Viewpoint Volume 4 Issue 1 Spring Equinox 2018 by VerdenGroup

WELCOME VIEWPOINT IS THE VERDEN GROUP'S QUARTERLY MAGAZINE PROVIDING OUR PERSPECTIVES ON THE BUSINESS OF HEALTHCARE

ABOUTVIEWPOINT

ABOUTTHEVERDENGROUP

ViewPoint is a digital publication that looks at the business of healthcare from the perspective of The Verden Group's consulting professionals and other colleagues working in the field.

The Verden Group is an innovative consulting firm focused on educating and empowering medical practices to navigate through the increasingly complex business of healthcare.

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We deliver expert consulting services and advice and with individuals and groups of any size, from start-ups to super groups. From credentialing to contract negotiations and management, marketing to social management, PCMH transitions and strategic retreats ? we are your Partner In Practice.

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INTHISISSUE GROWTH: IGP,MSOor CIN?

STABILIZEYOURFUTURE

08 SUCCESSIONPLANNINGANDVALUATION

21 HOWPATIENTENGAGEMENTISEVOLVING

Don't wait until it's too late - stabilize your future by being proactive now.

A look at the latest (technological) ways to engage with your patients.

25 TIMETOGROW?

Introtodynamic work design A look at how to take process improvement models to the next level.

Is it time to open an additional office?Dr. Jefferey Kile tells us how he did it.

IP,MedicaidandtheFederal 27 CBHudget: TakingStock of 2018

GOINGLARGE: WHAT'STHERIGHTMODEL FORYOURCOLLABORATIVEEFFORTS?

How Trump's budget will affect government funded programs this year and beyond.

If you are looking to grow through collaboration, you need to understand your options.

INTHISISSUE ALLABOUTMSOs

INTEGRATEMULTIPLEEMRS

UNDERSTANDINGMANAGEMENT SERVICESORGANIZATIONS

Our quarterly shout out to PCS clients that have achieved PCMH recognition.

Everything you need to know about MSOs: benefits, pitfalls and new models.

UPDATEDCPTCODES

CLINICALDATAINTEGRATION

PODCAST Verden's CEO visited NCQA's HQ in DC to talk about all things related to PCMH.

Jenna Mirchin brings us up to date on behavioral screening & assessment codes.

ROLLCALL

EVENTS&CONFERENCES Find us at these conferences and events across the country.

Why physicians don't need to jettison their existing EMRs in order to integrate.

THISISSUE'SCONTRIBUTORS STAFF Editor-in-Chief Susanne Madden Managing Editor Nicole Caldwell

dANFRIER,ESQ. Daniel B. Frier, Esq., co-founded the healthcare law firm Frier Levitt, LLC., in 2000. He serves as chairman of the firm?s Healthcare Department, and has dedicated his practice to representing all manner of healthcare providers. His article in this issue of Viewpoint breaks down the differences between CINs, MSOs and super groups for practices seeking to collaborate.

Jefferey kil e, MD Cover Design Scott Hodgson Web Master David Magbee

Jefferey Kile, MD, MHA, is owner of Pediatric Associates of Kingston. He has served as a pediatrician at the practice since 2003, and recently expanded his office locations to include one in Pittston, PA, and in this issue shares with us his insights on how to know when it's time to grow.

DAVIDMAGBEE

SUBSCRIBE Produced by The Verden Group, ViewPoint is available by free subscription and distributed seasonally. Print copies are available by request. Please contact us for pricing.

David Magbee is The Verden Group's credentialing consultant and head of special projects. In this issue, he brings us insights into how patient engagement is evolving through new technology solutions.

JENNAMIRCHIN, CPC,CPMA, CGSC Jenna Mirchin works for a 500-provider, multi-specialty group in New York as Senior Coding Manager, overseeing the group's Coding and Compliance Department. In this issue she provides updated CPT codes for behavioral health screenings and assessments.

pAULVANCHIERE.MBA

contact The Verden Group 48 Burd Street Suite 104 Nyack, NY 10960

877-884-7770 inquiry@theverdengroup.com www.VerdenViewPoint.com

Paul Vanchiere is president of Pediatric Management Institute, which he founded to provide an array of services for pediatric medical practices of all sizes focusing on financial and operational issues. He shares with us his insights in this issue's article "Succession Planning and Valuation."

CATHERINEVALYI / CLINIGENCE Catherine Valyi is Vice President of Marketing for Clinigence, a health information tech company providing software-as-a-service solutions for clinical data and patient care to healthcare providers and hospitals.

LETTERFROMtheEDITOR

Time for change?Assess it in terms of both growth and stability in order to take a solid step forward.

It may seem like we picked an odd title for this issue as stability and growth often seem to be going in two different directions. But we'd like you to consider them collectively: if your practice is relatively stable, perhaps there is no better time than now to solidify what you've built and consider growth to further your success: through expansion, collaboration, and technological investments to attract more patients or expand into new models of care. In order to grow successfully (and safety), you'll want to ensure that your practice has a measure of stability in terms of succession planning and valuation. Paul Vanchiere takes us through what to do to plan strategically (page 8). Turning to growth, Dr. Jeff Kile talked with me about how he decided it was time to open a second location after more than 50 years of serving the community from a single address (video cast on page 25), while Dan Frier, Esq. takes us through options for collaborating with others in the form of super groups, CINs and MSOs (page 17). And what are MSOs anyway? I provide you with a quick primer on that model (page 33). Verden's David Magbee rounds out our thinking with an exploration of the latest in technology for patient engagement, while our friends at Clinigence tell us why CINs and supergroups may not need to unify their EMRs into one platform in order to collaborate. While you are tackling the ideas of stability and growth, you might turn your attention to the idea of Dynamic Work Design. On-going process improvement is essential to developing a healthy practice, but unless you focus as much on your people as your processes, you are liable to miss the mark on true, sustained improvement. This issue offers an introduction to such principles (page 13). We've applied the same thinking to our e-magazine and have made two significant changes: a new layout that we think is easier to read and reference; and a new managing editor, Nicole Caldwell, whom we enthusiastically welcome to the team. In doing so, we offer much appreciation to our departing editor, Heidi Hallett, for helping us to build and grow ViewPoint Magazine.

Susannemadden 7

01 SuccessionPl anningand Val uation Paul Vanchiere, MBA President, Pediatric Management Institute

In addition to providing excellent care, successful medical practices have three things in common: a clear valuation formula, a straightforward succession plan, and a detailed outline of shareholder compensation. Insightful practice leaders know better than to kick the proverbial can down the road on preparedness issues; and being proactive starts with a fair, clear shareholder agreement. Medical practices need to be able to convey their business frameworks in a simple manner for physicians who might consider coming on board, and have everything in place should there be a sudden death, divorce, or other unforeseen circumstance. My rule of thumb: If you can?t explain your frameworks in more than a minute or two, it?s more complicated than it needs to be.

SUCCESSIONPLANNING&VALUATION Don?t rely on accountants to determine your value.

In any business, success starts with preparation. In early January 2000, my father Buzzy Vanchiere, MD, FAAP, was serving as managing partner for an 18-provider pediatric practice in Southwest Louisiana. The practice was detail-oriented and highly organized, with a clearly drawn up succession plan and shareholder agreement. At the time, my father and his partners were in the midst of finalizing the buyout of the practice?s senior partner, which was a clean, streamlined process thanks to everyone's preparedness.

Most practices rely on accountants to tell them the value of their practices. While this is helpful in some ways, too often accountants rely on "book value? (assets minus liabilities), along with the shareholders?total income and practice revenue stream, to determine a valuation. Such an approach can be disastrous. I once worked with a client who had eight providers generating more than $4 million in revenue each year. Book value would indicate that with all that money coming in, the practice was worth millions. Guess what? It?s not.

Then disaster struck. As his partner?s final day approached, my father had a massive stroke. The practice was suddenly faced with two simultaneous buyouts: a potentially detrimental financial blow for the remaining six partners. But not for this practice, which had readied itself for the unpredictable.

The most effective way to avoid negative consequences from unexpected events is to determine the actual value of the practice in advance, much like a prenuptial agreement determines the financial considerations in the event of a divorce. Because it is a certainty that every partner in a practice will need to be bought out at some point if the practice continues to operate, it is prudent to plan ahead for that inevitability.

After the initial shock subsided, the practice was able to quickly proceed with the plan that they already had in place. The buyout of the senior partner was unaffected while the life insurance previously purchased by the practice on each of the shareholders provided the liquidity to buy out my father?s interest in the practice. Since the pending buyout of the senior partner could have provided a timely reference for my father?s buyout amount, it was reinforced with a solid shareholder agreement.

Smart practices conduct annual updates to practice value. The process to do so should be quick and easy. Shareholders can take time each May (after filing the previous year?s tax return) to collectively update the valuation formula and make any necessary adjustments. Having a solid formula in place allows for quick and easy updates to the valuation.

The most notable item in the shareholder agreement was related to updating the practice?s value each year. My father and his partners reviewed the valuation formula annually, discussed any necessary adjustments, and signed off on updated values. In the case of a disagreement, the last agreed-upon valuation served as the amount for any buyouts over the next year. This process was particularly helpful in the case of my father: planning ahead allowed his partners to address the issues at hand as objectively as possible.

Philosophy, formula and adjustments play into your practice?s valuation. A common practice valuation approach seeks to establish the added benefit of owning the practice instead of being employed. For example, if a shareholder makes $250,000 for a given year and an employed physician at the same practice makes $180,000, the added benefit for owning the practice is $70,000. After applying a multiple to this number, adding the practice assets and deducting the practice liabilities, one should have a good handle on what the practice's per-shareholder worth actually is.

It is not uncommon that without clear and understandable shareholder agreements, individuals on each side of the transaction are prone to place their own personal interests ahead of the practice. Some practices simply pay out the departing partner (or his or her estate) a percentage of the remaining accounts receivables, while others account for any accumulated assets and incurred liabilities.

That?s why you want to value your practice in this way: You are dealing with buy ins and buy outs of shareholders, rather than looking to sell your practice to a venture capital company for profit maximization. (If that opportunity comes along, go back to the book value approach your accountant may recommend.) If the practice has more than one shareholder and one or more employed physicians, the process to determine the value is rather simple:

In all situations, it ultimately comes down to a dollar amount that all parties can agree on.

1. 2.

As such, The Verden Group and Pediatric Management Institute are often called in to review such situations to help find a fair position for both sides of the transaction to ensure that the practice emerges as financially viable coming out of the negotiations as it was going in.

Determine the average of the shareholder earnings; Compare shareholder earnings with the average compensation for the employed physicians in your practice (if all physicians are shareholders, find regional or national averages for comparison); Multiply the valuation basis times the number of years of projected earnings. This amount can vary from one to three years based on a variety of market conditions.

SUCCESSIONPLANINGANDVALUATION

Smart practices conduct annual updates to practice value. There are a number of changes to the formula that can be made from there, including: -

Taking the average shareholder salary for the previous two or three years; Adjusting average shareholder compensation based on whether monies have already been received, or if shareholders have previously taken lower salaries to fund practice projects expected to generate additional earnings in the future; Adjusting the years of projected earnings or average shareholder compensation to account for upcoming large capital expenditures; Adjusting for nuances in the shareholder compensation formula.

Your practice?s value may be different when it comes to selling to a hospital. In the event that a practice is looking to sell to a hospital (or any non-profit entity), the value of the practice is very different. But the days when hospitals hand over blank checks, like they did back in the 1990s, are long gone.

SUCCESSIONPLANNING&VALUATION -

Today, thanks to federal Stark Laws, hospitals are limited in what they can offer, and usually just purchase the tangible assets of the practice and provide salary guarantees for the physicians. Assets valuation can be as simple as the book value (total assets purchased minus accumulated depreciation), or a physical count of everything minus an amount for wear and tear. Salary guarantees are usually limited by a percentage of national salary benchmarks such as those published by MGMA, along with standard benefits packages offered to all employees of the organization.

Many hospitals will claim to offer flexible negotiation terms, but larger organizations usually have standard contracts with very little leeway to address specific concerns you may have, and many are underpinned by strict regulations.

Shareholder agreements should be decided by advisors and shareholders. Seasoned consultants, attorneys or accountants who understand the nuances of medical practices can guide you and your partners to develop an appropriate formula. But while practices often have competent legal advisors putting together such agreements, they occasionally lack the ?real life? experiences to include how common situations will be handled. Shareholders can use their own priorities to determine specifics that work for them. In this process, be careful to address the following details: Personal responsibility for coding audits: To avoid improper coding or documentation penalties and recoupments from affecting the entire practice, include a stipulation that providers are responsible for their own coding and documentation? as well as for error penalties. Neglecting to address this issue can spell disaster! In addition, include ?clawback? provisions specifying how potential recoupments will be handled after a shareholder is bought out or leaves a practice. Include these provisions in the employed provider?s employment agreement.

Don?t rely on accountants to determine your value.

Spouse approval: To avoid potential conflicts after a shareholder dies or goes through a divorce, ensure shareholders?spouses sign the shareholder agreement. This eliminates potential challenges to the practice valuation and buyout process. Such a requirement is quite effective when facing buyout opposition from an estate or soon-to-be-ex-spouse. Personal guarantees for financing: Shareholder agreements often have generic language about how personal guarantees for practice loans are handled. Address whether such guarantees are on a pro-rata basis and if shareholders will indemnify each other?s allocated guarantee. Whatever language you decide on needs to be correlated to the final loan agreements, which will likely take precedence over the terms of your shareholder agreement.

Consecutive days out of office: A practice retains overhead regardless of whether a shareholder is actively seeing patients. A shareholder who is away for an extended length of time can complicate a practice?s ability to keep up with such costs. Determine up-front how many days a shareholder can be away before enforcing an alternative compensation formula or buyout. Disability: The best shareholder agreements include a clause stipulating that compensation will continue at the usual rate until a shareholder?s disability policy kicks in. This requires shareholders to carry some sort of a disability policy that begins 45 to 60 days after the beginning of a disability. This provision minimizes the financial impact to the practice during a time when additional expenses may be incurred. Those shareholders who can?t obtain disability insurance may seek ways to escrow a portion of their salaries each year for such contingencies or provide an alternative compensation formula for them. Mediation or arbitration clauses: It is advised that a practice includes a mediation provision in case of stalemates over major decisions. Shareholders may call upon a neutral third party to facilitate a resolution in such instances. The agreement should further state the issue will be resolved by binding arbitration should mediation not work. These terms motivate involved parties to come to a consensus in the mediation phase. Without such verbiage, the mediation phase will lack the teeth needed to motivate a resolution. Medical malpractice tail coverage: The agreement should address how the tail coverage for a departing physician will be paid and whether or not this amount will be deducted from the buyout price. Tail coverage can be very costly, depending on how long the departing provider has been on the policy as of their last date with the practice, and whether it is a claims-made policy. Force out provision: Assuming the shareholder agreement contains the explicit formula to value the practice, there should be a premium allocation (10 to 25 percent) to be paid should a majority of shareholders wish to buy out a particular shareholder. This provides a financial incentive to carefully select partners aligned with the shareholders before adding a new partner. More importantly, it provides some motivation for all the partners to weather challenges. Failure to plan provision: Practices should have as much notice as possible of individual shareholder retirement plans, due to the time and expenses related to recruiting and grooming another shareholder. The agreement should stipulate that the buyout amount is discounted by 25 percent in the event of a physician not providing at least two or three years?notice of retirement. Obvious exceptions would apply for disability and death. Consideration should also be given to scenarios in which a shareholder loses his or her ability to be covered by medical malpractice, retain board certification, or remain on provider panels. Pledging of assets: The shareholder agreement should specify that individual shareholders cannot collateralize stock ownership; specifically, they can't pledge stock in the practice as guarantee for personal loans or the like.

SUCCESSIONPLANNINGANDVALUATION

Shareholder agreements should be decided by advisors and shareholders. -

Personal bankruptcy: Practices should seek legal counsel concerning how to minimize impact resulting from a shareholder filing for personal bankruptcy. The last thing a practice needs is third-party meddling. Future expansion and financing: Consider the following scenario. Two physicians invest $100,000 in a new location. Instead of taking a loan, they reduce their income for the year by $50,000 each. One of them dies during the next year and a significant portion of the valuation formula takes into consideration the ?benefit of owning the practice.? How do you compensate the heirs for the reduced income in the previous year and loss of benefit from that investment? While every situation is different, one way to mitigate this problem is to obtain outside financing to fund expansion efforts. While this does not mitigate all the issues, it does address one part of the equation. Similarly, care needs to be taken to avoid a scenario where a shareholder reduces his or her earnings in a given year in order to fund the acquisition, yet is bought out before the investment is recouped.

If you have concerns about your current agreements and / or lack of succession plans, there is no better time than now to begin to address those concerns. Start by reviewing your partnership agreements. Run scenarios such as described throughout this article: if your senior managing partner had a heart attack tomorrow, are their plans in place to quickly and deftly manage their departure? Don?t wait until you need a plan; get your plan in place well in advance of disaster and your partners will thank you for that in the future.

02 ANINTRODUCTIONTODYNAMIC WORKDESIGN Susanne Madden, MBA President & CEO, The Verden Group

I?m a self-proclaimed process nerd. As an MBA recipient in Management Systems, I?m very familiar with concepts like Lean Process, Six Sigma and other improvement methodologies. These processes are all concerned with designing and controlling processes for optimal efficiency (the ?how-to?), and not so much about the implementers of those processes. Being a topic of interest, I recently took a course through MIT Sloan called Business Process Design for Strategic Management. Much of the content focused on what?s referred to as ?Dynamic Work Design,?which hones in on how the people involved in carrying out the work handle their tasks. I couldn?t help but see the potential for greater success by deploying this type of process design to medical practices. Let me explain why.

AnIntroductiontoDynamic Work Design When we look at, say, lean principles, we can see plenty of opportunity to better designed work-flows in order to save time, cut out redundancy, and improve productivity. This concept works beautifully in machine-based environments, where there is a reasonable measure of confidence that processes will remain fairly static, routine and repeatable. But applied to service-based industries ? like medical practices ? and we see high variability in outcomes because there is less consistency in terms of repeatable processes. The reasons why are usually due to human interaction. Machines are great at doing the same task over and over; but introduce human interactions to the mix, and you now have inputs and outputs of much higher variability. Queue Dynamic Work Design, which is primarily concerned with focusing on the motivations and performance of the individuals conducting the work, as well as looking at who should be involved in problem-solving and escalation. By putting the focus on humans, their skills and adaptability, this methodology allows work to be designed around an organization?s most valuable resource: its people. Specifically, work design seeks to meet three key criteria:

There are three typical kinds of design.

To see why the potential for applying this concept to medical practices is so appealing to me, an understanding of the two more typical forms of design should be made clear: -

?Process design?? this is typically concerned with mapping out the major steps needed in order to, say, convert materials into a finished product or work through a project from start to finish along a timeline defined by a series of tasks. ?Organization design?? this typically focuses on the governance needs of organizations, addressing such things as reporting structures, resource responsibilities at various levels, and job assignments.

Understanding outcomes. The person doing the work should understand why they are tasked with the work and be able to use a variety of skills in executing that work. Allowing individual control. People find tasks more engaging when they have at least some input or control over how it is carried out. Building a rapid feedback loop. People draw more satisfaction from tasks when they are not conducted in isolation. Receiving regular and rapid feedback on performance can be critical to keeping people motivated.

Now, I am not suggesting that we throw out all the prior principles that have been used to subdivide and routinize tasks, as these approaches have continued to produce efficient results in practice. But, it would benefit us to look at better ways to bring people into the work equation, for two reasons. One, in service industries like medical practices our workers' performance is often how our practices are graded. And two, an engaged workforce allows for the development of appropriate organization culture and the ability to deploy change more rapidly in a highly dynamic environment. (See an article from the Summer Solstice 2017 issue, the ?The Psychology of Disney: Get Intentional With Employee Engagement?for more n that regard). And that?s where the ?dynamic?piece comes in.

Neither takes into much account the actual human beings who are tasked with carrying out the work assigned by such designs. That?s where dynamic work design comes in. ?Work design?focuses on designing work that accounts for the skills and capabilities of those who need to carry out the tasks. Too often, work design is based on an ?ideal? employee ? in practice we know that such an employee rarely exists! Due to that reality, work design attempts to create work that recognizes people?s strengths and weaknesses and creates a basis for developing work that will engage and satisfy those tasked with carrying it out.

An IntroductiontoDynamic Work Design On any given day at any medical practice, there are scores of processes that are challenged in one way one or another. Checking in a patient at the front desk is usually a smooth process: Verify patient name, date of birth, insurance information, and so on. But what happens when a patient?s insurance eligibility comes back as ineligible? Or the patient left his or her insurance card at home? Or they do not have their copay amount? Or, or, or? What then?

Medical practices are more dynamic than static in nature. To operate efficiently and effectively in such environments, it is paramount to empower people to have control in terms of how they respond according to their own skill sets, and to give them an understanding of what goal it is that they are trying to accomplish. These assets directly lend themselves to far superior customer service. When employees understand why they are doing the work, they are better able to make the appropriate adjustments to the static design when dynamic challenges arise. As such, an effective work system can be viewed as everybody knowing why they are doing what they are doing, and creating an ongoing method for everyone from the manager to the receptionist.

Static process steps for patient check-ins may be consistently challenged by other human beings not conforming to those steps when dealing with service-related matters. Practices therefore need to be thinking in terms of ?static?and ?dynamic?design when it comes to developing work-flow processes across its organization. -

Those methods can constantly be compared and adjusted as needed in order to more perfectly align with the intended outcome. Honing processes in these ways will always produce far superior results than trying to adhere to the principles of static design alone. When viewed from a "continuous improvement" lens, you can see how examination of the static design compared to the reality of variability would produce a method for determining dynamic work design at your practice.

Static design is captured through process diagrams, project plans, and organizational charts, readily identifying how things are supposed to work. We need these designs to provide the framework for how to get most jobs done. Dynamic design describes how a practice can respond when things don't go as planned.

Over the course of the next few issues, I will be exploring how to develop this method in such a way that it can be readily deployed in the independent practice setting. Or, if you are part of a larger group, CIN, IPA, or other collective, join us May 2-4 at the Pediatric Supergroup conference in Arlington, VA, where I will be presenting on Dynamic Work Design in person. Details below (click the image to connect to the site).

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03 GOINGLARGE: WHAT'STHE RIGHTMODELFORYOUR COLLABORATIVEEFFORTS? Daniel B. Frier, Esq. Co-Founding Member, Frier & Levitt

Everything seems to be changing in the way healthcare is delivered. From MACRA and ACOs to private equity practice roll-ups, and insurance company-owned practices to hospital-owned practices, the landscape of healthcare is constantly evolving. But one thing hasn?t changed. Physicians who wish to stay relevant (and busy, and paid decently) must align themselves with a larger organization of some type. Surely, there will always be the rare exception for discrete geographic regions where time seems to stand still and solo practicing physicians can still thrive. But these are outliers, plain and simple. Physicians have the option of synchronizing with hospitals or private equity groups, each of which has a specific agenda that may or may not align with the goals of physicians. For physicians wishing to remain relatively independent, however, these models may be less than ideal. For independent-minded physicians, there are three models offering alternatives: Integrated Group Practices (IGPs), Clinically Integrated Networks (CINs), and Management Services Organizations (MSOs).

GoingLarge: What'stheRight Model for your Col l aborativeEfforts?

One thing hasn't changed: Physicians wishing to stay relevant (and busy, and paid decently) must align themselves with a larger organization of some type. Integrated Group Practices (IGPs or ?Supergroups?) Arguably the gold standard for physician integration, IGPs are entities (usually LLCs) consisting of multiple physicians (single or multi-specialty) who operate as a single group medical practice and bill through a single tax identification number (TIN).

its direct expenses (e.g., rent, payroll, insurance), and the care center?s allocable share of common overhead. Although each doctor member/owner of the IGP will execute a single operating agreement and member services agreement detailing the rights and responsibilities of all members, the members of each care center will also execute distinct ?Care Center Agreements? among themselves. These agreements will replace the shareholder or operating agreements that formerly detailed the financial arrangements and commitments between the doctors of each legacy entity. Care center agreements legally obligate each doctor member of the applicable care center to the same types of obligations set forth in the legacy entity documents. The doctors affiliated with each care center are responsible for treating patients at their care center office, and for making most decisions that directly impact the operation of the care center.

Although the IGP is a single group practice, it usually consists of separate ?care centers,? each of which constitutes a separate ?satellite? office location or group operated by those doctor members of the IGP who are affiliated with that particular care center. Each formerly independent pediatric practice ceases to practice medicine as a separate company, and doctors comprise their own separate and distinct care center of the IGP. In general, a care center?s professional collections are distributed after subtracting

Although each care center practices with a certain amount of autonomy, each member is legally a member of the IGP. The obligations and relationships between members and care centers are defined by a company?s operating agreement. Some important characteristics of the proposed IGP model include the following:

GoingLarge: What'stheRight Model for your Col l aborativeEfforts? -

Former practice entities (e.g., each P.A., P.C., LLC, partnership, sole proprietorship) of the members (?Legacy Entity?) may remain in existence in order to serve as holding companies for the assets utilized at the corresponding care center (e.g., offices, equipment, computers, furniture, leases). The IGP may lease the assets from each legacy entity for use at the related care center, and the cost of the lease may be charged to the care center either through a management fee or directly. The name of each legacy entity may be licensed to the IGP so that the care centers can continue to operate under their former names. All professional services will be performed through, and billed by, the IGP under its TIN.

CINs A CIN is a network of providers sufficiently integrated at the clinical level, allowing the network to contract jointly with payers. Pursuant to DOJ and FTC Policy Statement going back as far as the 1990s, clinical integration involves a provider network?s ?active and ongoing program to evaluate and modify practice patterns by the networks?providers which create a high degree of interdependence and cooperation among the providers to control costs and ensure quality.?

Doctors will generally be in a better position to face the ever-changing and complex healthcare environment if they are part of a larger group of like-minded practitioners.

Physicians may form a CIN while remaining separate and distinct medical practices.

Administrative functions such as billing, collections, accounts payable, human resources, IT and payer contract negotiations are centralized and performed by staff hired to work for the IGP at the central business office. By way of compensation, each member will receive a regular draw and a monthly or quarterly ?true-up?based upon his or her care center?s ?profits.?

While there are many hospital-owned and -operated CINs, this is a model that also applies to independent practices. Physicians may form a CIN while remaining separate and distinct medical practices, provided they are willing to take substantial steps over time to integrate their clinical functions in a manner that enables them to engage in value-based contracts with payers. Integration designed solely to leverage size in order to negotiate higher fee-for-service reimbursement raises serious federal and state antitrust concerns. This was the trap many IPAs fell into over the past 20 years.

The basic theory behind IGPs is that doctors will generally be in a better position to face the ever-changing and complex healthcare environment if they are part of a larger group of like-minded practitioners. Some potential advantages of an IGP include its abilities to: -

Centralize time -consuming practice management functions such as billing, accounts payable, credentialing, negotiating with vendors, pension administration and human resources administration. This allows care centers to focus on patient care and practice-building. Allow physicians to share coding and billing best practices in order to optimize collections. Enable practices to negotiate more effectively with local hospitals (depending on the geographic scope of the practice).

Participate in a value-based healthcare model, which is fast becoming an important component of healthcare payments. Exchanging data and best practices may be simpler in a single practice setting with common IT systems. Invest in ancillary services and treatment modalities without violating the federal prohibition against self-referrals (?Stark?). Participate in an ACO or CIN more effectively as a group, or form its own ACO/ CIN at some point. Negotiate lower professional malpractice premiums and other costs typically incurred by healthcare practices. This ?group buying power? may also enable the IGP to negotiate more favorable deals for products and services such as bank financing, EMR and Practice Management software and medical supplies and equipment.

Understanding and being able to implement value-based contracting will likely be critical to a provider?s ability to function and thrive in the coming years. Payers (which now include insurers and self-insured employers) understand the limitations of fee-for-service reimbursement, and have begun to transition to payment models that reward quality and cost-savings. Value-based payment was tested by several payers in the late 1990s, but the available data was insufficient to accurately track and measure performance. Advances in data systems and data analytics have changed things dramatically. We?re now seeing major players implement value-based models, including Medicare, through initiatives such as the Shared Savings Program, as well as major commercial health insurance companies that have implemented similar models. In a shared savings model, providers are rewarded for reducing costs and improving quality over a defined patient population

GoingLarge: What'stheRight Model for your Col l aborativeEfforts? and/or based upon an ?episode of care? (e.g., a hip-replacement, an obstetrical delivery or managing a chronic illness). The future will likely involve more advanced models, such as bundled payments or even capitation, whereby providers take financial risk, and possibly even insurance risk, in the treatment of conditions or populations. These models will require networks of providers with a high degree of clinical integration. Forming a CIN may better enable independent physicians to participate in those models in the future.

MSOs have increased in popularity over the past several years because they enable groups of medical practices to share asingle, central business officein order to reduce costs through economies of scale, and start the process of integration without committing to the levels of integration required by a CIN or IGP. Additionally, because MSOs do not practice medicine, they may be owned by non-physicians. MSOs are therefore an attractive target for private equity funds seeking to invest in practice management companies, particularly in states with corporate practice of medicine prohibitions.

When assessing forming independently owned CINs (versus hospital-owned ones) Providers may opt for this model rather than an IGP for several reasons: -

Because they require the lowest level of integration, MSOs are arguably the simplest to form of the three organizations described in this article. They may also be used in conjunction with a CIN, thereby enabling both clinical integration, and systems integration, without requiring the participants to practice medicine under a single TIN entity.

CINs are simpler and less expensive to form from a legal perspective; CINs enable practices to remain independent while potentially benefiting from clinical integration with their colleagues; CINs may enable practices to work with one another and ?date? before ?marrying? into an IGP model.

MSOs

Daniel B. Frier, Esq. is a co-founding member of the law firm Frier & Levitt, LLC, and Chair of the firm?s Healthcare Departments.

MSOs have been around for many years, and have taken on a number of various forms and functions. For our purposes, an MSO is defined as a legal entity providing certain administrative and management services to medical practices that enable the practices to function. These services may include the provision of space, equipment, non-clinical staff, billing and collection, accounts payable, insurance credentialing and human resources.

Frier Levitt is devoted entirely to the practice of health care and life sciences law throughout the country. Mr. Frier can be reached atdbfrier@frierlevitt.com, or at 973-618-1660. (YOU CAN READ A RELATED ARTICLE 'WHAT YOU NEED TO KNOW ABOUT FORMNG A SUPERGROUP', here.

04 HOWPATIENTENGAGEMENT ISEVOLVING David Magbee Consultant, The Verden Group

We are living through a time of almost-daily technological advances. You don't have to love every aspect of this fact (plenty of us still prefer paper day planners to virtual calendars and newspapers to Kindles!); but like it or not, tech is here to stay. Luckily, these advances bring with them a myriad of conveniences: from the ability to book an entire vacation from your phone to checking mobile data usage without dialing a toll-free number. Yet too often, these conveniences stop at the door of medical practices. To increase patient engagement and streamline service processes, there are a number of advances providers would be wise to incorporate or risk being left behind. Here's a roundup of the latest engagement tools, from pre-visit to post-visit and beyond. PRE-VISIT We?re all busy. And finding the time to schedule an appointment for your own health can be daunting when it involves being put on hold for minutes at a time before having to negotiate available time slots and dates with a receptionist. Utilizing real-time online scheduling with appointment reminders and easy online rescheduling will not only engage the patient in preparing for their visit, but it also reduces staff hours on these tasks and increases profitability.

HowPatient Engagement IsEvolving integrated platform that further adds to the visit experience through a simple charting interface, and electronic prescribing to save more time for you and your staff by eliminating calls to pharmacies.

The healthcare industry has been slower to adopt consumer technological trends than most other industries mainly due to the nature of confidential information and regulations governing exposure of patient data. Advances in computing technology has supported the ability to maintain secure software environments to maintain the necessary HIPAA encryption standards, and the patient-provider experience is directly benefiting. A Validic survey reporting on trends in digital health shows 68 percent of survey respondents are better able to coordinate care by being able to manage more patients with fewer resources. By integrating vital information from EHRs into a seamless software solution, patients are enabled to actively engage in their care and providers are freed up to focus on the fulfillment of it.

Studies show an average of 75%of US patients demonstrate an interest in using telemedicine in lieu of an office visit.

Perhaps your existing EHR has this functionality. If not,there are many other third-party options you can easily integrate or operate alongside an existing system. This may be the single most convenient feature that you can offer patients, while at the same time reducing no-shows, eliminating phone traffic, and taking the load off of your office staff to manage appointment requests.

Telemedicine No conversation about patient engagement would be complete without talking about telemedicine. Advances in phones, computers and app technology allow for a direct-to-consumer application of telemedicine, improving patient care and creating potential savings by replacing physician?s office and ER visits. Utilizing telehealth applications has proven useful for minor acute illnesses in primary care. Angela Pantelas, director of telehealth strategy and operations at Allegheny Health Network, says patients typically seek treatment via e-visits (nonsynchronous electronic encounters) for sinus issues, urinary issues and cough. Embracing e-visits prevents primary care visits from bogging down the practice schedule.

HealthGrid is one CRM platform that performs these task with simple mobile appointment acquisition, and goes several steps further by providing patient care assessments and screenings to ensure patients are engaged in their healthcare experience. Through their mobile platform, the practice can automate the check-in process up to 24 hours before the patient?s visit, auto-populating their own personal demographic information right from their own device. Their mobile app even allows your patients to check in right from their device when they arrive.

During the visit

Studies show an average of 75 percent of USpatients demonstrate an interest in using telemedicine in lieu of an office visit. Utilization of e-visits and secure video consultations provides greater access to patients in rural areas where patients may put off proactive healthcare given travel times, or appointment availability. The increase in interest not only improves the process for patients, but offers the potential for major savings for clinical practices. Physicians are able to handle more patients than the traditional healthcare model allows, and the Rural Broadband Association says the USnational average per medical facility is estimated at $20,841.

Whether the patient or the provider would like to admit it, healthcare is a service industry. Most providers prefer to focus on delivering clinical care, rather than on the business of the healthcare. But focusing on the delivery of that service will enhance your practice?s reputation and help improve your practice workflow. Apple, Inc. is well known for its superior in-store customer service experience ? which is achieved by the company utilizing the very technology and hardware it designs develops and sells. Phreesia essentially emulates that experience and allows you to do the same in your practice. Its solutions have all of the same convenient features that allow patients to schedule their appointments easily and be reminded of them as they come up, sometimes even allowing for same-day scheduling. To take it one step further, Phreesia also has a suite of hardware that integrates with your EHRs to empower patients to check in virtually when they arrive. The ?PhreesiaPad?allows patients to verify their medical and demographic information, sign consent forms, and pay copays or outstanding balances right from their seats in the waiting room. Companies like this take advantage of the technological advances in cloud computing, wifi networks, and mobile device usage to add value to the patient-provider experience. Kareo is another easily

HowPatient Engagement Is Evolving Post-Visit

Alexa Asking Amazon?s Alexa advice seems a thing of the future, but an application for the device (Dr. A.I. by HealthTap) utilizes billions of data points and thousands of doctors to provide peer-reviewed possible diagnoses for the symptoms you?ve provided to the device.

Integrated systems like Kareo, Phreesia and HealthGrid (among many others) often cover many pieces of the practice management pie. While these new technologies bring conveniences into the practice experience like never before, they also allow providers to stay engaged with patients after they?ve left the office. These platforms come with secure patient-provider messaging through online portals, mobile apps for our devices, and text messaging. Whether it?s prescription refill requests or enhanced features like drug monitoring or notifications on first drug fills after your patient?s visit (a feature of Truveris, for example), there is great power in enabling both the patient and the provider with these new development in healthcare information technology.

Use of these data points, doctors, and other online databases paired with your personal health history can provide you insights into your own health and first steps to treatment or a physician visit. The power of using a voice-activated device has serious potential impacts for the aging population who may lose the health information they seek in the noise of the internet. Woebot Some companies are taking the utilization of article intelligence (like Amazon?s Alexa) to the next level by embracing the technology to fill major gaps in healthcare - mental health. Woebot is available 24/ 7 and doesn?t require an appointment with a mental health professional. It develops personalized dialogues with patients suffering from anxiety and depression, relying on the practices of cognitive behavioral therapy.

Using this technology to keep your patients engaged in their own healthcare and patient-provider experience improves healthcare outcomes while giving your practice an edge over the competition. Choosing the technology that is right for your practice, such as determining which solutions can fit best with your employees skill sets, integrate with your EHR technology and so on, is key to ensuring that you can reap the efficiency benefits associated with implementing such solutions.

Tools like this can have a major impact on the significant gaps in the mental healthcare infrastructure, and a Stanford University study reports reduced stress and anxiety in as little as two weeks with daily use.

The greatest benefit of all this technology is its empowering ability to help patients manage their own health. Giving patients ways to stay on top of prescription refills through reminders and notifications, allowing them to easily pay bills online, and providing easier ways of communicating and connecting with healthcare providers all create better outcomes in patient care, according to a 2016 NEJM Catalyst Patient Engagement Survey.

Patient engagement is all about empowerment. Patient engagement goes far beyond ensuring you?ve taken the necessary steps to have a website with patient resources and educational materials, or having a social media presence. In order to truly engage with your patients, providers need to allow empowerment through usability, understanding, and utility of technology.

There is no end to the solutions, apps, and offerings available. Take some time to check out offerings and see what may work in your practice and patients. Compare software and features side by side with sites like Digiteum, Capterra, Software Advice, and TechnologyAdvice, all of which allow you to search features, clinical applications, reviews, and compare selections.

There is no better place for that to be presented to patients than at the site of delivery of patient care.

Wearable devices merge records with real-time health monitoring. drchrono It?s impossible to discuss telemedicine and advancements in healthcare technology without mentioning wearables. Devices with specific purposes such as the Withings Blood Pressure monitor, or the PIP used specifically to track your stress levels have advanced in their connectivity and accuracy. Multi-purpose wearable technology such as Fitbit, Pebble, and Apple Watch have taken to the healthcare game as well, with applications that go beyond storing vital health information or tracking basic stats. drchrono provides easy access to individuals' personal health records across their Apple devices. The application also provides easily appointment scheduling, reminders, physician communication and the ability to pre-fill forms prior to a visit. A recent partnership between drchrono and Physitrak add a deeper level of patient engagement by facilitating secure video consultations, adding value to a practice with easy patient-doctor follow up.

SUPPORTING INDEPENDENT PRACTICES For your pract ice t o st ay independent , you need access t o: -

Medical supply pricing that larger practices & organizations demand Vaccine purchases with the lowest prices & highest rebate program A suite of expert services & products to best support your practice Contract Management, HR, Compliance, Grant Sourcing and more

WE MANAGE YOUR COSTS AND SERVICES, YOU MANAGE YOUR PATIENTS. Find out how you can join here: www.IPMSO.org

05 TIMETOGROW?

Dr. Jefferey R. Kile, MD, MHA, is owner of Pediatric Associates of Kingston (PAK). He has served as a pediatrician at the practice since 2003, and this year expanded PAK to include a new location in Pittston, PA, about 10 miles away from the original location. ?How people think of their healthcare has changed,? Dr. Kile said in a recent interview with Verden Group CEO and founder, Susanne Madden. ?When you look at the marketplace for healthcare ? or anything ? it?s pushed toward convenience. How can we get our brand to other places so people will come to us? There are pressures from various places like telehealth, and other competing healthcare systems where they have the money to get people to where they?re at. We had to get ourselves to where they are.? Here are some quick tips from Dr. Kile?s interview on how other independent practices can determine if it?s time to grow. Watch the full interview here. (https:/ / vimeo.com/ 261350166)

TimeToGrow? Excerpts from "Is It Time to Grow?"Video Interview With Dr. Jefferey Kile of Pediatric Associates of Kingston, PA

Dr. Kile?s advice on how to know if it?s time to grow: -

Dr. Kile?s pro tips practices for growing a medical practice:

Always test the waters first: Ask yourself, can we do this? Can we make it work? Take the time to assess whether your brand is established enough to move out further into the community. Constantly test the marketplace: Is there a population I can serve, who will come to me? Conduct a marketing analysis and financial analysis? numbers must validate your desire to grow. Take a critical look at a community?s demographics, population and location in order to objectively determine if your expanded practice could be supported. Be diligent about your homework. Dr. Kile spent 18 months to two years assessing the market before expanding. Make sure the final numbers line up. While expanding a practice is always ultimately a leap of faith with lots of uncertainty, the basics? such as rent and startup costs? have to make sense and be able to be supported. Survey your market to see what opportunities and threats there may be. Assess your threats and competition in order to determine whether you can be a competitor in your field. It?s time to grow if you know you can do it better than the competition: with a better space, better parking, and better proximity. Successful expansion relies not just on competing, but on thriving.

Spread yourself out into the larger community instead of making patients come to you at only one location. Meet people where they?re at. Make it easy for patients to find and get to you. People in rural areas have to travel. So being close to the highway can be a great decision. Look at patient populations. Don?t plant yourself in an area with no growth. Look at places that are growing, specifically places with children if you are a pediatrician. Create a ?heat? map. Where are the schools? Where are the children? Always consider the growth factor. Consider the added convenience for existing patients? can they have choice in accessing more than one location? Don?t assume that if you build it they will come. Think instead, how can I get my name out there to the masses? Be mindful of all marketing avenues available to you, and take advantage of them. Build on your existing brand name whenever possible.

06 CHIP,MedicaidandtheFederal Budget: TakingStock of 2018 Susanne Madden, MBA President & CEO, The Verden Group

President Trump signed a two-year budget on Feb. 9th, 2018, which was subsequently passed by Congress into law despite the fact that the Congressional Budget Office (CBO) had already calculated that the huge federal deficit would continue its upward trajectory. This budget raises the federal debt limit through September of 2019, and increases federal spending by trillions of dollars. Because of this the future economy of the country ? though not yet visible ? is skating around on ever-thinning ice. An additional $2.4 trillion in national debt will accrue beyond the CBO?s reported dollar amount, according to findings from the Committee for a Responsible Federal Budget. Cutting ?safety net? programs is a major goal of conservative Republican legislators as well as the Trump Administration. Therefore, limiting spending on health programs most beneficial to low-income, disabled, and elderly Americans? such as SNAP, CHIP and Medicaid? is now an even higher conservative congressional priority in order to decrease the future anticipated national debt. Hospitals, health centers and medical providers serving disadvantaged communities consequently face uncertain futures in terms of financial reimbursement and long-term sustainability. And yet, these health programs in and of themselves produce significant savings to us as a comprehensive society.

CHIP,MedicaidandtheFederal Budget CHIP decreases healthcare cost-burdens in the United States.

Of the nearly 81 million Medicaid recipients in 2014, only 27.4 million were adults. Eleven million those were permanently disabled individuals, and 7.3 million were elderly, according to a Kaiser Family Foundation report.

The Children?s Health Insurance Program (CHIP) was created in 1997 to reduce the spread of contagious childhood diseases (thereby promoting public health). Families exceeding the Medicaid income eligibility threshold who are unable to afford health insurance are enabled by CHIP to obtain health coverage for their children. Coverage for pregnant women earning up to 185 percent of the federal poverty level is also offered through CHIP in 19 states (per a March of Dimes issue brief).

Even high-income seniors can quickly drain their financial resources in order to pay expenses related to catastrophic health events and/or assisted living or nursing home facilities. Since nursing homes require the loss of all financial resources before payment assistance is available, Medicaid was the primary payer of nursing home care in the United States as of 2017.

Besides reducing the likely high costs associated with treating adult health conditions linked to childhood illnesses (e.g. infections causing intestinal dysfunction), ensuring the capacity of kids to receive healthcare reduces the likelihood of their developing one of the following chronic conditions that can lead to dependency by age 50 on federal SSDI financial support: -

Additional work requirements for Medicaid recipients will cause tens of thousands to lose benefits. In a major federal policy shift, the Trump Administration enabled states to impose work requirements on non-disabled adult Medicaid recipients in January 2018. Seema Verma (nominated by President Trump to be Administrator of the Centers for Medicare and Medicaid Services) authorized this shift. Kentucky became the first state to acquire federal approval, but nine other states are seeking to enact Medicaid work requirements: Arizona, Arkansas, Indiana, Kansas, Maine, New Hampshire, North Carolina, Utah and Wisconsin.

Chronic Obstructive Pulmonary Disease Type 2 Diabetes Profound hearing loss/ deafness Blindness Central nervous system deficits

In terms of total nationwide dollars spent, the top child healthcare category is well-newborn care (limited exclusively to babies delivered without complication), according to the February 2017 issue of JAMA Pediatrics. Not only does well-newborn care bolster infant normal growth and development, but it is also highly linked to cognitive and psychosocial development and functioning in adolescence and beyond.

Twenty paid or volunteer work hours per week are now required to enroll in Medicaid in Kentucky. The state has enacted an additional requirement that Medicaid recipients pay monthly premiums, with a failure to pay by the due date resulting in loss of Medicaid coverage). The state of Kentucky anticipates that the new work requirement will result in 95,000 Medicaid beneficiaries dropped from enrollment over the next five years, according to findings by the American Association of Retired Persons.

Medicaid provided coverage for 50 percent of all USbirths in 2015, as well as half of all healthcare for children aged 0 to 3. Meanwhile, Title V-Maternal and Child Health Block Grant funding covered services for around 2.6 million pregnant women, 3.8 million infants, and 3.5 million toddlers aged 1-3. While Medicaid costs incurred for care of pregnant women and children aged 0 to 3 totaled $34 billion, CHIP costs totaled $2 billion. Yet Republicans in Congress nearly allowed CHIP funding to expire, leaving enrollees in several states without CHIP coverage from December 2017 until its inclusion in the budget in early 2018.

Adding a work requirement for Medicaid eligibility may initially appear consistent with the work requirements under the federal SNAP or Temporary Assistance to Needy Families program. However, there is a critical difference. Health directly affects the ability of an individual to hold a job. Chronically ill workers not only have higher absenteeism rates, but they also can negatively impact the functioning and productivity of a workplace. The underlying shortsightedness of a Medicaid work requirement is the lack of recognition that many Medicaid recipients ? while not considered permanently disabled ? are coping with significant health conditions that preclude holding a job. For example, diabetic peripheral neuropathy can cause a burning sensation in the feet and hands, and back pain can make it difficult to sit for long time periods. Yet typical jobs available to adults with low educational and employment skill levels ? the majority of Medicaid recipients ? are either in the retail or service industries, both of which require either standing or sitting for long periods. Self-employed individuals may experience a decrease in income due to a health (or other) catastrophe, and therefore qualify for Medicaid. Ironically, the Medicaid work requirement may eliminate the capacity for recipients to become self-sufficient through self-employment, or cause these self-employed individuals to simply forego renewing their Medicaid enrollment and develop disabling health disorders.

CHIP,MedicaidandtheFederal Budget Continued funding for public health centers is uncertain.

Medicaid work rules will negatively impact recovering substance abusers.

The Health Resources and Services Administration website specifies that there are approximately 1,400 public health centers (operating more than 11,000 service delivery sites) across the US, and these serve nearly 26 million people.

The Trump Administration declared the opioid epidemic a health emergency in November 2017, and the new budget allots $6 billion to fight the opioid epidemic (to be allocated by congressional members). For recovering alcohol and opioid abusers, attending substance-abuse treatment programs may be essential to preventing a relapse. Therefore, it is possible that losing Medicaid coverage due to an inability to work the required weekly hours may create an unintended vicious cycle of worsening the opioid abuse epidemic? instead of contributing to its resolution.

Notably, public health centers primarily serve Medicaid enrollees and other low-income patients. Meanwhile, the Teaching Health Center Graduate Medical Education Program supports physician primary care residencies in low-income and medically under-served areas in 24 states; and primarily, in these health centers.

Mandatory funding for these two programs expired in 2017, and the Republican-dominated Congress only voted to reauthorize ? at reduced levels ? their short-term funding through March 31, 2018, per the National Academy for State Health Policy.

Public health center finances are well-recognized as typically strained, and $1.2 billion of the appropriated monies for public health centers in 2017 came from discretionary funding. There is consequently no guarantee that health center funding in 2018 will even remain at the same level as 2017. The Republican-promoted tax cut from December will likely reduce federal revenues, as well as spurring significant cuts to Medicaid and other programs aiding the poor.

The national debt will directly affect ?safety net? funding.

CHIP,MedicaidandtheFederal Budget

Women?s access to contraception is being stymied.

The conclusion is an unstable future. The ACA mandated that states comply with a national baseline of health insurance coverage, rather than enact laws in opposition to that national standard. As states rights proponents, President Trump and congressional Republicans (along with Supreme Court Justice Gorsuch) prefer a limited federal oversight role, in tandem with greater state power over decision-making.

Under President Trump, access to contraception is being thwarted on a myriad of fronts: Front Number 1: Reversing state Medicaid guidance under President Obama, the Trump Administration issued guidance essentially enabling states to restrict Medicaid funding based on failure to meet state-determined provider qualifications ? and specifically needed by states preferring to withhold reimbursement for services provided at Planned Parenthood clinics17, which in 2017 provided family planning services to 50 percent of Medicaid-enrolled women in most counties where the organization has clinics.

How does this bode for the country? The Wall Street Journal reports that Democratic- and Republican-controlled states are moving in opposite directions on health policy. One example of this is can be found in state requirements for short-term health plans, which most often do not cover preexisting conditions and maternity care. Given that Trump supports an increased availability of short-term health plans (with regulations left to states), some states are seeking to expand availability of these short-term plans. Others seek to restrict them.

Front Number 2: The Title X family planning program enacted under President Nixon has enabled provision of free or low-cost contraceptives to low-income but Medicaid-ineligible women through federal funds administered to state health departments and family planning clinics. Title X currently funds family planning services at around 4,000 clinics that serve roughly 4 million women. However, Title X federal funds for FY2018 remain unreleased while 60 percent of funded entities ran out of Title X dollars on March 31. Meanwhile, the Title X application approval process in 2018 was changed in accordance with Trump policy to emphasize funding of programs that include ?abstinence only? and ?natural? family planning methods.

The ripple effect is expected to promote increased instability for insurers and across the UShealthcare system as roll-backs to ACA provisions continue under President Trump. It definitely does not take a crystal ball to know that we will most certainly be paying for this instability and lack of common sense for future decades to come.

Front Number 3: The Affordable Care Act (ACA) mandated coverage for contraception by most private insurers, plus federally specific coverage requirements for family planning applicable to Medicaid (albeit with no existent federal definition of ?family planning?). In contrast to the Obama Administration, expanding the range of employers that can exclude contraceptives from their employer-provided insurance is a Trump Administration goal.

07 UnderstandingManagement Services Organizations Susanne Madden, MBA President & CEO, The Verden Group (Originally published in Physicians Practice)

We all know that there is a lot to manage in any medical practice. Human resource issues, payroll and benefits take significant time and effort to manage properly. Coding compliance and revenue-cycle management consumes much of a manager's time and effort. And making sure that you are receiving best pricing for supplies and services on top of all the usual day-to-day activities can simply be too much. That's where MSOs come in. These are entities designed to help you with the administrative, or non-medical, work involved in running a practice. These organizations may be owned by non-healthcare provider investors, by hospitals, by groups of physicians, be a joint venture between a hospital and physicians, or even owned by health plans.

UnderstandingManagedservices Organizations Making sure that you are receiving best pricing for supplies and services on top of all the usual day-to-day activities can simply be too much.

MSOs are evolving to tackle the growing demands of a value-based marketplace. With many insurers now tying reimbursement to quality and outcomes, tracking performance and being able to meet clinical measures and metrics is becoming as burdensome as any other administrative work within a practice, and so MSOs are stepping in to offer solutions. Some will even go as far as developing clinical guidelines and standards of care, providing care coordination services, and fully integrating members clinically in order to take advantage of upside bonuses and shared savings from insurers.

What MSOs do

Cautionary measures for signing on to an MSO

Here's a list of some of the areas in which an MSO can assist practices: -

While MSOs can provide the resources and support that you might need, it is critical that you fully understand the agreement that you are signing. The MSO should clearly spell out exactly what services are being purchased and the terms under which you are contracting. Make sure you understand any limitations associated with each service offering, such as the MSO billing and collecting from insurance companies but not managing patient collections, for example; and most critically, understand under what terms you may terminate the agreement including the amount of notice that needs to be given, how to buy back your assets (if you sold them), how to take your billing operation back in-house and so forth.

Operational issues Financial management Human resources and personnel management Staff education and training Coding, billing and collection services Providing and managing office space Discounts and provision of EHRs and medical equipment Regulatory compliance oversight and management Credentialing and contract management Savings with group purchasing Risk management

If you are joining an MSO that will purchase your assets, it is essential that the fee charged by the MSO is commercially reasonable and at fair market value. This is necessary in order to comply with safe harbors around Anti-Kickback, Stark, or Corporate Practice of Medicine statutes. Before agreeing to any price, get a fair market value opinion from an accountant or healthcare consultant who specializes in such transactions.

The benefits to practices joining an MSO The primary advantage to joining an MSO is to have access to management services and to ensure best (lowest) pricing on supplies and services. MSOs aggregate volume and as such, obtain economies of scale that allows them to obtain preferred pricing on everything from medical supplies to healthcare insurance.

Based on our clients' experience, the MSOs that work best are typically the ones that are well-established, have plenty of experience in a particular specialty, and have physician-led governance to keep the physicians' best interests at heart.

Many provide billing services allowing practices to outsource that altogether, and some offer significantly discounted EHRs where all members utilize the same vendor or platform.

Different MSO structures There are two types of MSOs: those that provide business services to practices, allowing them to remain quite independent of the MSO, and those that own (buy) the tangible assets of practices and manage them directly. In the latter example, the MSO owns the equipment, supplies, and office space and leases it all back to the physicians. That is, the physicians continue to practice in their existing office space and own their medical records, keep their existing insurance plan contracts, staff, and so on, but no longer own the administrative expense and burden of managing those assets. This restricts autonomy somewhat and while it does not go as far as the physician becoming an employee, it does make it much more difficult for a physician to terminate an agreement with an MSO. However, if you want to practice medicine without the headaches involved in administration, then this may be the model for you.

08 UpdatedCPTCodesfor Behavioral HealthScreenings andAssessments Jenna Mirchin, CPC, CPMA, CGSC

The primary steps in diagnosing patients with behavioral health problems involve conducting health screenings and assessments. There is a variety of current procedural terminology (CPT) codes to use for such assessments and screenings that pediatricians use for behavioral health, including many which have recently been updated. Here?s a guide to existing and updated CPT codes.

Updatedcpt codesFor Behavorial health ScreeningsAndAssessments The following codes are based on time. In order to bill for each, you must meet or exceed the time noted.

Preventative Health

99401 Preventive medicine counseling and/or risk factor reduction intervention(s) provided to an individual (separate procedure); approximately 15 minutes.

99402 Preventive medicine counseling and/or risk factor reduction intervention(s) provided to an individual (separate procedure); approximately 30 minutes.

99403 Preventive medicine counseling and/or risk factor reduction intervention(s) provided to an individual (separate procedure); approximately 45 minutes.

99404 Preventive medicine counseling and/or risk factor reduction intervention(s) provided to an individual (separate procedure); approximately 60 minutes.

The following codes can be used with a preventative health or a regular office visit. Offices establish protocols for age groups to say which assessments should be completed at a visit. All scoring and documentation is performed with standardized instruments. -

96110 Developmental screening with scoring and documentation. Examples: developmental milestone survey, speech and language delay screen.

96127Brief emotional and behavioral assessment with scoring and documentation. Examples: depression inventory, attention-deficit/ hyperactivity disorder (ADHD) scale.

96150 Initial health and behavior assessment that includes 15 minutes of face-to-face time with the patient. Examples: Health-focused clinical interview, behavioral observations, psychophysiological monitoring, health-oriented questionnaires.

96151 Health and behavior re-assessment that includes 15 minutes face-to-face with the patient. Examples: Health-focused clinical interview, behavioral observations, psychophysiological monitoring, health-oriented questionnaires.

Always check first with your local payers to make sure these codes are separately payable.

Smoking Cessation and Alcohol / Substance Abuse Counseling and Screening

96160 Administration of patient-focused health risk assessment instrument with scoring and documentation. Example: Health hazard appraisal.

ADHD These in-person services are usually performed during a preventive visit or an office visit while counseling the patient on a risky lifestyle choice that may lead to a health problem. The codes, which can be billed with other preventive medicine codes, are provided by a physician or qualified healthcare professional.

Treatment for ADHD often requires more time and/or visits than other diagnoses. Reporting your E/ M based on time for these visits can help to capture that extra effort. You must document what you discussed with the patient, such as medication, side effects, symptoms and signs. You are also required to document the total time of the visit and that more than 50% was spent counseling. 99214 Total time spent was 25 minutes, of which 20 minutes were spent counseling. -

Because the following codes are based on time, the midpoint amount of time should be met. -

99406 Smoking and tobacco use cessation counseling visit; intermediate, greater than 3 minutes and up to 10 minutes.

99407 Smoking and tobacco use cessation counseling visit; intensive, greater than 10 minutes.

99408 Alcohol and/or substance (other than tobacco) abuse structured screening (eg, AUDIT, DAST), and brief intervention (SBI) services; 15 to 30 minutes.

99409 Alcohol and/or substance (other than tobacco) abuse structured screening (eg, AUDIT, DAST), and brief intervention (SBI) services; greater than 30 minutes.

99203 Total time spent was 30 minutes, of which 20 minutes were spent counseling.

Obesity Counseling and Other Preventative Counseling Codes for obesity, family issues, and preventive work for behavior issues that can lead to health problems are billed by a physician or other qualified healthcare professional. These codes can not be billed with other preventive medicine codes (99381-99387 and 99391-99397).

Updatedcpt codesFor Behavorial health ScreeningsAndAssessments Utilizing Social Workers These services can be provided by a healthcare professional with training in health and behavior interventions. These may include physicians, psychologists, advanced practice nurses, or clinical social workers. Some offices now have social workers on-site to provide valuable counseling and intervention services for individual patients or group. In many instances, a social worker can be credentialed and contracted with insurance companies directly. He or she would then bill services separately, based on time.

behavioral/ psychiatric health problems (including revision for patients who become stagnant or whose status changes); facilitating and coordinating treatment such as psychotherapy, pharmacotherapy, counseling or psychiatric consultation; and continuity of care with a designated member of the care team. -

The following codes are based on time and can be billed with multiple units. -

96152 Health and behavior intervention, each 15 minutes, face-to-face

96153Health and behavior intervention, each 15 minutes, face-to-face; group (two or more patients).

96154Health and behavior intervention, each 15 minutes, face-to-face; family (with the patient present).

96155Health and behavior intervention, each 15 minutes, face-to-face; family (without the patient present). Example: 30 minutes spent with patient. 96152 - 2 units.

Required elements of this care: outreach to and engagement in treatment of a patient directed by the treating physician or other qualified health care professional; initial assessment of the patient, including administration of validated rating scales with the development of an individualized treatment plan; review by the psychiatric consultant with modifications of the plan if recommended; entering patient in a registry and tracking patient follow-up and progress using the registry (with appropriate documentation and participation in weekly caseload consultation with the psychiatric consultant); and provision of brief interventions using evidence-based techniques such as behavioral activation, motivational interviewing, and other focused treatment strategies. -

New CPT Codes Four new Medicare Part B billing codes became available in 2018 to report BHI services, from care management to psychiatric collaborative care. The codes may be used to bill for services outlined by the Psychiatric Collaborative Care Model (CoCM). In areas where a psychiatric consultant is required, he or she does not have to be participating with Medicare. Medicare makes payment to the billing practitioner directly for the service, so third-party contractors do not have to be Medicare participants.

99493 Subsequent psychiatric collaborative care management, first 60 minutes in a subsequent month of behavioral health care manager activities, in consultation with a psychiatric consultant and directed by the treating physician or other healthcare professional.

Required elements of this care: tracking patient follow-up and progress using the registry (with appropriate documentation); participation in weekly caseload consultations with the psychiatric consultant; ongoing collaboration with and coordination of the patient's mental health care with the treating physician or other qualified health care professional and any other treating mental health providers; additional review of progress and recommendations for changes in treatment (including medications) based on recommendations provided by the psychiatric consultant; provision of brief interventions using evidence-based techniques such as behavioral activation, motivational interviewing, and other focused treatment strategies; monitoring of patient outcomes using validated rating scales; and relapse prevention planning with patients as they achieve remission of symptoms and/or other treatment goals and are prepared for discharge from active treatment.

These codes are not limited to Medicare beneficiaries, and may be used to treat patients with any behavioral, mental or psychiatric condition being treated by the billing practitioner. This may include substance use disorders. For more information, visit cms.gov. Check with your commercial payers to determine whether they cover these codes. -

99492 Initial psychiatric collaborative care management, first 70 minutes in the first calendar month of behavioral health care manager activities, in consultation with a psychiatric consultant, and directed by the treating physician or other qualified healthcare professional.

99484 Services rendered using other BHI models of care. These include care management services for behavioral health conditions, as directed by a physician or other qualified health care professional, requiring at least 20 minutes of clinical staff time per month.

99494 Initial or subsequent psychiatric collaborative care management, each additional 30 minutes in a calendar month of behavioral health care manager activities, in consultation with a psychiatric consultant, and directed by the treating physician or other qualified healthcare professional. List separately in addition to code for primary procedure.

Required elements of this care include an initial assessment or follow-up monitoring (including the use of applicable validated rating scales); behavioral health care planning related to

09 CLINICALDATAINTEGRATION Catherine Valyi VP of Marketing, Clinigence

Clinical integration is a comprehensive, aggregated record of patients?medical histories - and a perfect example of the value of shared clinical data. Yet the thought of clinical integration is as perplexing as it is inspiring. Many providers struggle to manage data in their own electronic health records (EHR's), let alone to integrate data from other systems. Clinical integration has numerous meanings in health care circles. Some think it means that all providers will use the same EHR. Many think it represents interoperable methods of data sharing among many different systems. Others equate it with the requirements and goals of a clinically integrated network (CIN), such as improved value, physician leadership, best practices, performance improvement, and data sharing.

Clinical DataIntegration The gateway to MACRA success lies in integration. The 2017 introduction of the Medicare Access and CHIP Reauthorization Act (MACRA) reporting requirements provided greater significance to the concept of clinical integration. From the Merit Based Incentive Payment System (MIPS) to Alternative Payment Models (APM?s), it?s evident that leveraging clinical integration provides a springboard for quality improvement and reporting efficiency. Furthermore; CIN?s with a proven track record of clinical data management have demonstrated a strong foundation upon which to build an APM, such as an Accountable Care Organization (ACO).

2. Scores were improved when data was automatically extracted from the EHR throughout the year. They were impacted by two primary benefits: real-time progress reports for filling gaps in care, and reducing the likelihood that data would be ?missed? during annual reporting for clinical quality metrics. Common themes we observed in non-clinically integrated projects included charting inconsistencies, more gaps in care, and an increase in the time and efforts of reporting. Clinical integration and improved workflow turns clinical data into your superhero

We observed these clinical integration advantages first-hand among our customers at Clinigence. Whether reporting for MIPSor ACO measures, our clinically integrated customers had higher quality scores than those performing manual data collection. Even more intriguing was the fact that 100 percent of our clinically integrated ACO customers achieved shared savings.

These observations helped prove our hypotheses that unleashing the value of clinical integration hinges on an understanding of EHR workflows, an accurate data-mapping process, and engaging providers in real-time quality performance. Shifting all providers to the same EHR platform might not achieve the desired results of clinical integration. An example of this is when there are multiple locations in the same EHR to document information, and all of these possible locations are not mapped into the data aggregation and reporting scheme.

All providers using one EHR is a myth. These groups had multiple EHRs (and multiple instances of the same EHR). Thus, having a greater number of providers using the same EHR did not ensure better quality scores. This caused us to take a closer look at the common denominators of these groups? achievements. We observed two key factors that contributed to their success:

For more information, visit Clinigence at: https://www.clinigence.com/

1. The process of mapping to data in the EHR improved their scores because ACO stakeholders became more aware of the measurement requirements and the correlating documentation workflows. 38

AMANDA CI ADELLA Senior Consult ant

JULI E WOOD

- ROLL CALL-

Co-Founder

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

Children's Physicians, Jupiter and Palm Beach, FL

2014

Harmony Mills Pediatrics, Cohoes, NY

2014

Hirsch Pediatrics, Rockville, MD

2014

Pediatric Partners

2014

Schultz Pediatrics, Knoxville, TN

2014

The Pediatric Group Chantilly, Lake Ridge, Manchester and Patriot Square, VA

2014

Palm Beach Gardens, Jupiter and Boca Raton, FL

?A huge thank you to the consultant team ? it would never be more accurate to say ?We couldn?t have done it without them.?They really know all of the details, from logical to quirky, of how to do NCQA PCMH.? 39 ? Jeff Bernstein M.D.-Pediatric and Adolescent Care of Silver Spring

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JOINUSAt THESECONFERENCES&EVENTS PEDIATRICSUPERGROUPCONFERENCE -

May 2-4, 2018 Arlington, VA Register here: http:/ / www.pediatricsupergroup.com/

48thNATIONALimmunizationCONFERENCE& infl uenzasummit -

May 15-17, 2018; Flu May 17-18, 2018 Atlanta, GA Register here: https:/ / www.cdc.gov/ vaccines/events/ nic/ index.html

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June 19-22, 2018 Denver, Colorado Register here: https://www.pcc.com/uc-2018/

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November 2-6, 2018 Orlando, FL Register here: http:/ /aapexperience.org/