A PHYSICIANS INSURANCE PUBLICATION

THE

SUMMER 2014 PHYINS.COM

Evolving Practice Models

4 Taking Aim: Northwest Approaches to the Next Generation of Care

6 Unlocking Value with Clinical Integration: Independence through Interdependence

10 Taking Accountability for Population Health IN 1994, I was a young health Medicare Advantage contracts, we EDITORIAL STAFF care executive excited about health took some of our monthly capitation PUBLISHER care reform. Things didn’t work out like payments and added case managers Mary-Lou Misrahy SENIOR EDITOR many of us hoped. This go-round, I am and other patient support staff to reduce David Kinard both excited and apprehensive about hospitalizations and ER visits, saving MANAGING EDITOR health care reform and alternative money and enhancing patients’ lives. Kirstin Williams EDITOR delivery systems. Providers cannot fund this type of Elaine Riordan

innovation out of their existing fee-for- CONTRIBUTING EDITORS Jeff Ellis, JD The Polyclinic has participated service payments. Ray Herschman enthusiastically in health care Judit Olah, PhD innovation. Our efforts have included Lead, but don’t get too far ahead of the Greg O’Barr, M.Ed Martie Ross, JD full risk capitation, both commercial and market. There is a lot of rhetoric about Phyllis Simpson Sherard, PhD Medicare Advantage, incentive contracts moving from pay-for-volume to pay- CONTRIBUTING EDITORS—LEGAL Catherine Walberg, JD for-value, but the vast majority of our based on generic prescribing, ER use Kari Adams rates, hospital admission rates, etc. We payments are still for volume. Emphasize ART DIRECTOR were Washington State’s first Medicare “virtuous volume,” e.g., childhood Jerry Kopec, Mortise+Tenon immunizations, preventive care, and ADMINISTRATIVE SUPPORT ACO and first commercial ACO. We have Laura Brosten, Bonny McFarland participated in state collaboratives on regular care for chronic conditions. Nancy Reithaar diabetes, heart disease, and medical homes, and we have studied the efforts Follow the value equation, but recognize EXECUTIVE MANAGEMENT GROUP of others in the region and the nation. whether the market will reward increasing PRESIDENT AND CHIEF EXECUTIVE OFFICER What have we learned? the numerator or decreasing the Mary-Lou Misrahy denominator, or both: EXECUTIVE VICE PRESIDENT, CHIEF FINANCIAL OFFICER AND TREASURER Be careful how much you spend while Rod Pierson building new solutions. Elaborate SENIOR VICE PRESIDENT AND CHIEF INFORMATION OFFICER Quality + Satisfaction Leslie Mallonee organizational structures are less likely Value = to produce meaningful change than Total Cost of Care VICE PRESIDENT, GENERAL COUNSEL Catherine Walberg, JD programs that tighten the connection SENIOR VICE PRESIDENT, UNDERWRITING between patients and their providers. Rick Nauman Information technology systems can SENIOR VICE PRESIDENT, Total Cost Utilization x HUMAN RESOURCES AND ADMINISTRATION be an important element of improved of Care = Price Alison Talbot coordination of care, but they are only a tool. Without change in work processes BOARD OF DIRECTORS and incentives and accountability, We need to do this. If we can’t make Brian P. Wicks, MD, Chairman improvement is unlikely. a convincing case that our efforts will Ralph A. Rossi, MD, Vice Chairman reduce health care costs and deliver those Aparna Ananth, MD Lloyd David Don’t fall in love with models. Apply savings, then payers and purchasers will Jennifer Hanscom resources only where they can have simply push down our prices. John R. Huddlestone, MD real impact. Medical homes and case Chi-Dooh “Skip” Li, JD David McClellan, MD managers make great sense for the We don’t have much time. Timothy L. Melhorn, MD frail, elderly, and patients with multiple John Pasqualetto chronic conditions, but they are a waste Sheila Rege, MD David A. Russian, MD of resources for healthy 35-year-olds. Walter Skowronski Leslie A. Struxness, MD Josephine Young, MD Physician leadership is critical. Every organization may say it is “physician-led.” Lloyd David READ PHYSICIANS REPORT ONLINE www.phyins.com/Summer2014 The proof will be in whether physicians CEO CONTACT PHYSICIANS REPORT feel like they are leading. The Polyclinic [email protected]

HOME OFFICE: Payers must create funding to support Seattle, WA innovation by providers. In our full-risk Copyright 2014 Physicians Insurance A Mutual Company A PHYSICIANS INSURANCE PUBLICATION

FEATURES

6 Unlocking Value with Clinical Integration: Independence Through Interdependence

What exactly is a CIN and how does one work?

10 Taking Accountability for Population Health: The Role of Data

Using data to gain more control.

12 Medical Neighborhoods Are Transforming Care Delivery in Rural Settings 4 Taking Aim: Northwest Collaborating to solve the Approaches to the Next challenge of fragmented care. Generation of Care It is widely understood that the U.S. health system is the most costly in the world. Read how some Northwest facilities are organizing themselves to improve care and rein in costs for the next era.

ADDITIONAL FEATURES CME RISK MANAGEMENT MEMBER NEWS

16 Why the Coach 22 New: The 25 Taking Care: 26 Member Spotlight: Approach Works Coach Approach Your Peers Speak GreenField Health Up on Difficult Topics 20 Income Protection 23 Online and 26 New Members — Tools Specialty-specific Welcome!

24 Q&A with Mary 28 Trial Results McWilliams, Executive Director of the Washington GOVT AFFAIRS Health Alliance 30 Upcoming Election News: Is There SEND FEEDBACK a Doctor in the House? Tell us more about what you would like to see in upcoming issues. E-mail us at [email protected]. 4

Northwest Approaches to the Next Generation of Care Taking Aim

In 2008, when Don Berwick first coined the notion of a Triple Aim, little did the general public understand ­— or even most health care professionals — the impact this simple model would have on the U.S. health care system. Today, it is widely understood that the U.S. health system is the most costly in the world, accounting for 17% of the country’s gross domestic product with estimates it will reach 20% by the end of this decade.1 5 THE PHYSICIANS REPORT | SUMMER 2014

Change and improvement processes are rampant, they both see the emergency department as a leading and while Berwick’s vision of impacting care quality, indicator of how this new model can work. “In Yakima, population health, and reducing costs still remains there is a culture of first going to the emergency room elusive to most, the Northwest is home to several for care,” notes Spiegel. “In a rural population like ours, organizations aiming in the right direction. culturally, the ED is seen as a place to get primary care. The opportunity for us is not only to reduce the costs of One organization in Vancouver, Washington, is focusing care in the ED, but also to educate patients and change on physician-patient relationships to make a difference. their behavior in how they access care.” One common “We want to create a community solution,” says Duane method being experimented with is the use of urgent Lucas-Roberts, CEO of The Vancouver Clinic, about his care clinics. Physicians at Memorial Hospital, who Northwest Approaches to organization’s approach to developing a clinically integrated participate in SignalHealth, have opened up convenient network (CIN). “Our goal for Columbia IPA [independent care clinics in Yakima, which are less expensive than the Next Generation of Care practice association] is to create a coordinated approach to the ED — in large part due to the staffing of the clinics quality care, and lower costs at the same time. That goal by nurse practitioners who cost less than emergency isn’t anything new, but the way we are organizing ourselves medicine physicians. to achieve it is.”

It is easy to notice, as one “The result was a reduction in emergency surveys the region, that as groups organize themselves department visits — from 1,000 to 200 visits.” into CINs, each is doing it DUANE LUCAS-ROBERTS, CEO differently. Continues Lucas- THE VANCOUVER CLINIC Roberts, “We see ourselves as just a part of the overall solution. The hospitals are the other part. The patient plays Lucas-Roberts recalls his own emergency department a role, too. But we’re organizing ourselves ­— starting with challenges while working in Walla Walla, Washington. the physician and patient relationship. That’s where care “Our population was a full-risk Medicaid group of about really starts and it’s that ongoing relationship that will have 2,000 patient lives, most of whom were kids.” According the most impact.” to Lucas-Roberts, this population was running about 1,000 ED patient visits per 1,000 patients per year — While The Vancouver Clinic develops their physician-centric about five times higher than the commercially insured solution, just four hours away efforts are under way at population. “We knew we had to change patient behaviors Yakima Valley Memorial Hospital (YVMH), where the hospital but that ours needed to change first.” The clinic set up is leading a community-wide charge to create a CIN. But a system where the emergency department was required whereas The Vancouver Clinic efforts pivot around the to contact the primary care physician before seeing the primary care physician and patient relationship, YVMH saw patient except in emergent cases. The primary care the value of the hospital leading the charge and financing physician would consult with the patient and either see the start-up of Signal Health, LLC. the patient in the ED, or schedule an office visit. “The result was a reduction in ED visits — from 1,000 to 200 Headed by Dr. Richard Spiegel, Signal Health has recruited visits per 1,000 patients per year,” notes Lucas-Roberts. more than 300 physicians, which include all of the hospital’s employed physicians and others (about three-quarters of And this is possibly the most compelling and perplexing the total according to Spiegel) that are independent. “If we part of the new models of care — getting patients only deal with the outpatient or clinic side of care, we could to change their approach to their own health and hope to reduce emergency department visits, or testing. But consumption of care. The traditional fee-for-service we want to look at this as a system — hospital, outpatient, model, coupled with insurance programs that distanced ancillary services. We are all working as a whole toward patients from their care dollars, created a multi- quality, health, and cost.” generation mindset of how the insured health care system works: Physicians treat, patients consume, insurers pay. POINTS OF ACCESS This is the model that led us to today’s health care fiscal Though the fulcrum of their efforts may be different, (Continued on page 14)

1 Institute for Healthcare Improvement, “The IHI Triple Aim,” accessed May 29, 2014, www.ihi.org/engage/initiatives/tripleaim/pages/default.aspx 6 7 THE PHYSICIANS REPORT | SUMMER 2014

UNLOCKING VALUE WITH CLINICAL INTEGRATION Independence Through Interdependence Jeff Ellis and Martie Ross, Pershing Yoakley & Associates, PC

Fee-for-service reimbursement rewards Commercial insurers, as well as employers, also are independence: each provider is paid for providing aggressively pursuing value-based purchasing arrangements. More and more payers are introducing pay-for-performance a discrete service, without regard to others’ provisions in their standard provider agreements. performance. There is no incentive for providers to work together in providing patient care. Achieving measurable improvements in quality and efficiency demanded under these new payment models Value-based payment systems, however, demand requires coordination and collaboration among a interdependence: providers are rewarded for quality and community’s providers. Independent physicians are seeking efficiency achieved through collaborative care. ways to work together for these purposes while protecting their individual interests. The structure to develop and support such interdependence is the clinically integrated network, or CIN. Regardless of the Clinical integration is a new model for health care delivery. specific type of value-based payments — pay-for-performance, It promotes collaboration among a community’s independent shared savings, bundled payments, or global budgets — they providers to furnish high-quality care in a more efficient require that providers be accountable to each other and the manner. Physicians, hospitals, and other providers share community they serve. responsibility for, and information about, patients as they move from one setting to another over the entire course of Developing a CIN is a journey, not an event. The first step in their care. that journey is a common understanding of why everyone is suddenly talking about clinical integration, and what it means Working together, clinically integrated providers develop to the future of health care delivery. and implement evidence-based clinical protocols, focusing on patient engagement and coordinated management of THE TRANSITION TO VALUE-BASED high-risk and rising-risk patients. Utilizing shared information PAYMENT IS ACCELERATING technology, these providers conduct ongoing clinical care The Centers for Medicare and Medicaid Services (CMS) is reviews to identify opportunities for improvement and ensure promoting this transition in the Medicare program through adherence to protocols. a number of initiatives including, for example, the Medicare Shared Savings Program, value-based purchasing of hospital While the antitrust laws generally prohibit joint contract physicians, and bundled payments. negotiations among independent providers, those laws permit

(Continued on next page) 8

clinically integrated providers to collectively negotiate with providers. To the extent joint contracting is both necessary payers. Working together, these providers can compete for payer and subordinate to a CIN’s broader effort to improve quality contracts based on demonstrable quality and greater efficiency and efficiency, the government views CIN arrangements as in care delivery. beneficial to consumers and pro-competitive. Thus, providers’ full commitment to achieving critical integration is critical. In short, clinically integrated providers are accountable to each other and to the community they serve to deliver high-quality care A CIN IS NOT NECESSARILY AN ACO in an efficient manner. They accomplish this by (1) collectively The term clinically integrated network dates back to the mid- establishing and enforcing standards of care, (2) coordinating 1990s, when the FTC first acknowledged that independent patient care (especially for high-risk, high-cost patients), and providers working together to improve quality and efficiency could (3) jointly negotiating and managing payer contracts. engage in joint payer negotiations.

DEFINING THE INTEGRATED NETWORK The term accountable care organization was first used about A CIN is the lean infrastructure needed to support clinical a decade later in reference to a group of providers that assumes integration among a community’s independent providers. The responsibility to provide care for an assigned patient population. network develops a governance structure through which these Typically, an ACO bears some financial risk associated with providers develop and implement clinical guidelines, monitor providing such care. compliance, enforce standards, and reward performance. An ACO is a more formal arrangement, structured to satisfy Other network activities include, for example, identifying, specific payer requirements. For example, only an ACO that implementing, and maintaining supportive technologies meets certain regulatory requirements is eligible to participate in (including data analytics); analyzing care processes to the Medicare Shared Savings Program. identify efficiencies; encouraging patient engagement; negotiating pay-for-performance payer A CIN may elect to form an ACO contracts; and distributing incentive for purposes of contracting with payments to members. a particular payer. That decision, however, may be deferred until the While a hospital can provide CIN is fully operational. administrative expertise for a CIN, network leadership is shared with A CIN’s governance structure physicians. Physicians have the must further its members’ knowledge, skill, and experience needed common goals while protecting to achieve improvements in clinical their individual interests. This is quality and efficiency. achieved through the selection of governing board members, Unlike organizations such as integrated balancing voting rights among delivery networks (with hospital-employed participants, reserving certain physicians) and large multispecialty fundamental decisions to the physician practice groups, which base respective parties, delegating their clinical integration strategies on organizational functions through economic integration, a CIN respects and carefully drafted committee preserves the economic independence of its physician members. charters, and more.

Key characteristics of a successful CIN include the following: Before deciding on a particular structure, however, there should be consensus around common goals, i.e., identification of the • Well-defined governance structure to promote functions the CIN will perform. Stated another way, the form the organizational goals while protecting individual interests CIN takes should follow from the functions it will perform, not • Physician-driven, professional management vice versa. • Data-driven reporting, foundation, philosophy, or approach • Relentless focus on managing high-risk and rising-risk CINs fund their operations in a number of different ways, patient population including, for example, contributions from the participating • Adherence to evidence-based clinical guidelines hospital, physician dues, the sale of investment interests, Provider worries about federal regulators are well grounded. revenue generated by selling services, and withholdings from Since 2001, the federal government has prosecuted more than payer reimbursement and/or pay-for-performance payments. 30 provider organizations alleging price-fixing arrangements. PAY-FOR-PERFORMANCE AND SHARED SAVINGS The Federal Trade Commission (FTC), however, does not view PROGRAMS collaboration through a CIN as collusion among independent Under a pay-for-performance contract (often referred to as a 9 THE PHYSICIANS REPORT | SUMMER 2014

P4P contract), an individual provider CIN repays a portion of the difference. EVALUATING OPPORTUNITIES continues to submit claims and receive But if the actual cost is lower, the As CINs develop and mature, physicians fee-for-service reimbursement. If the will have many opportunities to affiliate CIN will receive a larger percentage provider achieves a certain goal specified with different networks. To evaluate those of the savings. in the contract, the provider receives opportunities, a physician should ask an additional incentive payment. A P4P critical questions regarding the CIN’s contract may provide for a penalty if a 6) The CIN decides how shared savings operations: provider fails to meet a specified target. (or losses) are distributed among its members. Typically, a portion is • What financial commitment is required Many commercial payers are looking retained by the CIN to pay expenses. and what financial rewards can be to include P4P provisions in their expected? contracts with individual providers. PHYSICIANS AS CIN MEMBERS • What is the CIN’s payer contracting Generally speaking, a CIN can negotiate To ensure compliance with the antitrust strategy? more favorable P4P terms. Also, a CIN laws, CIN participation should be open to • What support services does the CIN supports an infrastructure that enables its any physician who satisfies established members to achieve P4P measures. minimum requirements for membership provide to member physicians? and maintains compliance with specified • What experience does management Under a shared savings program, a performance standards. Part of the CIN have in operating a CIN? CIN is eligible to receive a portion of planning process involves identifying • What are the CIN’s technological a payer’s savings generated through reasonable and appropriate requirements capabilities? greater efficiency in care delivery. This is and standards. • What is the CIN’s operational plan accomplished through a multistep process: to improve quality and lower total Typically, a CIN’s governing body develops cost of care? a network participation agreement that 1) The payer assigns a specific patient • What are the opportunities for specifies the rights and duties of CIN population to the CIN, usually based members. Community providers are given physician involvement in CIN on patients’ primary care providers. the opportunity to review this agreement governance and operations? The payer calculates a total cost-of- prior to making a formal commitment to The answers to these questions will give a care benchmark for that population CIN participation. strong indication of the CIN’s likelihood for based on historical data. At a minimum, a physician member success. In turn, a physician’s affiliation of a CIN is expected to adhere to with a strong CIN likely will be a key factor 2) Both CIN and non-CIN providers CIN-approved protocols and otherwise in a physician’s ability to thrive under new continue to receive fee-for-service participate in and support CIN operations. payment and delivery models.PR PR reimbursement for all services Depending on decisions made by the furnished to patients in the CIN’s governing body, a participant’s MARTIE ROSS is a population. principal at Pershing ability to contract with payers Yoakley & Associates, PC independently or through another network and advises providers 3) At year-end, the payer calculates may be limited. navigating the ever- expanding maze of health its actual total cost of care for the care regulations. Prior to patient population, including services The implementation of clinical protocols PYA, she spent two decades as a health care and performance measures is an ongoing transactional and regulatory attorney. furnished by non-CIN providers. process of education and continuous JEFF ELLIS is a principal quality improvement. No provider will at Pershing Yoakley 4) If the actual cost is less than the be expected to perform at a certain level & Associates, PC benchmark and if specified quality without adequate support to achieve representing health care measures are met, the CIN will providers on matters such that goal. While the intent is to improve as corporate restructuring receive a share of savings based on quality and outcome metrics, successful of diverse health care a predetermined formula. If the CINs must be willing to terminate repeat systems, government regulatory compliance, mergers of health care entities, restructuring quality measures are not met, offenders. To protect individuals’ rights, of hospital-physician relationships, hospital however, the CIN does not receive the CIN may establish a review process medical staff matters, development of health to afford a physician the opportunity information technology, and the full range any shared savings. of business concerns faced by hospitals and to challenge an adverse decision. No related business entities. Mr. Ellis is also a trained mediator with the American Health 5) A CIN may opt for a “two-sided” participant should be excluded based solely on subjective criteria. Lawyers Association. shared savings program. If the actual cost is more than the benchmark, the 10 TAKING ACCOUNTABILITY FOR POPULATION HEALTH THE ROLE OF DATA

By: Ray Herschman, President, xG Health Solutions

For providers to accept accountability for population health and payments based on episodes of care, they need control. This control comes, in large part, from information.

Many providers now have access to rich and timely clinical Accountable care organizations (ACOs) and clinically integrated data through their electronic medical records (EMRs). networks (CINs) are emerging as contracting entities through However, it is not enough. Providers taking responsibility for which the full continuum of providers — hospitals, physicians, not only health processes and outcomes, but also the total ancillary service providers, and skilled nursing facilities — cost of care for a population, must have visibility to the place share accountability for the health of a defined population. of service, relative costs, and overall quality of care for their These organizations will increasingly be paid via value-based patients beyond their four walls. This information resides in reimbursement models that align economic incentives among administrative data held by payers. payers and providers. 11 THE PHYSICIANS REPORT | SUMMER 2014

These choices have long-term population is not practical implications for provider organizations’ or sustainable over time. budgets and focus. Build. Recognizing these limitations, How practices access some providers are investing millions payer information of dollars in technical infrastructure, Providers and payers who agree labor, and consultants to develop their that sharing information is key to own data intake, transformation, data measurably improving quality and warehousing, and analytic solutions. costs are in the midst of sorting out This can be all-consuming even with their roles in this new world. Payers one payer, not to mention multiple have long held data close, but new payers, each with their own data accountabilities are driving at least formats and idiosyncrasies. three different ways for providers to access administrative data. This path also requires corresponding investments in recruiting, hiring, and Borrow. Some providers rely on training clinical and medical economics quarterly paper reports or payer- analysts. Committing to tools, upgrades, specific Web portals to access and staff can be costly, overwhelming information about their patients. even large practices and drawing time While any information is welcome and financial resources away from for providers who have made do running the business, delivering high- without it for so long, this path quality care, and developing critical has several challenges. performance-improvement initiatives.

First, there is significant variation Partner. An emerging alternative is among payers in what reports they for providers to work with a neutral, provide, how they stratify risk, and third-party intermediary with experience how they categorize and group the managing the complexities of data. Second, each payer has only aggregating multi-payer data on behalf a percentage of a provider’s total of providers. This approach leverages patient panel, resulting in a lack of technical infrastructure and staff across credibility and stability in performance a broad pool of providers and patients measures. Third, the information is to drive down the costs for all users. often aggregated and latent, making it difficult to use for patient outreach Providers gain a “virtual single-payer and provider-level improvement. view” of the patient population they are accountable for managing. This “utility” Finally, because payers are challenged model is also beneficial to payers, with having to provide reports to their as they are relieved of the ongoing Implicit within value-based payment entire provider network, reporting is cost burden of dealing with hundreds arrangements must be access to relatively static and standardized. Far of point-to-point data transfers with this data so providers have the total more important than standardized each provider entity. Instead there is a picture they need to effectively manage reports is data interpretation which, trusted, neutral third party that acts as population health. Complete data and at the in-depth level necessary to a single hub through which their data is related analytic and decision support be a high-performing ACO/CIN, transmitted to providers in a secure and capabilities are foundational to provider has historically not been a core confidential manner. success in value-based care delivery. As competency of either carriers or providers start down the road of value- providers. From a provider perspective, Leveraging payer data based contracting, they face several using multiple sets of metrics and Once information is secured, whose job choices related to data and analytics. payer portals to manage a patient is it to interpret the information, size

(Continued on page 19) 12 Medical Neighborhoods Are Transforming Care Delivery in Rural Settings

By Phyllis Simpson Sherard, PhD, Judit Olah, PhD, and Greg O’Barr, M.Ed, Wyoming Institute of Population Health

Fragmented health care delivery systems are associated with inefficiencies, highly variable health outcomes, not being financially sustainable, and no longer being acceptable to patients, providers, and insurers. 13 THE PHYSICIANS REPORT | SUMMER 2014

Delivery system and payment reforms championed between hospitals and post-acute sites of care. by the Affordable Care Act recognize the fundamental Working with PCMHs and other providers, these RNs role of local communities, health plans, and medical work with patients to establish individualized care practices to develop multi-stakeholder initiatives to plans, improve the patients’ confidence to self- reform our nation’s health care. manage, increase patient and family engagement, and decrease health care costs by reducing avoidable However, in vast and sparsely populated states, hospital readmissions and associated penalties. accountable care organizations (ACOs) like those envisioned in the CMS Medicare Shared Savings Program may be unlikely to form. Wyoming, for Fourteen hospitals and 21 medical example, has virtually no managed care presence and is home to no large, integrated health systems practices, representing more than that span the entire state. Additionally, Wyoming’s 50% of Wyoming’s primary care most rural communities are located vast distances from the state’s two largest hospitals. To add to providers, are voluntarily participating the challenge, the rural settings lack specialty in this innovative initiative. services, and small hospitals lack the market power to contract for the services close to home that would be necessary to preempt referrals outside of the ACO. And yet, despite these 3. Telehealth Physician Desktop Solutions have obstacles, Wyoming is moving forward with a been deployed across Wyoming, expanding the statewide effort to transform rural care delivery. state’s telemedicine system to increase access to specialists, improve coordination between sites of The Wyoming Institute of Population Health, care for high-risk patients, and facilitate effective the recipient of a $14 million health care medical decision making. innovation award from the Centers for Medicare and Medicaid Innovation, has brought together 4. Pharmacists are being integrated with PCMH hospitals, providers, and communities all across interdisciplinary care teams to support medication Wyoming to address three drivers of rising health therapy management. These community care costs: 1) failures of care delivery, 2) failures pharmacists play a vital role as the medication- of chronic care management and transitions utilization connection between patients and their across sites of care, and 3) overtreatment, often health care providers. associated with failures of care coordination or care communication. Fourteen hospitals and 21 5. Access to donated, in-date, prescription medical practices, representing more than 50% of medications for uninsured and underinsured Wyoming’s primary care providers, are voluntarily patients has been expanded statewide to help participating in this innovative initiative. providers develop and support comprehensive care plans for low-income patients. Five key strategies are being implemented in Wyoming’s medical neighborhoods: Projected to save Wyoming an estimated $33 million in health care costs over three years, the initiative’s 1. Patient-centered primary care medical five component strategies have been designed to homes (PCMHs), focused on wellness and ensure that patients achieve the greatest possible care comprehensive primary care services, form the experience and benefit from well-coordinated, effectively core of Wyoming’s medical neighborhoods and communicated care and seamless transitions between serve as consistent, central coordinators of sites of care. care for medically complex patients. Quality Management and Payer Partnerships 2. Care Transition RNs provide education and In Wyoming’s medical neighborhoods, PCMHs provide facilitate continuity of medical care as a comprehensive framework for quality management. patients with complex conditions transition Participating PCMHs have become learning organizations,

(Continued on page 15) 14

(Taking Aim, Continued from page 5)

crisis and one that requires solutions by Health, Dr. Spiegel is leading the indicators that suggest the solution all parties — with patient behavior now charge to work out standards in to this shortage may also positively under the microscope. how their integrated physicians are impact cost, quality, and outcomes. approaching disease management, THE INFORMATION AGE COPD, or other clinical processes. A recent RAND report2 noted that “Population health management data They’re creating a provider portal where increased use of new models of and analytics is the key to all this,” says physicians can see how they’re doing on care could increase patient access Ann Wheelock, CFO of The Vancouver quality and cost metrics. to lower cost care, in settings that Clinic. But these are not new topics, foster a team approach and higher and something that health care has This type of approach also enables levels of communication about patient looked at before. “One of the reasons Signal Health to look at specific treatment. “Growing use of new why IPAs were not successful in the groups and see how they can address models of care that depend more 80’s was that there just wasn’t enough population health in different ways, on nonphysicians as primary care data, or the ability to analyze it like we and how the individual providers are providers could do much to reduce the do today.” Wheelock notes that today’s doing in working with those patients nation’s looming physician shortage,” ability to view patients both individually and groups. “We’re also building a said David Auerbach, the study’s lead and as parts of groups, to build and use health information exchange as a one- author and a policy analyst at RAND, reports about patient populations, helps to create care and case management “One of the reasons why IPAs were not successful strategies that have direct impacts in the 80’s was that there just wasn’t enough on patient health and lowering costs. “Even the ability to track patient follow- data, or the ability to analyze it like we do today.” up is better today than ever before with ANN WHEELOCK, CFO remote monitoring and in-home visits,” THE VANCOUVER CLINIC she says, noting that these new ways of delivering care are often less expensive stop location for patient information,” a nonprofit research organization. The in the long run. says Spiegel. “With this tool, we’re study noted that if nurse-managed less likely to miss or duplicate prior health centers were to account for just “We have a care management pilot care, and can track over-utilization 5% of primary care offered in the U.S. in two clinics and the hospital,” says of resources. Having this level of (currently it accounts for just about Spiegel at Signal Health. “We are data about patient interactions .5%), it would reduce the projected tracking the high-utilization, high- and health outcomes enables us to physicians shortfall by 25%. cost patients and providing nurse create performance reports for all care and case management. Some of our physicians.” And because care In addition, there’s a renewed focus in this involves patient education, calls, utilization and patient health outcomes primary care medical homes (PCMH), even home visits. We helped a female are linked to payment from payers and this time with a focus on their patient get better by just helping her physician compensation incentives, application in the commercial space. to organize and better understand this information is transparent to “Medicaid has used medical homes her medications.” The notion is that all physicians creating peer-level for a long time with great success,” if you can ensure a patient is taking accountability. notes Wheelock. Usually, when their medication correctly, using their patients join Medicaid, their insurer equipment properly, or even making it THE WHO & WHERE OF CARE initially assigns them to a primary care to their ongoing appointments, then Still, with a renewed focus on patient physician at a nearby clinic or health you will see lower instances of illnesses outcomes, cost containment, and even center. “Most commercial payers don’t becoming acute, and chronic patients updating payment models (bundled assign a primary care physician (PCP). getting better — leading to patients services, shared risk, and gain sharing), That’s been out of vogue for both the consuming less costly health care, and the Triple Aim that Berwick launched insurer and the patient. But we want less care in general. faces possibly its most daunting to encourage future payer partners to challenge: the projected physicians assign a medical home — it is going

But patient engagement and education shortage (mostly in primary care) over to be critical to our success.”PR PR is not the only answer. Over at Signal the next decade. And there are some

2 RAND Corporation, “Nurse-managed Health Centers and Patient-Centered Medical Homes Could Mitigate Expected Primary Care Physician Shortage,” accessed June 5, 2014, www.rand.org/content/rand/pubs/external_publications/EP51621. 15 THE PHYSICIANS REPORT | SUMMER 2014

According to the RAND report, to be delivered by physicians in an responsibility for participation, PCMHs account for nearly 15% of office setting, reducing the demand for consumerism, and outcomes, has primary care nationally. And though physicians by yet another 25%. stymied many seasoned professionals. their efficacy is still being tested, if And while some suggest that the best medical homes grew to provide half Which model to use and which path forward is simply to detach from of the primary care in the country, the providers to employ may seem simple a fee-for-service system and retool nation’s projected physician shortage and straightforward to the untrained to a value-based care model, or that could drop by another 25%. And lastly, eye. But finding a model that delivers the solution is in retooling the health the use of telehealth technologies or the right care, at the right time, at insurance model itself, perhaps in other electronic health applications the right place, delivered by the the end the target for health care is is suggested as another method of right professional, at the right price, not as narrow and singular as some reducing the amount of care having all overlaid with increasing patient proposals suggest.PR PR

(Rural Settings, Continued from page 13)

and clinical quality reporting patient populations have enabled the continuum and the community. and performance evaluation reporting transformation at the practice have become core functions level. All of Wyoming’s payers are It sounds very simple, but the medical of their practice increasingly responding to the quickly neighborhood concept, to be successful, management. Data on evolving PCMH quality and performance must create collaborative relationships quality, performance, evaluation transformation and offering among health care providers that and costs are available care management incentives to further previously viewed themselves as and used for learning and propel the momentum of quality disconnected, competing organizations. continuous quality improvement. Timely reporting capabilities in primary care. PCMHs are coordinating the care of analysis and practice-wide evaluation Though PCMHs were initially designed their patient panels and are reporting feedback allow for quick corrective within the rollout of CMS’s Pioneer improved clinical outcomes associated actions where needed; transparency ACOs, Wyoming has found its own with chronic disease management increases patient engagement, improves path to linking of performance-based and preventive screenings. Specialty provider satisfaction, and increases staff reimbursement relationships between providers are utilizing telehealth to engagement. care providers and its major payers. bridge geographic distances, and clinical site-to-site consultation is on PCMHs have made dramatic progress Critical Success Factor: the rise across Wyoming. Hospitals are in the area of quality metrics reporting Collaboration sharing accountability for the care of in Wyoming’s medical neighborhoods. Health care transformation requires complex, high-risk patients and are now Practices are now reporting to the a paradigm shift from the outdated collaborating on the development of Institute nine clinical outcome measures model of patient care delivered care transition plans. Wyoming, with its (five preventive and four high-risk in silos—a model posing danger historic tendency to form collaborative monitoring indicators). Cost-containment to patient care, satisfaction, and relationships that work, has developed goals (e.g., avoidable ED visits, hospital safety—to a care delivery model a unique solution to the challenge of admissions, and readmissions) have been that is well communicated and well health care reform.PR PR successfully linked with quality goals. coordinated across the care continuum. Population health delivered in a About the Wyoming Institute of Population With little experience in measuring medical neighborhood requires a Health: The Wyoming Institute of Population Health, a division of Cheyenne Regional and reporting cost and quality, the patient-centered care delivery model, Medical Center, is committed to building practices were initially challenged by comprehensive assessment of the bridges between communities and health systems. The Institute was created to the resource burdens associated with patient’s needs in a primary care setting, develop strategic platforms that proactively regular reporting. Over time, however, and development of individualized care address the evolving needs of patients, payer incentives and the Institute’s plans to manage and improve the health providers, and communities across Wyoming. (307) 663-2914 support to help the PCMHs identify and of that patient that draw upon a broad meaningfully manage their complex range of services across the health care 16

WHY THE Coach approach MAKES SENSE FOR MEDICINE 17 THE PHYSICIANS REPORT | SUMMER 2014

Vera started as a fitness organization. coaching into their practices. “A lot of people would show up to make good on a felt need to get in Vera teaches that one of the key shape, but a lot of what is really going differences between a provider and a on for them is ‘between the ears.’ At coach is that “the physician is doing Imagine your Vera Whole Health, we realized an the ‘telling’ by providing expert medical patient Annette works upstairs from opportunity to build relationships that guidance; the coach is doing the ‘asking’ your clinic at a company employing coach people into lifestyle change,” by drawing out of the patients the goals 500 people. Since she can easily pop says Schmid. Leveraging that insight, they think they can accomplish to downstairs between meetings for a same- Vera Whole Health now contracts with address the required changes in health day appointment to see you, you’ve seen medium-to-large employers, in parallel that are required,” says Schmid. “The more of her this year than her previous to an employer’s insurance plan, provider can spend an hour with the provider did during the past five years embedding primary care clinics on-site patient to develop a care plan, then take combined. She has kicked cigarettes, set that feature the pairing of physicians them to meet their coach.” Their coach goals for her exercise and diet, and lost and health coaches. Employers pay a sits with them to determine their health 23 pounds. Healthier than ever, she is per-member, per-month fee for their goals and the behavior changes that taking pride in living a lifestyle to fend employees and their families to use will help them become realized. Then off bigger health problems, such as heart Vera’s clinic services free of charge. the physician and coach will meet and failure or diabetes. For something Vera does not offer—an compare notes. “They are very much a MRI, for instance—Vera can refer to team; it is not a disjointed referral.” Combining proximity with coaching, the most cost-effective local resource, Vera Whole Health is improving health where patients can use their insurance Ryan feels that physical and mental and lessening the need for more plan benefits. health are completely intertwined. critical care—and the costs that go with it. Many health organizations are developing ways to increase efficiencies “YOU MAY HELP someone lose 10 pounds, while they deliver care, and Vera Whole Heath, in Seattle, has a model that is but what happens six months down the also getting health results. First, by road during a stressful event? Life is embedding their clinics within corporate going to happen, so our objective is to walls (or in very near proximity), they’re seeing patients who might not have help people develop the skills to self- previously sought care. Second, by manage, to be confident about managing pairing physicians with health coaches, themselves down the road.” they see greater patient activation. RYAN SCHMID, CEO VERA WHOLE HEALTH THE COACH APPROACH

“Having launched many fitness organizations, both nonprofit and for- “A good coach will sit down with a WHAT IS A HEALTH COACH profit, I have always been passionate ? patient to get a clear understanding of about helping people live well and Vera has two kinds of coaches: what’s going on with them mentally first, transform their health,” says CEO Ryan Care providers such as PAs, NPs, then address their health issues.” A good Schmid. “While I don’t have a medical physiologists, or dieticians who have coach is also not prescriptive, but taps background — I was a student athlete been specifically trained in coaching, into which stage of change the patient is with a business education — I knew that as well as coaches who are not licensed in — whether contemplation, preparation, the lifestyle and behavioral-change angle providers of any kind. To ensure the action, etc. Once they understand the was where I could make a difference.” quality and consistency that is required, patient’s mind-set, the coach draws out With 70% of costs lifestyle-related,* Vera’s entire care team completes the patient’s goals, addressing obstacles. patient behavior is an important part a rigorous, proprietary certification For instance, if patients say, “I’ve never of the equation — but one that providers process that includes 150 hours of lost 50 pounds, how am I going to do have little control over. hands-on training for integrating health this?” their coach may ask them what

(Continued on next page) *“Everyone Wins When Healthcare Is a Game,” Accenture, accessed May 14, 2014, http://www.accenture.com/us-en/Pages/insight-everyone-wins-healthcare-game.aspx. 18

skills or disciplines they used to achieve apply it to these micro-groups,” he says. are behavioral in nature. He says that their biggest goals at work, looking at Time and again, Vera makes the biggest when you do finally engage these non- how they can accomplish things that impact on the higher-risk patients with users, they are often shocked to realize initially seemed daunting. Patients gain the highest health care costs—bringing they have skin cancer, hypertension, confidence, then, by realizing how they down costs by improving their health Type II diabetes, or the like. already get themselves from point A to and helping them thrive. point B to reach goals. Vera’s close proximity to patients enables the clinic to provide more engaged, proactive, and preventive care; the care team is able to get very tuned-in to Doctors like this model of primary the effect daily life is having on their patients’ health. “Our providers are care because they are able to so connected to the organizations and their people. We treat each company spend more time engaging with as its own ecosystem. And due to our each patient, averaging 8-10 proximity, awareness and exposure are fundamental parts of our business patients a day. model’s success,” says Schmid.

RESULTS

Doctors like this model of primary care because they are able to spend “You may help someone lose 10 pounds, “Previously, health and fitness coaching was more time engaging with each patient, but what happens six months down the broad and not that well-defined. It was hard averaging 8-10 patients a day. They road during a stressful event? Life is to differentiate between coaches, and quality feel they are being paid to do what going to happen, so our objective is to was lacking or inconsistent,” says Schmid. they wanted to do in the first place — help people develop the skills to self- Vera Whole Health originally developed Vera take care of people, not adhere to manage, to be confident about managing University to train the health coaches they production quotas. themselves down the road.” pair with physicians in their own clinics. “Once we had mastered training our own coaches What’s in it for the employers is that POPULATION MANAGEMENT and greater staff on integrating coaching into they have healthier, happier, and As in much of health care today, data patient care, we realized there was a market for more productive employees. With is central. Vera tracks its own data, health coaching certification, so have made our convenient access to same-day visits and plus uses third-party software to access educational program available outside our own predictable, consistent care, employees claims outside of Vera. “Since we are walls.” Read more about The Coach Approach, a are thriving. As for costs, self-funded contracting with employers on top 2 1/2–day course offered by Vera University in employers saved 10-12% in their health of their health care plans, we have partnership with Experix, on page 22. care costs, with fully insured employers captive audiences. They are micro- seeing 8-13% in premium reductions. AWARENESS AND EXPOSURE audiences, actually. We have access For most companies, the Vera Whole to their employee claims data and can Schmid reminds us that the non-users of Health benefit is also a great recruiting slice and dice that data to target groups medical care are not necessarily healthy. and retention tool. with which we can make the biggest In fact, often they are an emergency impact,” says Schmid. They look at risk medical situation waiting to happen. “It is a bold statement for an employer stratification levels, targeting risky and “In some cases, close to one-half of to say, ‘We want to take care of you costly patients. But even with the ability the people on a plan do not generate as best as possible,’” says Schmid. to segment their micro-populations, a claim. Controversially, these stats He is particularly proud to list Seattle Vera concentrates on engaging 100% of get translated into the assumption the Children’s Hospital as one of Vera’s them. “We can have specific messages patients are healthy,” he says. Vera flagship clients. It says a lot that the or treatment plans by group. It is really discovers, as it begins to engage with people who take really good care of other exciting that we can take the best these new patients, that many of them people believe this model is the best way practices in population management and are walking around with conditions that to care for their own.PR PR 19 THE PHYSICIANS REPORT | SUMMER 2014

(Roll of Data, Continued from page 11) Partner. Alternatively, many insights, learning, and provider organizations are now methods to providers. and prioritize interventions, and seriously considering the value of recommend interventions? contracting with emerging To improve value for patients, The answer for most service organizations consistently improve the clinical care providers is that this focused on providing quality, and drive affordability overall, is no one’s job. Some data analytic providers need an unprecedented organizations find interpretation as a level of collaboration and partnership themselves with a service. This “service from payers. This collaboration should host of new tools and as a service” model include these key elements: reports, few of which is akin to “software as provide meaningful a service” in that both • Ready access to timely and insights into how and where centralized and distributed complete administrative and to prioritize energy and resources resources can be made available claims data to measurably improve patient care on demand, at a far lower cost than • Eligibility and benefits data for and meet financial targets. Reports and if those resources were owned or those patients attributed to them; tools are necessary, but insufficient hired by each individual provider • New reimbursement models to for providers to succeed as population organization. This new model, align incentives with value health managers. however, goes several steps further • Investments in both care to include regular access to highly management services within There are several options delivery specialized, dedicated analysts that provider organizations and systems have for moving from reports are accountable for and measured actionable information at the and information to action. on their success in helping providers patient, population, provider, and improve clinical outcomes and integrated delivery system levels Build. Well-trained, highly skilled clinical financial performance. and medical economics analysts are This type of collaboration and this level essential for sustainable and successful While some software and IT of investment were not priorities or population health management vendors are quickly recognizing the easily justifiable under traditional fee- organizations. Provider organizations necessary shift toward analytics, for-service reimbursement models. With can hire their own analytics teams, but not all organizations have analytic so many forces aligned around moving most have historically expertise tried and tested in a from volume- to value-based care, not needed to clinical environment. Key elements providers have a platform to negotiate develop of an effective analytic approach in the necessary control (through data) and hire either the build or partner model in exchange for taking accountability associates include the following: for improving population health and with these entering into reimbursement models cognitive • Dedicated, highly trained that align incentives intended to skill sets. analytic staff who have achieve this end.PR PR Acquiring and experience supporting clinical developing care teams with interpretation Ray Herschman is the these resources is of results and drill-down President and Chief Operating Officer of extremely difficult analyses based on provider xG Health Solutions, in today’s competitive marketplace. questions and hypotheses; the primary provider of Geisinger’s Health Furthermore, delivery systems will need • Direct access to experienced Care Performance to plan and budget for scaling their clinical, informatics, statistical, Improvement Intellectual Property analytic capacity across their entire and other subject matter (IP). xG Health provides experienced professionals to partner in developing enterprise to ensure the reliability, expertise to provide advanced and implementing strategies focused on consistency, and sophistication analytic insights; and improving quality and reducing the long- term cost of care. necessary to drive sustained • Ongoing innovation and learning, performance improvement as value- in order to continuously based payment evolves over time. bring new, market-leading 20 PERSONAL INSURANCE AS AN Income Protection Tool

The following stories are based on actual physicians and how they eased the financial burden on their families during an interruption in income.

Financial Ripple Effect out some minor memory errors they Additionally, when Dr. Byun moved his noticed in his work. Dr. Byun didn’t parents into an assisted care facility, he What happened hesitate to line up a series of tests, decided it was a good idea to purchase Dr. Byun’s parents left their home subsequently being diagnosed with a long-term-care policy for himself. country when he was young, seeking early-stage Alzheimer’s. better opportunities for their kids. The outcome Forever appreciative of the sacrifices The risk of continuing to practice As a result of his inability to work, Dr. his parents made during those hard with this diagnosis was too great. All Byun received maximum benefits on years, he was proud and delighted at once, Dr. Byun had to stop caring the individual disability policy (in this to be in a position of being able to for patients, and the financial drain case, a tax-free $16,000/month until provide for both his and his wife’s of future bills to support his own care age 67), and the lump sum disability parents alongside raising his own became very real. policy provided him $1 million after family of three girls. He and his 12 months, which went a long way to wife Song had ample homes, took The early plan meeting the financial needs for his wonderful vacations, and enjoyed When they formed the small clinic, extended family. a great lifestyle together. As the the partners decided to protect health of all the grandparents began themselves with individual insurance Moreover, his long-term-care policy to diminish, Dr. Byun’s medical policies rather than a group plan. So, would provide for the care he would background enabled him to have with both extended families relying eventually need in a specialized care an active voice in their care and on his earning power for support, Dr. facility as his condition progressed. provide for any medical needs that Byun decided to protect his income. Dr. Byun’s thoughtfulness about his came along. He secured an independent disability family’s unique needs reduced the policy that offered tax-free benefits. chances that his family would lose Years later, Dr. Byun left a large, Then, he eventually layered a lump everything he had worked so hard for, reputable clinic to start a smaller sum disability policy into the mix to and all that his parents had sacrificed clinic with two partners. One spring, further protect his long-term earning decades before. his neurosurgery colleagues pointed and equity in his practice. 21 THE PHYSICIANS REPORT | SUMMER 2014

Then she learned she had stage three after the three-month waiting period), cancer, and the diagnosis left them as well as a payout from her individual emotionally devastated. This had never disability (a tax-free $90,000 after been part of their plans. the three-month waiting period). In time, she recovered from her cancer The early plan surgeries and treatments, her personal After medical school, once Dr. Ross finance goals stayed on track, and started to earn at a high level, she the kids’ tuition bills continued to focused on paying off her school bills get paid. In fact, Dr. Ross and her and determined to never take her strong husband decided life was too short income for granted. As her family grew, and made arrangements to retire her income grew, and her family’s earlier than expected. financial goals came into sharper focus. She decided to use insurance as a tool Now that’s a plan. to protect her earning power. Though her clinic offered disability, the group policy only paid at 60% of her income with a cap of $10,000/month—which What to look for when would only amount to $120,000 considering various types annually before taxes. Her annual of personal insurance: salary was substantially more and she wanted a higher level of coverage, so Portability: Some policies can be carried she took on an additional individual with you when you change employers, disability policy with a benefit amount and some terminate when you leave — So Close to Retirement of $15,000/month that was portable, which leaves you at risk of being denied I Can Taste It so she could carry it with her should when you reapply. Find out if the policy she change employers. Unlike the group is portable from employer to employer. What happened policy, these benefits were nontaxable, At 62, Dr. Ross was at the final further enhancing her direct benefit. Caps on coverage: Most disability stages of a very successful career. policies are capped at 60% of your Early on, she had paid her own way The outcome income. In addition, many have a through school, launched her career in As a result of planning ahead, after monthly cap of $5K, $10K, or more. anesthesia, and started a family. Now, her cancer diagnosis Dr. Ross received Know what the caps are to better even with three kids in private colleges, the monthly maximum payout from her understand the income shortfall you’ll she and her husband were on track for group disability for the nine months she suffer if you are unable to work — and a comfortable retirement. was unable to work (a taxable $60,000 which products you might consider to help make up for it.

Taxability: The disability benefits provided by most large groups are taxable, but individual disability plans are often nontaxable.

Guaranteed premiums: An additional advantage of many individual policies is an option to lock in premium rates so they never increase for the life of the policy.PR PR

For more information about any of the policies discussed above, contact Janet Jay at Physicians Insurance Agency, at (800) 962-1399 or [email protected]. 22 CME

New Live Seminar The Coach Approach: Transforming Health Care through Patient Engagement

Studies show that half the patients who leave their primary • Display mindfulness while demonstrating the five Core care visits don’t understand what their doctor told them. And Coaching Skills for patient interaction the average adherence rates for prescribed medications are • Classify a patient’s stage of change according to the about 50%; for lifestyle changes, they’re less than 10%. Transtheoretical Model • Use Appreciative Inquiry to discover what motivates Improve your ability to communicate, listen, and affect your your patients to change patients’ lives. Learn the fundamentals of behavior change • Navigate ambivalence using the skills of Motivational and how to bring out the best in your patients. Coaching skills Interviewing help you increase trust, provide better quality care, improve • Develop methods to manage progress and patient compliance, and reduce risk. accountability to support a patient’s desired outcome

This is an interactive, 2½–day seminar, offering 18.75 AMA Developed by Vera University, a division of Vera Whole Health, PRA Category 1 credits TM, designed to introduce health care The Coach Approach is offered in partnership with Experix, a professionals to the spirit and practice of coaching. The wholly owned subsidiary of Physicians Insurance that provides training merges evidence-based behavior change methods continuing medical education and comprehensive risk with simple, yet powerful tools to help patients overcome management content. ambivalence and take ownership of their well-being. At course conclusion, participants will be able to

Registration Information

WHO SHOULD ENROLL COST Physicians involved in direct patient care with a desire to: This CME is included with a Physicians Insurance policy. • Improve the quality of patient care and satisfaction Nonmembers can enroll for $995. • Increase patient compliance and outcomes • Create dynamic provider/patient relationships that HOW TO ENROLL inspire and motivate change To register and get full course details, dates, and accreditation • Connect more meaningfully with patients, information, call or visit our Web site. coworkers and peers

UPCOMING SESSIONS • July 28-30 IN SEATTLE • September 8-10 www.phyins.com/CME (800) 962-1399 • November 6-8 23 THE PHYSICIANS REPORT | SUMMER 2014

Specialty-specific Online Courses

Teamwork, Communication, Managing Category II Fetal Heart Rate and Patient Safety in the Patterns: A Standardized Approach Emergency Department: As an obstetrical practitioner, you know the challenges inherent in managing Category II fetal heart rate patterns during labor. Case Studies Interpreting these tracings remains one of the most critical issues in obstetrics. We are pleased to announce a new tool that can help! As an emergency physician, you operate A simple, rational, evidence-based algorithm will be presented by under great time pressure within a high-risk, obstetrical patient safety leader Steven L. Clark, MD. high-volume environment. This self-study course will help you mitigate the risk by using This webinar will explain and demonstrate the algorithm, which evidence-based communication tools. The reflects a synthesis of medical evidence and current scientific course demonstrates through case examples thought. You will learn through examples of challenging fetal strips how to put the tools into practice, facilitate how to achieve compliance with the current standard of care in team effectiveness, and enhance patient managing this difficult clinical situation. safety. An interactive quiz at the end of each case reinforces key topics discussed Developed in conjunction with other leading experts, Dr. Clark throughout the course. highlights his article published in the August 2013 American Journal of Obstetrics and Gynecology. WHO SHOULD ENROLL Physicians of all specialties, clinical WHO SHOULD ENROLL practitioners, medical staff, health Obstetric physicians, general practice physicians, nurses and educators, and health administrators will mid-level providers caring for pregnant patients will benefit from benefit from this course. this course

FACULTY Dr. William Hurley FACULTY Dr. Steven L. Clark is a maternal-fetal is currently medical director medicine specialist and is medical director of of the Washington Poison Women’s and Children’s Clinical Services for the Center, chief medical officer Hospital Corporation of America. He has served as of Summit Pacific Medical president of the Society for Maternal Fetal Medicine, Center, attending physician chair of the ACOG Technical Bulletin Committee, and in the emergency department a board examiner. He has served on several ACOG at Harborview Medical task forces and committees, and as patient safety Center, and assistant clinical consultant to the U.S. Air Force Surgeon General. professor with the University He currently serves on the Scientific Advisory Board of Washington School of for United Health Care and on the Joint Commission Medicine. He helped to Perinatal Advisory Panel. He has published over 200 found and develop the University of Washington scientific articles and chapters, has edited several textbooks, including TeamSTEPPS National Training Program and has Critical Care Obstetrics, and serves as a peer reviewer for 23 national and been active in the study and teaching of teamwork international scientific journals. skills to improve patient safety since 1993. www.phyins.com/CME (800) 962-1399 www.phyins.com/onlineCME 24

with the Executive Director of the Washington Health Alliance

on price and quality of care, in the form MARY MCWILLIAMS of tools for the consumer. In the best cases, this kind of data is integrated at was appointed Executive Director of Puget the specific health plan benefits level, Sound Health Alliance in June 2008, after serving three years as a founding with a cost calculator on the plan’s Web member of its board of directors. Prior to site for consumers to evaluate costs and the Alliance, Mary was president and CEO quality as a part of their own choices. of Regence BlueShield in Washington, CEO of both PacifiCare of Washington Second, purchasers need access to and Providence Health Plans in Oregon, data so that they can evaluate new project director at the American Health models for networks and benefit Management and Consulting Corporation design, like ACOs, and understand outside of Philadelphia, and marketing the variation in provider performance director for the Rocky Mountain HMO in based on where employees seek care. Grand Junction, Colorado. She is a board This community-level view of cost and member of the Greater Seattle Chamber quality is important context for their of Commerce, Puget Sound Energy, and the Seattle Branch of the Federal Reserve benefits strategy. Bank of San Francisco. Lastly, neutral organizations like the Alliance, which brings parties together in The Washington Health Alliance (WHA) coming in 2018 — are incentivized to solving the challenge of cost and quality, has been monitoring and reporting on moderate costs below a certain level or can help moderate costs. Our primary health care in Washington State for 10 face an excise tax. Therefore, employers effort is to provide insights through years, with a goal of reducing costs and are increasingly interested in looking measurement and reporting of data on increasing quality. We recently spoke beyond the premium to the cost and cost and quality, so market participants with retiring executive director Mary quality of doctors and hospitals. They’re can identify what improvements are McWilliams to hear her views about cost making decisions on benefit programs needed at a community level. and quality. that favor high-value delivery systems in order to affect their trend line. For What can you tell us In recent years, reducing costs instance, some local employers like about underutilization of has become more and more King County and Washington State are Qeffective care? Qimportant to the work the now considering offering an accountable Alliance is doing, and is stated as the care organization (ACO) as a health care organization’s highest goal. What trends option to their employees. Some diagnostic and preventive are you seeing? services that have been shown What has been and will continue Ato be effective are underutilized. The group purchasers of to be critical to reducing costs? Examples are regular blood sugar health care, employers, and Q monitoring for diabetes and cholesterol Alabor trusts have historically testing for heart disease. The Alliance focused on premiums and service Several factors contribute to uses claims data on three million lives levels of health plans to drive their lowering cost—and data is at the to measure and report on the frequency purchase decisions. But those major Acenter of them. First off, there in which patients are receiving these purchasers — due to the Cadillac Tax* needs to be transparency of information services from their medical group.

*The Cadillac Tax refers to a provision in the Affordable Care Act that will levy an excise tax on employers whose health coverage exceeds a certain cost. 25

RISK MANAGEMENT THE PHYSICIANS REPORT | SUMMER 2014

BLOG: TREATING JOINT INFECTIONS stiffness, nausea, vomiting, light IN OBESE PATIENTS sensitivity, and confusion. It turns out TAKING CARE by Edward E. Leonard II, MD to be bacterial meningitis. Read how physicians are helping themselves and Obesity, now affecting more than their peers when things go wrong. Your 30% of the U.S. adult population, is associated with a wide range of increased medical risks and studies TAKING A ONE-MINUTE TIMEOUT peers have shown that obese patients are TO IMPROVE MEDICAL SKILL at a disadvantage when they develop AND HELP PATIENTS speak up pancreatitis or H1N1 infection. Read by Mary M. Mitchell and James K. cases studies on how treatments can Weber, MD differ for obese patients, especially on difficult related to infection. It’s impossible not to notice the extreme stress so many physicians endure every day. It’s hard to know topics DELIRIUM IN A HOSPITALIZED how many challenges to expect in ELDERLY PATIENT a given day. When a patient has a Visit the Physicians by Viral Shah, MD lot of questions, and there’s a full Insurance blog to load of patients in the waiting room, read more about the Delirium is not uncommon among the anxiety can mount. Read about following topics, written by our members. elderly patients in hospitals. Read creating moments of respite cases about situations that could to improve skill. happen to your parent or grandparent.

www.phyins.com/taking-care HELPING A SICK WHEN A PHYSICIAN IS PASSENGER ON A PLANE DEVASTATED BY THE by David McClellan, MD We focus on the prevalence of evidence- LOSS OF A PATIENT based practices with our Community by Ron Hofeldt, MD What do you do when you hear a flight Checkup Report, having just printed our attendant ask over the intercom, “Is seventh edition. This work has shown A primary care physician sees a there a doctor on the plane?” Read that protocols for effective care should longtime patient for her annual how this emergency physician has be used and reported publicly. physical, and all lab results are helped passengers with minor as well

Before you retire this summer, what is your focus in these Qfinal months?

We’re on the verge of major expansion work, both in Adeveloping an All-Payer Claims Database for the state, and expanding Alliance reporting statewide. I’ll be busy, keeping momentum up to the last minute so normal. Two weeks later, she sees as life-threatening conditions, and his these projects are up, running, and him for what she thinks is the flu, advice for physicians whose skills are poised for the next executive director presenting with symptoms of neck in need during flight. to lead through executionPR . PR 26 MEMBER SPOTLIGHT

FAST FACTS ESTABLISHED: 2001 LOCATION: PORTLAND, OR TOTAL STAFF: 40 CLINICS: 2 PHYSICIANS INSURANCE MEMBER: GreenField SINCE 2013 Health Remember Who You Work For

A phone call with the leadership at GreenField coach”— someone who works with them to get the waste out Health of Portland, Oregon, can leave you excited of everything they do. But their commitment to improvement and optimistic about the future of primary care doesn’t stop with the seemingly mundane (or not so mundane) medicine, and your mind racing with possibilities. efficiencies of clinic processes and protocols. It is much broader than that. When we caught Steve Rallison, GreenField

Health’s administrator, and Dr. David Shute, the For GreenField Health, they believe that health care today is medical director, on the phone to hear about their broken, but that they are precisely where the biggest impact model of delivery, it was clear they have a mission can be made. “Our purpose of existence is to care for people and to inspire them towards health,” says Rallison. “We to make a difference. USA Today must have noticed believe that the biggest area to make an impact is the delivery this as well when it featured them in a 2010 cover of primary care. Health care can be improved greatly if primary story as one of three innovative health programs care physicians are allowed to do what they are trained to do.” demonstrating the future of primary care.* Enter the membership model of care Established in 2001, GreenField has never known paper The membership model and its various cousins have been records, having only used EMR. And while they are always known as the subscription model, concierge model, boutique looking for efficiencies in their use of EMR, that’s just medicine, direct care, or even “cash only.” GreenField charges the tip of their efficiency iceberg: They also use a “lean an annual membership fee that is based on age, with discount

* Rita Rubin, “Innovative Health Programs Counter Primary Care Shortage,” USA Today, August 6, 2010, accessed May 12, 2014, http://usatoday30.usatoday.com/news/health/2010-08-16-1Aprimarycare16_CV_N.htm?csp=obinsite. 27 THE PHYSICIANS REPORT | SUMMER 2014

NEW PHYSICIANS INSURANCE MEMBERS: WELCOME!

Eugene Emergency Physicians Eugene, OR

Medical Imaging Northwest Tacoma, WA

Member Plus Family Health Bainbridge Island, WA

Sound Interventional Pain Management Auburn, WA

Valley Urology Center Renton, WA

rates for families or corporate groups, ranging from $12/ seeing up to 30 patients a day. GreenField Health has 30-50% month for youth, up to $65/month for those aged 70+. The fewer patient visits overall than most primary care clinics. Due membership fee helps pay for the customer-oriented parts to their delivery model and lower daily patient churn, Steve of medicine that are not covered by patients’ insurance — says they need approximately 1.4 exam rooms per full-time same-day appointments, relatively no waiting, non-rushed clinician, compared to 2-3 exam rooms that other primary care appointments, attentive follow-up, phone and secure e-mail clinics require. “We need 25% less space than a traditional contact with a provider, and access to care 24/7/365. clinic, further reducing costs.”

“Who do you work for?” At GreenField Health, no doubt everyone on that team has the same answer: The Patient.

“In essence, the fee covers the customer service and GreenField also has a very egalitarian culture. Notes Rallison, coordination of care that is critical to quality outcomes,” “There are no white coats, our doctors go by first name — Shute explains. Specifically, these are the elements that unless the patient prefers to call them ‘Doctor.’ Every team enhance patient-physician relationships and patient health, member here is valued and respected, regardless of their role, while helping patients avoid unnecessary visits and costs. and involved in creating results—including patients.” It’s According to Rallison, these are the elements that enable not lost on him that in a traditional, hierarchical structure, GreenField to deliver on their core values — relationship, the system works to make the physician’s day efficient, service, and reliability. so that there is no downtime in the machine—sometimes at great expense to staff and patient convenience. But “Our clinicians spend 50% of their time seeing patients and GreenField finds there are greater efficiencies overall with an the other 50% of their time doing non-visit-based care — on underlying foundation of respect and trust that comes in a the phone and through secure e-mail — that builds engaged less hierarchical culture. “It facilitates communication and is relationships and coordination of care,” says Rallison. A busy easier to share information, especially with a problem or an day for their physicians is seeing 9-10 patients, which is not opportunity for improvement. It increases patient activation. much by today’s standards; many other practitioners report Oh, and by the way,” he adds, “it’s more enjoyable this way.”

(Continued on page 29) 28 Trial Results The following summaries are Physicians Insurance cases that have gone to trial and are public record. In reporting these legal results, it is our goal to inform members about issues that impact health care professionals. While we share information we think may be informative, we choose not to disclose the names of participants when reporting these results.

Alleged Failure to Diagnose DEFENSE ATTORNEYS: Dan Keefe, PLAINTIFF EXPERTS: Robert Rand, MD, Edward Bruya, Keefe, King & Bruya, Neurosurgery, Santa Monica, CA; Daniel SPECIALTY: Emergency Medicine Spokane, WA Rovner, MD, Neurology, Los Angeles, CA; ALLEGATION: A 53-year-old male Donald Reay, MD, Pathology, Seattle, DEFENSE EXPERTS: James Nania, presented to the ER with complaints WA; Mariann Drucker, MD, Radiology, MD, Emergency Medicine, Spokane, of chest pain. A cardiac evaluation Seattle, WA WA; Russell Roundy, MD, Emergency demonstrated a normal EKG and normal Medicine, Spokane, WA; Gust Bardy, MD, DEFENSE ATTORNEY: Steven Fitzer, cardiac enzymes. It was felt the patient Cardiology, Seattle, WA; William Bennett, Burgess-Fitzer, Tacoma, WA had reflux disease. The ER physician MD, Cardiology, Spokane, WA called the physician covering for the DEFENSE EXPERTS: Robert Aigner, MD, patient’s primary care physician, and RESULT: Defense verdict, Spokane Neurology, Seattle; Michael Peters, MD, also told the patient to make a follow- County Superior Court, Judge Price Neuroradiology, Seattle, WA up appointment with his primary care COST TO DEFEND: $334,844 RESULT: Defense Verdict, Superior Court physician in two days. The patient did for Thurston County, Judge Berschauer not follow up and had a myocardial infarction 27 days later. The patient Alleged Misdiagnosis COST TO DEFEND: $139,751 alleged that if he had been hospitalized, SPECIALTY: Radiology and Neurology timely treatment would have prevented the cardiac injury. ALLEGATION: Misdiagnosis of spinal Alleged Negligent Prenatal lesion resulting in unnecessary spinal PLAINTIFF ATTORNEY: Mark Kamitomo, Care and Delivery surgery followed by post-surgical The Markam Group, Spokane, WA paraplegia secondary to cord compression SPECIALTY: Obstetrics PLAINTIFF EXPERTS: Richard Cummins, in a diabetic 36-year-old single male. ALLEGATION: The plaintiffs were parents MD, Emergency Medicine, Seattle, WA; Plaintiff alleged lesion was AVM and along with their fourth child. The mother’s John Olson, MD, Cardiology, Seattle, WA surgery was contraindicated. Defendants pregnancy was remarkable only for fundal diagnosed epidural lipoma at T1-T8. DEFENSE ATTORNEYS: Dan Keefe, height measurement and ultrasound Lipoma confirmed by pathologist. Keefe Bowman & Bruya, Spokane, findings consistent with a large fetus. Neuropathy justified surgical removal of WA; Mike McMahon, Etter, McMahon, Labor was induced and a spontaneous the lesion. Lamberson, Clary & Oreskovich, vaginal delivery accomplished. The Spokane, WA PLAINTIFF ATTORNEY: Matt O’Meara, mother alleged she should have been Tacoma, WA scheduled for a C-section, which would 29 THE PHYSICIANS REPORT | SUMMER 2014 have prevented an alleged brief shoulder MD, Obstetrics, Eugene, OR; Frank PLAINTIFF EXPERTS: Ray Bracis, MD, dystocia. The baby has mild Erb’s palsy Manning, Maternal Fetal Medicine, New Infectious Disease, Portland; Peggy and no cognitive deficits. York, NY Goldman, MD, Emergency Medicine, Seattle, WA; Tim Lovell, Orthopedic PLAINTIFF ATTORNEY: Richard Rogers, RESULT: Plaintiff verdict of Surgery Portland, OR $1,932,881, on appeal, Lane County Superior Court, Judge Rasmussen DEFENSE ATTORNEY: Brian Rekofke, PLAINTIFF EXPERTS: Thomas Thornton, Witherspoon, Kelly, Davenport & Toole, MD, Obstetrics, Portland, OR; Larry COST TO DEFEND: $837,990 Spokane, WA Shields, MD, Maternal Fetal Medicine, San Luis, CA; Thomas Benedetti, MD, DEFENSE EXPERTS: John Staeheli, Maternal Fetal Medicine, Seattle, WA; Alleged Failure to MD, Orthopedic Surgery, Richland; Brien Vlcek, MD, Pediatric Neurology, Diagnose Infection Craig Olson, MD, Emergency Medicine, Seattle, WA Spokane, WA SPECIALTY: Internal Medicine/ DEFENSE ATTORNEY: John Hart, RESULT: Defense Verdict, Superior Emergency Medicine Hoffman, Hart & Wagner, Portland, OR Court for Spokane County, Judge Austin ALLEGATION: Failure to diagnose DEFENSE EXPERTS: Mark Tomlinson, COST TO DEFEND: $138,359 shoulder joint space infection resulting MD, Obstetrics, Portland, OR; Mark PR PR in permanent loss of function in left arm Nichols, MD, Obstetrics, Portland, OR; in a 29-year-old female. Sean Blackwell, MD, Maternal Fetal Medicine, Houston, TX; Cristin Babcok, PLAINTIFF ATTORNEY: Dennis Clayton

(Member Spotlight, Continued from page 27)

Another key difference for GreenField is that there are no incentives for physician productivity, and the clinicians are paid a flat salary. Says Rallison, “People put their time where you put the incentive — such as making the physician’s day efficient. If you remove perverse incentives around volume, the physicians can more easily focus on their patients’ needs.” Shute agrees, “This frees up the physician to do the job as they think it should be done. Rather than seeing as many patients as possible, they can focus on providing care in the best way possible for each patient, putting the patient’s needs first.”

Recalling a previous leadership role in risk management training, David notes the importance of asking health care professionals the pivotal question, “Who do you work for?” At GreenField Health, no doubt everyone on that team has the same “This frees up the answer: The Patient. physician to do the job as they think it should Shute says this model is not necessarily easier on the physician, as they might spend just as much time — if not more — on e-mail and phone contact as they be done. Rather than would at a face-to-face appointment. They are just as time-pressed as high-volume seeing as many patients physicians, but devote their time to different processes to deliver care. The key as possible, they can point here is that GreenField’s delivery process is geared to be easier and more convenient for the patient. focus on providing care in

the best way possible for GreenField has long believed that delivering quality service and reliable care is each patient, putting the efficient for the system as a whole. “We’ve always been focused on comprehensive, patient’s needs first.” convenient care. With our service-oriented approach, we’re saving time for our patients, which saves them money — and, in turn, saves money for employers and Dr. David Shute, Medical Director, insurance companies. At the same time, our model allows for high engagement, so GreenField Health we’re improving health overall — further avoiding unnecessary procedures or use of expensive technology, and general system abuse,” says Rallison.PR PR 30 GOVT AFFAIRS

IS THERE A DOCTOR IN THE HOUSE? Government Relations Update

Physicians Insurance believes in working within the legislative and regulatory environment and is committed to physician advocacy at the state and national levels. As the only medical professional liability carrier based in the Northwest with an in-house lobbyist registered in Washington and Oregon, we work to defeat legislative initiatives that • create new causes of action against physicians • alter the standard of care against physicians • create strict liability • create onerous and unnecessary duties For more information on Physicians In addition, Physicians Insurance monitors changes in leadership in Insurance’s Government Relations and all three branches of government and seeks opportunities to support Community Outreach Program, contact candidates who advocate for quality health care and a balanced, fair approach to our members’ medical professional liability exposure. Anne E. Bryant, Senior Director of @ Government Relations [email protected] 31 THE PHYSICIANS REPORT | SUMMER 2014

OREGON’S EARLY DISCUSSION former House seat this election, challenging Republican Jesse Young, who was appointed to the seat in January. AND RESOLUTION UPDATE Dr. Schlicher graduated from Pacific Lutheran University in Tacoma before going to the University of Washington The Oregon Patient Safety Commission sought public School of Law and School of Medicine in Seattle. As a comment on the draft administrative rules required by physician and attorney, he brings a promising skill set to the Oregon Laws 2013, Chapter 5 (SB 483) to implement Washington Legislature. Early Discussion and Resolution. Learn more about Physicians Insurance offered oral and written public Dr. Nathan Schlicher at comment to address our concerns on behalf of http://nathanforhouse.com. physicians and their defense. We continue to work with the commission as we move forward to the July 1 • Supreme Court: Governor Jay Inslee recently appointed implementation. If you have questions or comments you King County Superior Court Judge Mary Yu to the would like to share with Physicians Insurance, please Washington State Supreme Court. Justice Yu replaced contact Anne Bryant ([email protected]) or Catherine Justice James Johnson, who had been the lone conservative Walberg ([email protected]). voice on the nine-member high court before his retirement.PR PR

As a reminder, the most important step you can take is to call your professional liability insurance carrier as soon as you receive a Notice of Adverse Health Care Incident, even if you are not sure it falls within the scope of the new law.

WASHINGTON ELECTION UPDATE

Washington State’s primary election will take place FOR MORE INFORMATION August 5th, and the general election will be November 4th. Washington’s “Top Two” primary election means ABOUT YOUR STATE ELECTIONS, that the two candidates who receive the most votes in the primary election advance to the general election, VISIT THE WEB SITE FOR YOUR regardless of their party preference. SECRETARY OF STATE • Senate: This year, 25 Senate seats — half the Senate — will be up for four-year term elections. Media attention will focus primarily on the races that affect members of the Senate Majority Coalition, which is the historical IDAHO move of two Democrats crossing over to caucus with www.sos.idaho.gov the Republicans to form a new majority controlling the Senate. One of those Democrats, Senator Rodney Tom, OREGON is not seeking reelection. http://sos.oregon.gov/elections

• House of Representatives: All 98 House of Representatives seats will be up for two-year term WASHINGTON elections. Dr. Nathan Schlicher, Gig Harbor emergency www.sos.wa.gov/elections room physician, announced his candidacy to return to the Washington State Legislature. Dr. Schlicher, who WYOMING won appointment to the Senate after Derek Kilmer left for Congress, was defeated by Republican Jan Angel in http://soswy.state.wy.us last November’s special election. He will seek Angel’s PRSRT STD US POSTAGE PAID SEATTLE, WA PO Box 91220 PERMIT NO. 794 Seattle, WA 98111 ADDRESS SERVICE REQUESTED

THE PHYSICIANS REPORT | SUMMER 2014

CME TRANSCRIPTS NOW AVAILABLE ONLINE 24/7

Tracking the completion of CME credits just got easier. Simply log in to the members-only area of our Web site to search the transcripts you need and download as a PDF.

Whether you are the physician who has completed CME with us, or the administrator who is tracking and managing an entire group, you can now easily get up-to-the- minute transcripts.

PDF DOCUMENTS If you practice in Washington, Physicians Insurance monitors whether or not you have met the state-mandated CME requirement. For your convenience, we will send information to help you satisfy your 3-year requirement as your individual deadline draws near. Watch for it!

www.phyins.com/transcripts