Viewpoint Volume 4 Issue 2 Summer Solstice 2018 by VerdenGroup

MAKEADIFFERENCE

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

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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.

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INTHISISSUE HELPINGPATIENTSUNDERSTANDCAREBETTER

MaketheRight IdeasAReal ity

08 13

HELPINGPATIENTSUNDERSTANDCARE BETTER:AREYOUTHETHREE-EYEDRAVEN?

Advocatingfor Chil drenSeparated FromFamil iesat THEBorder

Improve patient dialogue to change outcomes for the better.

A message from the President of the American Academy of Pediatrics

SharedDecisionMaking: Evolving Patient-Provider Rel ationships

APeDIATRICPRACTICELEADINGTHE WAYINRURALFLORIDA

A practice shares how they advocate for patients in rural Florida

How to engage patients and the role of the 'patient advocate'.

hat HealthcareDeregul ation 26 W Meansfor Providers

TakingActiontoMaketheRight IdeasAReal ity

The continuing effect of this Administration's assault on the AHA and safety-net programs.

Feel compelled to take action?Here's how to go about it.

INTHISISSUE GOGreeninyour office

MARKETINGYOURPRACTICETOEMPLOYERS

greenat home?GOGreeninyour officeToo

How to protect the planet at work as well as home. It's easier than you think.

UPDATEonCPTCODES

The time has come to market to a new 'customer' - employers.

HOWTOSTARTAPETITION

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

Jenna Mirchin tells us what we need to know about non face-to-face codes.

MARKETINGYOURPRACTICETO SELF-FUNDEDEMPLOYERS

Want to do something but don't know where to start?Learn how to get started here.

MAKINGTHECASEFORPCMH INCENTIVESTOYOURPAYERS Read highlights from a recent NCQA Webinar here.

THISISSUE'SCONTRIBUTORS STAFF Editor-in-Chief Susanne Madden

ANNAIALYNYTCHEV,PHD Anna holds a Ph.D. in Health Services Research, an M.P.H. in Health Policy and Management, both from the University of South Florida, and a B.A. in Psychology/ Pre-Med Program from Boston University and is The Verden Group's Senior Health Policy and Data Analytics Specialist.

Managing Editor Nicole Caldwell

HEIDI HALLETT Cover Design Scott Hodgson Web Master David Magbee

Heidi brings more than 15 years of experience in Marketing & Communications, wordsmithing and her creative flair to The Verden Group and ViewPoint magazine. She is both a contributor and past editor and provided thie wonderful doodles for this issue.

Nicol eCALDWELL

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.

Nicole serves as managing editor of Verden Viewpoint, while also providing day-to-day editing assistance for The Verden Group. She has almost 20 years of experience as an editor and writer, as well as degrees from Columbia University?s Graduate School of Journalism and Hampshire College.

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.

TIFFANYLAURIA

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

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

Tiffany Lauria is Verden's team Project Coordinator, Researcher, Practice Consultant and ?just get-it-done?go-to person. With a background in nursing and Clinical Research Coordination and Management, Tiffany is well versed in the mechanics of clinical practices and effective work practices across the spectrum of healthcare.

KRISTABOWMAN Krista is formerly a digital marketing executive that focused her efforts on delivering transformative business solutions for Fortune 500 companies. She has recently expanded her horizons into healthcare delivery and is The Verden Group's Executive Director of Business Development.

LETTERFROMtheEDITOR

Advocacy. It's what physicians do, every day. Local and global, part of a physician's calling is to 'help' .

Has the world gone mad? Some days it certainly feels that way. From foreign wars to the global stage to what is happening at our borders, it would appear that the worst of mankind is making its mark felt ever more strongly and many feel powerless to do anything about it. In times of despair we go looking for heroes. One of mine is Dr. Colleen Kraft, President of the American Academy of Pediatrics (AAP), who went to the Texas border to see for herself what is happening to those children abducted from their parents for the crime of crossing the border illegally. We've included an open letter from the AAP with permission and highlighted some of the work being done by the tireless Dr. Kraft and her colleagues on this issue. But it is not all doom and gloom. Our editor, Nicole Caldwell, author of Better: The Art of Sustainable Living, and CEO of Better Farm, a sustainability campus and animal sanctuary in Redwood, NY, offers tips on how to 'go green' at the office. Wondering what you can do to stand up for what's right? Tiffany Lauria walks us through how to take action and start a petition. We talked to a practice in north Florida on what it is like to advocate for a rural and vulnerable community, and two of our staff tackle the issue of patient advocacy: Anna Ialynytchev explores shared decision making and Krista Bowman takes a deep dive into helping patients understand care better, both of which provide insights into how your one-to-one advocacy efforts can return big dividends by improving patient outcomes. Jenna Mirchin gives us a quick update on coding rules, and no issue would be complete without an update from me on the latest political shenagigans shaping our healthcare system. Last but not least, I've included an articles relating to the self-funded employer market and would like to posit that physicians developing a direct-to-employer model embodies the highest level of advocacy for themselves. We are now in a market where Amazon + Berkshire Hathaway + JPMorgan have embarked on a mission to 'fix' healthcare. Do we look to new masters to tell physicians how best to deliver care or are we finally going to pivot to the most qualified directing the type of care we need? I retain hope for the latter. And stay tuned for developments on a new independent practice business association that we are working on, coming to you soon . . .

Susannemadden 7

01 HELPINGPATIENTSUNDERSTAND CAREBETTER: AREYOUTHETHREE-EYEDRAVEN? Krista Bowman

PATIENTADVOCACY Get the real story with two easy questions.

With the advent of democratized medicine, the roles of healthcare professionals are evolving. What was once a professor-pupil relationship has grown into an ambiguous partnership. Patients are taking a leadership position in their healthcare, even generating data themselves through health and fitness apps and programs. Further complicating the dynamic is on-demand access to medical records through sophisticated EHR platforms/ patient portals and the strength and ubiquity of social media. Never mind future medical record access within the looming mechanisms of blockchain.

It is helpful to consider the psychology of behavioral change to understand what healthcare providers can reasonably expect when implementing a new conversation. Most behavioral change strategies require informed discussions and a commitment to change on the part of the patient before any progress can be made. These methods require an investment from both the patient (motivation) and provider (engaged conversation and follow-up). Often, health professionals are reluctant to start these conversations anew for three reasons: one, because the conversation has already occurred with little to no success; two, explaining complex behavioral change strategies is time-consuming and challenging for patients to adopt; and three, the patient shows little motivation to change.

But data isn?t knowledge. And knowledge doesn?t always lead to action and better outcomes.

Furthermore, ?even when patients successfully initiate the recommended changes, the gains are often transient because few of the traditional change strategies have built-in mechanisms for maintenance.? So why waste valuable moments trying to initiate this change? Because when the right conversation is had with a motivated patient population, successes do occur. In fact, physician clarity and optimism can increase the chance of adherence success.

Patient health literacy may be worse than you thought. At its simplest, healthcare in the United States is nearly entirely dependent upon each patient?s comprehension of his or her condition and coordinating treatment, which includes complex written and spoken information. Not only are patients expected to be fluent in medical terminology so they can continue to manage their condition at home, they are expected to navigate a labyrinthine insurance system. If they do not understand what is shared in the exam room, they cannot take responsibility for their health or take necessary action.

So how can healthcare professionals apply behavioral science to help patients understand care better and guide them to positive outcomes? And what can be done to change the dynamic in the exam room today? Dr. Mark Spellmann, PhD, a clinical psychologist with a focus on designing behavior change and empowerment programs, asserts that applying the Chronic Disease Model and asking patients two critical questions can alter the doctor-patient communication in the exam room and change the relationship in real time.

In a study on healthcare literacy conducted by National Assessment of Adult Literacy (NAAL), nearly 90 percent of the cohort did not meet proficient levels of health literacy. More than 35 percent of that population operating with only basic or below rudimentary comprehension of their healthcare. ?Patients with the most extensive and complicated healthcare problems are at greatest risk for misunderstanding their diagnoses, medications and instructions on how to take care of their medical problems,? according to The National Center for Education Statistics.

1. ?How do you see yourself health wise?? -

Research consistently shows that physicians routinely overestimate the health literacy of their patient population, often assuming patients understand more than they do. Further, ?studies on doctor-patient communication have demonstrated patient discontent even when many doctors considered the communication adequate or even excellent.? One study cites a surprising ?75 percent of the orthopedic surgeons surveyed believed that they communicated satisfactorily with their patients, but only 21 percent of the patients reported satisfactory communication with their doctors.?

This allows exploration of the patient?s health self-concept Also ask: ?What?s the big-picture take on your health??

2. What are your biggest fears when it comes to your health? -

This generally requires more engagement from the patient and enables better understanding of the patient?s fears Also probe patient hopes by asking: ?What are you counting on doing that depends on your health??

PATIENTADVOCACY The answers to these questions illuminate what patients care the most about in the context of their their larger health identities. When patients feel understood, they understand.

One study typifies the success of follow-up in a hypertensive population. ?Weekly use of an automated telephone system improved medication adherence and blood pressure control in hypertension patients. This system can be used to monitor patients with hypertension or with other chronic diseases, and is likely to improve health outcomes and reduce health services utilization and costs.? The very act of asking patients about their care at home has the power to change the outcome.

Dr. Atul Gawande is an advocate of this approach with patients in end-stage disease. His writings demonstrate how key questions can evoke patients?assessments of their current and desired states, regardless of their conditions. He suggests that if patients, their families and their healthcare professionals learn to ask the right questions and really listen to the answers, healthcare will radically change.

The closer: from private patient advocates to patient engagement platforms Maintaining contact with a patient post-appointment has often fallen to overworked and understaffed practices. Private patient advocates are relatively new to the healthcare environment and could provide an interesting alternative. The advocate role is multi-faceted: interpreter, assistant, medial professional and extended family. As discussed, patients often do not know the type of questions to ask in the exam room and do not remember the physician?s instruction after they have left the practice or institution, which renders adherence to a treatment plan unlikely. As such, the most logical candidates for the position are veteran registered nurses, also known as RN patient advocates. RNs have the medical training, experience working directly alongside physicians and are comfortable shepherding families through the complexities of the healthcare system.

These questions redraw intimacy lines and open new dialogues where patients are more open to tools, future discussions, and change. Beyond the two-question dynamic, healthcare professionals should reflect on their current approaches to educating patients in the exam room. A 2015 study by Kelton Global found a communication gap between physicians and patients: ?Nearly half of all Americans avoided telling their doctor about a health issue because they were embarrassed or afraid of being judged, but also around a third say they have withheld details because they couldn?t find the right opportunity, didn?t have enough time during the appointment, or weren?t asked the right questions by their doctor.?

Physicians may fear that a private patient advocate could interfere with diagnoses and even question treatment plans. But that is not their objective.

Six steps to improving dialogue with patients: 1. Slow down

Fundamentally, private patient advocates can function as another key player on the treatment team. In fact, patient advocates can support the continuum of care by acting as an extension of the physician. They can ensure patients are clear on the specifics of the exam room/ post-op conversation, the provider?s direction, and what needs to be done to support adherence moving forward.

2. Use plain, medical language 3. Show or draw pictures 4. Limit the amount of information provided? and repeat it 5. Use the ?teach-back? technique

Think of it like this: The patient advocate is the Bran* to your Three-eyed Raven, Game of Thrones-style. Bran brings the Three-eyed Raven?s comprehensive understanding of past, present and future to guide those for whom he cares.

6. Create a ?shame-free? environment: Encourage questions. Conversations in exam rooms are changing, and so should the follow-ups. Doctor-patient communication research shows the value of adding an adherence question to each part of a treatment plan. This ensures that healthcare providers consistently ask, ?How are you doing taking the medication (or behavior change) I prescribed last visit?? Knowing the clinician will ask significantly increases adherence rates.

(* For the unfamiliar, Bran is a character on HBO?s Game of Thrones who is the physical embodiment of the omniscient greenseer, the Three-Eyed Raven. Greenseers have the power to perceive past, future, and current-but-distant events. The Three-Eyed Raven needs Bran to translate the insight into strategy for humans. I have no HBO disclosures.)

PATIENTADVOCACY What else can private patient advocates do for patients? -

Patients are the chief operating officers of their health care.

Educate patients and their families about patients? conditions. Outline questions a layperson wouldn?t know to ask for provider conversation. Act as liaison between patients and healthcare professionals. Explore treatment options following a diagnosis. Remain connected with patient, family and staff while a patient is hospitalized. Ensure insurance claims get paid.

Supporting the journey of every patient to good health has evolved and grown exponentially for today?s practices. Understanding the behavioral science behind patient motivations can help reframe a tired (and tiresome) doctor-patient dynamic. Using the two-question method in conjunction with private patient advocates or dynamic technology solutions can create a new kind of connectivity that helps mitigate miscommunication, improve patient adherence and eventually evolve the exam room experience. In The Patient Will See You Now, Dr. Eric Topol likens patients to chief operating officer of their healthcare (after a promotion from an entry-level position in the last decade) with ?periodic ad hoc reporting to the CEO, the doctor.? Patients have now assumed a more vocal and active role in their healthcare by riding this continuous wave of information.

Healthcare professionals are expected to do nearly all the above with every patient and a full schedule. So why would a physician consider supporting private patient advocacy? It could save time and money. Physician?s Practice posits, ?Many doctors would likely rather spend five minutes updating a knowledgeable professional rather than spend 20 minutes with an overwhelmed patient, knowing the advocate will educate his client later. By the same token, private patient advocates can bring physicians up to speed on a client?s status in the fraction of the time a patient could.?

Changing or even simplifying the conversation in the exam room, reframing and reconnecting to patients and exploring private patient advocacy and/or technology solutions will be critical in directing and motivating patients in the future. Because as Dr. Topol asserts, passive conversation and ?information alone rarely, if ever, change behavior.?

There is a growing number of technology solutions developed to address patient engagement and adherence for physicians who are not ready to explore private patient advocates just yet. Two examples are Memora Health and SeamlessMD. Memora Health is a health tech start-up focused on medical adherence for chronic illness. ?Felix? the AI digital care manager connects with patients via SMSand tracks wellness, patient-reported symptoms and patient responses to adherence-focused questions. A risk assessment algorithm tracks and reports trends to alert healthcare professionals when the patient is at risk for hospital readmission or the behavior becomes atypical. SeamlessMD is also a health tech start-up focused on patient engagement. Their solution helps patients and providers track a patient's progress pre-and post-op. Before a surgical procedure, the tool provides patients with interactive reminders and checklists to reinforce pre-op instruction. Post-surgery, the app offers digital check-ins, self-management tools, and educational materials, which can be tracked by the physician.

Though all patients are not created equal, the AMA has issued guidance on patient interpersonal communication, which can be applied to all levels of patient health literacy and are worth revisiting.

All three solutions provide proactive, preventive care to engage patients, align them more closely with the healthcare provider, and ultimately motivate behavior change and promote better outcomes.

PATIENTADVOCACY

02 SharedDecisionMaking: EvolvingPatient-Provider Anna lalynytchev, MPH, PHD Senior Health Policy & Data AnalyticsSpecialist

Throughout much of history, doctors made unilateral decisions about their patients?care. Patients had less access to medical information, and rarely questioned a doctor?s treatment decisions. In recent years, however, there has been a significant shift in the way medical decisions are made. Choosing treatment options is no longer the sole responsibility of a doctor; instead, patients today play an active role in decision-making and serve as their own advocates or work together with a patient advocate. Shared decision-making (SDM) allows a patient to choose his or her best treatment plan by aligning various risks and benefits with his or her own preferences and values. SDM in medical practice can be described as an interaction between the patient and provider, which allows the patient to play an active role in making decisions about tests, medications, procedures, referrals or behaviors.

Decision-making aids empower patients and facilitate communication. Patients struggling to navigate the complex healthcare system now have many resources at their disposal. The Dartmouth-Hitchcock Center for Shared Decision Making has been one of the leaders in empowering and engaging patients; with a website that contains a comprehensive database of interactive, decision-aid tools and online resources. In collaboration with the Informed Medical Decisions Foundation, this organization created free decision-support toolkits for primary health, specialty health, and training modules in decision support as a clinical skill. Several other noteworthy sources of decision aid tools include the Agency for Healthcare Research and Quality (AHRQ), Ottawa Hospital Decision Centre (OHDeC), Ask Me 3, and the Mayo Clinic Shared Decision Making National Resource Center. AHRQ?s SHARE Approach is a model of shared decision-making that includes five steps to help guide physician and patient communication around treatment options: 1. Seek your patient?s participation 2. Help your patient explore and compare treatment options 3. Assess your patient?s values and preferences 4. Reach a decision with your patient 5. Evaluate your patient?s decision Although AHRQ?s training workshops and webinars are created for providers, patients can gain valuable information and realign expectations of their role in the decision-making process based on best practices. OHDeC?s A-to-Z inventory provides a comprehensive, searchable database of decision aids by condition or medical topic for patients, parents and caregivers. This organization also provides research reviews, trainings and implementation-support resources. Ask Me 3, on the other hand, is a tool that can be used by all patients and applied to any condition. The Ask Me 3 tool is a simple, one-page document that can be printed and taken to appointments, and encourages patients to ask their provider three key questions to clarify their principle health concern options for getting better: 1. What is my main problem? 2. What do I need to do? 3. Why is it important for me to do this? The Mayo Clinic Shared Decision Making National Resource Center offers a handful of shared decision aids including those related to cardiovascular conditions, diabetes, depression and medication choices such as osteoporosis and anticoagulation medications. Importantly, any account of efforts to empower patients and improve healthcare quality through accessible and accurate information would be incomplete without noting the important work done by the Cochrane Collaboration. This international non-profit works with more than 130 countries around the world to share the most up-to-date, evidence-based research. Each Cochrane Review focuses on a specific healthcare issue; such as cranberries for preventing urinary tract infections, exercise

PATIENTADVOCACY

Patients struggling to navigate the complex healthcare system now have many resources at their disposal.

Potential roles of a patient advocate include: -

Helping the patient understand his or her condition and options for care Facilitating communication between the patient and provider Assisting patients with obtaining support services, financial assistance and legal help.

Advocates may work only with the patient, or interface with payers, employers, case managers, attorneys, and anyone else who may have an impact on the patient?s care.

for depression, or pulmonary rehabilitation for chronic obstructive pulmonary disease. All the available evidence on that topic is evaluated and the findings are summarized. Reviews also include a ?plain language summary? to make it easier for individuals outside of clinical and medical fields to interpret the results. To date, the Cochrane Collaboration has published 10,256 reviews.

Shared decision-making makes choosing care more empowering and less overwhelming. While the healthcare system can be overwhelming, it is important for patients to feel empowered and engaged when it comes to their healthcare. Organizations such as The Dartmouth-Hitchcock Center for Shared Decision Making, AHRQ, and the Cochrane Collaboration have been leaders in fostering and enabling SDM and continue to make important contributions in this area.

Patient advocates provide additional, real-time support. If patients find they need additional support beyond decision tools, they may have the option of obtaining a patient advocate. A patient advocate, sometimes also known as a patient representative or patient navigator, may be hired directly by the patient, appointed in-house by a healthcare facility, or may even be included as part of an employer?s benefits package. Some organizations, such as the not-for-profit Patient Advocate Foundation (PAF) provide services free of charge.

Patient advocates may also be an option for patients desiring additional assistance or support with their medical conditions. While the costs and services provided by an advocate can range significantly, the primary purpose of the advocate is to assist patients in getting the care they need and advocating on their behalf.

While a patient advocate?s role and level of involvement can vary, an advocate?s central purpose is to provide patients with support in meeting their healthcare needs.

Through resources such as decision-aid tools and patient advocates, patients can be better informed, prepared, and supported when making decisions about their health.

GETTINGINVOLVED

03 GETTINGINVOLVED: TAKINGACTIONTOMAKETHE RIGHTIDEASREALITY Tiffany Lauria Research & Project Coordinator

?A physician shall respect the law and also recognize a responsibility to seek changes in those requirements which are contrary to the best interests of the patient. A physician shall recognize a responsibility to participate in activities contributing to the improvement of the community and the betterment of public health.? ?excerpt from The American Medical Association?s Code of Medical Ethics A provider?s care is not limited to the immediate needs of his or her patients. Many providers have deep concerns for patients?overall well being, as well as their ability to maneuver through the healthcare system and social environment in which they function. Tantamount to this is an indivdual's ability to achieve affordable, excellent care and physician advocacy has significant impacts on multiple levels of patient care.

GETTINGINVOLVED

A single voice may not be enough to create a wave or needed disruption, but the combined voices and ideas of a dedicated group can foster change and help bring the right ideas into realized action plan.

Direct advocacy by providers eases patient burdens. On the patient-provider level, when a physician steps into the role of advocating for his patient?s needs, things happen. Patients have an easier time getting appointments with specialists or getting insurance coverage approval when a provider is willing to speak to those specialists or insurers themselves. Providers can positively impact direct patient care, and even the patient?s day to day routine, when forging connections with those along the care chain: school nurses, community organizations, non-profits and family caretakers. Strategizing legislation can help on a local, state and even federal scale. The word ?advocacy? is most often connected with the political arena, but providers should not underestimate their role in the creation of strategy and legislation that has a broader impact on healthcare across large populations.

Increased funding for research, tighter opioid-restriction laws, and mental healthcare initiatives are all areas in which providers have led the charge, demonstrating advocacy measures at the state and federal level to bring about change. A single voice may not be enough to create a wave or needed disruption, but the combined voices and ideas of a dedicated group can foster that change and help bring the right ideas into realized action plan. Honing advocacy skills begins at home For some providers, becoming an advocate may start with simple ideas sharing. For others, it may be finding the right outlet for communication. Sharing ideas openly and taking steps to bring those ideas to fruition will quickly unearth others who align with your goals? and some who don?t! Practice your diplomacy and debate skills to reach ?the many?.

GETTINGINVOLVED

Find like-minded organizations. There are so many opportunities to share and collaborate at the local level: -

Taking your advocacy efforts to the next level may require association with an organization that aligns with your ideals. You can blaze the trail yourself (indeed, many have); but having connections with like-minded providers in an organization that has the leverage and resources to reach out on the national level may provide the momentum you need. Networking in this way has the added benefit of inspiring collaboration to fine-tune your ideas.

Are you part of a larger medical group or physicians association? Offer to write a piece in the newsletter or make a presentation to the board or partners about a topic you feel strongly about. Explain why this topic or idea affects the group, and outline your recommended steps to a resolution so you aren?t seen as standing on a soapbox. Do you feel strongly about an issue that affects a particular population or sub-set of your community? Get community support through connections with affected members and create a local movement. If you would like to impact regulations affecting the local autism population, speak at a monthly meeting and get families involved in contacting their local city or county representatives. Write a web blog or connect with a regional newspaper and become their local expert on the topic. The exposure will aid in your efforts to enact change.

There are several organizations that dedicate resources toward advocacy, many of which focus on specific agendas such as the American Cancer Society?s Cancer Action Network and the Patient Centered Primary Care Collaborative. Research the particular diagnosis or area you are interested in to find any number of opportunities. Most larger medical associations, including The American College of Obstetricians and Gynecologists and the American College of Physicians, have advocacy arms providing opportunities for involvement. And if you need some additional resources, be sure to check out the National Physicians Alliance, Physicians Working Together, Partnership to Empower Physician-Led Care, and Physicians for Social Responsibility.

amessagefromtheAAPtoit's membership- june2018*

04 Advocatingfor Chil drenSeparatedFrom Famil iesat Our SouthernBorder By AAP President Colleen Kraft, MD, MBA, FAAP

A Message to the Membersof the American Academy of Pediatrics from Colleen Kraft, MD, MBA, FAAP, President of the AAP

Note: The Verden team had the privilege to attend the PCC User's Conference in Denver where Dr. Craft delivered a keynote about the efforts that the AAP is making on behalf of its membership and children in general. She highlighted how partnerships with industry partners like PCC and others , as well as with managed care plans, the CDC and VFC programs, are all vital in order to further pediatricians reach in helping children. We couldn't be more proud to have a representative like this advocating for independent medical practices, and she has been tireless in her work in helping to bring visibility to the separation of families at the border. We consider Dr. Craft one of our heroes and a true advocate for children and physicians. 20

Dear AAP Member: Many media outlets are now reporting about children being separated from families as routine government practice at the southern border of the U.S. This policy contradicts everything we know about promoting and protecting children's health. Our 2017 policy statement, "Detention of Immigrant Children," urges that separation of a parent or primary caregiver from his or her children should never occur, unless there are concerns for the safety of the child at the hand of the parent. The Academy's position opposing family separation stems from the serious health consequences that this practice has on children. As AAP president, I visited the border recently with other pediatricians and saw firsthand the devastating impact that family separation has on children. One image will last with me forever. A toddler girl I met at a shelter for unaccompanied children was crying uncontrollably; her face was bright red. She was inconsolable and wanted her mother who was separated from her when they crossed the border together. She needed the warm touch of her mother's hand or her soothing voice. I felt helpless. I shared this story in an op-ed I published in the Los Angeles Times after the visit. In early 2017 when a policy of separation was being contemplated, AAP spoke out and the policy was abandoned. In December when the policy was once again floated, the AAP was on-the-record, strongly opposing the practice for its detrimental health impacts on children. In fact, we wrote to the U.S. Department of Homeland Security (DHS) numerous times expressing our opposition and urging the agency to end the practice immediately. Our advocacy has not wavered since then. When the policy was formalized in early May, we immediately spoke out, and we continue to pursue a multi-faceted advocacy strategy to give these vulnerable children and families a voice. This is a child health issue. When children are separated from their parents, it can cause irreparable harm to their health. Highly stressful experiences, such as family separation, can disrupt the building of children's brain architecture. Prolonged exposure to serious stress - toxic stress - can harm the developing brain and harm shortand long-term health. Family separation robs children of the buffer that a parent or caregiver provides against toxic stress. The AAP's position has been amplified across state and national media outlets, and individual pediatricians have written in their local newspapers, including the Houston Chronicle and Winston-Salem Journal just this week. Members of Congress have also referenced AAP's position when affirming their own opposition to separation. Many of you joined our Day of Action to Protect Families days before the practice became policy. Recently, the AAP was one of 540 organizations to send a letter to DHS, calling for the agency to end the policy immediately. Your voice is critical to our efforts opposing family separation. Please consider contacting your members of Congress and telling them to urge DHSto end the separation of children and parents immediately. To email your federal legislators with this message, please visit the AAP's federal advocacy website. I want to thank you for the calls and emails you have sent. Please know I share your outrage and that as child health experts, we will continue to oppose family separation and other threats to child health at every turn. Sincerely, Colleen Kraft, MD, MBA, FAAP President, American Academy of Pediatrics @AAPPres

Dr. Craft and her colleagues have continued to advocate and speak out on this issue tirelessly over the last several weeks and will continue to do so until this heinous process is ended. * Reprinted By Permission of the American Academy of Pediatrics: A Message to its Membership (June 2018)

LEADINGTHEWAY

05 LEADINGTHEWAY: RURAL ADVOCACYWORKINFLORIDA Nicole Caldwell Managing Editor, ViewPoint

At North Florida Pediatrics (NFP), the care doesn?t stop when you leave one of their six locations. This facility, which doesn?t specifically employ psychiatrists, social workers or psychologists in their rural Florida locations, is nevertheless dedicated to the behavioral health and overall wellbeing of its community. NFP fights hunger with food drives and backpack programs for kids, fundraises for various childhood causes, and figures out ways to partner with outside services for care coordination NFP itself doesn?t provide, from behavioral health to dentistry. We got the opportunity to sit down with Dr. Pamela Santelices (or ?Dr. Pam,? as she likes to be called), who runs NFP along with her husband and a couple dozen other medical professionals. At the center of the practice?s multiple clinics is a staggering sense of advocacy that in theory could be replicated (at least in part) at any clinic in the country. Here?s what they do, and how.

LEADINGTHEWAY

NFP answers the call for behavioral health and care coordination. Not satisfied with the vacuum of behavioral health and care coordination resources in the area, NFP took great strides to partner with a local behavioral health organization to offer services, improve patient education, and boost community resources. The pediatrics service highlights the importance of community partnerships to help reduce mental health disparities, and the need for regional doctors to advocate for behavioral health services accessible within primary care. At the center of these efforts is Dr. Pam, who specializes in pediatric primary care and has vast experience in treating adolescent patients and patients with behavioral health disorders. She has served as a practicing clinician for more than two decades, with more than seven years at NFP. For NFP, it?s personal. ?I came from the Philippines,? Dr. Pam said. ?We both did.? (Dr. Pam and Dr. Samuel Santelices). ?In the Philippines, poor is poor. There are no resources, there is just ?make do?. The United States is a very rich country. But when we went to work in rural areas, we saw there?s just a different kind of need. There?s isolation . . . there are a lot of single parents. So if you serve a mostly Medicaid population, then you see it. Probably, our very thing is, we want to serve these kids. When we have our clinics, we want it to look like they?re better than the clinics of our friends who have clinics in rich cities.?

Not satisfied with the vacuum of behavioral health and care coordination resourcesin the area, NFP took great stridesto partner with a local behavioral health organization to offer services, improve patient education, and boost community resources.

?Beyond the structure, you feel like there is much more to reach. And it does also get really close to your heart. We want to empower our patients.? Partnerships are the product of intense, focused outreach. Every one of the six NFP clinics are rural, Dr. Pam explained. ?We?re regular primary-care providers, it?s like a one-to-one ratio between

?I?m also talking to the University of South Florida,? Dr. Pam said ?Our clinic is one of the pilot programs for behavioral psychology, we?re still exploring that. We have private psychiatrists we consult if we need to, but we do see not only ADHD but also autistic children, and children with mood disorders. We encourage nurse practitioners to go into licensing and registration [in that area].? Partnerships, Dr. Pam said, are the result of persistence and nothing more.

pediatricians and ARNPs and we have one PA, soon to be two, and around 20 in the group. We deal with a lot of behavioral [issues in] kids, just because there?s not a lot of easy access being in a rural area. About 10 percent of our visits are behavioral? , even before the push for including behavioral health in primary care. ?Basically, we partnered with Meridian? but not financially,? she said, ?it?s more to create easy access? they have psychiatrists and psychologists.? Meridian Health is a non-profit with roots in the community mental health movement that last year alone impacted 20,796 lives through 326,431 direct-care treatment visits.

?We tried for a partnership like this before, but it kind of just faded away. I had to actually sit down with the upper-level decision makers; and since then, we were able to get the kids prompt attention. We don?t have a counselor yet? though that?s in the works? but we have also sat down with everybody. If there?s a psychologist, or behavioral therapist, we invite them to the office and ask them to explain their services. We involved our referral department, which is a centralized service, and they know the resources for this area to help.? ?We have two nurse coordinators and they focus on our behavioral and general follow up: ER, labs, and so on. Our more experienced nurses that do that. Basically, all our MD?s are seeing behavioral health. If they?re new, we train them.? Advocacy takes time. And resources can be few and far between.

LEADINGTHEWAY

?Last year, we attended a summit for Florida behavioral health,? Dr. Pam said. ?There?s really a disconnect. And if you don?t actively, proactively seek what?s available, you won?t know. Doctors are really busy in the clinic. And luckily, our size is enough that I would be able to go out and find resources for this work. I can?t imagine being a single practitioner and doing that.? ?Years ago in 2010, we started administering fluoride applications for kids. Now everybody?s doing that. We?ll find access to the dentist also? it?s really, really hard to find a dentist.? Serving one of Florida?s poorest counties comes with other challenges: like being the only clinic for miles. So NFP was approached to see if the center could provide health care for students during school.

There?s a lot of legwork involved in boots-on-the-ground advocacy. ?I?m trying to reach out to the schools because I can see? We can be a resource to the school health also, especially in these smaller areas,? Dr. Pam said. ?Every time, in our company culture we do volunteer work. If they have something in their church, for example, we gladly sponsor. More or less every month, we sponsor something. Last month we sponsored March of Dimes , at the same time the Hunger Fight was able to donate food? If they have enough sponsors, they want to do a backpack program over the weekend because we do not know if these students are going to eat at all.? Dr. Pam stays humble about her advocacy work, conveying a sense of bewilderment at how anyone with the resources to help children, wouldn?t do so. She said this sort of support for her community is a welcome respite from what she terms ?the pressure of the everyday grind ? with all the regulation, lawsuits, and compliance.?

?The hard part of it is the rules and regulations, because we have to work with the department of health and the department of education at the same time,? Dr. Pam said. ?So it?s not too fast. The clinic will be at the school, in the school, for services throughout the school year with two exam rooms, I?m kind of excited about it because the population there is 90-percent Medicaid HMO. There?s really a need: a high poverty rate, a high pregnancy rate, so there?s really nothing there. And sometimes they can?t go to our clinic because there?s no transportation.? ?For those kids, school is an unsure environment. It?s their waking hours, and it?s good if you can kind of see them in school also. Also, my background, before joining my husband for almost 10 years, I was medical director for another poor county in Florida?s health department. I?m kind of aware of the services and the needs.?

Our thanks to Dr. Pam Santelices for sharing her journey 24

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REGULATORYUPDATE

06 WHATHEALTHCAREDEREGULATION MEANSFORPROVIDERS Susanne Madden Founder & CEO, The Verden Group

REGULATORYUPDATE Passage of the Republican-sponsored tax reform bill last December enables individuals to forego purchasing health insurance without paying a fine; effectively reversing the American Care Act (ACA) requirement.

Trump hasbeen in office for lessthan two years, but hasalready shown a striking disregard for ensuring that all Americans? particularly the most vulnerable among us? can accesshealthcare services

Meanwhile, the Department of Labor, consequent to a Trump executive order, has expanded the capacity for small-business membership in Association Health Plans (AHPs), while constricting the AHP regulatory authority of states by shifting this to the federal government. AHPs may pose a unique threat to healthcare providers, in that fraud has historically permeated AHP handling of medical claims. The persistent deregulation efforts of the Trump Administration have widespread ramifications for healthcare provisions across the United States, regardless of whether the ACA remains federal law under his tenure.

In a CMSmemo from last July, directors of state agencies that survey nursing homes for safety were discouraged from issuing daily fines for violations in favor of one-time fines, thereby sheltering nursing homes from the impact of receiving such fines. CMSalso proposed reversing an Obama-era rule prohibiting clauses in nursing home residents?contracts that require residents to use arbitration to settle disputes rather than seek redress in a court of law. As a concession to nursing home resident advocacy groups, the CMS-proposed rule requires the arbitration agreement be written in ?plain language.? Yet even the nursing home industry responded that ?plain language? is too vague for any actual enforcement. n the case of a hospitalized elderly person physically unable to return home, family members are likely to sign arbitration agreements just to ensure a residential placement for that individual, regardless of whether they understood the terms.

The Affordable Care Act benefit and payment parameters are out the window. The new rule for Affordable Care Act Benefit and Payment Parameters for 2019 went into effect June 18. This Department of Health and Social Security (DHSS) rule grants states an expanded role in what they can choose as an Essential Benefits Benchmark Plan. The near term impact is that it can aid insurers in limiting the actual essential health benefits (EHBs) offered within any specific EHB category.

Trump-era policies and safety-net program work rules set tough standards on the poor.

On the other hand, this can also leave insured people who need preventive care (or services within a different EHB category, such as mental health care) with fewer options. One of the two Trump Administration guidance documents included in this rule expands the hardship exemption, so more individuals can be exempt from purchasing state-required health insurance coverage. Also eliminated by this rule is the requirement for insurance marketplaces to have at least two Navigator entities to assist consumers in selecting appropriate insurance coverage. The SHVS perceives that this final rule reflects anti-ACA policy designed to expand the role of states in providing oversight and administering the ACA while simultaneously reducing federal ACA oversight.

Kentucky, Indiana and Arkansas became the first states to impose the Trump Administration?s Jan. 11 guidance enabling states to impose work requirements on Medicaid recipients. The following seven other states also applied for DHSSpermission to impose work requirements on their Medicaid enrollees immediately after issuance of the Trump guidance document: Arizona, Kansas, Maine, New Hampshire, North Carolina, Utah and Wisconsin. In May, New Hampshire became the latest state to impose a Medicaid work requirement. That state?s CMSwaiver also imposes premium co-pays for recipients with incomes exceeding 100 percent of the Federal Poverty Level (FPL). The National Academy for State Health Policy reports that 30 states have now proposed (or are in the process of) implementing Medicaid work requirements.

Caps on insurance premium increases are being loosened. The Centers for Medicare and Medicaid Services (CMS) rule pertaining to the Medical Loss Ratio (MLR) under state regulatory authority has also been changed from the previous version.

In April, Trump additionally signed an executive order called ?Reducing Poverty in America? that requires low-income recipients of food assistance (e.g., SNAP benefits), low-income housing subsidies and Medicaid to work or lose eligibility status.

The ACA mandated that premium rate increases of 10 percent or more in the individual market needed to be scrutinized by state regulators in order to determine the increases were reasonable. The new CMSrule raises that threshold to 15 percent. While insurance companies have reacted favorably, the resulting cost increase in healthcare services is likely to be passed on to healthcare facilities, medical providers, and patients.

Trump?s plan for cost-containment of prescription medications has faltered.

Medicare penalties enacted against negligent nursing homes have been eliminated. Under the leadership of Trump appointee Seema Verma, the CMS has instituted new rules curbing the oversight of nursing homes. The New York Times reported last November that the CMSwas scaling back the use of fines against nursing homes that place residents at risk of injury.

Although originally promised, President Trump decided against the federal government directly negotiating for lower drug prices for Medicare Part D recipients, as well as allowing USconsumers to import medications from abroad. In a recent speech (May 2018), timed to broaden appeal for his base ahead of the November congressional elections, Trump promised instead to provide private entities with more tools to negotiate better price deals. Stock shares of pharmaceutical and biotech companies? as well as Pharmacy Benefit Managers (PBMs)? immediately rose.

REGULATORYUPDATE Likewise, family caregivers seeking a nursing-home placement for elderly family members may face far greater risks of neglect or mistreatment by the nursing home due to a weakening of regulations for those entities and care requirements. That?s enough to make folks reluctant to move a loved one away family provided care.

A newsletter aimed at pharmaceutical and biotechnology industry members noted Trump?s proposed trade tariff aimed at China could actually increase the cost of medications in the US, since the FDA reported that 80 percent of active pharmaceutical ingredients used by USmanufacturers are imported from China. There are serious safety implications to regulatory rollbacks at the FDA.

The consequence of limiting access to preventive care is already well known to medical providers and other clinicians. The Congressional Budget Office calculated that the repeal of the ACA?s individual mandate by itself would increase the number of uninsured Americans to four million in 2019. Taken as a whole, the changes under the Trump Administration to Medicare, Medicaid and the private insurance industry will increase difficulties for patients in accessing healthcare. In turn, physicians, hospitals, and the entire healthcare delivery system will absorb the cost-burden created by the Trump Administration?s healthcare policies.

One of President Trump?s stated goals is a 75-percent roll back of FDA regulations. FDA Commissioner Scott Gottlieb was credited by the pharmaceutical industry and healthcare organizations with streamlining the FDA drug approval process. Indeed, the FDA in 2017 set an all-time record for generic drug approvals and novel drugs compared to any year after 1996. Gottlieb recently suggested that the legal status of rebates paid to insurers and Pharmacy Benefit Managers (PBMs) may be rescinded as a way to potentially reign in drug costs through increasing competition.

The time to act is now: Before healthcare facilities become overburdened with patients unable to pay their medical bills; or those with preventable illnesses that were left untreated are in critical condition.

Meanwhile ?Right to Try?legislation in May was signed into federal law by President Trump. This law allows terminally ill people the right to take experimental medications not yet approved by the FDA.

Overturning the ACA is a major goal of President Trump, so demonstrating it as a failure is a specific strategy he uses to garner public support for its repeal. But attempting to generate failure in the healthcare system does not bode well for healthcare providers or patients. It is imperative that we learn from the lessons of the past.

The jury is still out as to whether speeding up the availability of new medications was a safe policy or not, and whether reducing rebates will help control prescription drug costs in the future. The medical community has a responsibility to advocate for preserving and protecting the US healthcare system.

The last attempt at massive healthcare deregulation was under President Ronald Reagan. The adverse consequences from that effort included attempts at cost-control backfiring, and healthcare outcomes worsening.

Donald Trump has been in office for less than two years, but has already shown a striking disregard for ensuring that all Americans? particularly the most vulnerable among us? can access healthcare services. For Medicaid recipients, imposing a work requirement can mean choosing between going without health insurance or leaving a disabled child alone at home for hours, if the parent?s work hours do not match that of the child?s school or care program.

We need advocacy work from healthcare providers, insurers and patients in order to ensure that the quality of our healthcare system is not exchanged for short-term political achievements that foster a weakened governmental capacity to produce a healthier nation in the coming decades.

GOGREEN

07 GOGREENATWORK: EASYWAYSTO MAKEYOURPRACTICEECO-FRIENDLY Nicole Caldwell Managing Editor, ViewPoint

Advocacy takes many forms; but in the medical industry, there is no advocacy work more important than your own patients? health. And with what we know today, it?s impossible to separate the health of your patients from the environments that they?re in, including the medical office where you see them. Whether a clinic, specialty practice or urgent care facility, your medical office is the perfect place to set an example with an eco-friendly space. Those in the medical community have a unique opportunity and responsibility to connect aspects of patient health with the health of the environment. Your practice can support a healthy planet while also helping individuals with their own wellness. Here are some easy ways to green your office space. Invest in hypoallergenic, living plants. Studies show that green spaces improve moods and promote overall health? and eco-friendly spaces, where infection is prevented and stress levels are reduced, look great while also cutting indoor ozone. A doctor?s office isn?t the best spot to put a bunch of aromatic, blooming flowers on display, but it is a great place for air-purifying, non-blooming (read: hypoallergenic) plants like spiders, succulents, pothos and areca palms. With so many patients considering waiting rooms the worst part of doctor visits, a planter or two containing anxiety-reducing houseplants may be just what the doctor ordered!

GOGREEN you can rotate in and out every few months? Pictures of national parks, green spaces, animals and so on may help soothe patients and not become last month?s old news.

Play up the natural light. If you?re fortunate enough to have windows in your waiting room, turn down the electric lights! Sunlight is a natural mood enhancer, raises pain thresholds, and even has been linked to shorter hospital stays. Design elements like improved lighting helps doctors, too, contributing to a reduction in stress for staff and fewer medical errors.

While you are at it, take a look at the art hanging on your walls. Swapping out images for local photography of green spaces or paintings of local landscapes may be things that your patients recognize, can conjure good memories and feelings of peace.

Switch from fluorescent lights to LEDs.

Rethink your textiles.

Speaking of lighting, there?s almost nothing worse than linear fluorescent light fixtures. If you don?t have natural lighting, swap those outdated lights out for LEDs, which last forever and are far more relaxing and easier on the eyes; or full-spectrum fluorescent lighting, which has been linked to improved mental clarity and mood.

If you?re opening your own practice or considering a renovation, look into textiles that are stain-resistant and don?t require cleaning with harsh chemicals. Recycled wallpapers, no-VOC paint, natural fabrics and fewer chemical cleaners mean less ?off-gassing?of harmful chemicals into the air for your patients and staff to breathe.

Turn things off when your office is closed.

Companies like EcoLab, Method, Seventh Generation, and Mrs. Meyer?s (to name a few) offer eco-friendly cleaning products and solutions that use up to considerably less packaging and in 2017 alone, EcoLab alone conserved more than 170 billion gallons of water, saved 12 trillion BTUs of energy, and did kept 52.4 million pounds of waste out of landfills!

Power strips, timers, and motion-activated lights can all help you immensely with this. Remind employees to save their work on their computers, and shut down the power when they are done. While you?re at it, change your office thermostat by just a degree or two? down in the winter, and up in the summer. That action alone can knock a significant percentage off your electric bill while seriously cutting down on energy use.

Put your fish tank to work. Aquariums are a popular fixture in many doctors?offices. If you really want to go all-out, why not take it to the max and set up an aquaponics kit? The greens you grow can get given to staff or donated to a local food pantry. If you don?t have a fish tank, also consider a living wall, which doubles as an art piece.

Get your staff involved too by making a game out if it: set an office-wide goal of, say, reducing greenhouse gas emissions by 10 percent over the next year, and chart your progress with a wipe-off board in the break room. Ten percent may seem like a lot, but you?ll be surprised what a difference these little energy-saving actions make when you start analyzing your energy bills and consciously reducing your use.

Encourage environmental advocacy around the practice. Nothing promotes your own environmental advocacy like getting your staff involved. Develop an advocacy program that allows for sponsorship or assistance to various causes: adopt a section of highway, host a trash cleanup around town or on a nearby coast, or partner with a local farm for an event promoting local foods. And these activities will get you noticed and increase action in your community, bringing your advocacy work in-office out into the public.

Limit single-use items. There?s not much of a work-around for single-use items like needles, exam gloves, or paper exam-table covers. But you can do something about plastic cutlery in the break room, disposable Keurig cups, foam cups, and endless takeout containers by replacing them with reusable items that washed instead of tossed. Rethink unnecessary packaging and how things are disposed of, and invest wherever possible in more sustainable materials (including products you might recommend to patients). You can also look into sparkling water machines and water bottle refill stations to reduce waste for your staff and patients. And be sure to educate your staff on what can be sorted as recyclable waste and what cannot. Cancel your magazine subscriptions. One easy way to reduce waste around the office is to cancel all those magazine subscriptions. Replacing celebrity gossip or news periodicals (that can increase patient stress!) and use a lot of resources to print, why not pick up some coffee table books that

CODINGUPDATE

08 UPDATEONCPTCODES: NONFACE-TO-FACECODES Jenna Mirchin, CPC, CPMA, CGSC Two little-known CPT codes were added in 2017 that I?d like to bring to your attention. These are codes used for care that occurs before or after face-to-face encounters, and can be used to help compensate for care delivered to complex patients or during periods of complex case management, often when you are advocating for your patients! 99358 Prolonged evaluation and management service before and/or after direct patient care; first hour 99359 Prolonged evaluation and management service before and/or after direct patient care; each additional 30 minutes (list separately in addition to code for prolonged service) Both of these codes can be billed prior to, or following, a related, face-to-face encounter with the patient; and can be billed on the same day as the related E/ M service (99201-99205, 99211-99215) or on a separate date of service after in-person care was rendered. In order to effectively chart your note, you must document how much time was spent on the service. This amount must exceed 30 minutes (?31 minutes spent?) in order to bill the 99358 and the time spent must be aggregated on one date of service. Covered services include: -

Extensive medical record review or diagnostic study review Extensive telephone calls with patient, parent or guardian Meetings with family or caregiver without the patient

Note: You cannot use these codes for non-clinical intervention, documentation of medical records, forms or letters, and they cannot be billed by clinical staff without the presence of the billing provider. You can access more information about these codes here: -

NGSProlonged Services NGSProlonged Services FAQs AAPC

And as always, check with your local payers to see how they are covering these services and if they are separately payable.

09 Howtostart apetition Tiffany Lauria Research & Project Coordinator

In this modern age of technology and social media, one might think using petitions to influence decision-makers is a little old-fashioned. Actually, the opposite is true!

Petitions these days have gone high-tech. Anyone looking to gather support for an idea, proposal or demand can harness the power of the internet to gain rapid-fire exposure and thousands of signatures without ever having to canvass on the streets.

A number of sites are available to help you create and share your petition for signatures. Care2 Petitions, MoveOn and GoPetition will all walk you step-by-step through the creation of your petition and allow you to disseminate it for support and signatures. Even the White House has its own platform called We the People, which enables you to create and promote your petition right on the site. Even better, there?s a promised official response to any petitions that reach 100,000 signatures in 30 days (remember the 2013 petition for the creation of a Star Wars-esque Death Star?). Petitions get noticed, and they are here to stay. Here are some tips for making sure your cause gains serious traction: Know your audience. Are you writing to the local school board? The mayor of your city, or another government representative? The head of the national medical society? Knowing your audience will allow you to craft your message in the most appealing way.

Construct a clear message. Before you begin, write out your key points and streamline your goal. When drafting the message, always include a captivating title, an explanation of why you are requesting a change or action, and the exact action or goal you are requesting. Message statements should be brief, but must clearly get the message across in a few short statements. Research how many signatures you need. Depending on your audience, you may have to meet a specific number of signatures to ensure the petition gets reviewed. Promote your petition. If you?re using an online platform, you?ll receive a link to share with friends and family for their signatures. Ask your contacts to pass the link along to their own network, and to share it on their websites and social media accounts. Don?t forget to ask local or national organizations with a vested interest in your idea or demand to also promote your petition. Your petition is only as good as the number of signatures you gather, so get promoting! Stay the course. Continue encouraging others to support your cause. And never stop looking for ways to adjust your petition or ideas to reflect new research, compromise and growth. You can always adjust your angle and resubmit, or seek out a different route to open up the conversation.

ADVOCATINGFORCHANGE

10 MARKETINGYOURPRACTICE TOSELF-FUNDEDEMPLOYERS Susanne Madden Founder & CEO, The Verden Group First published in Physician'sPractice. Aug 27, 2017 Gastroenterologists might bundle consults with colonoscopies and follow up care into one amount. Bundling creates a value proposition for the employer whereby they understand an end-to-end cost for those services.

The self-funded employer market is growing with groups of 50 employees and beyond now entering the market. In fact, according to The Henry J. Kaiser Foundation's 2016 Employee Benefits Survey, 61 percent of covered workers are in a plan that is completely or partially self-funded, a market that has been steadily increasing, up from 49 percent in 2000.

Layering in telemedicine, instant messaging, and other options will make these offerings more attractive to employers too. Breaking away from a middleman allows for greater innovation.

Self-funded employers carry the obvious financial risk for employee healthcare claims rather than paying premiums to insurance companies to do so. As healthcare costs have continued to rise, many employers have sought out less expensive care, particularly on larger ticket items like joint replacements (which in turn has help to spur the medical tourism industry). But there are plenty of savings opportunities available in lower cost, more routine healthcare services too.

Development of services and offerings are typically stymied by insurance participation due to how those companies do (or do not) pay. The more service-oriented and convenient the models, the better chance you will have of contracting an employer to pay for those services directly. Third, you need to contact the employers and pitch your plan. Utilizing sourced contacts, send a letter detailing what you have to offer and your prices for each service. In determining those prices, take into consideration the savings inherent in not having to bill out claims to insurance companies, labor costs savings in avoiding administrative busy-work like prior authorizations and pre-determinations (calculated at 14 percent to 27 percent of revenue) (Health Affairs, July/August 2009, vol. 28 no. 4, 544-554).

What Does That Have To Do With You? As discussed in a previous Pearls column titled Physicians Contract with Self-Funded Employers , some medical practices are providing services directly to employers in order to cut out the middleman.

How Can You Engage Employers?

Offering services at a price point equal to or less than what they are currently paying through a claims benefit administration process (the insurance company), is an enticing proposition.

First, you have to find them. There are datasets available on the self-funded market (such as through judydiamond.com and the Self-Funded Employer Association) that allow you to identify employers in your area. This data usually contains the names and contact details of the executives in charge of the fund at each employer.

Keep it simple. A friendly, typed letter detailing your program, services or even just your desire to explore options should generate a call back. Don't expect to have all the answers; the starting point should be obtaining an understanding of what the employer needs may be and for them to understand what services ? and service enhancements ? you may be able to offer their employees. From there, you can build a new program together.

Second, you need to build a plan to offer these employers. Determine what services make sense to bundle. For example, in pediatrics you might bundle the well visits, vaccines, screening tests and average a number of sick visits per year and offer a per-patient, by age, annual charge to cover those visits.

JOINUSAt THESECONFERENCES&EVENTS FLORIDACHAPTEROFTHEAMERICANACADEMY OFPEDIATRICS -

August 31 - September 2, 2018 Orlando, FL Register here: http:/ / fcaap.org/events/

PCMHCONGRESS2018 -

September 14-17, 2018 San Diego, CA Register here: https://www.pcmhcongress.com/

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ADVOCATINGFORCHANGE

11 MAKINGTHECASEFORPCMH INCENTIVESTOYOURPAYERS Posted on June 5, 2018 to the NCQA Blog by Leah Kaufman

Last fall, I was talking with a practice manager at a small pediatric clinic in the South that just earned NCQA Recognition. This was his first time at the PCMH Congress. We talked for a while about a presentation we?d seen? on the transition to value-based care? and then he began to share some of the issues that arose when his practice tried to negotiate enhanced payment based on its recognition status. He asked me, ?Who?s providing incentives for PCMH practices in my state??

PCMH Incentives It was a familiar conversation, and his question was straightforward? but the answer is considerably less so. In NCQA?s directory of payers that offer incentives for PCMH recognition, there?s a caveat: Incentives may not be available in all markets, or to all practices. This, my new friend had found out. Many factors go into a payer?s decision to offer enhanced reimbursement, and small practices often struggle to make a case for receiving it. With the rapidly shifting payment environment, practices must learn to position themselves in a way that demonstrates their value and how their PCMH status helps them flourish in a value-based system. First and foremost, the PCMH model encourages all practice staff to work at the top of their license, saving practices time and money and increasing their operational efficiency. Superior tracking of tests and imaging results, performing medication reconciliation and better coordination of care increases patient safety. This not only appeals to payers, but also potentially sets the stage for a practice to pursue discounts on malpractice premiums.

ADVOCATINGFORCHANGE The Case for PCMH Medical homes are more likely to catch errors quickly, have better documentation and do a better job of educating their patients and engaging them as partners in their own care. By utilizing evidence-based decision support tools and routinely recalling patients for needed services, they?re more likely to see higher use of preventive care and improved management of chronic conditions, which reduces higher cost care down the road. Beyond that, with the medical home model?s focus on patient access, recognized practices tend to see higher rates of patient satisfaction? resulting in increased referrals and a reputation in the community as a high-quality partner in managing care for shared patient populations. Additionally, the proliferation of clinically integrated networks and ACOs can give small practices the opportunity to partner with larger organizations that have increased bargaining power, with the potential to receive enhanced PMPM payments or shared savings. On the consumer side of the house, we see an increasing number of tiered networks as health plans use reduced co-pays to steer members to the providers that offer the highest value, taking into consideration medical home recognition, patient utilization rates, claims cost and other factors. Yesterday?s Webinar* ? Showing Payers the Value of PCMH Recognition? discussed securing incentives for recognition. Susanne Madden, of The Verden Group, and an authority on physician reimbursement issues, provided insight into how payers approach value-based payment for PCMH. At the heart of many value-based contracts are HEDISmeasures, particularly in adult care. Practices may be able to receive incentives if they can demonstrate high-quality performance, based on meeting HEDISquality measures or on other factors such as self-reported measures, claims costs, patient utilization and other metrics. In some cases, payers include medical home recognition as a component of these programs. Some value-based programs award higher reimbursement rates based solely on PCMH recognition.

Making Your Case In summary, the answer to ?Who?s offering incentives?? might depend on how well a practice can make the case that delivery of higher-quality care deserves enhanced reimbursement. Practices must have good data to support this claim (for example, documentation of incentives from other payers), and must demonstrate the value they provide, both within the context of the larger health care system and in the communities they serve. We?ll have a recording of the Webinar available online soon. Check back for a link to the program. And for more information on incentives for recognition, visit The Recognition Program Resource Directory. * Webinar presenters were Susanne Madden (the Verden Group), Lori Francis (BCBSTN) and Dr. Kashyap Patel (Carolina Blood and Cancer Care).

Leah Kaufman: Leah is External Relations Manager for Recognition Programs at NCQA and has been with the organization since 2014. She connects primary and specialty care providers with resources to support practice transformation and movement towards value-based care delivery. She also manages strategic relationships with organizations focused on improving healthcare quality through patient-centered coordinated models of care.