Fellows Conference February 19 – 20, 2016 - CSRO

Fellows ConferenceFebruary 19 – 20, 2016

JW Marriott San Francisco Union Square515 Mason Street

San Francisco, California

Page 1 Coalition of State Rheumatology Organizations

CSRO Header

Page 1CSRO Fellows Conference

Table of Contents CSRO

Welcome Message .............................................................................................................2

Board of Directors ...............................................................................................................3

Meeting Guidelines .............................................................................................................4

Agenda ...............................................................................................................................5

Author Biosketches .............................................................................................................7

Program Materials

Paul H. Caldron, DO ..................................................................................................10

Madelaine T. Feldman, MD ........................................................................................19

Herbert S. Baraf, MD, FACP, MACR ..........................................................................24

Michelle Petri, MD, MPH ............................................................................................33

Jean Acevedo, LHRM, CPC, CHC, CENT .................................................................54

Douglas C. Conaway, MD ..........................................................................................68

Ethel Owen, CPC .......................................................................................................73

Aaron Broadwell, MD .................................................................................................79

James M. Dahle, MD FACEP .....................................................................................80

James S. Haliczer, Esq ..............................................................................................90

Suneetha Morthala, MD .............................................................................................96

Michael Schweitz, MD ..............................................................................................102

Steve McCoy, Esq ....................................................................................................103

Thank You to Our Corporate Partners .....................................................Inside Back Cover

Fellows ConferenceFebruary 20, 2016

JW Marriott San Francisco Union Square


CSRO Welcome Message

Welcome to the 2016 CSRO Fellows Conference. The CSRO developed this program in 2005 based on the idea of, “What we wish we knew before we went into private practice.” This will be our 12th year providing this forum.

The program is specifically directed to help rheumatologists who are finishing their training better understand their entrance and participation in the world of private practice. The topics range from interviewing for your first job to evaluating an employment contract. Our intent is to provide you a comprehensive perspective on all matters of practice management.

We are confident this information will be valuable to you in navigating the next phase of your professional career and our faculty and other community rheumatologists attending will be there to help ensure your success in this endeavor.

Sincerely,

Michael Stevens, MD, FACRCSRO President

Page 3Fellows ConferencePage 2 Coalition of State Rheumatology Organizations

Board of Directors CSRO

DIRECTORS

Jacob Aelion, MDArthritis Clinic371 N. Parkway, Ste 400Jackson, TN 38305(731) 664-0002 Fax: (731) 664-8412

Mark Box, MDKansas City Internal Medicine1010 Carondelet Drive, Suite 224AKansas City, MO 64114(816) 943-0706

Aaron Broadwell, MDRheumatology & Osteoporosis Specialists820 Jordan Street, Suite 201Shreveport, LA 71101(318) 221-0399 Fax: (318) 221-1940

Philippe Saxe, MD5130 Linton Blvd.Delray Beach, FL 33484(561) 495-0600

Michael C. Schweitz, MDArthritis & Rheumatology Associates1411 N. Flagler Dr., Suite 5600West Palm Beach, FL 33401(561) 659-4242

Joshua Stolow, MD8527 Village Drive, Suite 103San Antonio, TX 78217(210) 279-9074 Fax: (210) 693-1559

OFFICERS

PresidentMichael P. Stevens, MD, FACRSan Mateo Rheumatology101 S. San Mateo Drive, Suite 307San Mateo, CA 94401(650) 348-6011 Fax: (650) 348-6027

Vice PresidentMadelaine T. Feldman, MDThe Rheumatology Group2633 Napoleon Avenue, Suite 530New Orleans, LA 70115(504) 899-1120 Fax: (504) 899-2137

SecretaryGary R. Feldman, MDPacific Arthritis Care Center5230 Pacific Concourse Drive, Suite 100Los Angeles, CA 90045(310) 297-9221

TreasurerGregory F. Schimizzi, MDCarolina Arthritis Associates1710 S. 17th StreetWilmington, NC 28401(910) 762-1182 Fax: (910) 332-1111

EXECUTIVE OFFICE

Executive DirectorWendy J. WeiserWJWeiser & Associates, Inc.1100 E. Woodfield Road, Suite 350Schaumburg, IL 60173(847) 517-7225 Fax: (847) 517-7229

Associate DirectorJulia NorwichWJWeiser & Associates, Inc. 1100 E. Woodfield Road, Suite 350Schaumburg, IL 60173(847) 517-7225 Fax: (847) 517-7229

Government Relations DirectorJeff Okazaki, MBAWJWeiser & Associates, Inc.1100 E. Woodfield Road, Suite 350Schaumburg, IL 60173(847) 517-7225 Fax: (847) 517-7229

Associate Director, Industry RelationsJP BaunachWJWeiser & Associates, Inc.1100 E. Woodfield Road, Suite 350Schaumburg, IL 60173(847) 517-7225 Fax: (847) 517-7229


CSRO Meeting Guidelines

Mission Statement The Coalition of State Rheumatology Organizations is a group of state or regional professional rheumatology societies formed in order to advocate for excellence in rheumatologic disease care and to insure access to the highest quality care for the management of rheumatologic and musculoskeletal diseases.

Disclaimer StatementStatements, opinions and results of studies contained in the program are those of the presenters/authors and do not reflect the policy or position of the CSRO nor does the CSRO provide any warranty as to their accuracy or reliability. No responsibility is assumed by the CSRO for any injury and/or damage to persons or property from any cause including negligence or otherwise, or from any use or operation of any methods, products, instruments or ideas contained in the material herein.

Copyright NoticeIndividuals may print out single copies of slides contained in this publication for personal, non-commercial use without obtaining permission from the author or the CSRO. Permission from both the CSRO and the author must be obtained when making multiple copies for personal or educational use, for reproduction for advertising or promotional purposes, for creating new collective works, for resale or for all other uses.

Filming/Photography StatementNo attendee/visitor at the CSRO 2016 Fellows Conference may record, film, tape, photograph, interview or use any other such media during any presentation, display or exhibit without the express, advance approval of the CSRO Executive Director. This policy applies to all CSRO members, non-members, guests and exhibitors, as well as members of the print, online or broadcast media.

Agenda CSRO

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CSRO 2016 Fellows Conference

February 20, 2016JW Marriott San Francisco Union Square

All sessions will be located in Metropolitan A unless otherwise indicated.

SATURDAY, FEBRUARY 20, 2016OVERVIEW

7:00 a.m. - 7:45 a.m. Registration & BreakfastLocation: Metropolitan A Foyer

6:30 p.m. - 7:30 p.m. Reception & DinnerLocation: Skyline BC

GENERAL SESSION

7:40 a.m. - 7:45 a.m. WelcomeMichael P. Stevens, MD, FACRSan Mateo RheumatologySan Mateo, CA

7:45 a.m. - 8:30 a.m. State of RheumatologyPaul H. Caldron, DOArizona Arthritis Rheumatology AssociatesPhoenix, AZ

8:30 a.m. - 9:00 a.m. Federal Legislative UpdateMadelaine T. Feldman, MDThe Rheumatology GroupNew Orleans, LA

9:00 a.m. - 9:45 a.m. So You Want to Go Into Private PracticeHerbert S. Baraf, MD, FACP, MACRArthritis & Rheumatism AssociatesWheaton, MD

9:45 a.m. - 10:00 a.m. Break

10:00 a.m. - 10:45 a.m. *Systemic Lupus UpdateMichelle Petri, MD, MPHLupus Center at Johns Hopkins Outpatient CenterBaltimore, MD*This session is CME accredited by a third party, and is applicable to any physician in the room. Please see separate handout for full information.

10:45 a.m. - 11:15 a.m. Important Issues in CodingJean Acevedo, LHRM, CPC, CHC, CENTAcevedo Consulting, Inc.Delray Beach, FL

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CSRO Agenda

11:15 a.m. - 11:45 a.m. Practicing in a Multispecialty GroupDouglas C. Conaway, MDCarolina Health SpecialistsMyrtle Beach, SC

11:45 a.m. - 12:20 p.m. Practice ManagementEthel Owen, CPCArthritis & Rheumatology AssociatesWest Palm Beach, FL

12:20 p.m. - 1:15 p.m. Lunch Lecture: State Advocacy ParticipationLocation: Metropolitan Ballroom AAaron Broadwell, MDRheumatology & Osteoporosis SpecialistsShreveport, LA

1:15 p.m. - 2:15 p.m. Early Career Financial ManagementJames M. Dahle, MD FACEPThe White Coat Investor, LLCSalt Lake City, UT

2:15 p.m. - 3:00 p.m. Medical Malpractice and Risk ManagementJames S. Haliczer, EsqHaliczer Pettis & Schwamm Attorneys At LawFort Lauderdale, FL

3:00 p.m. - 3:15 p.m. Break

3:15 p.m. - 3:45 p.m. Pearls from Early Practice ExperienceSuneetha Morthala, MDSandhills RheumatologyColumbia, SC

3:45 p.m. - 4:30 p.m. After the Treatment DecisionMichael Schweitz, MDCSRO, Federal Advocacy ChairWest Palm Beach, FL

4:30 p.m. - 5:30 p.m. Physician Employment and ContractsSteve McCoy, EsqPatient First CorporationGlen Allen, VA

6:30 p.m. - 7:30 p.m. Reception & DinnerLocation: Skyline BC

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CSRO Author Biosketches

Jean Acevedo, LHRM, CPC, CHC, CENT Ms. Acevedo has over 30 years of health care experience. She has a particular expertise in chart audits, compliance and education relative to physician documentation and coding. Jean has also been an expert witness in civil litigation and an investigative consultant for the DOJ and FBI in Federal fraud cases.

Ms. Acevedo has demonstrated particular expertise in therapy and rehabilitation documentation and coding and is well known for her knowledge of hospice and palliative care physician services billing. Recognizing physician reimbursement is moving from a pure “fee for service” model to one reimbursing for quality and value, she is helping ACO’s and their physicians understand the rules and nuances of diagnosis coding and the impact on Medicare Risk Adjustment (MRA) coding.

She is a workshop presenter for the AAPC and co-author of the Academy’s Compliance Toolkit. Jean is an instructor at Florida Atlantic University where she teaches the regulatory compliance modules of FAU’s Certificate in Medical Business Management program, and a member of several Coding Institute Editorial Advisory Boards. Jean has been a Participant in CMS’ Medicare Provider Feedback Group, CMS Division of Provider Information Planning and Development since 2007 and is a member of the Jurisdiction 9 MAC’s Provider Outreach and Education Advisory Group.

She is a frequently sought after speaker as she possesses the unique perspective of avoiding risk and liability while optimizing reimbursement in the highly regulated health care industry.

Herbert S. Baraf, MD, FACP, MACR Dr. Baraf is the senior member and managing partner of Arthritis and Rheumatism Associates, the largest private practice rheumatology group in the United States with 18 rheumatologists. In 1982 he founded The Center for Rheumatology and Bone Research, the research division of his practice. In that capacity he has served as principal investigator on over 350 clinical trials studying new therapeutics for more than a dozen rheumatic disorders including gout, Sjogren’s syndrome, rheumatoid, psoriatic and osteoarthritis. Dr. Baraf has co-authored several publications concerning therapeutics in the rheumatic diseases and has presented his research at meetings of the ACR and EULAR. He lectures widely on the manifestations of and treatment for the rheumatic diseases. He has a special interest in the management of gouty arthritis.

A nationally recognized authority on issues of rheumatology practice management, Dr. Baraf has been an invited speaker at regional and national meetings throughout the United States on topics of practical importance to practicing rheumatologists. He has presented workshops and lectures on clinical practice to graduating fellows for the past several years at meeting of the ACR and the CSRO.

Dr. Baraf is a Clinical Professor of Medicine at The George Washington University, School of Medicine and a Clinical Associate Professor of Medicine at the University of Maryland School of Medicine. He is a Fellow of the American College of Physicians. In 2012 he was designated as a Master of the American College of Rheumatology (ACR). He was subsequently honored with the Paulding Phelps Award by the ACR for his “contributions to patient care, rheumatology and the practice of medicine.” Dr. Baraf received his medical degree at SUNY Downstate and did his Internal Medicine training at George Washington University. His fellowship in rheumatology was completed at Duke University.



Aaron Broadwell, MD Dr. Broadwell received his undergraduate degree from Rhodes College in Memphis, Tennessee before he went on to receive his medical degree from the University of Texas Medical Branch. Following this, he completed his residency in internal medicine at the Mayo Clinic, Jacksonville, and then a fellowship in rheumatology at Scripps Clinic in La Jolla, California. Dr. Broadwell is currently a partner at Rheumatology and Osteoporosis Specialists in Shreveport, Louisiana. He is also a consultant and/or speaker for Abbvie, Amgen, Pfizer, Genentech, Mallinckrodt, Eli Lilly and UCB.

Dr. Broadwell has received various honors such as the Alpha Omega Alpha Honor Medical Society, Phi Kappa Phi Honor Society and the William L. Marr Award in Medicine. He is a member of the American Medical Association, American College of Rheumatology, American Society for Bone and Mineral Research, International Society for Clinical Densitometry, and Rheumatology Alliance of Louisiana, where he is also a board member and the vice president.

Paul H. Caldron, DO Dr. Caldron received his medical degree at Oklahoma State University. He completed his internal medicine residency and rheumatology fellowship at the Cleveland Clinic Foundation in Ohio. Dr. Caldron began practice in 1984 as assistant clinical professor of medicine at Northwestern University Medical School with a private office in Winnetka, Illinois. In 1994 Dr. Caldron was a cofounder of Arizona Arthritis and Rheumatology Associates, PC (AARA). He is a fellow in the American College of Physicians and the American College of Rheumatology and holds a clinical assistant professorship at Midwestern University Arizona College of Osteopathic Medicine. Dr. Caldron completed an MBA at the Thunderbird School of Global Management in 2002.

Douglas C. Conaway, MD Dr. Conaway is a rheumatologist currently working in a multi-specialty group in Myrtle Beach, South Carolina. He did his undergraduate studies at Rice University, medical school at Baylor, and internal medicine training at the University of Oregon Hospitals and Clinics. He spent five years in the Air Force as a flight surgeon, and then finished rheumatology training at Temple University School of Medicine. After another 12 years in Philadelphia on the faculty at Temple, he moved to his current position in private practice.

For a number of years, he gave the rheumatology section of the Internal Medicine Board Review at the ACP national meeting, and he is currently active in the RAPP group, a national group of rheumatologists trying to make the practice of rheumatology more efficient by incorporating new clinical modalities such as biomarkers and ultrasound and systems tools such as population management.



James M. Dahle, MD, FACEP After growing up in Alaska, Dr. Dahle did his undergraduate work and played on the hockey team at Brigham Young University before attending medical school at the University of Utah. He then completed an emergency medicine residency at the University of Arizona, finishing in 2006. He subsequently spent four years on active duty working in Air Force and Navy hospitals on four continents before joining a small democratic group in suburban Utah in 2010, where he currently works full-time and serves as the department chair. In residency, he became interested in personal finance and investing after feeling ripped off by financial professionals, and began a long process of educating himself and others about these important topics. In 2011, he started The White Coat Investor, the most widely read, physician-specific personal finance and investing website in the world, which is visited by over 65,000 unique individuals each month. A year ago he published his first book, The White Coat Investor: A Doctor's Guide to Personal Finance and Investing, and it has remained an Amazon best-seller since publication.

Madelaine T. Feldman, MD Dr. Feldman is a partner at The Rheumatology Group in New Orleans, a founding member and past-president of the Rheumatology Alliance of Louisiana (RAL), and past-president of the Louisiana Rheumatism Society. Dr. Feldman also holds the positions of clinical associate professor and preceptor at Tulane University School of Medicine and Foundations in Medicine respectively. She has been named one of the “Top Doctors” in New Orleans for the last seven years. In addition to being president of RAL, Dr. Feldman is also a board member of CSRO. She is a fellow of the American College of Rheumatology, and a member of the ACR insurance subcommittee. Dr. Feldman completed her BA in biology and theater from Newcomb College/Tulane University, and continued her education at Tulane University Medical School by completing her MD and post-doctoral training with an internship and residency in internal medicine, and a fellowship in rheumatology.

James S. Haliczer, Esq Mr. Haliczer is a partner with the firm of Haliczer, Pettis & Schwamm, P.A. which has offices in Fort Lauderdale and Orlando. He concentrates his practice in the litigation of significant professional liability, personal injury/wrongful death, and commercial cases on behalf of both plaintiffs and defendants. He has lectured extensively on many topics including courtroom dynamics, negotiation strategies, COBRA, legal ethics, and recent developments in various areas of the law. Mr. Haliczer has been included in Who’s Who in America, Who’s Who in the World, Who’s Who in American Law, Who’s Who in Finance and Industry and Who’s Who in the South West and was recently included in Florida Trend Magazine’s inaugural issue of Legal Elite. He received his JD from the Stetson University College of Law in 1981.



Ethel Owen, CPC Ethel Owen is the Administrator for Arthritis & Rheumatology Associates of Palm Beach, Inc., a seven-physician single specialty rheumatology practice in Palm Beach County, Florida. Ethel is responsible for managing three office locations. The practice offers ancillary services including three infusion centers. The primary goal of the practice is to provide excellent rheumatologic care to patients. Ethel has over 35 years’ experience serving the medical industry.

Ethel has been a Certified Professional Coder and a member of the American Academy of Professional Coders since 1997. Her coding responsibilities have included outpatient surgical coding, E & M coding, chart documentation training, ICD-10 training for physician and support staff. She has an extensive background in medical management, staff motivation, reimbursement strategies, and successful implementation of medical office policies and procedures.

Ethel is a member of several professional organizations including The National Organization of Rheumatology Mangers, NORM. She has been an active NORM member since 2006 and a Board of Director since 2007. Currently she has the privilege of serving as President of NORM.

Steve McCoy, Esq Mr. McCoy graduated from the University of Virginia School of Law in 1997. He spent 11 years in private practice as a partner in the health law section of Williams Mullen, in Richmond, Virginia, where he represented physicians, hospitals and other health care providers. He left Williams Mullen to serve as general counsel to Patient First Corporation, a provider of primary and urgent care services that employs over 450 physicians and extenders at 63 locations in Virginia, Maryland, Pennsylvania and New Jersey, and treats patients during more than 2.4 million visits annually. Mr. McCoy is the past chair of the Health Law Section of the Virginia State Bar and is currently a member of the Board of Governors of the Virginia Bar Association’s Health Law Council.

Suneetha Morthala, MD Dr. Morthala’s fellowship training in rheumatology was completed at the prestigious University of Pennsylvania Hospital in Philadelphia, Pennsylvania. Dr. Morthala graduated Cum Laude from Universidad Iberoamericana (UNIBE), Dominican Republic, with her medical degree. She started her internship training at the prestigious University of Pennsylvania, New York Methodist Hospital in Brooklyn, New York. Dr. Morthala completed her final year in residency training in internal medicine at Drexel University College of Medicine in Philadelphia.

Dr. Morthala is board certified in both rheumatology and internal medicine. She is also a Fellow with the American College of Rheumatology.

Dr. Morthala participated in clinical research involving Systemic Lupus Erythematosus (SLE) while at the University of Pennsylvania. After serving almost four years as an assistant professor at the University of South Carolina School of Medicine, and having worked with Lexington Rheumatology for three years, she started Sandhills Rheumatology, her private practice

Dr. Morthala has three beautiful children with her husband also Dr. Morthala a psychiatrist working in private practice in Elgin, South Carolina (Kershaw County Psychiatry LLC).



Michelle Petri, MD, MPHDr. Petri is a professor of medicine in the division of rheumatology at Johns Hopkins University School of Medicine and Johns Hopkins Hospital, where she has worked since 1986. Dr. Petri earned her BA in biology from Harvard-Radcliffe College in 1976 and went on to complete her medical degree at Harvard Medical School in 1980. She did her internship and residency at Massachusetts General Hospital in Boston, and went on to do two fellowships at the University of California, San Francisco. She received her MPH from the Johns Hopkins University School of Hygiene and Public Health in 1990, following a year of teaching at the University of California, San Francisco, and four years of teaching at Johns Hopkins. She is the director of the Hopkins Lupus Center.

Michael Schweitz, MD Dr. Schweitz completed a seven year undergraduate and medical school program at the George Washington University in Washington, DC, in 1972. He completed his internal medicine training at GW and his rheumatology fellowship at Georgetown University in 1977. He then entered private practice in West Palm Beach, Florida.

Dr. Schweitz is a partner in Arthritis and Rheumatology Associates of Palm Beach, an eight physician single specialty practice in Palm Beach County. He is a Fellow of the American College of Physicians and the American College of Rheumatology. He served as a member of the Committee on Rheumatologic Care. He is a past president of CSRO and the Florida Society of Rheumatology where he continues to sit on both executive committees. He is an active member of the American Society of Clinical Rheumatology.

He has served on the Board of Directors of the Arthritis Foundation at both state and local levels for many years and for the past 33 years has donated his time in helping to staff a free arthritis clinic for medically indigent patients in Palm Beach County.

Dr. Schweitz has been recognized in “Best Doctors of South Florida” and “America’s Top Physicians.” His personal interests include wine collecting and wine education, as well as collecting first edition crime fiction.


CSRO Program Materials

7:45 a.m. - 8:30 a.m.

State of RheumatologyPaul H. Caldron, DO


CSRO Program Materials1/26/2016

1

THE STATE OF THE STATE OF RHEUMATOLOGYRHEUMATOLOGY

Paul H. Caldron, DO, FACP, FACR, MBACoalition of State Rheumatology Organizations

Fellows Conference

February 20, 2016San Francisco, California

USA

Prosperity risingThe Success of Global Development –And How to Keep It GoingForeign AffairsMonday, December 14, 2015

Steven RadeletDonald F. Henry Chair in Global Human DevelopmentGeorgetown University

Global Health

1960 22% f LMIC t i di d b f 5 2013 5%• 1960 22% of LMIC countries died before age 5; 2013 5%

• 1990 Diarrhea killed 5 million children; 2014 1 million

• Half as many people die of malaria as in 2000

• Deaths from HIV and TB have dropped by one-third

• Chronic hunger has dropped almost half since 1995

• Life expectancy up one-third in LMICs (from 50 to 65) since 1960

• All countries involved, even the worst governed

Overview

Rheumatology as an IndustryHistory and Perspectives

Rheumatology as a Service BusinessDurable concepts

Where Are We GoingHow do we develop Sustainable Systems

US Rheumatology Manpower Distribution

75 % Private Practice (proportion owned by rheumatologists unknown)

16 % Academic

9% Government and Industry

Industry Analysis of Rheumatology

The Bigger View

• Strong professional associations (guilds) – ACR, EULAR

• Strong scientific and technological advances in the 1990s forward

• Strong market – large and expanding

• Relatively decreasing numbers of rheumatologists

Why the decrease?

ACR Projections, published 2000


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2

American College of Rheumatology (ACR)Work Force Study 2006

Projection 2005 – 2025

N b f h t l i t ill i b 1 2%Number of rheumatologists will increase by 1.2%

Demand for rheumatology services will increase by 46%

2013-2014 48% of Fellowship applicants are IMGs

Radiology-Orthopedics-Anesthesiology-DermatologyR-O-A-D to riches

Why Do We Love Rheumatology?

Intellectual Stimulation

Considered Intellectual (Respect of Colleagues)

< Opportunity Cost


Lifestyle (Few emergencies)

Long-term Relationships With Patients

Income

Exciting new therapies

< Opportunity Cost

?

Medscape Lifestyles Survey 2012; mean


• Law of Supply and Demand not working

M k t Di t ti

The Bigger View

• Market Distortions

Payers – Government Managed CareAnti-trust laws – Insurance may collude on price

Physicians may not collude on priceCognitive/Procedural Discrepancy

Lack of business and economic knowledge in rheumatologists An Inconvenient Truth

The State of Rheumatology

• Cost Consciousness – A learned and tested performance characteristic

Becoming a BusinessmanAn Inconvenient Truth

• Profit Motive - The morality of wealth accumulation

• Who should profit? – An underlying question to stewardship of the profession and meeting the demand for services, grounded in economic reality

• Working in the Business vs. Working on the Business Both necessary and Both honorable

Forces Governing An IndustryForces Governing An Industry

Threat of New Entrants

B i i

ME Porter. Competitive Strategy

Evolution in Rheumatology Manpower Dynamic

US Rheumatology• Pallet of management services• Membership fees, access to services• Pathways: Aggregated data for sale• Management Group• Capitalization

Membership in LLC, Curascripts

American Arthritis and Rheumatology Associates• Multistate group – single Federal Tax ID• Common EHR• Educational business unit• Pathways: Aggregated data for sale• Management Group (Bendcare); Percent of revenues• Capitalization

Membership in LLC (ownership shares)

Industry Rivals

Threat of Substitutes

Bargaining PowerOf Buyers

BargainingPowerOf Suppliers

US Rheumatology Network (USRN)• Network for contract negotiation• Pallet of management services• Favorable supply pricing - must procure buy-and-bill pharmaceuticals through McKesson• Capitalization

McKesson

Arizona Arthritis and Rheumatology Associates, PC• C-corporation - All shareholders are practicing rheumatologists• Single group, fully integrated management structure. 9 offices, all metros of Arizona• Pooled investment, risk• Selective recruitment• CORRONA database; Pathways: Aggregate data for sale• Integrated business units (physician – APC teams)• Integrated business units (“ancillaries”)• Exploring contiguous cross-(state)border growth• Capitalization

Self


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Strategies for Addressing the Shortage of Rheumatologists

See Only Immunological Disease

Design More Efficient Practices

Advanced Practice Clinicians (NP/PAs)

Attract New Blood

Challenge to US Rheumatology in the New Millennium

Guiding Principles for Promoting the Profession of Rheumatology

1. The greatest risk to the quality of care of a patient with rheumatic disease is: The unavailability of a rheumatologist

2. Private practice rheumatologists must optimize business practices

To optimize profitability

To compete for young doctors

To meet the US demand

Company

Setting the promiseEnabling the promise

Where most of the failures are:Building the internal customer.

Don’t create expectationsthat can’t be met.

Managing the Internal Environment

Services Marketing Triangle

Setting the promise(what I’ll do and what I’ll not do)

CustomerStaff Member(internal customer)

Delivering the promise

Enabling the promise(let the staff member know what the promise is)“Internal Marketing”

promiselet the staff member know

Managing the External Environment

Evaluation and Management—Contracts

Functional Relationships with our Exchange NetworkSuppliersppOther consultantsLegal entities and regulators

Cooperating with our professional organizations to influence policy in Government and Managed Care

Vertical and Horizontal Integration

LaboratoryX-rayDensitometryMRIDiagnostic / Interventional USOrthotics Supportive devices

Infusion ServicesClinical researchPhysical / Occupational TherapyElectrodiagnostic StudiesCORRONA Database EntryTheralogix

Vertical and Horizontal Integration

Rheumatologist’sCore Competency

Diagnosis and TreatmentBuyersSuppliers

Owning the BuildingGroup Purchasing Organization

Employer based Contracting

Orthotics, Supportive devicesNon Pharmacy Dispensing Site

TheralogixComplementary Therapies

ACR Benchmarking Survey 2003

Direct Correlation with Ancillary Services

Proper coding ( ICD 9)Proper coding ( ICD-9)

Minimal delays in seeing patients

Use of Physician Extenders (Nurse Practitioners/Physician Assistants)


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Personal Sources of Compensation

Rheumatologists practicing in private practice indicate nearly three-fourths of all personal sources of compensation come from direct patient care.

2009 Benchmark Survey – Private Practice Findings

(n=186)

Have we done the right thing?

Can we create a more sustainable practice model?

• 4% annual increases in HC costs 2000-2009• 0.3% annual increases 2009-14• Possibly temporary related to 2008

economic downturn• 6-8% expected increase over 2015-2035

2009


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Reforming US Healthcare – The Value Agenda

Porter M, Lee T. The Strategy That Will Fix Health Care. Harvard Business Review ; October 2013

Public Health and Medico-legal Evolution

2014 US Surgeon General Report Health care costs of smoking $289 billion(four times the federal budget for education)US smoking rates 42% in 1965

18% in 2013

Public Health and Medico-legal Evolution

2014 US Surgeon General Report 2014 US Surgeon General Report Health care costs of smoking $289 billionHealth care costs of smoking $289 billion(four times the federal budget for education)(four times the federal budget for education)US smoking rates 42% in 1965 US smoking rates 42% in 1965

18% in 201318% in 201318% in 2013Savings from smoking bans begin immediately

Obesity – 1/3 of Americans are obeseCDC – Health care costs $142 Billion

18%18% in 2013Savings from smoking bans begin immediatelySavings from smoking bans begin immediately

Obesity – 1/3 of Americans are obeseObesity – 1/3 of Americans are obeseCDC – Health care costs $142 Billioncosts $142 Billion

“Choosing Wisely” in Rheumatology

The ACR established a Top 5 Task Force to oversee the creation of the following recommendations:

1. Don't test antinuclear antibody (ANA) subserologies without a positive ANA screen and clinical suspicion of immune-mediated disease.

2. Don't test for Lyme disease as a cause of musculoskeletal symptoms itho t an e pos re histor and appropriate e amination findings

Reforming US Healthcare – The Value Agenda

without an exposure history and appropriate examination findings.

3. Don't perform MRI of the peripheral joints to routinely monitor inflammatory arthritis.

4. Don't prescribe biologics for RA before a trial of methotrexate (or other conventional non-biologic DMARDs).

5. Don't routinely repeat DXA scans more often than once every 2 years.

www.rheumatology.org www.acponline.org

Healthcare EvolutionMegatrends (a la John Naisbitt)

• Pressure on US physicians – the perfect storm: Consumerism Payers Peer pressure Litigious environment EHR/MU/Pay-for-performanceHeavy schedules

• Pressure on rheumatologists: Existential pressure on solo/small practice - complexity of execution. Move to employed status and potential exploitation. Other responses are hard to understand (US Rhm, USRN, AARA, AzARA)

• Big Data implementation/Predictive Analytics/Population Management vs. personal care – more relevant in alternative payment models

• Success in rheumatology will require the skill of team management and development of efficient operating systems

Healthcare EvolutionMy Take…Dramatic changes in other sectors:

• Travel – Airlines, Uber, AirBNB

• Education – MOOCs, Community College, distance, mergers

• Communication – mobile, devices, payment

• Entertainment - movies television news

You are the generation that can handle this

Entertainment movies, television, news

• Banking, finance –Mpesa, crowd sourcing/lending facilitators (“Fintech”)

• Medical technology – human exoskeletons, self-driving cars, CRISPR-Cas9 gene splicing, oncology/ immunology therapeutics momentum

• Healthcare – expect continued change to outpatient management, “population management”, bundling, “direct or concierge” modeling, risk shifting and sharing, measures, big data implementation


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6

THE STATE OF THE STATE OF RHEUMATOLOGYRHEUMATOLOGY

Paul H. Caldron, DO, FACP, FACR, MBACoalition of State Rheumatology Organizations

Fellows Conference

February 20, 2016San Francisco, California

USA


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8:30 a.m. - 9:00 a.m.

Federal Legislative UpdateMadelaine T. Feldman, MD



1

MADELAINE T. FELDMAN, M.D.

ASSOCIATE PROFESSOR OF MEDICINE, TULANE UNIVERSITY MEDICAL SCHOOL

GOVERNMENT AFFAIRS, RHEUMATOLOGY ALLIANCE OF LOUISIANA

VICE PRESIDENT, COALITION OF STATE RHEUMATOLOGY ORGANIZATIONS

I would rather regret the things that I have done than the things that I have not" ~ Lucille Ball

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Not yet determined


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4

QUESTIONS?


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9:00 a.m. - 9:45 a.m.

So You Want to Go Into Private PracticeHerbert S. Baraf, MD, FACP, MACR



1/27/2016

1

Starting a Career in Private Practice

Confessions of a Managing Partner

Herbert S. B. Baraf, M.D., FACP, MACR Clinical Professor of Medicine

George Washington University Managing Partner

Arthritis and Rheumatism Associates Washington, D. C. Wheaton, MD.

CSRO Fellows Conference JW Marriott San Francisco Union Square

San Francisco, California February 20 2016

The Medical Student s Dilemma Getting Even

86% of 2013 Graduating Seniors Had DebtDeDAverage Debt $169,900

>$100,000 79%

>$150,000 63%

>$200,000 40%

>$250,000 19%

>$300,000 7%

http://aamc.org/programs/firstdebtfactcard.pdf

So You Want to Go into Private Practice?

Practice Setting

The Interview

The Contract

Building Your Practice

Business of Practice

Practice SettingAcademic GovernmentIndustry Hospital or Health System Private Practice

Solo or group single specialty multi-specialty

Large or small Rural, urban or suburban


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Solo PractitionerCons

•Reduced practice coverage for time off

•Lack of cost sharing • labor, rent and supplies

•Financial insecurity if time off is required - illness,maternity, etc.

•Less $$ support for expansion

•More vulnerable to competition

Thomas E. Sullivan, M.D., Models in Medical Practice, 2002

Pros

•Decision Autonomy

•Complete oversight of business operations

•Total control over strategic planning and practice future

•Consistent relationships with patients

•Opportunity to determine practice revenue

Single Specialty Group

ConsReduced input into business decisions Complex division of revenues and costs Politics in the group varies with practice size For large practices:

Is there an ideal size? Duplication of expense with multiple offices


Pros

•Potential for improved office efficiencies

•Stable coverage for time off

•Potential for cost sharing

•Work/Life Balance

• Increased negotiating power with payers and others

Multi-Specialty GroupCons

Reduced input of individual physicians into decision making Subjugation of individuals needs to those of the groupHigher overhead costs Need to cover areas of medicine outside of your expertise Complex revenue division

crediting downstream revenue uneven investing in new technologiesThomas E. Sullivan, M.D., Models in Medical Practice, 2002

Pros

Flexibility to respond to market forces

Marketing and name recognition

Negotiating power with insurance carriers and vendors


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Employed Practitioner


Cons

Less or little involvement in practice decision making

Staffing levels Policies and proceduresBilling operationsRetirement planning

Larger organizations tend to be more bureaucratic

Looking for Opportunities

Focus on where you want to live

Classifieds/ACR Website

Local medical society

Program director

Networking

Headhunter

Cold-calling

Timing is Everything!


Practice Setting

The Interview

The Contract



The ProcessInitial Interview/Contact

Write a thank you note!

Second look

Meet all the physicians

Meet staff

See the facilities

Write a follow-up note!


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•Be specific Reference specific people you met and information you gathered from the interview. •Reference the next step Use the letter to

sound positive and forward thinking • I look forward to working with you or• I look forward to receiving your offer letter.• If the position requires a second interview: • I look forward to meeting with you again soon.

•Check grammar and spelling!

What Are You Looking For?

Fulfillment?

Good personality fit?

Highest possible income?

A challenge?

Part time or full time?

A good practice?*

What Are You Looking For?

Clinical research

Teaching opportunity

Ultrasound

Interventional rheumatology

Chance to innovate or build something new?

A job?

Clues to a Good Practice*Forward-thinking

Acquisitive or defensive

HMO penetration

Ancillary services

Respectful of one another

Prior history with new physicians

Strong management

Other ConsiderationsIs staffing adequate? Does the office layout work well? Is there space for you? Are the physicians open to new ideas? How competitive is the market place? Will you be incentivized? How quickly will you be busy? Is your spouse on board?

What Are They Looking For?An employee?

Another body to do the work (a schlepper) A chance for a buyout? A special skill or demographic? A partner? Someone to participate in practice building?

New location A new skill Share overhead Share responsibility Market strength


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•Prepare questions to ask employers •Practices are looking for the best cultural fit," •Prior to interview, take time to reflect on the

kind of impression you want to make. •Practices want candidates that will be a

constructive member of a group - it is helpful to demonstrate: •accountability•ability to lead •a good collaborator or team player,"

•The biggest error interviewees make:

•not asking questions relating to physician input

in decision-making and opportunities for

expertise contribution

•Do your homework to ask proper questions

•Be on time and dress appropriately


Practice Setting

The Interview

The Contract



The Contract• How long until partnership • Restrictive covenant • Incentives • Perks • Malpractice, health, life and disability • Gas, auto expenses • Meetings, dues, subscriptions, vacation• Moving expenses

• Call Schedule • Leaving a practice • Going to part time • Covering your tail

The Contract•Partnership

• When does it begin?

• Do you get to parity?

• Are some partners more equal ?

• How is income divided?

• What is the buy-in arrangement?

•Buying a practice


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The Contract

•Everything is negotiable

•Some things are more negotiable than others• The second to join

• The eighth to join

•All parties in a negotiation have to win

The Contract

Keep Your Eye on the Prize!

The Contract

Its the Partnership, Stupid!

The Contract

Get an attorney

Discuss with your peers

Fairness comes in many forms

Once You Have Accepted

Start working immediately on State license application

Hospital privileges

Insurance credentialing

Bad things happen to those who don t!


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Practice Setting

The Interview

The Contract



Paradigm shift: Busy is Good!

Practice Building 101

•Humility

•Eagerness

•Visibility

•Accessibility

•Make yourself known

Practice Building 101• Be a consultant

• Call on all consults but get off phone quickly

• Get letters out; attractive and readable

• Make impressions and advice accessible

• Take great care of your patients

• Show interest in them

• Being kind and concerned is just as important as being right

Practice Building 101• Put some talks together and give them

• Grand rounds

• Departmental meeting of internal medicine, FP, ortho

• Patient groups

• Community service • Arthritis Foundation/Lupus Foundation/Scleroderma

Federation

• Religious, ethnic, service organizations


Practice Setting

The Interview

The Contract




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Insurance Company• A business designed to be a clearing house for

funds used to finance health care • Collection of premiums - payout of benefits = profit • Such companies do not provide health care • They pay for health care • Profit is derived by paying.... • Less for services • For fewer services

• Their goal: earn a profit for investors • The Golden Rule

Business Concepts• What are receivables? • What are payables? • Payer mix? • What s a PPO, HMO, POS, Indemnity

plan?• ACA and the narrow network• What s a co-pay? • What does it mean to participate... • with Medicare? • with the Blues, a PPO, or an HMO?

Physician as Government Contractor

I m from the Government... and I m Here to Help You

• HIPAA• Stark• OSHA• CLIA• E & M coding compliance • Medicare Modernization Act • P4P/Quality/PQRI/PQRS • Meaningful Use and the EHR • Price controls and the SGR • ACA• ACO s, Bundled Payment and PCMH

Be Careful Out There!


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Program Materials CSRO

Page 33CSRO Fellows ConferencePage 32 CSRO Fellows Conference

1/27/2016

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Insurance Company• A business designed to be a clearing house for

funds used to finance health care • Collection of premiums - payout of benefits = profit • Such companies do not provide health care • They pay for health care • Profit is derived by paying.... • Less for services • For fewer services

• Their goal: earn a profit for investors • The Golden Rule

Business Concepts• What are receivables? • What are payables? • Payer mix? • What s a PPO, HMO, POS, Indemnity

plan?• ACA and the narrow network• What s a co-pay? • What does it mean to participate... • with Medicare? • with the Blues, a PPO, or an HMO?

Physician as Government Contractor

I m from the Government... and I m Here to Help You

• HIPAA• Stark• OSHA• CLIA• E & M coding compliance • Medicare Modernization Act • P4P/Quality/PQRI/PQRS • Meaningful Use and the EHR • Price controls and the SGR • ACA• ACO s, Bundled Payment and PCMH

Be Careful Out There!

10:00 a.m. - 10:45 a.m.

*Systemic Lupus UpdateMichelle Petri, MD, MPH

*This session is CME accredited by a third party, and is applicable to any physician in the room. Please see separate handout for full information.



Systemic Lupus UpdateMichelle Petri, MD, MPH

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Evaluation and Management of Systemic Lupus Erythematosus, 2015

Michelle Petri, MD, MPH Professor of Medicine,

Johns Hopkins University School of Medicine Director, Hopkins Lupus Center

Baltimore, MD

February 20, 2016 CSRO

JW Marriott San Francisco, CA

• This CME activity is intended for practicing physicians, and other health care providers who may treat patients who have Systemic Lupus Erythematosus.

• There is no fee for participation in this CME activity.

This program is made possible through an

educational grant from UCB, Inc.

Accreditation

This activity has been planned and implemented in accordance with the accreditation requirements and policies of the Accreditation Council for Continuing Medical Education (ACCME) through the joint providership of University Health Services Professional Education Programs (UHS-PEP) of Virginia Commonwealth University Health System and Miller Professional Group. UHS-PEP is accredited by the ACCME to provide continuing medical education for physicians.

UHS-PEP designates this live activity for a maximum of 1.0 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

CME Credit Statements

To receive continuing education credit, please complete the evaluation and Verification of Participation form and submit following the meeting. Credit Statements will be mailed within four weeks of activity completion.

IT IS ALSO A REQUIREMENT UPON EACH SPEAKER TO NOTIFY HIS/HER AUDIENCE

WHENEVER OFF-LABEL USE IS DISCUSSED.

Please Complete and Return

In the CME section of your meeting folders you will find the

• Program evaluation form

• Verification of participation form

These documents are used to evaluate the effectiveness of our programming, and to justify future educational programs of this quality.

Please be sure to return these completed forms to the speaker at the end of the program.

Please be aware you will receive (via e-mail) a follow-up questionnaire similar to the educational effectiveness survey you will complete for this program. It will come from the e-mail address [email protected]

Please be sure to return the completed follow up questionnaire.




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Conflict of Interest Disclosures

Presenters

Michelle Petri, MD has reported participated in clinical trials for GSK, Medimmune, Pfizer and UCB; and is a Consultant for GSK, Pfizer, UCB and BMS.

The Planners of this activity report the following disclosure information:

John Boothby, Director, Continuing Medical Education, UHS-PEP has nothing to disclose.

Alan Epstein, MD is a member of the Speaker’s Bureau for Abbvie, Janssen, BMS, Celgene, Pfizer, Genentech and GSK.

Max Hamburger, MD is a member of the Speaker’s Bureau for UCB, BMS, Abbvie, Crescendo Bio and GSK; and is a Grant Recipient for UCB, BMS and Abbvie.

Objectives Upon completion of this program, attendees will be able to:

• Evaluate the importance of the disease burden in SLE, consequences of inadequate disease control, and consequences of inflammatory burden on patients, their families, their communities and the healthcare system;

• Describe and discuss the impact of disease activity on patient outcomes, and the challenges of implementing treat to target concepts as applicable in the management of this highly pleomorphic disease;

• Apply current concepts of management including approaches to measurement of organ inflammation and/or involvement and disease activity;

• Collaborate with patients in the implementation of treatment goals; and

• Apply the principles of evidence based medicine to optimize SLE patient care by

1) Effectively using currently available tools for assessing disease activity in patients with lupus; evaluating the EULAR monitoring guidelines and applying them into the care of their lupus patients; and

2) Applying the treatment strategies from the EULAR and ACR guidelines and SLICC in their clinical practices and thereby optimizing patient care and functioning.

Treat to Target(s)

The Lupus 12 Step Program Michelle Petri MD MPH

Johns Hopkins University School of Medicine

1. Classification Criteria Help in Everyday Practice (i.e. Diagnosis)

SLICC* Classification Criteria At least 1 clinical + at least 1 immunologic

criterion (for a total of 4) OR

lupus nephritis by biopsy (in the presence of ANA or anti-DNA antibodies)

Petri M et al. Arthritis Rheum. 2012;64:2677-2686.

*Systemic Lupus International Collaborating Clinics

SLICC has recommended that BOTH the revised

ACR criteria AND the new SLICC classification criteria be used

SLICC Revision of ACR Classification Criteria Clinical Criteria 1. Acute/subacute cutaneous lupus 2. Chronic cutaneous lupus 3. Oral/Nasal ulcers 4. Non-scarring alopecia 5. Inflammatory synovitis with physician-observed swelling of two or more joints OR tender joints with morning stiffness 6. Serositis 7. Renal: Urine protein/creatinine (or 24-hr urine protein) representing at least 500 mg of protein/24 hr or red blood cell casts 8. Neurologic: seizures, psychosis, mononeuritis multiplex, myelitis, peripheral or cranial neuropathy, cerebritis (acute confusional state) 9. Hemolytic anemia 10. Leukopenia (<4000/mm3 at least once) OR Lymphopenia (<1000/mm3 at least once) 11. Thrombocytopenia (<100,000/mm3) at least once


DERMATOLGIC

4 OTHER SYSTEMS

HEMATOLOGIC




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SLICC Revision of ACR Classification Criteria Immunologic Criteria 1. ANA above laboratory reference range 2. Anti-dsDNA above laboratory reference range (except ELISA: >2-fold laboratory reference range)

3. Anti-Sm 4. Antiphospholipid antibody lupus anticoagulant false-positive test for syphilis anticardiolipin — at least twice normal or medium-high titer anti-b2 glycoprotein 1

5. Low complement low C3 low C4 low CH50

6. Direct Coombs’ test in absence of hemolytic anemia


2. Understand Lupus Activity Indices Used in Clinical Trials

(Measure Activity That is Really Lupus)

Physician’s Global Assessment (PGA)

0 1 2 3 ‘Severe’ means the worst in the universe of lupus,

not the worst for an individual patient

1. Furie, RA et al. Arthritis Rheum 61:1143-51. 2. Petri et al. J Rheumatol 1992;19:53-9.

• Used to assess the patient’s overall condition

• A visual analogue scale (10cm) ranging from 0–3 points (no activity to severe life-threatening activity)

• -point increase (10%) = clinically-relevant worsening1

• Correlates with other disease activity indices2

Petri M at al. N Engl J Med. 2005 Dec 15;353(24):2550-8;

SELENA-SLEDAI

SELENA-SLEDAI Flare index

Petri M at al. N Engl J Med. 2005 Dec 15;353(24):2550-8;

9 Organ Systems are individually scored: Constitutional, Mucocutaneous, Neuropsychiatric, Musculoskeletal, Cardiorespiratory, Gastrointestinal, Ophthalmic, Renal, Haematological Each organ is scored for severity over the past month: based on the net impact of individual symptoms A=severe B=moderate C=mild D=inactive organ E=never active organ

Symptom Last Month Progress This Month Score Organ System

Severe Arthritis Same or Worse A Musculoskeletal

Severe Arthritis Significantly Improving B Musculoskeletal

No Rash New Severe Rash A Mucocutaneous

Severe Rash Significantly Improving B Mucocutaneous

Moderate Rash Significantly Improving C Mucocutaneous

BILAG 2004




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SLE Responder Index (SRI) Used in Belimumab Phase III Trials

1. Petri M at al. N Engl J Med. 2005 Dec 15;353(24):2550-8; 2. Hay EM, et al. Q J Med. 1993;86(7):447-458; 3.Navarra SV, et al. Lancet 2011;377:721-31.

SRI

SELENA-SLEDAI ≥4-point reduction in

SELENA-SLEDAI score1

Assesses 24 weighted variables to indicate

overall disease severity

BILAG No new BILAG A or

2 new BILAG B organ domain scores2

Measures flare activity and severity across

8 organ domains

PGA No worsening in PGA (<0.3-point increase)3

An overall assessment of changes in patient condition

and disease severity

SRI Responders Had to Meet All 3 Criteria

Landmark assessment All organs with moderate or severe activity at baseline (BILAG A) have improved: BILAG A (severe) improves to B (moderate) C (mild) or D (no activity) BILAG B (moderate) improves to C (mild) or D (no activity) and There is no worsening by BILAG, SLEDAI or Physician’s Global Assessment (PGA may not increase by more than 10% of the scale)

BILAG-based Composite Lupus Assessment: BICLA Used in Epratuzumab Phase II and III Trials

SLE Responder Index: Responders vs Nonresponders

Furie R et al. ACR 2011; Strand V et al. ACR 2011

Parameter SRI Resp (n=761)

SRI Nonresp (n=923)

> 7 point reduction 40.3% 1.3%

# organ domains improved (BILAG/SS) 1.45/2.00 0.40/0.39

% Change in PGA -58.3% -34.9%

Severe flare rate (SLE Flare Index) at wk 52 6.2% 29.1%

Reduction in prednisone to <7.5 mg/d 25.5% 16.4%

Increase in prednisone to >7.5 mg/d 4% 22%

Changes in DNA/C3/C4 -34%/14%/40% -26%/9%/29%

SF-36: PCS/MCS (MCID=2.5) 4.9/4.4 2.6/1.7

Fatigue (FACIT/SF-36 Vitality; MCID=4/5) 5.2/10.4 3/6.5

Furie et al. Lupus Sci Med. 2014 Jun 26;1:e000031. doi: 10.1136/lupus-2014

3. Avoid Maintenance Prednisone > 6 mg

Prednisone Is Directly or Indirectly Responsible for 80% of Organ Damage over 15 Years

Gladman DD, et al. J Rheum. 2003;30(9):1955-1959

CVS=cardiovascular system; GI=gastrointestinal; MSK=musculoskeletal NP=neuropsychiatric




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A Prednisone Dose of 6 mg or More Increases Organ Damage by 50%

Prednisone Average Dose Hazard Ratio

>0-6 mg/day 1.16

>6-12 mg/day 1.50

>12-18 mg/day 1.64

>18 mg/day 2.51

Thamer M et al. J Rheumatol. 2009;36:560-564.

Adjusted for confounding by indication due to SLE disease activity

Prednisone Itself Increases the Risk of Cardiovascular Events

Prednisone use

Observed

Number of CVEs

Rate of Events/1000

Person-Years

Age-Adjusted Rate Ratios

(95% CI)

P Value

Never taken 22 13.3 1.0 (reference group)

Currently taking

1-9 mg/d 32 12.3 1.3 (0.8, 2.0) 0.31

10-19 mg/d 31 20.2 2.4 (1.5, 3.8) 0.0002

20+mg/d 25 35.4 5.1 (3.1,8.4) <0.0001

Magder LS, Petri M. Am J Epidemol. 2012;176:708-719.

4. Non-immunosuppressive Immunomodulators Can Control Mild-Moderate SLE, Helping to

Avoid Steroids

Immunomodulators

• Hydroxychloroquine1

• Vitamin D2

• Prasterone (synthetic dihydroepiandrosterone, or DHEA)3

1. Petri M. Lupus. 1996;5(Suppl 1):S16-S22. 2. Petri M et al. Arthritis Rheum. 2013;65:1865-1871 . 3 Petri M et al. Arthritis Rheum. 2002;46:1820-1829.

Hydroxychloroquine as Background Therapy

Reduction in Flares Canadian Hydroxychloroquine Study Group. N Engl J Med. 1991;324:150-154.

Reduction in organ damage Fessler BJ et al. Arthritis Rheum. 2005;52:1473-1480.

Reduction in lipids Petri M. Lupus. 1996;5(Suppl. 1):S16-S22. Wallace DJ et al. Am J Med. 1990;89:322-326.

Reduction in thrombosis Pierangeli SS, Harris EN. Lupus. 1996;5:451-455. Petri M. Scand J Rheumatol. 1996;25:191-193.

Improvement in survival Alarcon GS et al. Arthritis Rheum. 2005;52:S726. Ruiz-Irastorza G et al. Lupus. 2005;14:220.

Triples mycophenolate mofetil response

Kasitanon N et al. Lupus. 2006;15:366-370.

Prevents seizure Hanly JG et al. Ann Rheum Dis. 2012;71;1502-1509.

Hydroxychloroquine for Lupus Nephritis

Continuing hydroxychloroquine improves complete response rates with

mycophenolate mofetil

Kasitanon N et al. Lupus 2006;15:366-370.




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Criteria of Low and Higher Risk for Developing Retinopathy

Low Risk Higher Risk

Dosage < 6.5 mg/kg hydroxychloroquine < 3 mg/kg chloroquine

>6.5 mg/kg hydroxychloroquine > 3 mg/kg chloroquine

Duration of use < 5 years > 5 years

Habitus Lean or average fat High fat level (unless dosage is appropriately low)

Renal/liver disease None Present

Concomitant retinal disease

None Present

Age < 60 years > 60 years

Marmor MF et al. Ophthalmol 2002;109:1377-82.

Only SLE Patients with Visual Symptoms Need High Tech hsUHR-OCT (Optical Coherence Tomography) or mfERG (multifocal electroretinogram)

Rodriguez-Padilla JA, et al. Arch Ophthalmol 2007;125:775-80.

• Optical Coherence Tomography • Serous retinopathy

• Multifocal Electroretinogram • Cataracts

Common Causes of Abnormalities

Top: Normal Spectralis spectral domain optical coherence tomography (SD OCT) image with intact photoreceptor inner segment/outer segment junction (IS/OS). Bottom: Spectralis SD OCT from the left eye of patient 10 showing the “flying saucer” sign of hydroxychloroquine retinopathy, an ovoid appearance of the central fovea created by preservation of central foveal outer retinal structures (seen between the black arrows) surrounded by perifoveal loss of the photoreceptor IS/OS junction, and perifoveal outer retinal thinning. Abbreviations: ILM, internal limiting membrane; IPL, inner plexiform layer; OPL, outer plexiform layer; ELM, external limiting membrane; RPE, retinal pigment epithelium. From: Chen E1, Brown DM, Benz MS, Fish RH, Wong TP, Kim RY, Major JC. Spectral domain optical coherence tomography as an effective screening test for hydroxychloroquine retinopathy (the “flying saucer” sign). Clin Ophthalmol. 2010 Oct 21;4:1151-8. doi: 10.2147/OPTH.S14257.

High-Speed Ultra–High-Resolution Optical Coherence Tomography Findings in Hydroxychloroquine Retinopathy¹ Question: are early toxic effects from hydroxychloroquine

(HCQ) detectable by hsUHR-OCT before clinical signs or symptoms

Fifteen patients referred for evaluation of HCQ maculopathy were studied.

Six age-matched patients with normal visual function were studied with hsUHR-OCT

hsUHR-OCT abnormality severity of maculopathy seemed to correlate with severity of mfERG and visual field testing

Unable to find an asymptomatic patient with evidence of definite damage on hsUHR-OCT ¹Julio A. Rodriguez-Padilla, et al, Arch Ophthalmol. 2007;125:775-78J0

Increasing 25-Hydroxy Vitamin D Modestly Helps Disease Activity and Urine Protein/CR

Disease Measure Slope over range

of 0-40 ng/mL (95% CI)

P-value Slope over range

of ≥ ng/mL (95% CI)

P-value

Physician’s Global Assessment

–0.04 (–0.08, –0.01) 0.026 0.01

(–0.02, 0.04) 0.50

SELENA-SLEDAI –0.22 (–0.41, –0.02) 0.032 0.12

(–0.01, 0.24) 0.065

Log Urinary Protein/Creatinine

–0.03 (–0.05, –0.02) 0.0004 –0.01

(–0.01, 0.00) 0.24


SELENA-SLEDAI = Safety of Estrogens in Lupus Erythematosus National Assessment version of the Systemic Lupus Erythematosus Disease Activity Index.

Model allowing slope to differ before and after 40 ng/mL




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20-Unit Increase in 25-Hydroxy Vitamin D • 13% decrease in odds of having a PGA score of

1 or more

• 21% decrease in odds of having a SLEDAI score of 5 or more

• 15% decrease in odds of having a urine pr/cr > 0.5

Petri, et al. Arthritis Rheum 2013;65:1865-71

Vitamin D May Have Cardiovascular and Hematologic Benefits

Targher G et al. Semin Thromb Hemostasis. 2012;38:114-124.

Vitamin D Reduced Thrombosis in Some Clinical Studies

• Cancer RCT: calcitriol+docetaxel vs. docetaxel (P=0.01)1

• General population lowest tertile of vitamin D: • 37% (CI 15-64%) increased rate of VTE2

• Higher rates of VTE in African-Americans3

• VTE are seasonal: highest risk in winter; sunbathing reduces rise of VTE by 30%4

• Honolulu Heart Program: Low vitamin D predicted 34-year incident stroke in Japanese-American men. HR 1.22 (CI 1.02-1.47), P=0.0385

• Asian Indian cohort: mean vitamin D lower in CAD P=0.0366

1. Beer TM et al. Br J Haematol. 2006;135:392-394. 2. Brøndum-Jacobsen P et al. J Thromb Haemost . 2013;11:423-431. 3. Grant WB. Am J Hematol. 2010;85:908. 4. Lindqvist PG et al. J Thromb Haemost . 2009;7:605-610. 5. Kojima G et al. Stroke. 2012;43:2163-2167. 6. Shanker J et al. Coron Artery Dis. 2011;22:324-332.

DHEA (Prasterone) 200 mg Daily

• NOT FDA-approved • In women with disease activity, reduction in prednisone to 5 mg day achieved in 51 vs 29% on placebo (P=0.03).1

• In women with disease activity, improvement or stabilization achieved in 58.5% vs. 44.5% on placebo (P=0.017)2

1. Petri M et al. Arthritis Rheum. 2002;46:1820-1829. 2. Petri M et al. Arthritis Rheum. 2004;50:2858-2868.

Prasterone Reduces SLE Flares DHEA and Bone Density

• Prasterone provides mild protection against bone loss

• At month 18 with 200 mg vs. 100 mg: Dose-dependent increase in spine BMD (P=0.02)

Sanchez-Guerrero J et al. J Rheumatol. 2008;35:1567-1575.




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5. Treatment of Lupus Nephritis is NOT Just Immunosuppression!

ACR Guidelines for Kidney Biopsy

Indications for Kidney Biopsy* Increasing serum creatinine without compelling alternative causes (eg, sepsis, hypovolemia, or medication)

Confirmed proteinuria of 1.0 gm/24 hours (either 24-hour urine specimens or spot protein-creatinine ratios)

Combinations of the following, assuming the findings are confirmed in at least 2 tests done within a short period of time and in the absence of alternative causes:

• Proteinuria 0.5 gm per 24 hours plus hematuria, defined as 5 RBCs per HPF

• Proteinuria 0.5 gm per 24 hours plus cellular casts

*All recommendations are level of evidence C. Hahn BH, et al. Arthritis Care Res. 2012;64:797-808.

EULAR Guidelines for Kidney Biopsy

Indications for Kidney Biopsy Level of

Evidence Statement Strength

Any sign of renal involvement; in particular, urinary findings including reproduci le proteinuria ≥ 5 g hours especially with glomerular haematuria and/or cellular casts

2 C

Clinical, serological or laboratory tests correlate modestly with renal biopsy findings. Proteinuria of ≥ 5 g hours

2 B

Bertsias GK, et al. Ann Rheum Dis. 2012;71:1771-1782.

Adjunctive Therapy for Proteinuria

ACE-inhibitor

Angiotensin receptor blocker Duran-Barragan S, et al. Rheumatology 2008 47:1093-1096.

Spironolactone 25 mg or eplerenone 50 mg Epstein. Am J Med 2006;119:912-919.

ACR Guidelines: Adjunctive Therapies All SLE patients with nephritis should be treated with a background of

hydroxychloroquine unless there is a contraindication (level C evidence)

For patients with proteinuria 0.5 gm/24 hours (or equivalent by protein/creatinine ratios on spot urine samples), a blockade of the renin–angiotensin system, which drives intraglomerular pressure, is recommended (level A evidence for nondiabetic chronic renal disease)

Target blood pressure of 130/80 mm Hg (level A evidence for nondiabetic chronic renal disease)

Statin therapy should be introduced in patients with low-density lipoprotein cholesterol 100 mg/dL (level C evidence)

Women of child-bearing potential with active or prior lupus nephritis receive should counseling regarding pregnancy risks conferred by the disease and its treatments (level C evidence)

Hahn BH, et al. Arthritis Care Res. 2012;64:797-808.

EULAR Guidelines: Adjunctive Therapies Angiotensin-converting enzyme (ACE) inhibitors or angiotensin

receptor blockers (ARBs) for proteinuria or hypertension (level of evidence: 2; strength of statement: B)

Cholesterol lowering with statins for persistent dyslipidaemia (strength of statement: C)

Hydroxychloroquine (level of evidence: 3; strength of statement: C) Acetyl-salicylic acid in patients with anti-phospholipid antibodies

(strength of statement: C) Calcium and vitamin D supplementation (strength of statement: C)

Bertsias GK, et al. Ann Rheum Dis. 2012;71:1771-1782.




Page 9 of 20

Initial Therapy: Class IV

ACR – Mycophenolate mofetil (2-3 gm total daily orally) or IV cyclophosphamide along

with glucocorticoids is recommended (level A evidence) • Evidence suggestions that mycophenolate mofetil may be more likely to

induce improvement in patients who are African American or Hispanic EULAR

– Mycophenolic acid (mycophenolate mofetil target dose: 3 g.day for 6 months or mycophenolic acid sodium at equivalent dose) (level of evidence: 1; statement strength: A) or low-dose intravenous cyclophosphamide (total dose 3 g over 3 months) in combination with glucocorticoids (level of evidence: 1; statement strength: B) are recommended as initial treatment as they have the best efficacy/toxicity ratio

Hahn BH, et al. Arthritis Care Res. 2012;64:797-808. Bertsias GK, et al. Ann Rheum Dis. 2012;71:1771-1782.

Non-Caucasians Do Better with Mycophenolate

0

10

20

30

40

50

60

70

Asian Caucasion Combined Other* African American

Mycophenolate Mofetil IV Cyclophosphamide

P = 0.24

P = 0.83 P = .03

P = 0.39

Post Hoc Analysis

Resp

onde

rs (%

)

*Includes African Americans. Isenberg D, et al. Rheumatology (Oxford). 2010;49:128-140.

Initial Therapy: Class IV How Much Steroid? ACR

– Pulse IV glucocorticoids (500-1000 mg methylprednisolone daily for 3 doses) in combination with immunosuppressive therapy is recommended, followed by daily oral glucocorticoids (0.5-1 mg/kg/ day), followed by a taper to the minimal amount necessary to control disease (level C evidence)

EULAR – To increase efficacy and reduce cumulative glucocorticoid doses,

treatment regimens should be combined initially with 3 consecutive pulses of IV methylprednisolone 500-750 mg, followed by oral prednisone 0.5 mg/kg/day for 4 weeks, reducing to 1 mg day y -6 months

Hahn BH, et al. Arthritis Care Res. 2012;64:797-808. Bertsias GK, et al. Ann Rheum Dis. 2012;71:1771-1782.

There May Still Be a Role for Rituximab: Can We Avoid Steroids?

Condon MB, et al. Ann Rheum Dis. 2013;72:1280-6; Fischer-Betz et al. J Rheumatol. 2012;39:2111-7.

Multitarget Therapy for Induction Treatment of Lupus Nephritis

Multi-Target (Tacrolimus + MMF) IV Cytoxan

Complete Remission 45.9% 25.6%

Overall Response 83.5% 63.0%

Liu Z, et al. Ann Intern Med 2015;162:18-26.

Lupus Nephritis Maintenance Therapy : MMF is Superior to Azathioprine

Time to treatment failure Time to renal flare N=227

Dooley MA, et al. N Engl J Med. 2011;365:1886-95. Not FDA-indicated for SLE




Page 10 of 20

Lupus Nephritis: Other Options • Belimumab

• Not studied specifically in SLE patients with active nephritis1,2 • Leflunomide

• For mild-to-moderate SLE disease3

• Induction therapy for renal flare4,5 • Tacrolimus

• Consider in MMF-resistant or partial response patients, alone or in combination6-

9,12 • Approved for treatment of LN in Japan • For severe nephritis (Class IV/V)6,10

• Rituximab • LUNAR trial was negative11

1. Navarra S, et al. Lancet. 2011;377(9767):721-31; 2. Dooley MA, et al. ACR/AHCP annual meeting. November 4-9, 2011;Chicago, IL; 3. Tam LS, et al. Lupus. 2004;13:601-4; 4. Wang HY, et al. Lupus. 2008;17(638-44); 5. Tam LD, et al. Ann Rheum Dis. 2006;65:417-8; 6. Yap DY et al. Nephrology. 2012; 10.1111/j.1440-1797.2012.01574.x; 7. Li X, et al. Nephrol Dial Transplant. 2011; doi: 10.1093/ndt/gfr484; 8. Cortes-Hernandez J, et al; Nephrol Dial Transplant. 2010;25(12):3939-489. 9. Lanata CM, et al. Lupus. 2010:19(8):935-40. 10. Szeto CC, et al. Rheumatology. 2008;47(11):1678-81; 11. Rovin BH, et al. Arth Rheum. 2012; doi: 10.1002/art.34359. 12. Chen W, et al. Lupus. 2012:21(7):944-952.

Leflunomide, tacrolimus, and rituximab are not FDA-indicated for SLE

6. Biologics in SLE

There are Many Potential Targets for SLE Biologics

M. Ramanujam and A. Davidson. Arthritis Research and Therapy. 2004. 6:197-202.

Adapted from Ramanujam M, Davidson A. Arthritis Res Therapy. 2004;6:197-202.

X

TACI-Ig BAFF-R-Ig Anti-BLyS

X X CTLA4Ig

X

X E-mab CTX

Anti-CD40L Anti-CD40L X

X Sifalimumab

X Anti-IL-6

A Post-hoc Analysis Identifies SLE Patients Likely to Respond to Belimumab

Characteristics associated with greater treatment effect (p<0.1) Complement: low C3/C4 (vs normal) Steroid use: greater (vs no/less) Characteristics not associated with treatment effect (p>0.1) Study Region Race

van Vollenhoven, et al. Ann Rheum Dis, 2012. [April Epub ahead of print, doi: 10.1136/annrheumdis-2011-200937].

The Subgroup with BOTH High Anti-dsDNA and Low Complement is About 20% More Likely to

Respond to Belimumab

van Vollenhoven RF, et al. Presented at EULAR 2011; May 25-28, 2011; London, UK

A Post-hoc Analysis Shows the Organ Systems that Respond to Belimumab

Improvement = decrease in SS score within an organ domain

Manzi S, et al. Ann Rheum Dis, 2012. [May Epub ahead of print, doi: 10.1136/annrheumdis-2011-200831].




Page 11 of 20

Belimumab Reduced Severe Flares

Cervera R, et al. Presented at EULAR 2011: Annual European Congress of Rheumatology; May 25–28, 2011; London, UK

Open label 296 patients

SLE Responder Index Year 2 – 57% Year 7 65%

Anti-dsDNA 40-60%

Prednisone 50-55

Seven Year Followup on Belimumab

Ginzler EM, et al. J Rheumatol. 2014;41:300-7

1Tedder T F & Engel P. Immunol Today. 1994;15:450-454. 2Mok M Y. Int J Rheum Dis. 2010;13(1):3-11. 3Dörner T et al. Int Rev Immunol. 2012;31:363-378. 4Sieger N et al. Arth Rheum. 2013;65:770-779.

Epratuzumab (Anti-CD22) Mechanism of Action 2. CD22 negatively

regulates the BCR on B cells3

Effector molecule recruitment3

CD22

1. Antigen binds to the BCR and induces B cell

activation1,2

Cascade of downstream signalling leading to calcium influx1

Gene transcription1

B cell activation2

BCR

CD79α/β

5Carnahan J et al. Clin Cancer Res. 2003;9:3982S-90S. 6Qu Z et al. Blood. 2008;111:2211-2219. 7Rossi E A et al. Blood. 2013;122:3020-3029. 8Jacobi A M et al. Ann Rheum Dis 2008;67:450–457.

3. Emab binds CD22 and acts as a regulator of BCR-driven

activation of B cells3

Internalisation5 and removal of BCR

proteins from the B cell surface7

Reduced calcium flux4

Reduced BCR signalling4

B cell modulation8

Localisation4

CD22 phosphorylation5,6

Internalisationremoval of BCR

proteins from the B cell surface

Reduced calcium flux4

Reduced BCR signalling4

B cell modulationB cell modulation8

Localisation4

CD22 phosphorylation

This

doc

umen

t is

for i

nter

nal u

se o

nly

Epratuzumab is not currently approved for the treatm

ent of SLE

Glossary

Epratuzumab Mechanism of Action Epratuzumab induces the loss of BCR-related proteins from the B cell surface in vitro

Adapted from Rossi, E. et al. Blood. 2013; 122(17):3020-29

% o

f unt

reat

ed

Epratuzumab

Labetuzumab (isotype control)

CD22 internalised into B cells

CD19 trogocytosis on to monocytes

Experiments with Daudi B cell line and primary human monocytes

Experiments with primary human B cells

7. SLE Pregnancy is High Risk

•4,500/year U.S. SLE pregnancies

•20-fold increase mortality

•OR 1.7 C-section

•OR 2.4 Preterm labor

•OR 3.0 Pre-eclampsia

Ginzler EM, et al. Am J Obstet Gynecol. 2008;199:127.e1-6

Adverse Pregnancy Outcome

APO No APO

LAC 39% 3% (p < 0.0001)

Lockshin MD et al. Arthritis Rheum. 64:2311-8, 2012.




Page 12 of 20

Comparison of Heparin/Aspirin vs Aspirin for Pregnancy-APS

Author Year Size Comparison Arm 1

Comparison Arm 2

Study Outcome

Kutteh 1996 50 Heparin initiated at 10,000 units daily in 2 divided doses

Aspirin 81 mg/day

Aspirin 81 mg Heparin/aspirin

Rai 1997 90 UF Heparin 5000 units twice daily

Aspirin 75 mg

Aspirin 75 mg Heparin/aspirin

Farquharson 2002 98 LMW Heparin 5000 units

Aspirin 75 mg

Aspirin 75 mg No difference

8. Progress on Coronary Artery Disease

Coronary Artery Disease in SLE

• Substantial increased risk that cannot be completely explained by traditional Framingham risk factors1

• Hospitalization for acute myocardial infarction (AMI) 2.3

times higher in SLE2

• Risk of cardiovascular events is 2.66 times higher in SLE vs Framingham cohort3

1. Esdaile JM, et al. Arthritis Rheum 2001;44: 2331-7; 2. Ward MM. Arthritis Rheum. 1999;42(2):338-46; 3. Magder LS, Petri M. Am J Epidemiol. In press.

How Can We Detect Cardiovascular Disease Early in SLE?

• Coronary calcium CT1 • Carotid duplex2 • In the FUTURE, techniques such as coronary CTA can detect early noncalcified coronary plaques3

1. Kiani AN et al. J Rheumatol. 2008;35:1300-1306. 2. Maksimowicz-McKinnon K et al. J Rheumatol. 2006;33:2458-2463. 3. Kiani AN et al. J Rheumatol. 2010;37:579-584.

Prevention of CAD in SLE

Atorvastatin Did Not Change

1. Coronary calcium 2. Carotid intima media thickness 3. Carotid plaque

Petri M et al. Ann Rheum Dis 2010;70:760-765. Schanberg LE et al. Arthritis Rheum. 2012;64:285-296.




Page 13 of 20

• Assess traditional cardiovascular risk factors and treat to target • Hypertension • Obesity • Hyperlipidemia (hydroxychloroquine) • Smoking • Sedentary Lifestyle • Diabetes (hydroxychloroquine)

• Statin did NOT reduce progression in mice3 nor in two clinical trials:

• Adult1 • Pediatric2

• Mycophenolate: slowed progression in mice3 and transplant patients4

• Prednisone > 10 mg

increases CV event risk5

Can We Reduce Cardiovascular Risk?

1. Petri MA, et al. Ann Rheum Dis. 2011;70(5):760-5; 2. Schanberg LE, et al. Arthtiris Rheum. 2012;64(1):285-96; 3. van Leuven SI, et al. Ann Rheum Dis. 2012 ;71(3):408-14; 4. Gibson WT, Hayden MR. Ann N Y Acad Sci. 2007 Sep;1110:209-21; 5. Magder L, et al. Am J Epidemiol. 2012; in press.

9. Prevention of Thrombosis in SLE: Are We There Yet?

Lupus Anticoagulant Is More Highly Associated With Thrombosis Risk

Petri M, et al. Ann Intern Med. 1987;106(4):524–531.

Derksen RH, et al. Ann Rheum Dis. 1988;47(5):364–371.

Ginsberg JS, et al. Blood. 1995;86(10):3685–3689.

Horbach DA, et al. Thromb Haemost. 1996;76(6):916–924.

Simioni P, et al. Thromb Haemost. 1996;76(2):187–189.

Wahl DG, et al. Lupus. 1997;6(5):467-73.

Somers E, Magder LS, Petri M. J Rheumatol. 2002;29:2531–2536.

Time Since SLE Diagnosis (years)

Cum

ulat

ive

S(t)

If Lupus Anticoagulant is Present, There is a 50% Chance of Thrombosis

Aspirin Insufficient for APS Prophylaxis

Aspirin has NOT been proven effective to reduce thrombosis from antiphospholipid antibodies Ginsburg KS, et al. Ann Intern Med. 1992;117:997–1002; Erkan et al. Arthritis Rheum 2007;56:2382-2391.

Erkan et al. Arthritis Rheum. 2001;44:1466–1467.

Hydroxychloroquine Prevents Thrombosis in SLE

Study Study Design Outcome

Wallace et al, 1987 retrospective P < 0.05

Petri et al, 1994 prospective cohort OR 0.3

Ruiz-Irastorza et al, 2006 prospective cohort HR 0.28

Tektonidou et al, 2009 case-control HR 0.99

Jung et al, 2010 nested case-control OR 0.31

Petri M. Curr Rheumatol Reports 2010:13:77-80




Page 14 of 20

10. Don’t Make Fibromyalgia WORSE (It’s Bad Enough as it is!)

Treating Pain: Tai Chi

12 weeks 79% of tai chi group vs 39% of control had clinically meaningful improvement* (P=0.0001) 24 weeks 82% of tai chi vs 53% control had clinically meaningful improvement (P=0.009)

FIQ=fibromyalgia impact questionnaire; *”clinically meaningful” change in FIQ = 8.1 points

Wang C, et al. N Engl J Med.2010;363(8):743-754.

Fatigue • Among most common complaints in lupus patients (50-

80% of patients)1

• Chronic fatigue does not correlate with disease activity2

• Highly correlated with fibromyalgia, pain, depression,

sleep abnormalities, poor quality of life2-5

• Associated with reduced physical fitness6

1. Tench CM et al. Rheumatology. 2000;39(11):1249–54; 2. Wang B, et al. J Rheumatol. 1998;25(5):892-5; 3. Gladman D, et al. J Rheum. 1997;24:2145-9; 4. Bruce IN, et al. Arthritis Rheum. 1998; 41(suppl.9):S333; 5. Carr FN, et al. ACR/AHCP annual meeting. November 4-9, 2011;Chicago, IL.

Exercise for SLE-related Fatigue

Clinical global impression change score

No (%) in exercise group (n=33)

No (%) in relaxation group (n=28)

No (%) in control group (n=32)

Very much better 3 (9) 4 (14) 1 (3)

Much better 13 (40) 4 (14) 4 (13)

A little better 5(15) 4(14) 3(9)

No change 6(18) 10(36) 14(41)

A little worse 4(12) 4(15) 10(31)

Much worse 2(6) 2(7) 1(3)

Very much worse 0 0 0

Tench CM, et al. Rheumatology. 2003;42:1050-54.

11. Don’t Forget New Information on Common Drugs

Cardiovascular Risk of NSAIDS

Salvo F, et al. Cardiovascular events associated with the long-term use of NSAIDs: a review of randomized controlled trials and observational studies. Expert Opin Drug Saf. 2014;13:573-85.

Chinthapalli K. High dose NSAIDs may double the risk of heart attacks and heart failure, says new study. BMJ. 2013;346:f3533.

Trelle S, et al. Cardiovascular safety of non-steroidal anti-inflammatory drugs: network meta-analysis. BMJ. 2011;342:c7086.




Page 15 of 20

New Data on PPIs

Proton Pump Inhibitors Increase Osteoporotic Fractures Yu EW, et al. Proton pump inhibitors and risk of fractures: a

meta-analysis of 11 international studies. Am J Med. 2011;124:519-26.

Maggio M, et al. Use of proton pump inhibitors is associated with lower trabecular bone density in older individuals. Bone. 2013;57:437-42.

Ding J, et al. The relationship between proton pump inhibitor adherence and fracture risk in the elderly. Calcif Tissue Int. 2014;94:597-607.

Moberg LM, et al. Use of proton pump inhibitors (PPI) and history of earlier fracture are independent risk factors for fracture in postmenopausal women. The WHILA study. Maturitas. 2014;78:310-5

Proton-Pump Inhibitors Increase Risk of Cardiovascular Events Ghebremariam YT, et al. Unexpected effect of proton pump

inhibitors: elevation of the cardiovascular risk factor asymmetric dimethylarginine. Circulation. 2013;128:845-53

Zou JJ, et al. Increased risk for developing major adverse cardiovascular events in stented Chinese patients treated with dual antiplatelet therapy after concomitant use of the proton pump inhibitor. PLoS One. 2014;9(1):e84985.

Shih CJ, et al. Proton pump inhibitor use represents an independent risk factor for myocardial infarction. Int J Cardiol. 2014;177:292-7.

Leonard CE, Comparative Risk of Ischemic Stroke Among Users of Clopidogrel Together With Individual Proton Pump Inhibitors. Stroke. 2015 Feb 5. pii: STROKEAHA.114.006866. [Epub ahead of print]

12. Don’t Confuse Permanent Organ Damage with Active SLE or Co-

Morbidity

Percentage of Patients With Permanent Organ Damage

Chambers SA, et al. Rheumatology (Oxford). 2009;48:673-675.

One-Third of SLE Patients Accrue Permanent Organ Damage Within 5 Years of Diagnosis

Percentage of Patients With Permanent Organ Damage

Perc

ent o

f Pat

ient

s With

SDI

≥1

5 Years (N=232)

1 Year (N=232)

10 Years (N=232)

15 Years (N=143)

20 Years (N=75)

25 Years (N=6)

0.11 0.42 0.77 1.01 1.26 2.17 Mean

Damage Score

etrospective analysis of records for patients with ≥1 years of consistent follow-up presenting at the University College London Hospital SLE clinic. Year 0 represents time of diagnosis. Mean age at diagnosis was 31.2 years, 95% of patients were female, 72% were white, 14% were black, 10% were Asian (Indian), and 4% were "other."

Percentage of Patients With Organ Damage Over 5 Years of Follow-up (N=298)

Disease Activity Over 5 Years of Follow-up (N=298)

Patients Still Accrue Organ Damage Even With Low Disease Activity

Urowitz MB, et al. Arthritis Care Res. 2012;64:132-137.

Mea

n To

tal S

LEDA

I-2K

Years in Registry

Perc

ent o

f Pat

ient

s W

ith S

DI >

0

Years in Registry

Prospective analysis of patients in the SLICC cohort recruited within 15 months of diagnosis and followed annually for ≥5 years. Mean age at enrolment: 35.3 years; 87% female; 55% white, 12% black, 14% Asian, 16% Hispanic, 2% “other.” At enrollment, mean disease duration=5.5 months; mean SLEDAI-2K score=5.9.




Page 16 of 20

Myasthenia Gravis0.2%

Headache44.9%

Mood Disorders15.4%

Myelopathy1.1%

Pyschosis2.0%

Polyneuropathy3.3%

Mononeuropathy2.2%

Acute Confusional State3.6%

Cerebrovascular Disease4.9%

Cognitive Dysfunction5.3%

Anxiety Disorder5.8%

Autonomic Disorder0.2%

Demyelinating Syndrome0.3%

Movement Disorder0.9%

Aseptic Meningitis0.8%Neuropathy, Cranial

1.4%

Seizures and Seizure Disorders

7.7%

NP Events at Enrollment (n=1404) (637 Events in 413 Patients)

Hanly JG, Urowitz MB, et al. Arthritis Rheum 56:265-73, 2007.

Headache Differential SLE headache

Migraine headache: worsened by SSRIs Katsiari CG, et al. Headache 2011. Tjensvoll AB, etal. Cephalalgia 2010;31:401-408.

Cerebral venous sinus thrombosis (if LAC+)

Drug headache: NSAIDs, IVIG

Infection

Tumor

Heal Your Headache. D Buchholz and SG Reich. Workman Publishing Co., 1st ed., 2002

Headache in SLE Headache is NOT increased in SLE compared to

controls Mitsikostas DD, et al. Brain 127:1200-1209, 2004. Whitelaw DA, Spangenberg JJ. Lupus 18:613-617, 2009.

Mood Disorders Depression very common: 20%

Utset TO et al. J Rheumatol 21:2039-2045, 1994.

Depression correlates with cognitive impairment Petri M, et al. J Rheumatol 37:2032-2038, 2010..

Depression may be related to SLE Utset TO et al. J Rheumatol 21:2039-2045, 1994.

– Neuropsychiatric lupus OR 3.43 p=0.0005 – Secondary Sjogren’s OR 2.97 p=0.0006

Cognitive Impairment is Frequent at Baseline in an Inception Cohort

Scale Mean±SD (range)

SELENA SLEDAI 3.9±4.6 (0-28)

SLICC Damage Index 0.7±1.1 (0-4)

Krupp Fatigue Inventory 4.7±1.7 (1-7)

Calgary Depression Scale 5.0±4.6 (0-18)

Automated Neuronetics Assessments Matrix (ANAM):

1 SD below controls: 60%

2 SD or more below controls: 19%

Petri M, et al. J Rheumatol 37:2032-2038, 2010

Cognitive Impairment at Diagnosis of SLE Improves or is Stable Over Time

Cognitive impairment is common at baseline

It improves over time

Depression is the MOST important associate




Page 17 of 20

Additional Slides

ETIOLOGY Multifactorial Predisposing genetic factors---2/3risk Environmental factors---1/3 risk Development of autoantibodies linked to pathologic manifestations Preclinical phase with autoantibodies present years before clinical disease

Autoantibodies Precede the Diagnosis Of SLE By Years

Arbuckle MR, et al. N Engl J Med. 2003;349(16):1526-33.

Clinical SLE Preceded by Complicated Autoimmune Changes ANA, Anti-Ro, Anti-La, Antiphospholipid antibodies appear first Anti-dsDNA antibodies appear next Anti-Sm and Anti-RNP antibodies appear just before disease onset The number of autoantibody types continues to increase until the time of diagnosis

Immunopathogenesis




Page 18 of 20

Induction of Surface Blebs during Apoptosis

Rahman A, Isenberg DA. N Engl J Med 2008;358:929-939.

Mechanism Summary-I In SLE patients there is defective clearance of apoptotic cells Leads to exposure of intracellular immunogenic components Taken up by DC and presented to autoreactive B cells In the right genetic environment, these B cells may become activated to produce autoantibodies

Mechanism Summary-II Once autoantibodies (particularly anti-DS DNA) are present, they can complex with DNA exposed on dying cells Results in high levels of IFN- production IFN- encourages a feed-forward mechanism of continued plasma cell activation to produce increased amounts of autoantibodies and encourage further disease progression and tissue destruction

The interferon signature and its regulation in SLE More than half of patients with SLE show a dysregulation in the expression of genes in the IFN pathway The type I I s are potent cyto ines I and I and also mediate the Th1 response, sustain activated T cells, sustain B cell survival, and lower the B cell activation threshold These responses propagate proinflammatory cytokines, contributing to chronic inflammation and tissue damage IFN also acts as a bridging mechanism between the innate and adaptive immune systems One of the mechanisms of action of Plaquenil is to inhibit interferon alpha production by pDC’s (also inhibits TLR signaling)




Page 19 of 20

Complement Split Products Bound to RBCs May Help in Diagnosis of SLE

SLE Other Diseases

Normal Healthy

EC4d Net MFI (CI 95%) 17.6 (15.2-20.0) 6.3 (5.7-6.8) 5.3 (4.6-6.1)

BC4d Net MFI (CI 95%) 110.4 (96.3–124.5) 34.9 (26.1–41.6) 23.5 (21.4–25.6)

PC4d Net MFI (CI 95%) 16.2 (12.0–20.5) 3.6 (3.0–4.2) 2.0 (1.2–2.8)

ECR1 Net MFI (CI 95%) 13.3 (12.4–14.1) 16.1 (15.1–17.1) 20.7 (19.6–21.7)

Kalunian KC. Abstract 597. Presented at: American College of Rheumatology, 2011.

ANA=antinuclear antibodies; BC4d=complement C4d levels on B cells; ds=double-stranded; EC4d=complement C4d levels on erythrocytes; ECR1=complement receptor 1 levels on erythrocytes; MFI=mean fluorescence intensity; MVC=mutated citrullinated vimentin antibodies; PC4d=complement C4d levels on platelets;SLE=systemic lupus erythematous

Detection of New Clinical Activity in SLE

Variable Detected Number of visits with new variable (N=173)

Number of patients with ≥variable (N=127)

Cast 16 16 Hematuria 10 9 Proteinuria 15 15 Pyuria 42 35 Low complement 55 45 DNA antibodies 36 32 Thrombocytopenia 8 7 Leukopenia 7 7 Serum creatinine 9 8 Hemoglobin 6 6

Frequency of New Isolated Variables of Interest in 515

Key point: Patients should be followed with clinical and laboratory measures every 3 months

Gladman DD, et al. Abstract 2301. Presented at American College of Rheumatology Annual Meeting. 2011.

Hormone Replacemant Therapy

The largest study of 351 postmenopausal women with SLE suggested only a small increase in the risk of flares

Buyon et al, Ann Int Med 2005;142:953

Oral Contraceptive Therapy Double blind, randomized, noninferiority trial. 183 women with inactive(76%) or stable active(24%). Severe flares occurred in 7.7%receiving OC’s and 7.6%receiving placebo. Rates of mild-moderate flares were 1.40 flares per person-year in patients on OC’s and 1.44 flares per patient-year for subjects receiving placebo. Conclusion: oral contraceptives do not increase the risk of flare in women with SLE whose disease is stable.

Petri et al. NEJM 353;24:2550, 2005.

Rate of SLE Mortality Remains High Relative to the General Population Age 16-24---19.2X Age 25-39---8X Age 40-59---3.7X Age >60------1.4X

Bernatsky S, et al. Arthritis Rheum. 2006;54:2550-2557.

Work Loss Is a Common Consequence of SLE • At baseline, 26% were aged 18-34 years and 60% were

35-55 years – Individuals who reached age 65 without work loss were

censored • Overall, 33% (160/484) of patients stopped working during

the 4-year follow-up period • Work loss associated with incident SLE manifestations

by Year 4: – Musculoskeletal: 34% (58/170) – Neuropsychiatric: 38% (68/179) – Thrombotic: 58% (34/59)

Yelin E, et al. Arthritis Care Res (Hoboken). 2012;64:169-175.




Page 20 of 20

ORGAN DAMAGE

Despite Improvements in Survival Rates, SLE Remains a Chronic Disease With Higher Than Expected Mortality Rate

• Survival rates significantly improved in patients diagnosed 1980-1992 vs patients diagnosed 1950-1979

• However, survival is significantly worse than in the general population

Uramoto KM, et al. Arthritis Rheum. 1999;42:46-50.

CONCLUSIONS 1) SLE is a complex disease with predisposing genetic and environmental factors. 2) SLE is difficult to diagnose. 3) SLE is not a pain disease. 4) Limit the use of Prednisone. 5) Selecting treatment can be difficult, but data are emerging that can help.

6) Follow renal disease with urine protein/creatinine ratio. 7) Risk of coronary heart disease greatly increased in patients with SLE. 8) Hydroxychloroquine 9) We have a lot of work to do: pt dx’ed at age 20 has 1/6 chance of dying by age 35



10:45 a.m. - 11:15 a.m.

Important Issues in CodingJean Acevedo, LHRM, CPC, CHC, CENT



Coding for the Practitioner

Jean Acevedo, LHRM, CPC, CHC, CENTC

Prepared forCoalition of State Rheumatology Organizations’National Rheumatology Fellows Conference

February 2016

Disclaimer

Agenda

Payer Documentation RequirementsMedical Necessity

a/k/a being able to keep the money!Evaluation & Management ServicesDiagnosis Coding and Paying for Value


Page 1 of 13



PAYER DOCUMENTATIONREQUIREMENTS

ValidatesThe site of service

Is it appropriate for the service and patient’s condition?

The appropriateness of the services providedNot experimentalMeets but doesn’t exceed patient's medical needOrdered and performed by qualified personnel

The accuracy of the billingCPT/HCPCS codes accurately represent what is documentedICD 9 (ICD10) codes are supported by clinical documentation

Identity of the care giver (provider)Who personally performed the service?Legible signature

Medical Record Documentation

Medical Record Documentation

Each encounter shouldBe complete and legibleEvery page in the chart should have the patient’sname and date of service.Document the reason for the encounter

a/k/a “medical necessity”Have a documented impressionHave a documented plan of care/f upBe dated and have the identity of the provider

Sign, initial, typed name on dictationAll providers and staff


Page 2 of 13



So, in plain EnglishThink of Medicare as any other healthinsuranceCertain items/services are covered

And others are notAnd those that are, must meet the coveragecriteria

That the service is “reasonable and necessary” orbe one of the preventive benefits

Much of this is defined in NCDs and LCDs fornon E&M services provided by physicians.

Evaluation & ManagementBasics

CPT®:E&M Services Guidelines

New and Established Patient“solely for the purposes of distinguishing between new and establishedpatients, professional services are those face to face services rendered byphysicians and other qualified health care professionals who may report[E&M] services…“An established patient is one who has received professional services fromthe physician/qualified health care professional of the exact same specialtyand subspecialtywho belongs to the same group practice within the pastthree years.“….where a physician/qualified health care professional is on call for orcovering for another physician/qualified health care professional, thepatient’s encounter will be classified as it would have been by thephysician/qualified health care professional who is not available. Whenadvanced practice nurses and physician assistants are working withphysicians, they are considered as working in the exact same specialty andexact same subspecialty as the physician.”


Page 3 of 13



7 Components DefineE&M Services:

Key components inselection of level

HistoryExaminationMedical decisionmaking

Ancillary elements inselection of level

CounselingCoordination of careNature of presentingproblem (medicalnecessity)Time

Use of Time: If a visit consists predominantly ofcounseling or coordination of care, time is the keyelement to assign the appropriate level of E&Mservice

Office/outpatient settingFace to face time refers to patient time with thephysician only.Counseling by other staff does not count.Duration of c/cc may be estimated but must berecordedTotal duration of the visit also documented.Do not round up!

99214 = 25 minutes99215 = 40 minutes35 minute visit is a 99214

“Results” visit

At least 45 minutes w/patient >50% discussing labresults, lifestyle changes and medications to helpmanage symptoms; new diagnosis of Lupus. Allpatient questions answered. Long discussionregarding her desire to get pregnant.


Page 4 of 13



Most visits are coded based on the3 Key Components

1. History2. Physical Exam3. Medical Decision Making

#1: Documentation of History

History elementsChief Complaint (CC)

“Left knee pain for past 3 weeks” (explicit)“Doing well since adding Ultram.” (inference is that visit is tof/up on medication change)

History of present illness (HPI)Review of systems (ROS)

Series of questions about past or present symptoms

Past, family and/or social history (PFSH)

#2: Documentation of Exam(1995 DG)Comprehensive: Gen’l multi system (8+ OS) orcomplete single system organ system exam.


Page 5 of 13



Documentation of Exam*Problem Focused A limited exam of the affected body

area or organ system (1+ BA/OS)

Expanded problem focused

A limited exam of the affected body area or organ system and any other symptomatic/related area(s)/system(s) (2-7 BA/OS)

Detailed An extended exam of the affected body area(s) or organ system(s) and any other symptomatic or related area(s)/system(s) (2-7 BA/OS)

Comprehensive Gen’l multi-system (8+ BA/OS) or complete single organ system exam.

#3: Medical Decision making(2:3 variables required)

1. The number of possible diagnoses/number of managementoptions that must be considered

2. Amount/complexity of medical records, diagnostic tests,&/or other information obtained, reviewed and analyzed

3. Risk of significant complications, morbidity &/or mortality, aswell as comorbidities associated w/the patient’s presentingproblem(s), the diagnostic procedure(s), &/or possiblemanagement options

Each variable can be one of four levels: from minimal/none to extensive/high.

Briefly: Medical Necessity & EMRsDocumentation software may facilitate carry oversand repetitive fill ins of stored information.Even when a “complete” note is generated, onlymedically necessary services for condition of patientat time of encounter as documented can beconsidered when selecting appropriate level of E/Mservice.Information not pertinent to patient’s condition attime of encounter cannot be counted.

Patient seen in ‘routine’ follow up of stable OA.History is “comprehensive” including past, family &social history. Was it “medically necessary” to repeatthese history elements?


Page 6 of 13



New patient visit/consults99203/99243/99253

Detailed historyHPI – 4+ROS – 2 9PFSH – 2:3

Detailed exam2 7 BA/OS

Medical decision makingof low complexity

3:3 Key Components

Established patientoffice visit

99213Expanded problem focusedhistory

HPI – 1 3ROS 1

Expanded problem focusedexam

2 7 BA/OSMedical decision making oflow complexity

2:3 Key Components

99204/99244Documentation Required (all of the below)1. Comprehensive History

Chief complaintHPI (4 or more elements; e.g. location, severity, quality, timing,context, modifying factors, etc.)ROS – 10 or more systemsPast/Family/Social History

2. Comprehensive Exam (8 or more organ systems)3. Medical Decision Making of Moderate Complexity (at least 2 of the

following)Moderate # of diagnoses or management options

New problem with or w/o a work upModerate amount or complexity of data (to be) reviewedModerate degree of risk

Prescription drug management

99214Documentation Required (2:3 Key Components)

1. Detailed HistoryChief complaintHPI (4 or more elements; e.g. location, severity, quality, timing,context, modifying factors, etc.)ROS – 2 9 systemsOne of Past Medical/Family/Social History

Listing medications = medical history2. Comprehensive Exam (8 or more organ systems)3. Medical Decision Making of Moderate Complexity (at least 2 of the

following)Moderate # of diagnoses or management options

3 stable chronic conditionsModerate amount or complexity of data (to be) reviewedModerate degree of risk

Prescription drug management


Page 7 of 13



The Move From VolumeTo Paying for Value

Background

On 1/26/15, HHS Sec’y Sylvia M. Burwellannounced measureable goals and a timelineTo move the Medicare program, and ourhealth care system at largeToward paying providers based on the quality,rather than the quantity of care provided topatients.


Page 8 of 13



Background

The goal:Tie 85% of all traditional Medicare payments toquality or value by 2016, and90% by 2018.

The Value Modifier and Physician FeedbackPrograms are part of a strategy to achievethese goals

Value Based Payment ModifierCurrent Fee Schedule payment method does notcontain incentives for physicians to focus on:

The quality & outcomes of all the care furnished tobeneficiaries,The relative value of each service they furnish or order,orThe cumulative costs of their own services and theservices that their patients receive from otherproviders.

Value Based Payment Goals:Improve qualityLower per capita growth in expenditures

26

Physician Benchmarking: QRURQuality Resource and Usage ReportsFind yours at https://portal.cms.gov

Must have an IACS/EIDM accountCare and cost data for from 2014 claims dataLists all Medicare FFS patients you submitted aclaim for in that period of time

Costs incurred by youCosts incurred by unaffiliated providers

High cost/low quality, average, or Low cost/highquality?


Page 9 of 13

Page 65CSRO Fellows ConferencePage 64 CSRO Fellows Conference


Value Modifier Policies for 2017Payment at risk is 4.0%, with potentialupward adjustment of up of +4.0x (‘x’represents the upward paymentadjustment factor)Cost/Quality Low

QualityAvg

QualityHigh Quality

Low cost +0.0% +2.0x* +4.0x*Avg. cost 2.0% +0.0% +2.0x*High cost 4.0% 2.0% +0.0%

Eligible for an additional +1.0x if reporting clinical data for quality measures and average beneficiary risk score in the top 25 percent of all beneficiary risk scores

In the background, patient costs are being riskadjusted based on beneficiary health statusand demographic characteristics

Chronic conditions, age, sex, original Medicareentitlement, disability & Medicaid status areincluded in the formula

What Diagnoses Should be Reported:ICD 10 Official Guidelines

For reporting purposes the definition for “otherdiagnoses” is interpreted as additional conditions thataffect patient care in terms of requiring:

clinical evaluation; ortherapeutic treatment; ordiagnostic procedures; orextended length of hospital stay; orincreased nursing care and/or monitoring.

Documentation RequirementsAdditional Coding Guidelines:

Face to face visitDocumentation must show how chronic condition isbeing treated, managed, or assessedEach diagnosis must have an Assessment and a Plan

Assessment PlanStable MonitorImproved d/c MedsTolerating meds Continue current medsDeteriorating Refer to/for…

Sample Language

Example 1: Lupus, stable well controlled. Continue Plaquenil.Example 2: COPD, stable onAdvair

Additional Documentation TipsDocument all causal relationships

Coders are not allowed to make assumptions when assigning adiagnosis code

Be descriptiveThink in ink

Only document “history of” when the condition nolonger exists or in no way impacts your currenttreatmentDo document co existing conditions/comorbidities thatare addressed or that impact your treatment

HypertensionAmputationsDiabetes Mellitus

Times they are a changing…Ten years ago….

There was no PQRS or EHR MUIt was unheard of for Medicare Part B to pay for non face to face services

TCMCCMACP

ACOs were like unicorns: you may have heard about them, but no onehad ever seen one.MSSP looked like a typo for “Medicare Secondary Payer,” not MedicareShared Savings ProgramA Modifier was a 2 digit suffix for coding, not a method for payingdoctors (Value Based Payment Modifier)Bundled payment meant edits in the Correct Coding Initiative, ratherthan one payment to cover all providers involved in an episode of care

Total knee replacement, for example


Page 10 of 13



Documentation RequirementsAdditional Coding Guidelines:

Face to face visitDocumentation must show how chronic condition isbeing treated, managed, or assessedEach diagnosis must have an Assessment and a Plan

Assessment PlanStable MonitorImproved d/c MedsTolerating meds Continue current medsDeteriorating Refer to/for…

Sample Language

Example 1: Lupus, stable well controlled. Continue Plaquenil.Example 2: COPD, stable onAdvair

Additional Documentation TipsDocument all causal relationships

Coders are not allowed to make assumptions when assigning adiagnosis code

Be descriptiveThink in ink

Only document “history of” when the condition nolonger exists or in no way impacts your currenttreatmentDo document co existing conditions/comorbidities thatare addressed or that impact your treatment

HypertensionAmputationsDiabetes Mellitus

Times they are a changing…Ten years ago….

There was no PQRS or EHR MUIt was unheard of for Medicare Part B to pay for non face to face services

TCMCCMACP

ACOs were like unicorns: you may have heard about them, but no onehad ever seen one.MSSP looked like a typo for “Medicare Secondary Payer,” not MedicareShared Savings ProgramA Modifier was a 2 digit suffix for coding, not a method for payingdoctors (Value Based Payment Modifier)Bundled payment meant edits in the Correct Coding Initiative, ratherthan one payment to cover all providers involved in an episode of care

Total knee replacement, for example


Page 11 of 13



The Future

Phased outin 2018:

PQRSVBMEHR MU

But rolled upinto MIPS

Merit Based Incentive Payment System (MIPS)Payment in 2020 based on CY 2019 data100 Point Scale

Quality: 30 pointsResource use: 30 pointsMU: 25 pointsClinical Practice Improvement: 15 points

Payment Adjustments± 4% 2020± 9% 2024

In ConclusionFee For Service will still be here

Document and code your visits, x rays and proceduresthoroughly

Clinical indications and rationale: document your thought process

As payment continues to move towards value, paint acomplete picture of your patients

Include co morbid chronic conditions as they impact the highquality/low cost to low quality/high cost continuum.1. Patient with RA is anticipated to have $x costs this year2. Patient with RA, DM, Hypertensive heart disease is expected to

have $xxx costs this year.If your patient’s actual costs were $xx, in #1 you’re high cost, but in#2, you were a low cost provider.

Questions?


Page 12 of 13




Page 13 of 13



11:15 a.m. - 11:45 a.m.

Practicing in a Multispecialty GroupDouglas C. Conaway, MD



1

MULTISPECIALTY GROUP PRACTICE

How does it work?How does it work?

TYPES OF MULTISPECIALTY PRACTICES

HOSPITAL BASEDACADEMICORTHO/RHEUMORTHO/RHEUMINDEPENDENT M/S GROUP

OVERRIDING CONCERNS

Patient CareRisk vs RewardRisk vs RewardControl over destinyGood governance

OUTLINE

Hospital based PracticesIndependent M/S GroupWhy Join One?Wh t A th C f

Macro ConcernsMicro ConcernsLaboratoryWhat Are the Concerns for

You?Control Your DestinyGood GovernanceCompensationRisks

yInfusionsImagingMid Levels

HOSPITAL BASED PRACTICE‐> REASONS

Steady Income Salary, IncentivesPerhaps Paid Whether Patients Come or notpNo “Skin in the Game” so no Capital Risk“Turn key” PracticeKnown (?) Governance

INDEPENDENT MULTISPECIALTY GROUP

Small < 50 PeopleLarge > 50 PeopleComposition


Page 1 of 4



2

WHY WOULD YOU JOIN ONE?

Negotiating PowerShared Risk

Economies of ScaleEHR Choice Already Made

Built in ReferralsOffice ManagementRecruiting

MentoringControl Your Own Destiny

WHAT ARE THE CONCERNS FOR YOU?Good GovernanceSolvency of PracticeBilling Operation

LeverageSuppliersInsurersBilling Operation

Allocation ofExpensesBuy In?

Hospital(s)Is EHR Useful?Will They Help YouInnovate?

M CRO INFLUENCES

Practice GeographyHospital RelationshipHospital RelationshipACA EffectsPopulationManagement

CONTROL YOUR OWN DESTINY

Who Controls Your Schedule?What Does “On Call” Mean?

Can You Innovate?InfusionsUlt dWhat is your Overhead?

VacationsWho Gets Outside Income?LecturesClinical Trials

UltrasoundMid Level hiring“Supergroup” AssociationsPopulation Management

GOOD GOVERNANCE

The CEO is Important!Is there an Oversight Board?Mission Statement?Is There Transparent Cost Accounting?Outside Auditing?Can You View detailed ?Communication

COMPENSATIONInitial GuaranteeWho is Binding You with the Guarantee?Salary plus Incentives MGMA GuidelinesOth Rh t l i t ’Other Rheumatologists’ Pension Contributions / 401k, 403bAncillary ServicesHealth InsuranceAdvertising


Page 2 of 4



3

RISKS Revenue FluctuationsBad Debt is Real MoneyInteractions with EmployeesInteractions with EmployeesPoor ManagementUnforeseen Circumstances

MICRO CONCERNS

LaboratoryInfusionsInfusionsImagingMid Levels

LABORATORY

Is There In House Lab?Revenue Stream?Specialty Labs Vectra , etc.

INFUSIONS

Who Gets the Revenue?Who Does the Authorizations?Does Billing Coordinate with

Suite Set UpRoom/ ChairsNon Drug InventoryEHRDoes Billing Coordinate with

Prior Authorizations toMinimize Bad Debt?How Do You buy the Drugs?

EHRScheduling

Infusion NursesProtocols

M/S IMAGING‐ GROUP SUPPORT?RadiographsUltrasound/ MRI State by State rulesUltrasound is the Present and the FutureDiagnostic vs ProceduralDiagnostic ProtocolsTechnician TrainingWhich Machine?Who Reads Them?

Mid Level Providers

Do You Need One?How do You Find One?Prior Experience?

ShadowingInjection techniqueDidactics

Risk Models

CompensationIncentives

Scheduled but CommonPatientsWhen Independent?


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4

OVERRIDING CONCERNS

Patient CareRisk vs RewardRisk vs RewardControl over destinyGood governance

“It’s the Patient, Stupid!”

“If the Doctor Ain’t HappyIf the Doctor Ain t Happy…Ain’t Nobody Happy….”


Page 4 of 4



11:45 a.m. - 12:20 p.m.

Practice ManagementEthel Owen, CPC



1

Practice ManagementCSRO Fellows Conference

February 20, 2016

Ethel Owen ‐ Administrator Arthritis & Rheumatology Associates of Palm Beach, Inc West Palm Beach, FL

Physicians & Administrator

Clinical Managers

PracticeStructure

And Physician Associates

Check in, Check‐out, In‐Fusion, Lab &

X‐ray Staff

MA’s RN’s

Mid‐levels

Business Personnel

Billing ManagerBilling Staff

Administrative Staff

Written Protocols for Every Operation

Effective Office Management

Team Work Staff training and in‐

i

Assign Responsibility Regularly review staff

fservicesCommunication between physician, front office and back office

performanceEnsure compliance and regulatory standards

Practice Management

PHYSICIAN ENCOUNTER

Scheduling

First ImpressionProfessionalism Set the expectationsWhat does the patient need to bring to their appointmentCancelation policy


Page 1 of 5



2

Check In

Focus on customer ‐smile and greet patient

Review demographics C ll t t t di b l a d g eet pat e t

Review “Patient Information Form (PIF)” with patient

Copy of insurance card (both sides) and pharmacy cards

Obtain Patient Signature Check referral status Review Office Policies Collect co‐payment

Collect outstanding balances Verify insurance and pharmacy informationCollect co‐pays at check‐in

ConsequencesofImproperCheckIn Consequences

• New number must be tracked downWasted staff and/or ph sician time• Wasted staff and/or physician time

• Physician cannot reach patient during workday• Cannot implement response to abnormal tests until evening or next day

Result: Delayed care and

Physician Encounter Physician EncounterPhysician obtains historyExamines patientOrders diagnostic imaging and laboratory

Charge Capture Office Visit Level In Office LabsInjections imaging and laboratory

testsEnters data in to EHRImplements treatment planCalculates disease activity score

Injections Medications Procedures X‐rays

Physician Encounter –Diagnosis Coding Diagnosis to Support Medical Necessity

ICD‐10 Is more than a method to communicate a patients diagnosis to an insurance carrier to receive patients diagnosis to an insurance carrier to receive payment Reduces Compliance RiskDiagnosis Codes Support Procedures and Orders Paints the Picture for the Payer Proper ICD ‐ 10 documentation enables quality patient management and ensures proper reimbursement

Documentation to SupportMedical Necessity


Page 2 of 5



3

Coding and Documentation

Monitor coding and documentation compliance with l l f d i l iregularly performed internal reviews

Utilize services of coding consultants to perform periodic audits Employ outside consultants through legal council so all findings are attorney‐client privilege Managing documentation within practice is vital

Documentation is Key toEverything!

Tell the story Support medical necessitySupport medical necessityExcellent Patient CareClaims Payment Keeping your MoneySuccessful Practice

Consequences of Up‐coding and Down‐coding

Level 3

Level 4

Level 5

After

If documentation and coding protocols were in place and adhered to, proper E&M coding for Level 3 and 4 for these two physicians would have resulted in an increased annual reimbursement commensurate with work done.

0 10 20 30 40 50 60 70

Level 1

Level 2Before

Check OutAncillary Protocols Verify physician orders Schedule ancillary service in accordance with orders Document service provided Track services provided in‐office and at referral facility

• Tickler or alert system to ensure follow through and patient compliance

Follow up appointments Comply with payer requirements for Ancillary Services

• In office vs. referral lab

Check Out

Review follow‐up care with patient Provide patient with applicable written/printed i i instructions Review outside referrals, Imaging, PT, LabsCollect deductibles and coinsurance, Schedule follow up visit

Business Office Management


Page 3 of 5



4

Business Office

Define roles Cross train Knowledge of contracts and allowablesUpdated fee schedules Procedures – Up to Date bundling editsKnowledge of managed care policies and proceduresEffective communication

Pre‐Encounter Admin. “Access Management”

Patient‐Doctor Encounter

Back‐Office Administration

Practice Mgmt. System

Rejection/ Denial Mgmt.

Every step exists to increase the likelihood that each claim is reimbursed

Office Claims Management Process

Eligibility

Patient Portals & Kiosks

Patient Self Registry

MedicalNecessity

ReferralAuthorization

Benefit Authorization

Concurrent Denial Mgmt./ Length of Stay Mgmt.

CodingUtilizationMgmt.

Government/ Regulatory Compliance

Billing

Claims Editing

Bad Debt. Mgmt.

EDI*

A/R Mgmt.

Contract Mgmt.

g y Denial Mgmt.

* EDI – Electronic Data Interface

Business OfficeConduct daily billing audits Submit claims dailyDocument proof of timely submission Maintain current fee schedulesTrack denials by procedure, by department, by doctorRun missing ticket reports

Accounts Receivable ManagementAccounts Receivables (A/R) is money owed for services renderedSources of Revenue

I C iInsurance CompaniesFoundations/Industry Co‐Pay CardsPatients

Co‐pays Coinsurance Deductibles

Accounts ReceivablesManagement

Robust Practice Management SystemProvide Reports Aged Account BalancesgIncome by Location Income by Doctor Rejected Claims Report

By Doctor By Location By Procedure

Features of a Good PracticeManagement System

Robust system for preparation and submission of claims Ability to load and maintain payer fee schedules Ability to load and maintain payer fee schedules Ability to track claims

Knowledge of payment terms by payer Ability to scrub claims Modifiers

Diagnosis code and procedure mismatch


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5

ConsequencesofImproper eeche u e

Payer reduces all evaluation and management codes y gby 15%Payer reduces J code reimbursement by 2%Lost revenue to practice Inaccurate data collection by payer


Page 5 of 5



12:20 p.m. - 1:15 p.m.

Lunch Lecture: State Advocacy ParticipationAaron Broadwell, MD



1:15 p.m. - 2:15 p.m.

Early Career Financial ManagementJames M. Dahle, MD FACEP




Page 1 of 9

1/29/2016

1

James M. Dahle, MD, FACEP

CSRO Fellows Conference

February 20, 2016

Money Doesn’t Bring Happiness (at least beyond ~$75K)

You didn’t go into medicine primarily for the money and

neither did I

Ignore money at your own peril

Ripped Off-Recruiters, realtors, lenders, insurance agents, financial advisors, appraiser, pp

May 2011- The WebsiteFebruary 2014- The BookMillionaire By 38

Website is for profitFree to you, but I sell ads on itAll financial conflicts of interest disclosed

Book sales pay me royalties/ f ll f d1/2 of my income still comes from medicine

I am not a licensed accountant, attorney, or financial advisorThis presentation is for entertainment and informational purposes only, and IS NOT accounting, legal, or financial advice.

1. The Secret to Physician Financial Independence2. Continuing Financial Education3. Choosing an Advisor4 A Student Loan Plan4. A Student Loan Plan5. An Insurance Plan6. A Home Purchase Plan7. An Investing Plan

Make a lot of moneyDon’t spend a lot of moneyMake your money work as hard as you doDon’t lose your moneyy y

CreditorsTaxesDeath, disabilitySpeculative investments

You’ve already won the game (the rest is easy)Convert your high income into a high net worth




Page 2 of 9

1/29/2016

2

LIVE LIKE A RESIDENT!

Live like a resident while in trainingContinue to live like a resident for a few more yearsCarve out a massive chunk of your income Carve out a massive chunk of your income with which to build wealth

Pay off loansSave up down paymentMax out retirement accounts

Then enjoy the good life after 2-5 years

Average Rheumatology Salary~$215KAverage Fellow Salary ~ $55KExample$210K Gross$210K Gross$161K Net$50K to liveLeaves $111K to build wealth$200K in loans can be gone in 22 months

Buy a multi-million dollar house before you graduate with zero downBuy a “doctor car” and a “doctor’s spouse car” on credit before you graduate

You aren’t what you driveEnroll 4 kids in private schoolsEnroll 4 kids in private schoolsGrow into or beyond your income as quickly as possibleDrag your loans out for decadesSpend $225K on an income of $200KAssume a 4X increase in gross income = a 4X increase in net income

Plan to pay more in tax than you made as a fellow

1. The Secret To Physician Financial Independence2. Continuing Financial Education3. Choosing an Advisor4 A Student Loan Plan4. A Student Loan Plan5. An Insurance Plan6. A Home Purchase Plan7. An Investing Plan8. An Estate Plan9. An Asset Protection Plan

Med School/Residency made you a clinical expertNo business trainingNo personal financial or investment trainingNo personal financial or investment trainingA Pension Manager in a “401(k) World”Family CFONot automatic




Page 3 of 9

1/29/2016

3

You must spend time learning about finances/business

You cannot win the game if you don’t learn the rulesContinuing financial education

Follow a blog or twoRead a financial book each year – The $2M Book

Hire professionals to teach you, not just do it for you

You must also spend the time to take care of your finances/business

You cannot be “100% clinical” and be financially ysuccessful


Remember that personal statement

"You are engaged in a life-and-death struggle You are engaged in a life and death struggle with the financial services industry. ... If you act on the assumption that every broker, insurance salesman ... and financial advisor you encounter is a hardened criminal, you will do just fine.“- William Bernstein, MD

10) Unsolicited emails9) Typical internet forum8) The Doctor’s Lounge7) Family or friend who recently started with financial services firm6) Anyone you attend church with5) Your stomach4) Your TV3) Your insurance agent2) Local stock broker1) Local bank or credit union

1) Commitment to professionCFA, CFP, ChFC, CPA/PFS

2) More experience than you3) No commissions (Fee-only)4) Fid i D4) Fiduciary Duty5) Knowledge of investing literature6) Experience with physician-specific issues

TaxesStudent loan issuesRetirement account issues




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If you pay just 2% of your portfolio each year in fees, commissions, and expenses, how much less would you end up with?

30 years, 8% pre-fee returns, saving $50K a year.$6.1M vs $4.2M$ $Is that advisor really worth nearly $2M to you?

5+ years of your gross salary? $80K/year in retirement?

Even after-inflation it’s still > $1M ($3.5M vs $2.5M)

Neufeld- Journal of Financial Planning 2014

1) Commissions loaded mutual fundscommissions on insurance-based investing products (3-8% load, high expenses, bad products)

2) Asset Under Management Fee ) g(0.15%-2%) ($1500-20,000 on a $1M portfolio)

3) Annual retainer ($1000-5000) or set fee for plan ($500-2000)

4) Hourly rate (typically $150-400/hour)

All have conflicts of interest, but look at the bottom line – how much per year for how much work


Started Med School in 1999- Tuition was $10K per yearMean debt in 1999 ~$122K (Inflation adjusted) Mean educational debt in 2015 ~ $230K for DOs, $183K for MDs$300-$450K is becoming more common No more subsidized loans starting 2012Government won’t refinance them when rates fallCurrent resident loans? 5.4%-10%

Monthly payment on $400K at 7.5% = ~$4900 per month for 10 yearsIf Gross income = $210K, and net income = $161K, $4900 per month is 37% of net incomeIt’s only getting worse




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5

ICRIBRPAYEREPAYEREPAYEPSLF

If you owe money, you need to become an expert in this or hire an expert in this.

#People

PovertyLine

150% ofPoverty Line

$50K 150% ofPoverty ICR IBR PAYE REPAYE

1 11,770 $17,655 $32,345 $539.08 $404.31 $269.54 $269.542 15,930 $23,895 $26,105 $435.08 $326.31 $217.54 $217.54115,930 $ , $ , $ $ $ $3 20,090 $30,135 $19,865 $331.08 $248.31 $165.54 $165.544 24,250 $36,375 $13,625 $227.08 $170.31 $113.54 $113.545 28,410 $42,615 $7,385 $123.08 $92.31 $61.54 $61.546 32,570 $48,855 $1,145 $19.08 $14.31 $9.54 $9.547 36,730 $55,095 $0 $0.00 $0.00 $0.00 $0.008 40,890 $61,335 $0 $0.00 $0.00 $0.00 $0.00

Payments have nothing to do with interest ratePayments have nothing to do with debt burdenThey are based solely on income and number of people in your familyof people in your family

Income Based RepaymentThe New, Better ICR (lower payments, more hardship features)Only income-based plan allowed if you have y p yFFEL loans instead of Direct LoansPayments = 15% of Discretionary Income with a maximum of regular payment on a 10 year planTaxable forgiveness after 25 years of paymentsPayments count toward PSLF

Pay As You EarnThe New, Better IBR Not eligible if loans from pre-2007 or if no loans after 2011-must use IBR insteadloans after 2011-must use IBR insteadPayments = 10% of Discretionary Income with a maximum of regular payment on a 10 year planTaxable forgiveness after 20 years of paymentsPayments count toward PSLF

Revised Pay As You EarnThe New, Better and Worse PAYEPayments = 10% of Discretionary Income WITHOUT a maximum WITHOUT a maximum Taxable forgiveness after 25 years of payments (20 for undergrad loans)Payments count toward PSLFSubsidized interest during residencyHigher Payments AFTER residency




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Public Service Loan ForgivenessICR, IBR, PAYE, and REPAYE payments count120 payments while working for a 501(c)3Tax free forgivenessTax-free forgivenessMost residencies and fellowships are 501(c)3sMost academic positions are 501(c)3sMany doctors working at non-profit hospitals are not employees of 501(c)3sVA, military, CHCs, public health etc

Why PSLF WorksLower payments during trainingAmount forgiven = difference between residency payments and regular paymentsresidency payments and regular paymentsAmount forgiven equals about what you owed at med school graduation

PSLF best option if you qualifyMany 501c3 jobs don’t even pay less (yet)

The Gamble and its solution

Student Loan RefinancingImpossible after 2008 Financial Crisis (in reality after rates went up in 2006)Possible again starting in 2013T i l f di i h d fi i lTypical rates for an attending with good financials

Variable 5 year of 2-4%Fixed 5 year of 3.5-5%Variable 10 year of 3-4.5%Fixed 10 year of 4.5-6%

You can typically get these once you have an attending contract in hand

You must qualifyAll docs not offered the same ratesYou may not be offered the same termsHighly dependent on debt levels income Highly dependent on debt levels, income levels, and credit

Darien Rowayton Bank (DRB)Social Finance (SoFi)Common BondCredibleCredibleLend KeyEarnestLink Capital 10+ more

Darien Rowayton Bank$100 a month payments in trainingRates at high end of ranges

Link CapitalLink Capital$0 payments in trainingRates at high end of ranges

RePAYE may be betterLower payments vs more interest




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1/29/2016

7


1. High deductibles, low premiums2. Health Insurance3. Term Life Insurance- Buy $1-5M of 30 year level4 Disability insurance4. Disability insurance5. Umbrella Policy- Buy $1-5M6. Malpractice7. Don’t Mix Insurance and Investing

Doctors, especially new ones, don’t need Whole Life

1. The Secret To Physician Financial Independence2. Continuing Financial Education3. Choosing an Advisor4 A Student Loan Plan4. A Student Loan Plan5. An Insurance Plan6. A Home Purchase Plan7. An Investing Plan

Your Home- The biggest expense of your lifeRent for a few months = unpressured buyerNegotiate well

Your realtor works for the sellerKnow what a house is worth and don’t overpay

Buy what you need, not what you want or think you deserve

Higher taxes, principal, interest, utilities, furnishings, maintenance etc.$2250 roof vs $14000 roof

Higher taxes, principal, interest, utilities,

Image Credit: Brendel, Wikimedia

Mortgage no larger than 2X your income (even though a calculator will tell you 4-6X is okay)y)All housing expenses (including utilities) < 20% of total income , not 28%/36% the industry uses.

20% down saves you moneyPMI, lower rate, lower fees, fewer points etcDoctor loans available, but not necessarily better

Refinance when rates dropThe Benefits of the No Cost MortgageThe Benefits of the No-Cost MortgageTry to avoid telling anyone you’re a doctor or you’ll pay the doctor priceThe Radiologist Next Door

$630K vs $482K. Both now worth ~$630K again.Same schools, same nice view




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1/29/2016

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1. The Secret To Physician Financial Independence2. Continuing Financial Education3. Choosing an Advisor4 A Student Loan Plan4. A Student Loan Plan5. An Insurance Plan6. A Home Purchase Plan7. An Investing Plan

You need a plan likely to succeed no matter what happens in the futureNobody knows nothingCXO Advisory group evaluated stock market CXO Advisory group evaluated stock market predictions

6,582 stock market predictions1998 to 2012 68 gurus47.4% accurate

On Persistence in Mutual Fund Performance, Carhart, 1997

Analyzed 1892 funds from 61 93Analyzed 1892 funds from 61-93Average actively managed fund underperformed by 1.8%.

"Of the 355 equity funds in 1970, fully 233 of those funds have gone out of business. Only 24 outpaced the market by more than 1% a year. These are terrible odds."

Jack Bogle

• "A low-cost index fund is the most sensible equity investment for the great majority of investors. My mentor, Ben Graham, took this position many years ago, and everything I have seen since convinces me of its truth." • Warren Buffet

Broadly diversified between asset classesStocks, bonds, real estate etc

Broadly diversified within asset classesIndex funds hold thousands of securities

Low cost2-20 basis points per year2 20 basis points per year

Appropriate amount of riskFixed asset allocationRebalance periodically

When you realize “nobody knows nothing” it frees you to quit wasting time on activities that don’t add value

Asset protectionMost states protect 401(k)s and IRAs from your creditors

Estate planningEasy to designate beneficiaries plus stretch IRAsEasy to designate beneficiaries, plus stretch IRAs

Cheaper rebalancingNo taxes due upon selling an asset

Better behaviorPenalties make it less likely you’ll raid the account inappropriatelyBut still plenty of ways around Age 59 ½ rule




Page 9 of 9

1/29/2016

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Lower taxes = Higher returns

Source: Retire Secure by James Lange

Everyone is different. Learn what you have.403(b)-$18K + match401(k)/Profit-sharing plan- $53KDefined benefit/Cash Balance plan- $10-200KDefined benefit/Cash Balance plan- $10-200K457 Plan- $18KIndividual 401(k)- $53KPersonal “backdoor” Roth IRA- $5.5KSpousal “backdoor” Roth IRA-$5.5K“Stealth” IRA- $6,650

1. Live Like A Resident2. Read a Financial Book/Blog Every Year3. Hire a low-cost, fee only advisor or DIY4 Go for loan forgiveness or refinance loans4. Go for loan forgiveness or refinance loans5. Health, disability, term life, umbrella6. Buy a home when job is stable, don’t pay PMI7. Use primarily index funds as investments

[email protected]://whitecoatinvestor.comBook available on Amazon



2:15 p.m. - 3:00 p.m.

Medical Malpractice and Risk ManagementJames S. Haliczer, Esq


CSRO Program Materials1/2 /2016

1

THE ANATOMY OFTHE ANATOMY OFA LAWSUITA LAWSUIT

SaturdaySaturday,, February 20, 2016February 20, 2016San Francisco, CASan Francisco, CA

JAMES S. HALICZER, ESQ.JAMES S. HALICZER, ESQ.HALICZERHALICZER, PETTIS & SCHWAMM, P.A, PETTIS & SCHWAMM, P.A..FORT LAUDERDALE, FLORIDAFORT LAUDERDALE, FLORIDA

THETHE ANATOMY OF A LAWSUITANATOMY OF A LAWSUIT

THE BEGINNINGTHE BEGINNINGHowHow do they start?do they start?

THETHE MIDDLEMIDDLEWhat What happens next?happens next?

THE ENDTHE ENDWhenWhen do they stopdo they stop??

AND, WHAT CAN I DO ABOUT IT?AND, WHAT CAN I DO ABOUT IT?

THE BEGININGTHE BEGINING

How do they start?How do they start?

•• Medical BasisMedical Basis

•• Legal BasisLegal Basis


Medical BasisMedical Basis

•• WhereWhere•• InIn--patientpatient•• OutOut--patientpatient

•• When, the ABC’sWhen, the ABC’s•• AngerAnger•• Bad outcomeBad outcome•• CommunicationCommunication


The Legal BasisThe Legal Basis

•• VVaries from state to statearies from state to state

•• All have these elementsAll have these elements•• DutyDuty•• DutyDuty•• BreechBreech•• Proximate causeProximate cause•• DamageDamage


DUTYDUTY

•• What is the duty?What is the duty?

…reasonable care on the part of a physician is …reasonable care on the part of a physician is that level of care skill and treatment which in light of that level of care skill and treatment which in light of that level of care, skill, and treatment which, in light of that level of care, skill, and treatment which, in light of all the surrounding circumstances, is recognized as all the surrounding circumstances, is recognized as acceptable and appropriate by similar and reasonably acceptable and appropriate by similar and reasonably careful physicians. Fla. St. careful physicians. Fla. St. 402.4402.4

•• Where Where does it come from?does it come from?•• Physician/patient Physician/patient relationshiprelationship•• WhenWhen does does physician/patientphysician/patient

relationship relationship existexist??


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2


BREECHBREECH

•• SOCSOC established by experts, yours and established by experts, yours and theirstheirs

•• Experts Experts use many resourcesuse many resourcesExperts Experts use many resourcesuse many resources•• Battle of Battle of expertsexperts


BREECHBREECH

•• SOCSOC established by experts, yours and established by experts, yours and theirstheirs

•• Experts Experts use many resourcesuse many resourcesExperts Experts use many resourcesuse many resources•• Battle of expertsBattle of experts

•• Doctors Doctors vs vs LawyersLawyers•• The experts are doctorsThe experts are doctors


PROXIMATE CAUSEPROXIMATE CAUSE

•• What is proximate cause?What is proximate cause?

… negligence is a legal cause of the damage if it … negligence is a legal cause of the damage if it directly and in natural and continuous sequence directly and in natural and continuous sequence directly and in natural and continuous sequence directly and in natural and continuous sequence produces or contributes substantially to producing the produces or contributes substantially to producing the damage…Fla. St. 402.6damage…Fla. St. 402.6

•• Experts and Experts and treaterstreaters

•• Hotly contested issueHotly contested issue


DAMAGESDAMAGES

•• Economic/TangibleEconomic/Tangible

•• NonNon--economic/Intangibleeconomic/Intangible


EEconomic/tangible damagesconomic/tangible damages

•• Past wages, medical and out of pocket Past wages, medical and out of pocket expensesexpenses

•• Future wages medical and outFuture wages medical and out--ofof--pocketpocketFuture wages, medical and outFuture wages, medical and out ofof pocketpocketexpensesexpenses


Page 2 of 5




NonNon--economic/intangibleeconomic/intangible

•• P&SP&S –– the 800 the 800 lblb gorillagorilla

•• Not calculableNot calculable

•• The eye popping headlineThe eye popping headline

NY DAILY NEWS ‐ Jan. 11, 2014


NonNon--economic/intangibleeconomic/intangible

•• P&SP&S

•• Not calculableNot calculable

•• The eye popping headlineThe eye popping headline

•• Legislative responsesLegislative responses


The ProcessThe Process

•• Suit Suit is filedis filed

•• Sheriff shows up at your doorSheriff shows up at your door

THE MIDDLETHE MIDDLE

WHAT HAPPENS NEXT?WHAT HAPPENS NEXT?•• A lot!A lot!

•• Record reviewsRecord reviews

•• Motions and hearingsMotions and hearings

•• MultipleMultiple deposdepos•• 100’s of thousands of dollars spent on 100’s of thousands of dollars spent on

costscosts


WHAT’S MY INVOLVEMENT?WHAT’S MY INVOLVEMENT?•• ConferencesConferences

•• InterrogatoriesInterrogatories

•• Requests for ProductionRequests for Production

•• DepositionsDepositions

•• Trial PreparationTrial Preparation

•• TrialTrial

•• AppealAppeal


Page 3 of 5




•• ConferencesConferences

•• Attorney/clientAttorney/client

•• InterrogatoriesInterrogatories

•• Written questionsWritten questionsqq

•• Requests for productionRequests for production

•• Medical and business recordsMedical and business records

•• Time commitmentTime commitment


•• DepositionsDepositions•• Three areas of inquiryThree areas of inquiry

•• Education, training & experienceEducation, training & experience•• The factsThe facts•• The standard of careThe standard of care

•• Best practicesBest practices•• 3 L’s3 L’s•• 5 best answers5 best answers•• SpeculationSpeculation•• Factual testimony/attorney as advocateFactual testimony/attorney as advocate

•• Time commitmentTime commitment


•• Trial preparationTrial preparation•• Time intensiveTime intensive•• DeposDepos vs. trial testimonyvs. trial testimony•• Time commitmentTime commitment

•• TrialTrialTrialTrial•• Game dayGame day•• AttendanceAttendance•• Time commitmentTime commitment

•• AppealAppeal•• WaitWait•• TimeTime commitmentcommitment

THE ENDTHE ENDHow do they stop?How do they stop?

•• WinWin•• Have a drinkHave a drink•• No monies paidNo monies paid•• Report your victory when askedReport your victory when asked

THE ENDTHE ENDHow do they stop?How do they stop?

•• LoseLose•• Have a drinkHave a drink•• Money is paidMoney is paid

•• Verdict/judgmentVerdict/judgment•• SettlementSettlement

•• Reports are madeReports are madeReports are madeReports are made•• State agenciesState agencies•• NPDBNPDB

•• Possible investigationsPossible investigations•• Questions fromQuestions from

•• Malpractice Malpractice carriercarrier•• Hospital medical staff officeHospital medical staff office•• Managed careManaged care

•• Publicity and the impact on your practicePublicity and the impact on your practice

THE GOOD NEWSTHE GOOD NEWSANDAND

THE BAD NEWSTHE BAD NEWSTHE BAD NEWSTHE BAD NEWS


Page 5 of 5



THE BAD NEWS: YOU’LL THE BAD NEWS: YOU’LL PROBABLY GET SUEDPROBABLY GET SUED

THE GOOD NEWS: NOT A SINGLE THE GOOD NEWS: NOT A SINGLE REPORTED DEATH REPORTED DEATH

PROXIMATELY CAUSE BY BEING PROXIMATELY CAUSE BY BEING PROXIMATELY CAUSE BY BEING PROXIMATELY CAUSE BY BEING SUEDSUED

AND, WHAT CAN I DO ABOUT IT?AND, WHAT CAN I DO ABOUT IT?

•• Risk reductionRisk reduction

•• Winning StrategiesWinning Strategies

WHAT CAN I DO TOWHAT CAN I DO TOREDUCE MY RISK?REDUCE MY RISK?

•• Communicate with patientsCommunicate with patients•• Explain Explain test test resultsresults•• Tell them what to expectTell them what to expect•• Tell them what happenedTell them what happened

T t th ith di itT t th ith di it•• Treat them with dignityTreat them with dignity•• One hour lateOne hour late--apologize, profuselyapologize, profusely•• Listen to them Listen to them –– show you careshow you care•• Spend a little timeSpend a little time

•• These have a high rate of ROIThese have a high rate of ROI

WHAT CAN I DO TO WIN?WHAT CAN I DO TO WIN?

•• DocumentationDocumentation

•• Pay attentionPay attention

•• Don’t alter medical recordsDon’t alter medical records

•• Don’t be afraid to call Doc 911Don’t be afraid to call Doc 911

•• These have a high rate of ROIThese have a high rate of ROI


Page 5 of 5



3:15 p.m. - 3:45 p.m.

Pearls from Early Practice ExperienceSuneetha Morthala, MD



1

ADVENTURES IN RHEUMATOLOGY:ADVENTURES IN RHEUMATOLOGY:Pearls for Early Practice

Suneetha Morthala, MDFebruary 20,2016

Employment OptionsEmployment Options

Private Practice (Partnership Option)

Hospital Owned Practice (Employed)

Academic Practice

You’re Hired!You’re Hired!

The Beginning of a Very Exciting Time

You are in a totally different world than fellowshipy p

You are NOT as prepared as you think you are

Navigating your new environment is challenging

Building a practice requires significant effort

Private PracticePrivate PracticeIs ANYTHING but boring

Requires skills different from academia

making the initial diagnosismaking the initial diagnosis

communicating with patients about diseases, medications and “other options”

building relationships with patients and peers

becoming a sophisticated business person

The First Three MonthsThe First Three Months

Getting your name “out there”

Adjusting to a new office environmentAdjusting to a new office environment

Getting to know your new colleagues

Dealing with the private practice patient

Studying for (and PASSING) the Boards

Building Your Building Your “Brand”“Brand”Market yourself: carry business cards, visit close practices

Announcements of your arrival, website bio with interests

Become active in your local medical society

Lecture with specialty societies, hospital grand rounds

Communicate with referring physicians with prompt notes and phone calls when appropriate

Look up the specialty of your referring physicians, get to know PCP’s in your area


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2

The OfficeThe Office

Learn everyone’s name and their role in the practice

Establish a relationship with your office managerEstablish a relationship with your office manager

Talk with medical assistant(s) about your workflow

Delegate administrative duties

Ask for what you need to succeed

New ColleaguesNew Colleagues

Find new mentors

Be forthright about your weaknessesBe forthright about your weaknesses

Ask questions!

Observe different patterns of workflow

Be considerate, but don’t be a doormat

New PatientsNew Patients

Every patient is a potential new referral source

It’s not as complicated as it was in fellowship

Even if its not complicated, it may be new to you

Ancillary services will aid in diagnosis and build revenue

Stick to Rheumatology

The “Real World” PatientThe “Real World” PatientOsteoarthritis/Sports Medicine

Rheumatoid Arthritis/Psoriatic Arthritis

GoutGout

Positive ANA

Osteoporosis

Fibromyalgia

Everything Else

The BoardsThe BoardsBoards are TOUGH, but FAIR

Use late fellowship “down time” to study

Study time is very limited once you are practicing

develop a study schedule in fellowship and stick to it

If you can, avoid “extra duties” (call/consults) until after the test

The Second ActThe Second Act

Busier schedule --Going from Five to Fifteen Patients in a day

Adj ti A ill U d E l ti C diAdjusting Ancillary Use and Evaluating CodingPatterns

Practicing new skills

Managing difficult patients


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3

Managing Your ScheduleManaging Your Schedule

New Patients--compensate for less time by frequent return visits

Bring chatty and complicated patients back often

Evaluate how far behind you are running, and make adjustments if you can

talk to your MA, front desk about how he/she can help you function better

review patient charts before they arrive

The Challenging PatientThe Challenging Patient

The sick patient who is getting sicker

The non-compliant patient

The hypochondriac patient

The demanding patient

The unsatisfied patient

The malingering patient

The One Who Keeps You The One Who Keeps You Up At NightUp At Night

Don’t forget the value of a great history--consider revisiting it

Go back to the booksGo back to the books

Order as many consults, tests as you need

Ask for advice from your peers

If they are not responding like you think they should, question your diagnosis

If you are stuck--send them to an academic center

The One Who Ignores The One Who Ignores Your OrdersYour Orders

Make sure they understand what you want them to do, and WHY

Consider external factors (cultural, social, economic)Consider external factors (cultural, social, economic)which may affect their ability to comply

Be flexible if you can

Document clearly and heavily

Never lose your temper

The “Chicken The “Chicken LittleLittle"" PatientPatientIf they have myriad complaints and a positive review of symptoms, it’s probably fibromyalgia

Listen to their full story at least one time

Do not dismiss their fears out of hand

Bring them back often, and give them extra time

Build trust and do not over treat

Get information from all their providers

The “Its All About Me!” The “Its All About Me!” PatientPatient

Provide the best service you can

Create realistic expectationsCreate realistic expectations

Keep the lines of communication open

Follow through on your promises

Maintain your boundaries


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4

The Impossible to Please The Impossible to Please PatientPatient

Consider every patient (even this one) as a potential referral

Some patients just are not a good fit for you

Get to the heart of the problem

Be polite, and help them find another provider who better fits their needs

Don’t take it personally

The Malingering PatientThe Malingering PatientBeware of the amazing sob story

Document, Document, Document, but avoid a chart war

Get records from other providers, and from the pharmacy before prescribing opioids or committing to a treatment plan

Opioid contracts

Remember your right to dismiss a patient

Your Bad DaysYour Bad DaysJuggling a busy practice and a personal life is harder than you would suspect

Bad news: You will make multiple mistakes

When you discover a mistake evaluate why itWhen you discover a mistake, evaluate why itoccurred and whether there is an adjustment you can make to prevent a recurrence

If you are overwhelmed, make adjustments in your schedule and seek guidance from your mentors

Don’t beat yourself up

Keep your life as balanced as possible

Your Third ActYour Third ActMost days are full days

More follow up patients than new patients

Confidence and autonomy is growingConfidence and autonomy is growing

You now have a small trusted group of referring doctors

You are building a reputation in the community

It feels more like “your” practice

A Maturing PracticeA Maturing Practice

As you get busier, your days will get (even) longer

Use your lunch hour for phone calls, lab and x rayy p yreview, forms

Make sure that if it can be done by another person, it is

Consider saving the notes for later

ReRe--Evaluating Your Skill Evaluating Your Skill SetSet

Now’s the time to take a break, and consider some CME

Work on perfecting your new skill setWork on perfecting your new skill set

Read about issues you are confronting but feel unprepared for

If applicable, begin learning about practice management


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5

Preparing for PartnershipPreparing for Partnership

Talk to your business manager about your coding, ancillary use patterns, projected income

Compare your productivity to your peers

Ask your partner(s) about how you are performing

Consider whether this situation is meeting your expectations

Questions to Ask Questions to Ask YourselfYourself

Do I have the kind of practice I envisioned?

If not, what can I do to build “my” practice?

Can I see myself here in the long term?Can I see myself here in the long -term?

Should I renew my contract? How can I make changes to better my environment?

What are my new interests?

How can I grow my expertise in these areas?

The Finish (? Starting) The Finish (? Starting) LineLine

The first year of practice is incredibly exciting!

You are not yet the doctor you will be

You will be challenged every day

The rewards are great if you are in the right place

The contract is the engagement. The partnership is the marriage. Choose wisely!

LongLong--Term SuccessTerm Success

Set short-term goals

Monitor healthcare industry trends

Use Data and Benchmarking tools

Be open to change

Avoid burnout

Balance your personal life

THE END!THE END!THE END!THE END!Good Luck!


Page 5 of 5



3:45 p.m. - 4:30 p.m.

After the Treatment DecisionMichael Schweitz, MD



4:30 p.m. - 5:30 p.m.

Physician Employment and ContractsSteve McCoy, Esq



1

Employment Contracts and Related Issues: Guidance for Physicians

CSRO Rheumatology Fellows ConferenceCSRO Rheumatology Fellows ConferenceFebruary 20, 2016

Stephen C. McCoy

Outline: What We Will Cover Today

• Critical Areas of Physician Employment Agreements

• Due Diligence Investigation of Medical Practices

• Hospital and Health System Employment

Employment Agreements: 4 Critical Areas

• Think of your employment relationship in 4 component parts and review your contract with these in mind:

1. How do my employer and I work together?2. How does my employer work with other health care

providers?3. How does our relationship end?4. What happens after my employment ends?

Opening Thoughts (cont.)

• Focus on what happens when things go wrong. • Both employers and physicians tend to ignore their

employment agreements when things are going well.Read your contract as if you are unhappy and want to• Read your contract as if you are unhappy and want toleave.

Phase 1: Working Together

• The basics:– Term: How long does your contract last? – Description of your obligations: Read and understand.

How much discretion does your employer have to changeHow much discretion does your employer have to changeyour duties? This is a critical area in the current health reform environment.

– Record-keeping / billing / coding requirements: Avoid promises that make you personally liable for errors.

– Representations and Warranties: Make sure these are accurate. Correct any inaccuracies before signing.

Phase 1 (cont.): Compensation

Compensation:a. Salaryb. Salary plus bonus (production-based or fixed)c. “Pure” production models - You are paid based on your productivity (charges or collected revenuesYou are paid based on your productivity (charges or collected revenues

less allocated expenses)- Your production will be negative for the first several months of

practice . - This means you will not be paid under a pure production model

- You are likely to be “net” negative for the first 12- 18 months- Avoid pure production models during first 2-3 years of practice.


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2

Phase 1 (cont.): Benefits

Understand your benefits:(1) Salary and Bonus;

- Understand how these work. Ask for models.(2) Health and disability insurance (employee and dependents);

- Watch for spousal exclusionsWatch for spousal exclusions(3) Professional dues, licenses and insurance;(4) CME Allowances; (5) Recruitment Incentives and any obligation to repay;

- Remember that these are (generally) taxable (6) Vacation / Sick Leave.

Phase 1 (cont.): Professional Liability Insurance

The Basics:• Employer should pay for coverage • Usually written with “Per Incident” and “Annual

Aggregate” limitsgg g• Know the Cap in your State (if applicable)• Get and Keep a Copy of the Policy or (at least) of the

Acord 25 Form (sometimes referred to as a “face sheet”)

• Know and follow your employer’s reporting procedures, if any

Liability Insurance (cont.)

Two Types of Professional Liability Coverage:

(1) Occurrence-based Coverage- Covers a specified period of time, regardless of when a claim is

mademade- Expensive; Uncommon outside of health systems

(2) Claims-Made Policies- Coverage is contingent upon a claim being made within the

policy period - Know your “retroactive date” and make sure your coverage is

appropriate- We will discuss “tail” coverage later

Working Together (cont.)

Avoid or limit indemnities whenever possible

An indemnity is an agreement that you will pay any costs or expenses that arise as a result of your actions or failures to act - Acts and omissions that trigger an indemnity obligation are usually specified y but the description may be as general as “physician’s acts or omissions”

Your employer should insure against such losses and should not look to you personally to make the employer whole

Working Together (cont.)

Here is a sample indemnity provision. Avoid the language in yellow (particularly) and negotiate for the underlined text if you can’t avoid the indemnity altogether:

If any claim should be asserted against Employer for Physician's ti iti i d i th t f Ph i i ’ l tactivities occurring during the term of Physician’s employment

and arising out of alleged malpractice, third party payor (e.g. Medicare, Medicaid, or private insurance) reimbursement or claim submission, or tax deficiencies relating to disallowed business expenses incurred by Physician, Physician (or Physician's estate) shall bear the financial responsibility therefor to the extent any such claim would not otherwise be covered by insurance required to be maintained hereunder.

Working Together: Buy-In Provisions (non-institutional practices only)

What You Should Bargain For:(1) Decision time-line included in the contract(2) Price or methodology included in the contract

- Discuss tax-advantaged methods (3) Other requirements specified in the contract(4) Right to buy-in to ancillary businesses (and terms) (5) The right to leave with limited consequences if you

are not offered the opportunity to buy in


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3

Phase 2: It’s Not Me, It’s You(Ending the Employment Relationship)

Employment agreements terminate in 3 ways:1. Expiration (this is rare);2. Termination with cause (more common but still

rare – under 10%); 3. Termination without cause (most common).

Phase 2 (cont.): Termination

Termination with “Cause”:(1) Material breach / failure to comply with policies

of Employer;** (2) Failure to maintain license / privileges / Right to Participate with

Medicare and/or Medicaid;Medicare and/or Medicaid;(3) Felony or “moral turpitude;”(4) Loss of insurance (vs. insurability);(5) Disability / Substance Abuse;(6) Inaccuracy of warranties / representations;(7) Failure to meet clinical performance measures.**

**Contract should give you the right to cure, and you should have copies of applicable policies and performance measures.

Phase 2 (cont.): Termination

Termination Without Cause: This Agreement may be terminated by either party without Cause upon ninety (90) days' prior written notice to the other party.

• Standard contract provisions - not cause for alarm.• Ask for reciprocal notice periods.• Focus on other contract provisions that are triggered by

termination.

Phase 3: It’s Over, but It’s Not OverRestrictive Covenants

The Employer’s Purpose: To prevent you from building a patient base, then leaving and taking your patients with you to a second employer or to your own practice.

G l P hibi i h h i i iGeneral Prohibition: the physician may not practicemedicine

• in competition with his/her employer• within a defined area• during or after employment• (if after) for a set period of time

Non-Competes (cont.)

Physician non-competition agreements are enforceable in most states.

How is a covenant not to compete enforced?1. Injunctive Relief (the court orders you to stop)2 M D (th t d t f l )2. Money Damages (the court orders you to pay your former employer)3. “Later of” Clauses 4. Awards of Attorneys Fees and Costs5. Loss of Tail Coverage and other post-termination benefits*6. Chilling Effect on Prospective Employers*7. Expense and Uncertainty*

*Note that these can occur even without litigation

Non-Competes: What are your options?

Before you sign:• Review with counsel and understand the restrictions

– Ask yourself: can I live with this?– Take extra care if you are married to a physician

If possible negotiate a m t all e ercisable b o t• If possible, negotiate a mutually exercisable buy-out– One year of compensation is a typical measure

• Negotiate other limitations– e.g., Not applicable if group terminates without cause or fails to offer

equity ownership– Hospitals may agree to restriction on employment by other health

systems / large competitors but not by independent or small group employment


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4

Non-Compete Options (cont.)

After you sign:• Don’t leap before you look!• Consult with counsel before terminating employment• Always keep a copy of your contractw ys eep copy o you co c

Phase 3 (cont.): Tail Coverage

Extended Reporting Endorsements- a.k.a. “tail coverage”- provides coverage of prior acts following termination of

l i d iclaims-made insurance- Negotiate for cost-sharing. Your employer enjoys some

benefit from tail coverage and cost-sharing is becoming more prevalent- Negotiate for permission to maintain continuing claims-

made coverage (generally only possible if you move within the state)

Phase 3: Other Post-termination Items

• Observe any notice periods

• Watch for other contract provisions with post-p ptermination effects:– Confidentiality provisions– Repayment obligations

Due Diligence: Kicking the Tires

Ask questions about practice organization:• How is the practice organized? Is it owned by a health system,

health plan-affiliated, or private?• How old are the partners / shareholders?• Who last made partner? On what terms?• How is call shared? How is holiday coverage apportioned?• How (and how much) are partners compensated? What are

regional averages in your specialty?• Are the younger physicians happy? How many have left?

When? Why?• Do the practice physicians own other businesses or property

used by the practice?

Due Diligence (cont.)

Ask questions about the practice’s planning:• Does the practice have a long-range plan? What is it?• Is the local health system purchasing physician practices? Does the

practice compete with local system-affiliated practices?• Is the practice in a Medicare ACO or Clinically Integrated Networks? Is p y g

it participating in other coordinated care initiatives? Are those being considered? Do they exist in the market?

• Does the practice have an electronic medical record (EMR)?• If not, where is it in the transition to EMR? How does the practice plan to

pay for EMR? What is the projected effect on physician compensation?• Does the practice prescribe electronically? If not, why not?• Does the practice participate in commercial insurers’ coordinated care

initiatives? What has its experience been?• How has the practice been affected by health reform?

Due Diligence: Medicare Electronic Health Record Incentive Program

This program imposes penalties on physicians who do not successfully demonstrate “meaningful use” of an EHR

• Physicians who provide >90% of their services in hospitals (POS 21 or 23) are exempt – this will include many or most residents

• “Newly eligible” practitioners can apply for exemption for up to 2 years, as well – this generally will extend exemption post-residency but application is required

• Discuss your eligibility and status with your new employer – you may need to apply for a “hardship exemption” to avoid penalties


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5

Hospital Employment of Physicians

Critical Issues:1. Compensation

– Negotiate to 75th percentile of MGMA compensation (available online and through your attorney)Negotiate for signing bonuses / moving allowances– Negotiate for signing bonuses / moving allowances

– Watch for changes in compensation structure in later years of contract

– Watch for restrictions that make it difficult for you to leave and stay in the area

2. Description of services and limits on hours3. Restrictive covenants and performance measures (understand)3. Recoupment of payments (avoid)

Hospital Recruitment Assistance and Salary Guarantees

1. Watch provisions that trigger repayment obligations– For recruitment assistance, repayment is typically required if

you leave the hospital’s service area during the subsidy period or the 2-3 year period following the end of the subsidy Repayment should be a practice obligation unless you breach– Repayment should be a practice obligation unless you breach

2. The practice should not restrict your ability to remain in the hospital service area following termination

3. Consider the tax impact of signing a note

Hospital Recruitment Assistance (cont.)

4. Understand how debt forgiveness works– Tax planning is critical to handle discharge of

indebtedness (DOI) incomeN i f f i– Negotiate for separate payment of practice expenses and physician compensation to minimize DOI income

• Your collections should go first to pay your compensation, then to practice expenses

Final Thoughts

• Get and keep a copy of your contract and other practice policies

• Walk through the termination of your contract before you sign ityou sign it

• Avoid / understand contract language that makes you personally liable for claims or requires to you to repay money

• There are no handshake agreements• Hire an attorney to review and advise

Contact Information

Stephen C. McCoy, Esq.Vice President/General Counsel/Privacy OfficerPatient First Corporation 5000 Cox RoadGlen Allen, VA [email protected](804) 822-4490 (w)(804) 370 1041 (c)


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