamacare benefit plans when patients do not have the personal financial resources to pay those bills. Unlike hospitals that can renegotiate contracts with commercial insurance plans seeking increases in reimbursed rates and pleading for additional Medicare of Medicaid funding, physician reimbursement is virtually capped, the private physician has little to no ability to raise rates, or get paid those higher rates because of increased patient bad debt. There are few, if any, ?self-pay?patients that are paying the physician?s charges to offset losses from bad debt or for that matter rising operating costs.

As described in the book I coauthored, The Patient, The Doctor and The Bill Collector, this makes the physician the beneficiary or victim of the outcome of the Obamacare debate. For all its flaws, patients cannot pay what they cannot afford, and physicians cannot maintain their practice without having paying patients.

Medicare and Medicaid have been far less than kind to physician incomes, as they receive nominal increases in compensation compared to their operating cost increases. Increases that are so limited; they do not even to keep pace with inflation. For example, between 1998 and 2010, the cost of operating a medical practice increased 54 percent, Medicare rates increased 11 percent. Obamacare made additional funds available for increased Medicaid payments, but they remain below that of commercial rates in the market. The same is true for Medicare.

Patients with insurance (or Obamacare) coverage protect themselves and even the physician from financial ruin. It is hard to find reliable information on the level of medical debt that physicians?experience since medical practices generally operate on cash-based accounting principles. By operating on a cash basis, income is only recognized when cash is received, and expenses, only when paid. This scenario does not account for the recognition of bad debt as an expense, and there are no central reporting requirements as there are with hospitals. Some industry experts believe that bad debt can run as high as 5.9 percent to 14 percent of a physician?s billings.

In the past, commercial payers had been the funding source to cover shortfalls in governmental payments. Today, payers are reimbursing at the lowest levels and still maintain an adequate physician network. For the physician in private practice, the squeeze is on.

A 2010 report from the Medical Group Management Association indicated that on a per-physician basis, bad debts averaged $12,480 for an individual primary care physician, rising to $27,077 for an individual surgical specialist. The publication Health Affairs estimated that in 2013 uncompensated care for office-based physicians totaled $10.5 billion. In a 2012 survey , the Physicians Foundation found that 62 percent of physicians said they provided $25,000 or more every year in uncompensated care. While Obamacare helped create more ?insured? patients, it has in some respects not been kind to physicians, for they have had to absorb the large hit from deductibles and co-insurance built into the 17

What Should Physicians Do?

?mills?or public health or community health centers, all of which cost more than care from the private physician.

Losses stemming from patient medical debt are one more factor driving practices to change: to survive, they must change.

Some physicians choose to pass the potential for medical debt to others by requiring patients to provide credit cards to be billed for patient financial responsibilities. Intellectually, physicians know that they may have condemned their patients to interest rates as high as 24 percent and strong collection practices by the card issuer.

With no meaningful way to increase revenue (after all, there are only so many hours in the day and what physicians are selling, in reality, is their time), physicians must approach every aspect of their practice with a commitment to squeeze revenue and reduce expenses.

Others choose the business approach, turning over unpaid accounts to collection agencies, knowing that their patient will be hounded. Even if successful, at best this will result in the physician paying the agency a 30 percent to 50 percent collection fee.

The approach to patient debt is especially problematic for physicians because they function with both their head and their heart. In their head, they understand that to continue practicing medicine they must find ways of capturing revenue from any source available, including holding the patient responsible for their portion of the bill. Within their heart, they know that meeting the need for revenue can be accomplished to the detriment of the very individuals that they are supposed to serve. It is a conflict that is most troubling to physicians.

All undesired but necessary Hobson choices. Patient debt and its contribution to the financial instability of the private practice of medicine is one more factor in the loss of private practices. Physicians are leaving private practice in increasing numbers, with just one-third expecting to continue working as independent practitioners beyond 2016 according to a study from Accenture.

Self-preservation drives many physicians into Hobson-like choices (take it or leave it), which hardens the heart and forces them to go for the money.

Their report found that the number of independent physicians dropped from 57 percent in 2000 to 49 percent in 2015 and predicted that the number would drop further, to 33 percent.

If they can afford to lose patient volume, then physicians withdraw from lower-paying health plans, which often means dropping Medicaid, cutting off services to the poor in their community.

The causes are reimbursement pressures and overhead cost increases. While patient medical debt is not the sole factor, losses from uncollectible patient receivables is a contributing factor

The consequences for the patient is a loss of continuity of care, and for society the losses often come in the form of the patient seeking care in higher cost hospital emergency rooms, poor quality Medicaid

? NCQA UPDATE ?

AMANDA CI ADELLA, MPH, CCE PCMH Specialist & Senior Consultant

WHAT YOU NEED TO KNOW ABOUT PCMH 2017

In April 2017, the National Committee for Quality Assurance (NCQA) launched the redesigned Patient-Centered Medical Home (PCMH) 2017 program. Here?s what you need to know about this fourth iteration of the PCMH Standards, and how you can begin working with the program.

Goals and Focus of 2017 PCMH 2017 requirements continue to focus on quality and accountability of the practice but aims to reduce the administrative burden of paperwork and repetitive tasks that we have seen in previous versions of the program. The goals of PCMH 2017 are to -

Support practices with transformation by providing more personalized service and a user-friendly approach, Identify best practices that strengthen the medical home model of care, and Measure progress more frequently to ensure improvement is a priority

PCMH 2017 builds on and integrates concepts from PCMH 2014, such as providing 24/7 access to care, reinforcing the care team, integration of behavioral health, coordinating care transitions, and measuring improvement of quality measures. In addition, the redesigned program has created a new format for the ?standards and guidelines?. In previous iterations of the program,the Standards were organized around ?elements?and ?factors?; these are replaced with ?concepts?, ?competencies?and ?criteria?. -

Concepts are the foundation on which a practice builds a medical home Competencies organize the criteria in each concept area Criteria are individual structures, functions and activities that indicate a practice is operating as a medical home

Concept Areas There are many similarities between the previous Standards and the new Concepts. The following are the Concept Areas and a crosswalk to where they map to PCMH 2014: Team-Based Care and Practice Organization (TC) Helps structure a practice?s leadership, care team responsibilities and how the practice partners with patients, families and caregivers. -

Aligns with PCMH 2014: 2B and 2D

Know and Manage Patients (KM) Sets standards for data collection, medication reconciliation, evidence-based clinical decision support and other activities. -

Aligns with PCMH 2014: 2C, 3C, 3D, 3E, 4A, 4C, 4D and 4E

Patient-Centered Access and Continuity (AC) Guides practices to provide patients with convenient access to clinical advice and helps ensure continuity of care. -

Aligns with PCMH 2014: 1A, 1B, 1C and 2A

Care Management and Support (CM) Helps clinicians set up care management protocols to identify patients who need more closely-managed care. -

Aligns with PCMH 2014: 4A and 4B

Care Coordination and Care Transitions (CC) Ensures that primary and specialty care clinicians are effectively sharing information and managing patient referrals to minimize cost, confusion and inappropriate care. -

Aligns with PCMH 2014: 5A, 5B and 5C

Performance Measurement and Quality Improvement (QI) -

Aligns with PCMH 2014: 6A, 6B, 6C, 6D and 6E

Improvement Helps practices develop ways to measure performance, set goals and develop activities that will improve performance.

No More Recognition Levels: Pass or Fail under PCMH 2017 PCMH 2017 eliminates the three recognition levels that are based off the previous 100-point system and removes the must-pass elements. Now in order to achieve recognition under PCMH 2017 practices must -

Meet all 40 core criteria in the program, and Earn 25 credits in elective criteria across 5 of 6 concepts

NCQA has also eliminated the previous three-year recognition period.

PCMH 2017 is organized around a three-step process going forward: 1. Commit: Learn About Recognition Eligibility and the Recognition Process New practices will start with ?commit?.Practices will complete a self-assessment and work with a NCQA representative to coordinate a PCMH 2017 evaluation and plan. 2. Transform: The Evaluation Process Some recognized PCMH practices will move to the transform stage. Submit data and documentation through the Q-PASS system and participate in virtual reviews to show progress. Practices will participate in up to three virtual check-ins over the course of 12 months. After the final check-in, recognition is obtained. 3. Succeed: Keeping Your Recognition Some recognized PCMH practices will move directly to succeed. Annual check-ins required to sustain the practices recognition. Annual check-ins include attestations of policies and procedures and submission of key data. The succeed part is meant to continually strengthen the medical home model of care: promoting quality improvement and patient care. The following decision trees can help you understand your options: 2011 Decision Tree (http://www.ncqa.org/Portals/0/Programs/Recognition/PCMH/PCMH Decision Trees PCMH 2011.pdf?ver=2017-03-03-103447-910) 2014 Decision Tree (http://www.ncqa.org/Portals/0/Programs/Recognition/PCMH/PCMH Decision Trees PCMH 2014.pdf?ver=2017-03-03-120644-523)

Primary Changes in PCMH 2017 from PCMH 2014 PCMH 2017 has a heavier emphasis on integrating behavioral health into the practice. An elective credit under TC competency B asks for at least one qualified care manager to coordinate behavioral health needs. Conducting depression screenings for adults and adolescents is now a core criteria. Core criteria must be met to become recognized under the program. Reviewing controlled substance databases, obtaining ÂŠ Marvelcriteria Studios/ /that Paramount Picturesat prescription claims data, and conducting oral health risk assessments fall under elective are aimed providing comprehensive care that addresses more than the patients?health condition. Organized team-based care is vital to an efficient and effective medical home; NCQA has added a core criteria to identify a lead clinician of the medical home and staff person to manage the medical home transformation process. PCMH 2017 aligns with current public and private initiatives to support a practice through multiple ventures. The changes to the PCMH program allow practices to grow in the direction that is most meaningful to them and most helpful to their patient population.

10 Tips for a Successful PCMH Transformation

- ROLL CALL-

You can complete a successful transition under the PCMH 2017 Standards by following a few tried-and-true steps: -

Start with strong physician and administrative leadership. You must have support for the project!Engage your PCMH team, which means, talk to everyone in your practice about what it means to be a medical home and each person's role within it. Become educated on PCMH 2017 by reading the Standards and Guidelines and talking to practices in your area that have become NCQA PCMH recognized. Then take advantage of the free webinar trainings at ncqa.org. Communicate with all staff about the transformation as you are working through it. Celebrate the milestones. Encourage participation! Conduct a gap analysis to determine where the work is needed. Revamp current processes or workflows, making one change at a time. Staff are better able to absorb slow-and-steady changes rather than rapid-fire transitions. Create processes and workflows that reflect the way your practice operates, and strive to improve them over time. Improve documentation throughout the office at every level, from administrative procedures to delivery of patient care. Re-evaluate, reiterate and reinforce your processes and PCMH concepts frequently.

At The Verden Group's Patient Centered Solutions, 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 achieved NCQA PCMH Recognition this season!

PRACTICE

STANDARD

LEVEL

Parkside Pediatrics (Verdae, SC)

2014

Children?s Healthcare

2014

Kevin Norwitz, MD, NY

2014

BCD Health Partners (Woodcliff Lake, Denville & Westwood, NJ, locations)

2014

Pediatric Associates of Brooklyn, NY

2014

All Starr Pediatrics, PA

2014

Cary Pediatric Center, NC

2014

Associates, PA

Solicit frequent feedback from your patient - they will let you know if the changes are working.

? PAYER NEWS ?

ANNA I ALYNYTCHEV, MPH, PHD Senior Health Policy & Data Analytics Specialist

SCREENI NG FOR DEPRESSI ON: HOW POLI CI ES DI FFER ACROSS FOUR OF THE LARGEST US I NSURANCE COMPANI ES Depression is one of the most common mental health illnesses in the U.S., affecting children, adolescents, adults and the elderly. In a given year, approximately 16.1 million (6.7%) adults ages 18 or older, 2% of children and 5-8% of adolescents suffer at least one major depressive episode. Characterized by persistent sadness and loss of interest, depression can affect thoughts, feelings, and behaviors. Depressed individuals display symptoms including changes in sleeping, eating, energy and concentration. Depression is also the most common mental illness in those who commit suicide. Notably: More than a quarter of individuals with major depression who commit suicide are obtaining psychiatric services at the time of their death. Approximately 50% of those who commit suicide saw their general practitioner during the three months leading up to their death.40% of individuals saw their practitioner the month prior to their death. 20% of individuals were seen within a week of their death. Due to the high prevalence of depression and the potentially devastating outcomes of untreated depression, appropriate and timely screenings are vital. Screening for depression may need to occur throughout the lifespan and across healthcare settings. Therefore, providers in a range of specialties such as Internal Medicine physicians, OBGYNs, Pediatricians and Geriatricians, may all be called upon to provide depression screenings. The Affordable Care Act, the healthcare reform law passed in 2010, required that all Marketplace health plans and many other plans cover depression screening without patient cost-sharing. In order to identify how medical healthcare professionals can be reimbursed for depression screening services, we reviewed current commercial policies on screening of depression among four of the largest health insurers in the U.S.: Aetna, Cigna, UnitedHealthcare, and Anthem BCBS.

Table 1 below presents a summary of depression screening policies for these insurers and their corresponding CPT and HCPCS codes for obtaining reimbursement for these services (when using CPT 96127 and / or HCPCS S0302).

Table 1: Insurance Policies for Screening of Depression with Corresponding CPT and HCPCS Codes Insurance Company

Pol icy

CPT & HCPCS Codes

CIGNA

Depression screening is covered under the ACA, without cost sharing to members when provided by Network physicians. Depression screening may be administered as part of a wellness examination.

Billed in conjunction with any of the following codes

Frequency of Wellness Exams: 1a. Ages 0 to 5: According to the American Academy of Pediatrics (AAP) Bright Futures Periodicity Schedule 1b. Ages 5 and above: Annual wellness examination Preventative Care Screenings and Interventions may be provided as part of a wellness examination or at a separate encounter: 2. Annual Depression Screening: adolescents and adults including pregnant and postpartum women

UNITED HEALTHCARE

Depression screening is covered under the ACA, without cost sharing to members when provided by Network physicians. 1a. Depression Screening in Children and Adolescents USPSTF Rating (Feb. 2016): B

1a. 99381, 99382, 99391, 99392, 99461 1b. 99383, 99384, 99385, 99386, 99387, 99393, 99394, 99395, 99396, 99397, G0402, G0438, G0439, S0610, S0612, S0613 2. G0444 All allowed with any diagnosis code 1a. 96127, G0444 ICD-10-Diagnosis Code Z13.89 required for 96127 only 1b. 96127, G0444

The USPSTF recommends screening for major depressive disorder (MDD) in adolescents aged 12 to 18 years. Screening should be implemented with adequate systems in place to ensure accurate diagnosis, effective treatment, and appropriate follow-up. 1b. Screening for Depression in Adults USPSTF Rating (Jan. 2016): B Recommendation: The USPSTF recommends screening for depression in the general adult population, including pregnant and postpartum women. Screening should be implemented with adequate systems in place to ensure accurate diagnosis, effective treatment, and appropriate follow-up.

ANTHEM

Depression screening is covered under the ACA, without cost sharing to members when provided by Network physicians.

Codes were not provided with this policy.

1. Child preventative care ? screening tests: Depression screening 2. Adult preventative care ? screening tests: Depression screening

AETNA

Depression screening is covered under the ACA, without cost sharing to members when provided by Network physicians. 1a. Depression screening is covered in all adolescents age 11-19 during annual physical exams. 1b. Depression screening is covered for ages 13 to 19 years during annual physical exams. 1c. Depression screening is covered in all adolescents at risk ages 11-19 during or outside of physical exams. 1d. Depression screening for adults is a covered preventative service with no member cost sharing. 24

96127 in conjunction with ICD-10-Diagnosis Code Z13.89

Our review revealed some differences between the Payers. One difference found was in the specification of age categories and allowable frequency of screening within those age categories: Cigna cites coverage policies in three instances: congruent with Bright Futures guidelines (0-5 years of age), annually from ages 5 years and up as part of wellness exams, and in adults as a yearly screening with or without a wellness exam. UHC?s policy recommends depression screening in adolescents (defined as ages 12 to 18) and for all adults. Anthem does not specify ages in their policy, and Aetna covers screening at any time for at risk adolescents (defined as ages 11 through 19) and annually for members 11 through 19 who are not at risk. Other differences included: The specific mention of pregnant and/or postpartum women by Cigna and UHC. Mention of screenings being performed during annual physical exams by Cigna and Aetna. Differing policies were cited as the basis for screening recommendations: Cigna ? Bright Futures Periodicity Schedule. UHC ? U.S. Preventative Services Task Force (USPSTF)A mention of screening for Major Depressive Disorder (MDD) specifically by UHC. MDD is typically what is referred to simply as ?depression?but a Depressive Episode may be a part of MDD an isolated event. Aetna differentiates between adolescents who are at risk with those who are not at risk, specifying that adolescents not at risk can receive screenings annually during physical exams but does not mention any such limitations for at risk youth. UHC specifies the acceptable environment and procedures for screening stating that ?Screenings should be implemented with adequate systems in place to ensure accurate diagnosis, effective treatment, and appropriate follow-up.?Aetna offers a Primary Care Program to support screening in this setting. One notable similarity among all four insurers was that within the specified age ranges and frequencies, notation was made that depression screenings provided by in-network physicians were covered with no patient cost-sharing (i.e. copayments, co-insurance, and deductibles). Given the variation in ages and frequency however, it is recommended that your practice periodically review behavioral health screening policies to ensure that you are complying with the terms required by each insurer to appropriately seek reimbursement.

SEARCH MEDICAL POLICIES ANYTIME, INSTANTLY. At The Policy Authority, we make it our business to know health care insurance company policies inside and out. SUBSCRIBE TODAY 25

? INDUSTRY NEWS ? SUSANNE MADDEN, MBA, CCE CEO / CoFounder / Editor

WORLD HEALTH CARE CONGRESS 2017 One of the highlights of the year for me is attending the annual World Healthcare Congress event in Washington, DC, every spring, and this year was no exception. The Congress is an opportunity to bring together policy makers, payers, employers, healthcare systems, providers and other stakeholders to discuss current challenges and trends in the healthcare industry and share ideas, solutions and concepts.

avenues of care for more rapid identification of mental health issues and enhancements in the way that Behavioral Health issues are treated.

The health care industry is a rapidly evolving environment at any given time; with this year?s change in administration and the GOP?s focus on repealing the Affordable Care Act, a country facing an opioid epidemic of crisis proportions and a pervasive climate of political contention, this year?s conference discussions were lively and pointed, especially around potential upcoming reforms and impacts to the industry.

One of the most anticipated keynote presentations was the opener panel discussion on Policy and Market Forces Impacting Health Care. The panel consisted of Chet Burrell, CEO of Carefirst BCBS; Dr. Paul Grundy, CMO of Healthcare Transformation, IBM; Dr. Robert Pearl, CEO of The Permanente Medical Group / Federation; and Dr. Charles Sorenson CEO of Intermountain Healthcare.

In addition, with the implementation of the mental parity act beginning to show results, there was a heavy focus on Behavioral Health, including identifying needs for further change in this area. Specifically, many of the conversations highlighted the need for integration of this field into other

Condensing two and a half days of talks into a brief summary here is no easy task: following are summaries from some of the best panels and keynotes this year . . .

Policy and Mar ket For ces I m pact ing Healt h Car e

The conversation kicked off with Charles Sorenson (Intermountain) stating that we are incentivizing the wrong things: health care is mainly the business of ?sick care?and that ?we cannot pay less for keeping patient well than we do for treating them once they are sick?. Changes in the delivery of care, particularly preventive care, is crucial to creating better outcomes. Chet Burrell (CareFirst) discussed how his organization

Chet Burrell, CEO of Carefirst BCBS, Dr. Paul Grundy CMO of Healthcare Transformation, IBM, Dr. Robert Pearl CEO of The Permanente Medical Group / Federation; and Dr. Charles Sorenson CEO of Intermountain Healthcare

assessed the range of cost across specialists: prices ranged as much as 200% between specialists. And once the data was shown to primary care physician referrers, the referral patterns changed dramatically. ?You have to share data with the primary care physicians if you want to shift costs and you have to share the savings back to them to compensate for the extra work involved in running ?medical homes?. I couldn?t help but smile to hear that from an insurance executive, for it sounds like he is one of the few that actually ?gets it?.

can't focus on just quality and cost, there has to be collaboration in the equation too. He cites the example that ?40% of stroke related deaths are due to the failure of the health care system to do what it is supposed to do?. (He?s written a book about it too: Mistreated, you can watch a preview here. He also states that the #1 procedure in the US is ?arthroscopy, even though physical therapy will accomplish the same outcome?[more cheaply and less invasively]. Why? ?If you meet with a surgeon, they recommend what they do and not what they don't do?. Where there is cost transparency, and further, cost tied to outcomes, we would be able to make better decisions beyond the fragmentation of care providers. Does 'cost transparency' exist yet? "We could be there quickly", says Pearl, ?but the Payers are not driven to do more?(yet).

Frankly, I began to like Burrell more and more as he spoke about the fact that "shifting risk to physicians sends them running to big hospital systems for cover" which ?only drives up costs?. Further, he stated that making sure that the risk is "upside only" is critical to engaging primaries and helping them transition to patient-centered medical home and value based payment models. While I know some of our clients may not have had the best of experiences with CareFirst, this guy at least speaks our language and appears to want to support the independent physician.

Paul Grundy, the CMO and Director of Healthcare Transformation at IBM, voiced the thought that transformation can only occur with a ?three-legged stool?: benefit re-design, payment re-design, and practice re-design all have to occur in order for the system to truly transform. This thought was echoed by the other panelists, who decried the current system as rewarding caring for the sick, with not enough investment for keeping people well.

He backed up his points with specific examples: the biggest driver of admissions is the 'multiple chronic disease' patient (those that have osteoarthritis, hyper-tension etc.) "because there is a lack of follow up with these patients, no-one is going to their homes", where homes are the place where you've got the most non-compliance. Sending "nurses out to patients homes dramatically changed admissions and cost", so these are the places that we should be investing in. Robert Pearl (Permanente) said that we

Providers are not getting paid very well to prevent illness, so the incentive is missing to truly motivate effective change. Nothing new here, but it seems that Payers are finally beginning to take notice. Grundy scored points with me when he talked about ?the ridiculousness of the $11 per hour employee with a $3000 deductible?- healthcare is simply not 27

accessible under that model. ?Benefit redesign is important but other options need to be focused upon too?. Let me suggest direct contracting between employers and physicians, for example . . .

Shif t t o Value-Based Car e In the Shift to Value-Based Care, panelists Devi Prasad Shetty, MD, Founder Narayana Hospitals, India; Michael Tarnoff, MD, CMO, Medtronic; and Kurt Wrobel, CFO, Geisinger Health Plan, moderated by Robert Pearl, MD, CEO, The Permanente Medical Group, we heard some controversial talk from Tarnoff (Medtronic) stating that ?Payers need to determine price?and help push that to providers ?to drive out the cost?.Frankly, that?s how things work today for most providers participating in Payer networks. However, he further illuminated the point by offer the example of bundled payments for procedures stating that ?when providers have limits they help push the cost out of the equation?, such as determining more efficient and effective ways to provide services under a limited cap. Wrobel (Geisinger) tackled that by stating ?risk in bundled payments for procedures is fine but must be defined around only certain procedures. It can't be done across the board?.

Regarding telehealth, the panel was unanimous that we need to bring health care service up to the same level as other service industries. You "wouldn't bank with a bank that didn't offer ATMs, or go to the travel agent to pick up your airline tickets" (Robert Pearl, Permanente) so ?why are still sitting in doctors' waiting rooms for simple care?? To emphasize that point, Chet Burwell (CareFirst) talked about its investments in the medical home and how well that initiative had been for the company and their members?health. He highlighted the members overall admission rate: 50 per 1000, not bad. But in the sickest 2% of patients, the admission rate is actually 1000 per 1000. So what will be the impetus behind reversing the trend where the most dollars are spent on the fewest, albeit sickest, patients? The Patient Centered Medical Home model has matured beyond showing promise and is producing dividends. Increasing numbers of employers are working directly with local primary care providers due to self-funded arrangements (and innovative physicians) and have shown significant cost decreases under this model.

The panel went further and discussed that changes must come not just to contracting, payments, and utilization (which are all key to controlling costs) but that new types of procedures (and how existing procedures are delivered) are also necessary. Taking better advantage of minimally invasive surgery, for example, is necessary to reduce costs and speed recovery times, so focusing on training programs for physicians is another piece of the puzzle that can be applied to creating larger scale change.

However, the panel concluded that we cannot get there on PCMH alone; additional stimulators for change are necessary at every level of the care delivery system.

The conversation took a fascinating turn when Dr. Shetty (Narayana) discussed his hospital?s focus on high volume, low cost procedures. Dr. Pearl visited Dr. Shetty's hospital in India and witnessed 37 heart surgeries being done in one day. Dr. Shetty made the point that this sort of high volume ensures that he and his team are as efficient as possible: they develop their doctors to have high expertise through repetition, and they have to utilize every efficiency in order to meet that kind of volume. Should we be looking at closing or limiting hospitals here to consolidate volume on expensive procedures requiring high levels of expertise in order to drive down costs and promote better outcomes?

Moving from procedures to drugs, the panelists contemplated how can we possibly have value when we have such escalating drug costs? Some solutions revolved around bundling drugs into treatment of care - if so, better decisions can be made about how to treat based on both cost and outcome. For example, prescribing heartburn medication for an overweight patient doesn't solve the problem that is driving the symptom. If drug costs get bundled into overall treatment plans, then it shifts the focus to treating root causes rather than treating symptoms,which is expensive and endless.

only been able to do so because Cleveland is a very 'data-rich' organization, thereby facilitating the development of best practices around protocols and processes relatively easily. Cleveland owns its health plan for employees and so it has been able to 'bend the curve' and drop the cost of care by putting employees in 'disease programs' to address their underlying diseases. Wyllie made the point that government needs to move into the space where it is focused on pre-empting disease through better population health programs.

Beyond t he Dr ug du Jour : Leverage Behavioral Healt h, Pr event ion, and Policy t o Cur b t he Opioid Epidem ic

Paym ent Transf or m at ion The Payment Transformation panelists consisting of Alefiyah Mesiwala, MD, Former Medical Officer, Centers for Medicare and Medicaid Innovation (CMMI); Former Senior Policy Advisor, National Economic Council, The White House; Jose Vazquez, Co-Founder, University of Maryland Medical System Health Plans; and Robert Wyllie, MD, CMO, Lerner College of Medicine, Cleveland Clinic, moderated by Stephen Krupa, CEO, HealthEdge, had plenty to say about how quality should drive payments.

In this talk, panelists readily agreed that increased education efforts centered on both physicians and patients is the key to curbing the addiction epidemic. The panelists included Howard A. Zucker, MD, Commissioner of Health, New York State; Richard L. Snyder, MD, Senior Vice President and Chief Medical Officer, Independence Blue Cross; Bernadette M. Melnyk, PhD, RN, VP for Health Promotion, University Chief Wellness Officer, Dean and Professor, College of Medicine, The Ohio State University; Tom Hill, Vice President of Addiction and Recovery, National Council for Behavioral Health; Moderated by Jayne O?Donnell, Healthcare Policy Reporter, USA Today.

Mesiwala (CMMI) stated that providers that participate in CMS programs should be getting credit for their good work with other types of Payers too. If they are innovating under Medicare, their contracts across payers should be reflective of that innovation and cost reduction. I couldn?t agree more. If you incentivize physicians to drive the cost out, they can afford to spend the time to do that. If you incentivize for only certain classes of patients (e.g. Medicare) but not others, you either create a fragmented delivery system depriving patient classes of needed innovation or you depress the providers?abilities to deliver more innovation by stretching the incentive in one class across all of their operations.

Howard Zucker, the Commissioner of Health for New York State, highlighted some of the efforts that NYS has been making in increasing education to providers in an effort to reduce the number of opioid prescriptions being written, hence lowering the incidence of opioid addiction. For example, by July 1, 2017, all DEA licensed providers must complete a Mandatory Provider Education program consisting of three hours of course work or training in pain management, palliative care, and addiction, and once every three years thereafter.

Dr. Wyllie (Cleveland Clinic) discussed that his organization has moved to same day appointments for up to 60% of patients, through a combination of tele-health, in-person, email communications and messaging. It has created 'pathways' to decrease variability of how patients are being treated but has

While the dissemination of information and education to patients was addressed, the focus was clearly on providers and the need for a shift in ?recognizing that the same approach providers are attempting to undertake with other chronic illnesses 29

needs to be applied to Behavioral Health issues as well?.Preventative care, early intervention, and care coordination are not just for diabetes and heart disease, but must apply equally to Behavioral Health and addiction issues too; however, without appropriate training designed to have providers ask questions about patients behavioral and mental health, the same ?medical home?focus will be unable to be applied.

Clearly, the increased focus in the industry on Behavioral Health is being driven economically while providers, payers, regulators, and patients themselves recognize the failings of the system and are keen to better address Behavioral Health and addiction issues through greater focus and deploying new tactics for care.

The Deliver y Syst em Over haul: How Medical Gr oups of t he Fut ur e Will Connect acr oss t he Cont inuum of Car e

Conversely, the panelists considered that Behavioral Health providers should also be on the alert to screen for medical issues that can be readily identified and help patients to get the clinical care they need too. In other words, integration across specialties was considered as the way forward for a more holistic approach to individual healthcare.

Part of the difficulty in addressing Behavioral Health concerns stems from the continuing fragmentation of care and lack of communication between care providers and systems. This lack of communication and coordination prohibits providers from having much needed information available to diagnose patients more rapidly and therefore help decrease costs. The Delivery System Overhaul: How Medical Groups of the Future Will Connect across the Continuum of Care panel consisted of Jonathan Bush, CEO, Athenahealth, Dr. Steven Corwin, CEO, New York-Presbyterian, and Dr. Craig Samitt, CCO, Anthem, moderated by Dan Diamond, host of Pulse Check and author for Politico.

From the payer perspective, companies are struggling with meeting the cost of the opioid epidemic. Richard Snyder, Senior VP and CMO of Independence Blue Shield, shared some statistics to highlight the extent of the opioid issue regionally. Independence last year (2016) ?saw 3,400 members in active treatment, but of these, over 700 were still being prescribed opioids by unsuspecting or facilitating MDs?. By Independence?s estimate, the cost of an opioids-use disorder patient who is getting prescribed opioids in their plan is around ?$28,000 year, compared to $4,000 a year?for a typical non-addicted patient.

Athenahealth?s exuberant CEO, Jonathan Bush, dived right in and addressed some of the difficulties that his company and its clients have confronted when trying to access patient data across systems.

Delivery System Overhaul panel, from left to right: Dan Diamond, Author (Politico Pulse), Steven Corwin, MD, CEO (New York Presbyterian), Craig Samitt, MD, Chief Clinical Officer (Anthem), Jonathan Bush, CEO (AthenaHealth)

Dr. Samitt (Anthem) stated that interoperability is a ?collaboration issue. The 'will' is not there to share across platforms?and that "Payers have the greatest amount of data, providers have the most acute data, and patients have the most relevant data, but it is not accessible".

Providing some relief from the discussion of big data, Dan Diamond (Politico) asked ?If you can ask Trump to do anything, what would it be?? -

It is really challenging to get providers to share the data; Dr. Samitt posits that data should not be proprietary but should be a shared resource. That may be so, but Jonathan Bush (Athena) raised the issue that simply deciding to share data does not make it legal. Loosening restrictions are moving forward a bit, but not quickly enough.

The simplest place to start (and the most data rich one) is in the sharing of Medicare and Medicaid data. Bush stated that there are right now ?too many controls and barriers on the data?but that ?Payers are now giving claims data to Athena, helping to create visibility across the spectrum of a patient's care".

Much of the problem in creating a longitudinal shared patient record still falls to interoperability issues.

Bush (Athena) - "Go golf" and open up the restrictions on data. The big opportunity is around cost, so the wider the (data) view, the better we can hone in on more effective, coordinated and efficient care. The government could release the anti-kick back statute to help with that. Corwin (NY-Pres) ? ?the ACA needs to be repaired but not replaced?. You need to reduce high-cost utilization by insuring people so that they can access care, and timely. Focus on insuring more people, and providers and insurers can focus on bringing costs down. Samitt (Anthem) ? ?pressure on payment and delivery system reform should be strengthened?. We haven't encouraged partnerships between Payer + Provider + Patient. We have to create a better platform for collaboration.

Pat h t o Digit al Revolut ion and Technology Transf or m at ion

Steven Corwin, the President and CEO of NY Presbyterian, states that they currently have ?6,000 interfaces, and are actively working to get it down to 3,000!?and that ?the linkage exchange looks like a set of spaghetti wires?. Add to that legitimate concerns over cyber-security (NY Presbyterian now has insurance up to $100 million dollars compared to $2.5 million four years ago), and the issue of fully integrated communication across the continuum of care can readily be seen as an area in it?s infancy, with only minor advancements being made so far relative to the needs identified. Dr. Samitt (Anthem) mused ?Do we need to interconnect everything? How about we concentrate on what needs to be fixed first, rather than spending capital?on 'boiling the ocean'.

Of the transformative role that technology can have in improving the delivery care, many of the advances in the technology space are related to communication between patients and providers. On the panel of the keynote address Path to Digital Revolution and Technology Transformation sat Alan Warren, PhD, Chief Technology Officer and Senior Vice President, Oscar Health; Todd Hixon, Managing Partner, NAV.VC; Sumbul Ahmad Desai, MD, Vice Chair of Strategy and Innovation, Department of Medicine, Stanford Medicine Associate Chief Medical Officer, Stanford Healthcare Executive Director, Stanford Center for Digital Health; moderated by Merrill Goozner, Emeritus Editor, Modern Healthcare. Dr. Sumbul Ahmad Desai, Vice Chair of Strategy and Innovation at Stanford Medical, posited that one of the most important uses for technology right now is patient engagement. There are multiple channels available for patients to connect to their providers now - the ?bricks and clicks?as she called them - include both in-person contacts and bi-directional online communications. On the payer side, Oscar Health?s CTO, Alan Warren, 31

stated that 30-40% of its members engage via telemedicine, and he discussed how they actively ?encourage the use of communicating technologically from the point that a patient is initially engaged?in their app while looking for a physician. The patient is provided several options on how to get treated: from a free telemed call, to a PCP visit with co-pay, to an urgent care visit with a higher copay. The presentation of these options with free technology use for engaging with a provider encourages engagement in the telemed platform first. Of course, one of the most critical uses of the newest technologies is more accurate capturing of data. Data is not limited to claims data, which can be easily aggregated in most cases, rather organizations like Stanford are working on ?creating large data warehouses where all types of data?, from claims to genomics to clinical research data, can be collected and ?used for predictive analysis, not only to provide more informative care but also to better understand individual patients?and to determine which products and services to make the most sense for patient populations. The conversation wound its way back to the lag in technological interoperability, and how this is holding up data use until a smoother way is found. So much promise, but still so many barriers!

Congressman Burgess (R-TX) closed with saying that ?it is critical that we get our (reauthorization) work done. The Medicaid CHIP program is coming up in September?and Burgess is hopeful that there ?will be bipartisan support even under the current political climate?.

Healt h Car e Ref or m in t he Age of Tr um p The closing keynote is usually delivered by a person of significance in the political sphere and this year was no exception. Health Care Reform in the Age of Trump was delivered by Andy Slavitt, Former Acting Administrator, Centers for Medicare & Medicaid Services (2015-2017), and this was by far my favorite hour at the conference. Slavitt opened by stating that ?we need to shift the focus from ideas to 'execution'. We've been talking about health reform in rooms like this for years and years, with little changing until the ACA. Well that accomplished some things but not others. Accomplished cutting the uninsured rate in half! We gave people peace of mind, which is an enormous change?.

Federal Healt h Ref or m s: An MD?s View f r om t he Hill I particularly enjoyed hearing the thoughts of Congressman (R-TX) Michael C. Burgess, MD, on Federal Health Reforms. He began by stating that "the provider must be the advocate of the patient" and this is not effective "when the physician is 'owned' by a hospital", health care system etc. "Change in healthcare delivery must be patient-centric". Communication innovations will come via apps and wearable devices and that ?making regulations supportive of that is necessary?. Burgess was the architect of MACRA getting passed, and more recent legislation passed ?Cures for the 21st Century?that ensures funding for science and boosting research and eases the development and approval of experimental treatments as well as reforms federal policy on mental health care. Congressman (R-TX) Michael C. Burgess, MD 32

We also accomplished making a dent in health care costs and have seen the ?lowest medical cost trend in over the last 7 years?. . . ?95% of quality measures have improved every year over 7 years? . . . and ?the number of Americans bankrupt by health care costs has declined 25%?. He spent some time discussing what the ACA ?didn?t do?and why that has been a driver in the perception that it is ?failing?in some way. -

?It didn't go far enough to provide subsidies to the middle class. Employer-sponsored care is subsidized by offset taxes, government beneficiaries and those under the 400% of poverty line get subsidized. Those 400%+ do not, that's the middle class. We should have increased subsidized to account for sicker risk pool in middle class?. ACA did ?not figure out competition well enough. There wasn't enough competition in some markets (like rural Missouri) to make it work. Some insurance companies underpriced their products?but also stated that ?this year about 1/2 made money, next year all should make money?. It ?didn't foresee all the lawsuits and issues pulling it apart?.19 states did not expand Medicaid, which ?dramatically increased the cost in those states?and that ?the fund that was designed to stabilize that was cut off?which created some new payers going out of business, and so on.

So where are we now? Slavitt said that ?most people thought 'Repeal and Replace' meant making things better. And that has not been the case. We expect Congress to reflect our needs and concerns?and ?in a very short period of time Americans have become much more involved in their health and health benefits?, because they ?are frustrated that government has not lived up to that?. His closing thoughts were that ?we can all get on board with a better solution to solve where the ACA has failed?. Taking more ?people off of coverage, increase costs and undermining their protections, will not work?for the People. ?Undermining the exchanges by cutting funding is one way to drive enrollment down?. But his final statements said it all ?we are now asking the question: is the government acting in good faith? We never thought we'd have to ask that?. . .

If you are interested in attending next year?s conference, you will find details here: http://www.worldcongress.com/events/HR18000/ Andy Slavitt

?BEHAVIORAL HEALTH AND OTHER RESOURCES? There were plenty of behavioral health tips and resources shared at the WHCC 2017 conference, as well as recommended reading (and book promotions!) Here are some of the best of them: -

Here's a handy implementation guide for developing a behavioral health collaborative care model in your practice from the AIMS Center The Kennedy Forum, an organization working toward lasting change in the way mental health and addictions are treated in our healthcare system through parity, transparency, integration, technology, brain health and fitness, Interested to learn more about measurement-based behavioral care? Read Michael Schoenbaum, PhD's paper here: A Tipping Point for Measurement-Based Care Read about Elisabeth Rosenthal's book: 'Why an Open Market Won?t Repair American Health Care' - How Healthcare Became Big Business and How You Can Take It Back'' here Check out Dr. Robert Pearl's new book 'Mistreated: Why We Think We're Getting Good Health Care - And Why We Are Usually Wrong' by viewing a video here Read about Congress passing the '21st Century Cures Act, boosting research and easing drug approvals'

? REVISIT ?

SUSANNE MADDEN, MBA, CCE

CLICK ON THE

CEO / CoFounder / Editor

MICROPHONE TO LISTEN

A CONVERSATI ON WI TH CHRI STOPH DI ASI O, MD Last year Susanne spoke with Dr. Christoph Diasio about how his practice successfully incorporated mental and behavioral health into Sandhills Pediatrics in North Carolina. We couldn't publish a Behavioral Health issue without reposting this fascinating conversation. 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 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. 35

Click image to read Dr. Diasio's bio.

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.

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

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.

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.

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 opportunity, you should jump on it. This particular individual did an extraordinary job... 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.

Listen to the rest of the interview online here . . . .

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.

? SPOTLIGHT ? INTERVIEW WITH KENNETH FENCHEL CEO & CoFounder| Independent Pract ice MSO

TIFFANY LAURIA Practice Consultant

I recently had the opportunity to check in with Kenneth Fenchel, Co-Founder and CEO of Independent Practice MSO (IPMSO), to discuss why the time is right for a ?different?type of Management Services Organization (MSO) and where the company sees its role in meeting the needs of independent practices. T: I know that you have spent over 25 years assisting medical practices to grow and thrive, especially in the area of finance and cost savings. From your perspective, what are some of the best practices, or tips, that you most commonly tell your clients to implement in those areas? K: Too often practices have been using the same workflows and ordering patterns from the same vendors and suppliers that they signed with at the birth of the practice. Often, it?s just easier to do things this way. It takes a significant amount of time and effort to vet new vendors and suppliers and to confirm that you are (or are not) getting the best pricing from those companies. In most cases, the practice is missing out on discounts and savings because they just do not know they are available. And, as all who run medical practices know, they are bombarded daily with different sales reps promising discounts and savings - that in the end simply may not be there. Despite the red herrings, it is important for practices to review pricing for all medical suppliers and services on a regular basis. Most vendors do not notify you of price increases ? only potential, hard to achieve discounts - and that of course can result in costs creeping ever upward. Cost / overhead containment is an ongoing process. This can be hard to control but it can and must be done for the health of the practice. T: We deal with a lot of MSOs and MSO-type companies on behalf of our clients at The Verden Group. And we see that many practices consider outsourcing their core practice functions to these types of companies. Why do you think that many organizations are heading in this direction? K: Small and medium size practices do not have the purchasing power of large organizations and therefore often cannot get quantity discounts. And they do not have the time to fully vet all of the vendors in the market to see

what pricing and discounts are available. I think it?s a combination of the time, plus the honest desire to offload some of these decisions so that they can focus on actually delivering quality healthcare.

specific needs of our members. One such solution that we use ourselves is the use of a national Professional Employer Organization (or PEO). The Verden team had researched this last year (see Is A PEO Right For Your Practice) and ultimately decided to move forward with that solution themselves.

T: You have mentioned to me before that the impetus for creating IPMSO was to offer something ?different?than other MSO-type companies. Can you elaborate?

Essentially, the PEO is the staff?s employer and effectively we reap the benefit of streamlined payroll services, enjoy compliance assistance, maintain up-to-date employee handbooks, and can offer a full package of medical, dental and vision coverage, along with 401(k) plans, life and disability insurance and a range of other perks that just wouldn?t be possible for a small firm like ours. There is nothing quite like vetting a vendor directly: between reaping large savings (about $1000 per employee per year compared to before we joined the PEO) and receiving peace of mind by outsourcing the HR aspects, our experience has made us big fans of this solution.

K: The IPMSO was created to be an organization that independent practices can use to gain volume price discounts that only large organizations now receive. There are two things that make us different from other MSOs. First, we do not want to run or manage your practice - most MSOs contractually retain the right to have impact on your decision making and control how practices run. Contrary to that model, we offer discount prices and services in an ?a la carte?manner, so that practices can choose to take advantage of just one or all of our services based on their immediate needs,. Secondly, there are no long- term commitments or contracts. A practice may use our services for a onetime situation then decide to take over the process internally once the issue has been resolved. A common example of this may be when a practice hires a new physician. Some practices utilize our services to get the physician credentialed and contracted, then take the process back in-house to keep all documents up to date and manage re-credentialing activities. Other practices like us to continue to monitor and update CAQH and supply insurance companies with documents and information as requested. We are happy to work with practices either way that best fits THEIR needs.

Furthermore, we really like that this solution meets our mission head on in helping smaller practices to stay independent by competing with larger organizations, as this PEO has affordable health insurance plan offerings available to practices as small as two employees . . T: Do you see IPMSO as having a role in actively helping practices to navigate towards financial improvements and improved process goals? K: Of course! The company was started out of the identified need to help independent practices to not just survive but to actively thrive in this market, so a natural starting point for us is in helping our members to cut costs that improve the bottom line. We aggregate discounts, services, pricing and rebates through our custom negotiated contracts and links into national buying contracts with vendors like McKesson and PracticeWell, as well as niche services where we seek out best pricing, best service and best solutions for our participants. It?s not only satisfying to put these best-in-the-nation deals together, it?s also really fun to calculate the savings for each participant practice as they evaluate our offerings! I didn?t know that saving practices significant cash could be so rewarding, but

T: I understand HR functions are one of the most challenging issues faced by medical practices - it can be daunting to learn about labor law, stay in compliance and juggle all of the aspects inherent in managing employees. What is IPMSO doing to tackle this area? K: I am glad you asked that question. Human resource (HR) functions can truly be a drain on any practice?s financial and staff resources. In smaller practices, these functions are likely falling onto one of the physicians or partners - certainly not the best use of that doctor?s time! So we offer a range of solutions to meet the

here I am, enjoying every minute of it. But to get back to your question about actively helping practices to navigate ? you can?t do that without actively listening to clients. Changes in a practice can occur weekly with the rapid pace of business that we are in. We continually talk through what problems need to be addressed and what solutions we can bring to bear on the situation. In fact, we consider ourselves not just problem solvers: rather we subscribe to The Verden Group?s motto of being ?solution creators?. Why wait for a problem when you can create a solution before it becomes an issue in the first place? That?s what we are about. We deliver savings to help practices get immediate relief, then we discuss the issues and goals of the practice and develop plans to prioritize solutions. Working in such a collaborative way enables us to curate the best solutions for each individual group and provides the back up and resources the practice needs to thrive independently.

Find out how you can join here: www.IPMSO.org

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VIEWPOINT 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,Am anda Ciadella, Anna I alynyt chev, Tif f any Laur ia, Rober t Gof f , Whit ney Sm it h ViewPoint is a seasonal publicat ion, dist r ibut ed digit ally ÂŠ The Ver den Gr oup 41