Wmmagazine Final August Edition

WWAMI 101 Election 2010Gubernatorial Candidates & Health Care

Childhood and Adolescent Obesity

wyom

ing

M E D I C I N EAdvancing the healthcare dialogue in Wyoming communities

Volume 1. Number 2.

GrowingOurOwn

a publication of the WYOMING MEDICAL SOCIETY AUGUST 2010

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national perspectives

Health ReformThe Fallout from the Congressional Shout-out

Kimble Ross

Around WyomingP16

Jonathan Green offers a closer look at Wyoming WWAMI students. Learn about the students’ journeys in selecting medicine, choosing the University of Wyoming and the University of Washington to become part of Wyoming’s medical future.

Legal CornerP19

Dray, Thomson & Dyekman, PC attorney Nick Healey, JD, and James (Jim) Dobbyn educate pro-viders about “Negotiating Reim-bursement In A Payor Contract.”

p12

Growing Our OwnWyoming WWAMI and Our Next Generation of Doctors

Marguerite Herman

To Your HealthP30

Wyoming Pediatrician and Former President of the American Academy of Pediatrics State Chapter, W. Joseph Horam, MD, speaks to the issues of “Childhood and Adolescent Obesity.”

cover story

Cover photo: Jesse Sullivan of Freckle Photography. Featuring Left to Right: Paul Johnson, MD, Beth Thielen, Derek Nevins, MD, & Five-year-old Jackson Sullivan

contentWM

2010 Gubernatorial Candidatestalk to the issues of health care in our state and what they will do to help Wyoming’s future.

Dennis E. Curran

p9communityp10

www.TheChildrensHospital.org

www.TheChildrensHospital.org/SaintJoseph

Expert Care for Kids in the Rocky Mountain Region

The Children’s Hospital in Coloradooffers the highest quality pediatric programs in patient care,

education, research and advocacy.

Wyoming providers have convenient access to hundreds of pediatric

and adolescent specialists at one of the nation’s best hospitals for

children. In addition, our specialists provide more than 80 outreach

clinics throughout Wyoming each year.

Pediatric and adolescent clinics include: • Cardiology • Pulmonary Medicine • Endocrinology • Rehabilitation Medicine • Genetics and Metabolics

To learn more about our world-class facility, cutting-edge clinical

programs and research opportunities, please visit our website.

One Call 24-hour consultation, referral, admission and information for healthcare providers

One Call provides physicians with easy access to information, resources and the region’s largest array of pediatric specialists 24-hours-a-day.

Use One Call for: • Consultations and diagnostic dilemmas

• Arranging patient transport

• Outpatient referrals

• Professional support/continuing education

• Inpatient admissions

• Identification of pediatric subspecialists

• Any other questions

(720) 777-3999 (800) 525-4871

www.TheChildrensHospital.org

www.TheChildrensHospital.org/SaintJoseph

Expert Care for Kids in the Rocky Mountain Region

The Children’s Hospital in Coloradooffers the highest quality pediatric programs in patient care,

education, research and advocacy.

Wyoming providers have convenient access to hundreds of pediatric

and adolescent specialists at one of the nation’s best hospitals for

children. In addition, our specialists provide more than 80 outreach

clinics throughout Wyoming each year.

Pediatric and adolescent clinics include: • Cardiology • Pulmonary Medicine • Endocrinology • Rehabilitation Medicine • Genetics and Metabolics

To learn more about our world-class facility, cutting-edge clinical

programs and research opportunities, please visit our website.

One Call 24-hour consultation, referral, admission and information for healthcare providers

One Call provides physicians with easy access to information, resources and the region’s largest array of pediatric specialists 24-hours-a-day.

Use One Call for: • Consultations and diagnostic dilemmas

• Arranging patient transport

• Outpatient referrals

• Professional support/continuing education

• Inpatient admissions

• Identification of pediatric subspecialists

• Any other questions

(720) 777-3999 (800) 525-4871

6 wyoming medicine August 2010

Not many doctors practice medicine in Wyoming.With a total of about 1000 physicians practicing in the state, Wyoming has the smallest number of doctors of any of the 50 states. Perhaps more telling is the fact that even for our small population we have one of the lowest numbers

of physicians per 100,000 people: according to 2007 data from the American Medical Association Wyoming is 47th in the country in number of physicians per capita. What can be done to recruit doctors to come to Wyoming? Our cover story in this edition of WYOMING MEDICINE is about one of the truly great programs Wyoming has going for it: the WWAMI medical education program. Through the WWAMI program, Wyoming students have the opportunity to attend medical school and then return to Wyoming after they fi nish medical school and residency to pay back their school debt. The WWAMI program also allows students from other states to spend time in Wyoming as part of their medical education. Because of programs like WWAMI, as well as the University of Wyoming Family Medicine

Residency Programs in Casper and Cheyenne, the state has been able to recruit a number of great physicians to our state.

I would like to take this opportunity to thank the four individuals who volunteered to be on our cover:

Listed from left to right, Dr. Paul Johnson, Beth Thielen, Dr. Derek Nevins, and fi ve-year-old Jackson Sullivan.

All four were good sports about being cover models and very generous with their time. Thanks also to the Governor’s mansion in Cheyenne for letting us use their beautiful grounds for the photo shoot.

Dr. Johnson and Dr. Nevins are examples of the WWAMI program at its best. Both completed their fi rst year of medical school in Laramie and then went on to fi nish their other three years of medical school at the University of Washington.

Dr. Johnson is originally from Laramie, Wyoming. After graduating from medical school and completing an ENT residency at Columbia University he returned to a serve Wyoming at a private practice in Cheyenne. Dr. Nevins is originally from Wheatland and is now a second year resident at the University of Wyoming Family Medicine Residency in Cheyenne. Hopefully

from The ediTorBy: Robert Monger, MDChief Editor

from The ediTorBy: Robert Monger, MDChief Editor

“Wyoming has the smallest number of practicing doctors of any of the 50 states.”

wyom

ing

MEDICINEAugust 2010

The Wyoming Medical Society (WMS) is the premier membership organization dedicated to promoting the interests of Wyoming physicians and physician assistants through advocacy, education and member services. WYOMING MEDICINE (ISSN-2154-1681) is published bi-annually by WMS at 122 East 17th Street, Cheyenne, Wyoming 82001. Contact WMS at (307) 635-2424 or [email protected]

WYOMING MEDICAL SOCIETY LEADERSHIP

MAGAZINE EDITORIAL BOARD

SubscriptionsTo subscribe to WYOMING MEDICINE, write to WMS Department of Communications, P.O. Box 4009, Cheyenne, WY 82003. Subscriptions are $10 per year.

Articles published in WYOMING MEDICINE represent the opinions of the authors and do not necessarily refl ect the policy or views of the Wyoming Medical Society. The editor reserves the right to review and to accept or reject commentary and advertising deemed inappropriate. Publication of an advertisement is not to be considered an endorsement by the Wyoming Medical Society of the product or service involved. WYOMING MEDICINE is printed by Print By Request, Cheyenne, Wyoming.

Postmaster:Send address changes to Wyoming Medical Society, P.O. Box 4009, Cheyenne, WY 82003.

PresidentVice President

Secretary/TreasurerPast PresidentAMA Delegate

AMA Alt. DelegateExecutive Director

Gerrie Gardner, DOCynthia Casey, MDMichael Tracy, MDReed Shafer, MDRobert Monger, MDStephen Brown, MDSheila Bush

Chief EditorPublisherMemberMemberMemberMemberMember

Robert Monger, MDSheila BushSteve BahmerDennis CurranWendy CurranDennis EllisPennie Hunt

There are more pieces to the medical practice puzzle than ever before. We’ve been helping Wyoming physicians fit

those pieces together for 30 years.

DRAYTHOMSON

DYEKMAN, PC

AND

The Wyoming State Bar does not certify any lawyer as a specialist or expert. Anyone considering a lawyer should independently investigate the lawyer’s credentials and ability, and not rely upon advertisements or self-proclaimed expertise.

w w w . d r a y l a w . c o m n 3 0 7 . 6 3 4 . 8 8 9 12 0 4 E . 2 2 n d S t r e e t , C h e y e n n e , W Y 8 2 0 0 1

There are more pieces to the medical practice puzzle than ever before. We’ve been helping Wyoming physicians fit

those pieces together for 30 years.

DRAYTHOMSON

DYEKMAN, PC

AND

The Wyoming State Bar does not certify any lawyer as a specialist or expert. Anyone considering a lawyer should independently investigate the lawyer’s credentials and ability, and not rely upon advertisements or self-proclaimed expertise.

w w w . d r a y l a w . c o m n 3 0 7 . 6 3 4 . 8 8 9 12 0 4 E . 2 2 n d S t r e e t , C h e y e n n e , W Y 8 2 0 0 1

he will choose to stay in Wyoming after he completes his residency training.

Beth Thielen is a M.D. /Ph.D. WWAMI student at the University of Washington. She is originally from Minnesota and is currently completing her 3rd year family medicine clerkship at the residency program in Cheyenne; she will return to Wyoming next spring for a surgery clerkship in Casper. Prior to her participation in the WWAMI program Beth had never been to Wyoming.

Beth is a good example of how the WWAMI program is more than just a one-way street for Wyoming students to go out of state to medical school. Through Wyoming’s participation in the WWAMI program, medical students and residents from other parts of the country have the opportunity to come to Wyoming for part of their medical school or residency training. Hopefully some of them will fall in love with our great state and return here to practice someday. Wyoming voters have many options to choose from this year for governor, and in another story in this issue we profile six of the candidates. All six participated in a candidate forum at the Wyoming Medical Society Annual Meeting at Jackson Lake Lodge in June, and our article highlights some of their thoughts about health care issues.

No matter who you decide to support in this year’s election, please remember that we owe a debt of gratitude to all the candidates who are running for elected office. Each one of these individuals spends many months away from their families traveling around the state, in the public eye, just for the opportunity to possibly become a

public servant. Thanks to the six candidates we review in our story for making the time to attend the WMS forum, and thanks to all of the candidates running for office this year for your willingness to serve Wyoming.

Congratulations to Nick Morris, M.D., a fine physician from Powell, Wyoming, who is the winner of this year’s Wyoming Medical Society Community Service Award. The award is presented each year at the WMS Annual Meeting, and you can read about

Dr. Morris’ many accomplishments in this edition of Wyoming Medicine. Nominations for the 2011 Community Service Award will be taken by the WMS next spring, so start thinking now about who you might want to nominate.

We at WYOMING MEDICINE would like to hear from you! If you have any questions, or suggestions about how we can make the magazine better, please email us at [email protected].

Thank you for reading Wyoming Medicine. WM

“The WWAMI program is more than just a one-way

street.”

from the editor WM

7 wyoming medicine January 2010

307-577-2372 • www.WyomingMedicalCenter.com

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Wyoming Medical Center Ranked Best Quality (#1) in Wyoming for Spine Surgery

for 2010 by HealthGrades®, an independent health care rating organization that evaluates over 5,000 hospitals across the country on clinical outcomes. You can trust your health care

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G U I D I N G A M E R I C A T O B E T T E R H E A L T H C A R E ®


G U I D I N G A M E R I C A TO B E T T E R H E A LT H C A R E ®


GUIDING AMERICA TO BETTER HEALTHCARE®

307-577-2372 • www.WyomingMedicalCenter.com

Five-Star Rated for Back and Neck Surgery without Spinal Fusion

Wyoming Medical Center Ranked Best Quality (#1) in Wyoming for Spine Surgery

for 2010 by HealthGrades®, an independent health care rating organization that evaluates over 5,000 hospitals across the country on clinical outcomes. You can trust your health care

to a hospital that has always been here for you and your family. Quality care, delivered in a highly professional manner, by people who care about you.

Wyoming Medical Center

Clayton E. Turner, M.D.Board Certi� ed Orthopaedic Surgery

Brian Wieder, M.D. Board Certi� ed Neurosurgery

Joseph Sramek, M.D. Board Certi� ed Neurosurgery



G U I D I N G A M E R I C A TO B E T T E R H E A LT H C A R E ®


GUIDING AMERICA TO BETTER HEALTHCARE®

Will Wyoming’s next governor be a help or a hindrance, a leader or a laggard, in supporting quality medical and health care in the state during the coming four years? The answer appears to be positive, judging from a recent Wyoming Medical Society forum.

While sometimes short on specifi cs, all six major candidates for governor say they are committed to making quality health care a continuing top priority in Wyoming. Some even are championing another run at tort reform.

And all of them are hoping for support from the state’s medical community as they square off in the Aug. 17 primary election to determine the Republican and Democratic nominees.

The top contenders -- Republicans Matt Mead, Rita Meyer, Ron Micheli and Colin Simpson and Democrats Pete Gosar and Leslie Petersen – were invited to answer questions about health care at an early-morning candidate forum at the WMS annual meeting in Grand Teton National Park June 12.

Meet the candidatesMead, a Cheyenne attorney and rancher, is a former U.S. attorney and the grandson of the late Gov. and U.S. Sen. Clifford P. Hansen of Jackson.

Meyer is completing her fi rst term as state auditor, the state’s payroll offi cer. She is a retired Wyoming Air National Guard colonel with combat command experience in Kuwait and

Afghanistan and was chief of staff for Gov. Jim Geringer.

Micheli is a fourth-generation Wyoming rancher from Fort Bridger in Uinta County. He served 16 years in the Wyoming House of Representatives and headed the Wyoming Department of Agriculture under Geringer.

Simpson, a Cody lawyer, has served 12 years in the Wyoming House of Representatives and was speaker the last two years. He is the son of former U.S. Sen. Alan K. Simpson.

Gosar, a Laramie businessman and pilot for the Wyoming Aeronautics Division, is a political newcomer but is actively campaigning and has name recognition as a University of Wyoming football standout

two decades ago.

Petersen, a retired Jackson real estate broker, was state Democratic Party chair until she entered the governor’s race. A longtime conservation lobbyist, she served for six years as a Teton County commissioner and ran unsuccessfully for secretary of state in 1982.

The other Republican candidates are Alan Kousoulos, a Wyoming Department of Transportation employee from Cody; John Self, a retired Sheridan businessman

making his third bid for the Republican nomination: and Tom Ubben, a Kinder Morgan employee from Laramie.

The other Democrats are Al Hamburg, a retired house painter from Torrington making his 17th bid for state or federal elected offi ce; Rex Wilde, a cabinet manufacturing company employee from Cheyenne; and Chris L. Zachary, a retired federal and state psychiatrist from Cheyenne.

Scope of practiceFrom the very fi rst question, the candidates were quick to show their general support for the medical community. The fi rst question involved scope of practice, and candidates were asked specifi cally whether they would support so-called “sunrise” legislation to require at least a year to study proposals to allow various health-care professionals to expand their practices.

Gosar said he thinks it is important to health-care consumers that they have confi dence in their providers, and he said he thinks discussions about professional standards are important. He also used his opening answer to emphasize the importance of good health care in general. “When wealth is lost, nothing is lost,” he said. “But when health is lost, something is lost.”

Mead spoke more directly to the sunrise question, stressing the importance of giving as much notice as possible when discussing scope of practice issues to “avoid last-minute consequences.” “Too often, you get in a rush to pass legislation, and too often you get unintended consequences,” he said.

Meyer, married to a dentist, recalled battles over allowing expanded practice by denturists and declared that “patient safety is always paramount.”

Continued on page 14

2010 gUBernaTorial elecTionCan Wyoming’s Next Governor Heal Health-care Pains?

By: Dennis E. Curran

community WM

August 2010 wyoming medicine 9

“Grow your own” has become the conventional wisdom in Wyo-ming’s efforts to recruit and retain physicians. By all indications, the state has found the solution in the WWAMI program. After 13 years, it has a stellar performance record in its mission to supply Wyoming’s rural residents with primary care and specialty physi-cians.

“It has vastly exceeded my greatest expectations,” said Wendy Curran, who was the deputy director of the Wyoming Medical So-ciety when the program began. “We believed if we got close to 50 percent return rate for the students, we would be wildly success-ful.” In fact, about 70 percent of the Wyoming students who attend medical school under the WWAMI program are coming back to the state to practice.

The name represents the fi ve states that participate in the same contract program with the University of Washington to prepare physicians to practice in a rural setting: Washington, Wyoming, Alaska, Montana and Idaho.

The keys to success of WWAMI (pronounced “whammy”) are the focus on rural medicine - for Wyoming residents - paid for by the state - with an obligation to come back and practice in the state or repay the some $150,000 Wyoming has spent to send them to medical school, with interest. Another key element is students’ preparation at the University of Wyoming before going to Seattle.

The obvious benefi ciaries of WWAMI are the medical stu-dents and the Wyoming folks who can fi nd the medical care they need, if not in their hometown then in a commu-nity close by. Other benefi -ciaries are the hospitals and clinics who hire these talented young physicians, the University of Wyoming and the entire community of health care providers in the state. So continuing support for WWAMI comes from the Wyoming Medical Society and the Wyoming Hospital Association and of course the Wyoming Legislature, which ap-propriates money every two years to send Wyoming students to medical school.

Here Is THe “GrOWING yOur OWN” sCeNArIO IN WyOMING: A high school student is interested in health sciences. A guidance counselor encourages the student to check out the WWAMI pro-gram and talk to Assistant WWAMI Dean Matt McEchron, PhD, at the University of Wyoming.

The student (who is a certifi ed resident of Wyoming and might be from Casper or Alpine or Saratoga) completes a pre-med un-dergraduate degree program at the University of Wyoming or any other college. The student applies to the University of Washington School of Medicine. (WWAMI helps the student prepare for the Medical College Aptitude Test and polish interviewing skills.)

The student is interviewed by the WWAMI Admissions Commit-tee in hopes of securing one of 16 slots for the Wyoming WWAMI class.

Once admitted, the student takes the fi rst year of medical school in Laramie. Then the student has the option of participating in a four-week Rural/Underserved Opportunities Program (RUOP) ex-perience throughout the WWAMI region. Wyoming has 14 RUOP sites. So the Wyoming student we are following might spend a month with Don Kirk, MD, in Thayne or Larry Kirven, MD, in Buffalo or 12 other locations. The student then heads to Seattle to complete the second year of medical school.

GrowingOur Own in

Wyoming Derek Nevins, MD ~ Resident

By: Marguerite Herman

During the third and fourth years, this student may rotate through all fi ve WWAMI states and complete required and elective clerk-ship rotations with the following extra options:

• Apply to be one of 12 students from each WWAMI class of 200 to spend 20 weeks of the third year in one rural commu-nity. This is the WWAMI Rural Integrated Training Experi-ence (WRITE), with rotations in family medicine, internal medicine, pediatrics and psychiatry. The student also com-pletes an elective rotation. The WRITE sites in Wyoming are in Powell and Lander.

• Apply for one of four Wyoming Rural Clinical Experience spots. If selected, the student will complete four or more of their six required third-year clerkships in Wyoming

After the four years of medical school it is time to complete a resi-dency in a specialty and look for employment back in Wyoming. After graduation from residency, the WWAMI physician returns to Wyoming to practice medicine for three years, comfortable with the practice of medicine in a rural environment, and wants to stay for the long term.

And that is how it is playing out.

Richard Hillman, MD, is the clinical dean for WWAMI in Wyo-ming. He is a member of the WWAMI “team” for all the clinical activities in Wyoming. (The WWAMI team includes the Univer-sity of Washington, University of Wyoming, Wyoming Medical Society and Wyoming Hospital Association). Dr. Hillman has the critically important job of fi nding clinical sites for the third and fourth year clerkships in Wyoming.

“We’re looking for quality physicians in their practice and in their professionalism. They must be willing to teach and work with stu-dents as a team,” Dr. Hillman said. “Part of the problem is these physicians are so busy, they just can’t work with students.”

For the physician mentors, the rewards are huge, Dr. Hillman said. In addition to a small stipend, they get faculty status at the Univer-sity of Washington, and they have Internet access to its fi rst-class research library. Plus, the University of Washington brings them to Seattle once a year for continuing medical education.

Curran, who is the health policy analyst for Wyoming Gov. Dave Freudenthal, said she has seen this connection of mentors to the top-rated University of Washington medical school have the effect of retaining rural doctors in Wyoming. “Instead of just sitting in your offi ce in Buffalo, you make sure your skills are up to date, and you’re working with brilliant young minds,” she said. The ex-perience invigorates the doctor with a fresh perspective and con-nections with the cutting edge of his or her area of practice.

And there’s more. Dr. Hillman said the WWAMI students who are in Wyoming for the RUOP experi-ence present a great recruiting op-portunity for hospitals and doctors. “You don’t have to spend $100,000 recruiting for unknown physicians,” he said. About 300 students rotate through Wyoming for 4-6 weeks each year. “The communities, hospi-tals and doctors need to take advan-tage of that and recruit them when they’re here,” he said. “This is a great opportunity we’re missing right now.” The WWAMI program is relatively new in Wyoming, just 13 years old, and we’re still learn-ing how to put all this together for the best for our state.

“It’s a lot better than recruiting doctors for Wyoming whom no-body wants,” he said.

A sign that the Wyoming program has reached a level of maturity is the participation of WWAMI alumni in recruiting and mentor-ing current students. The doctors who have been “grown” are now cultivating future Wyoming physicians, for instance WWAMI grad Blaine Ruby, MD, who was a preceptor for rural surgery in Buf-falo 2009-2010. Adam Peters, MD, of Cody, Gentian Scheer, MD, and Justin Hopkins, MD, in Lander hosted students for the RUOP experience in 2009.

Another sign is the quality of students we are sending to Wash-ington. The University of Wyoming has sharpened its pre-med and fi rst year programs, and other WWAMI team members have helped students with clinical experience, MCAT preparation and

cover story WM

Beth Thielen ~ WWAMI Student



Now that the multiple federal health system ‘reform’ deeds are done, the blogosphere and journals are fl ush with prognoses from cynics, polemicists, and optimists, left, right and centrist, on what’s next. Don’t expect a consensus in your professional lifetime. This kind of creative disrup-tion transcends anything physicians have experienced since Medicare was birthed in 1965, or perhaps even when Abraham Flexner produced his book-length, seminal report in 1910.

This article maintains that unless you are a closeted policy wonk, there is little rea-son to wring your hands over esoteric and out-of-your-immediate-reach concepts like insurance exchanges, long-term health in-surance and other risk pools, still pending federal transfers to buttress Medicaid or SCHIP, or even the tough federal over-sights of the health plans, especially when the earth is moving in multiple directions under your feet. The following proposes fi ve practice-specifi c, game changing the-ses and offers some brief discussion on their underlying logic—all rebuttable and subject to contradiction—that they are ar-guably the more infl uential factors at the exam room level in this phone-book thick body of federal law:

Thesis I: Forget Repeal - Get Real: Really more a caveat than an independent variable in this grand lab experiment: Re-versing what’s been done is problematic at best, given the time lines and institutional and legal barriers. There will undoubtedly be revisions and course corrections, but the general policy direction won’t change.

Thesis II: Integrate or Die: The macro trend in Horizontal and Vertical Integra-tion—and its alter ego, consolidation—will accelerate, given the powerful incentives to come together (or starve out of network). Does small group and solo practice go the way of the brontosaurus?

Thesis III: Triple Threat in the Execu-tive Branch: Congress did a triple play handoff (to mix sports metaphors) to the agency side, creating three distinct entities that can, and will make unilateral decisions about who, where, and when to pay for ser-vices without having to seek Congressional permission.

Thesis IV: Coming off the Bench? Phy-sicians have been mostly on the sidelines in this game by their disparate views, leav-ing the major players on the fi eld—hospital systems, payers, employers, and others on the capital-intensive side of the ledger to infl uence the next iterations. And therein lies their opportunity.

Thesis V: Providers Will Get RAC’d: An unprecedented consolidation of effort and resources by the feds to ‘recover’ fraudu-lent services or simply overpayments will round up the usual suspects, then shotgun the whole herd and separate the sheep from the goats post mortem. Call it , ‘leave no outlier behind.’

Following that batting order, here is a little more elaboration on the game changers within that medical practice context.

Thesis I: Forget Repeal - Get Real:It’s not just that those horses have stam-

peded out of the barn—Congress has been known to reverse itself. However, there are considerable political barriers and econom-ic realities this go-round:

1. Payment realignments, the most sig-nifi cant inspiration among practice variable catalysts, were proceeding with or without changes in federal law. The SGR debacle, now in its 7th year, is an unsustainable trend, a collision course with physicians that sooner, not later, get a phase-in treatment. It is not driving system reform, but rather is chasing it, if for no other reason than because the patches continue to enable an expiring payment methodology.

2. Medicare’s pilots along the array of ‘quality/value’ options such as episod-ic payment, value based purchasing, pay for performance, and in-patient service bundling-- are on the precipice of widespread adoption. Commercial payors are quick to adhere to those policies, making any federal change private-sector-metastatic. Think of Never Events as the market adaptive model. In the fall of 2008, Medicare came up with six ‘never events’ they would not reimburse, and within weeks the commercial payors said ‘me too’, followed by several hospi-tal systems. One system, Geisinger, raised the ante by guaranteeing some treatment episodes. AHIP has reported considerable interest among the plans to retool all contracts to an RBRVS methodology, and most contracts al-ready include a clause hinging Medi-care reimbursement changes to their provider fee schedules.

The falloUT

The Downstream Flushing Effects of What Congress Did, and Didn’t Do

By: Kimble Ross


from The

congressional shoUT-oUT:vs Inaction

The Litigation Center of the American Medical Association and the State Medical Societies is committed to protecting doctors and upholding the highest standards of patient care.

In courtrooms across America, we are achieving legal victories that preserve the rights of physicians, promote public health and protect the integrity of the profession.

Whether we are challenging managed care organizations’ payment practices or preserving the autonomy of the hospital medical staff, one thing remains constant: The Litigation Center is an active force fighting for physicians’ rights.

Learn more on how The Litigation Center can help you: www.ama-assn.org/go/litigationcenter

Membership in the American Medical Association and the Wyoming Medical Society makes the work of The Litigation Center possible.

Join or renew your memberships today.

In actIon

www.ama-assn.org www.wyomed.org

The falloUT

The Downstream Flushing Effects of What Congress Did, and Didn’t Do

By: Kimble Ross

congressional shoUT-oUT:vs Inaction

The Litigation Center of the American Medical Association and the State Medical Societies is committed to protecting doctors and upholding the highest standards of patient care.

In courtrooms across America, we are achieving legal victories that preserve the rights of physicians, promote public health and protect the integrity of the profession.

Whether we are challenging managed care organizations’ payment practices or preserving the autonomy of the hospital medical staff, one thing remains constant: The Litigation Center is an active force fighting for physicians’ rights.

Learn more on how The Litigation Center can help you: www.ama-assn.org/go/litigationcenter

Membership in the American Medical Association and the Wyoming Medical Society makes the work of The Litigation Center possible.

Join or renew your memberships today.

In actIon

www.ama-assn.org www.wyomed.org


“This should be a process that includes proper credentialing, education, and training for all professionals,” she said, calling for plenty of notice when scope of practice issues are discussed.

Micheli said it’s important that “we do everything we can to make sure we have quality people” treating patients. “It’s incumbent on all of us to make sure people out there are qualifi ed to provide these services.” However, Micheli noted that as a 16-year veteran of the Wyoming Legislature, he was not sure how the legislative logistics would allow for a one-year notifi cation period.

Petersen agreed the

sunrise concept

“is a grand idea” and

said she certainly

is for appropriate

credentialing of all health-care practitioners, but she noted that “few things fl y through the Legislature” anyway. “I can see where it would be very advantageous, but in actuality I would think it’s unlikely,” she said.

Simpson noted he has dealt with “quite a few scope of practice issues” during his legislative tenure, and he said he wants to continue working with WMS on those issues, because “patient safety is very important.” But he said a one-year notice requirement is “probably unrealistic.”

New look at tort reform?The six candidates were less in agreement over alternatives to achieving meaningful medical liability reform in Wyoming, but they all appeared open minded to discussing alternatives.

Wyoming’s medical liability laws do not limit damages for non-economic losses,

such as pain and suffering, and doctors contend that this lack of “caps” is causing rates for medical liability insurance to soar out of control in Wyoming. All six neighboring states allow caps on damages, and all have lower liability insurance rates.Wyoming voters in 2004 narrowly rejected a proposed constitutional amendment that would have allowed the Legislature to impose caps, and two candidates - Micheli and Meyer - urged the doctors to take up the battle again because they believe the political climate has changed.

“I would encourage you not to give up on this, and I would hope that the Wyoming Medical Society would not back off on this issue,” Micheli said. “I believe you cannot have a meaningful discussion about health-care reform without a discussion about tort reform.”

Meyer termed herself “a vocal advocate for tort reform” and charged that medical liability concerns “continue upward pressure on the cost of health care.”“It will not resolve all of our health care issues, but it is part of the equation,” she said. “We are surrounded, as you know, by other states that have initiated tort reform, and it’s working in those states.”

Review Panel alternative?Mead said he hopes recent efforts to strengthen the state’s Medical Review Panel will help limit frivolous lawsuits and avoid rising costs, but he said he views tort reform as a “critical issue” because of the importance of quality health care for Wyoming residents and the importance of quality health care in economic development and physician recruitment.

Simpson, viewed by many doctors as a tort reform opponent, said he voted for the legislation in 2004 and is “open to conversations and negotiations” about the issue, though he emphasized he also believes “very strongly in personal rights and the right of a jury trial” and believes the amount of the cap suggested in 2004 --

$300,000 -- is “too low.”

Petersen said she is “somewhat open” to caps on damages if they are high enough. She said she isn’t sure what the amount should be, but “I certainly do not think that $300,000 is high enough.” She also said she was not sure it has been “clearly articulated” how caps would stabilize or reduce medical costs, but “overall, I have a very open mind on the question, and I appreciate your comments and wisdom.”

Gosar said he looks at the issue as a patient and health consumer and thinks that “a common sense approach” is needed. “You have the world you would like, and you have the world you have,” he said. “The people of Wyoming rejected health care reform…. The Medical Review Panel seems to me a common sense approach…. (that could avoid going to court and encouraging people) to sit across the table and talk.”

Health IT hot topicAll six candidates voiced support for expanded use of information technology in health and medicine, though they were a little short on how to pay for it. “This is an opportunity for Wyoming, not only to help people but also to increase jobs,” said Gosar. “I think that’s the future … and can make your jobs (as doctors) easier.”

Mead agreed, calling health IT “vital” to Wyoming. But he stressed that the state must provide for uniformity in electronic medical records. “We cannot have multiple systems,” he said. “The state has to take charge on this. The state has to provide real leadership on this so we’re all on the same page.”

Meyer followed, saying the call for state leadership is fi ne, but the “big, big gorilla on the backs of health-care providers is who’s going to pay for it.” Some federal stimulus dollars are available, but they won’t be enough, she warned, “and there are vendors out there just waiting to snooker you.”

Continued from page 9communityWM

agreed the

“is a grand

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Micheli, noting that former Gov. Jim Geringer was way ahead of his time in connecting communities with information technology, said health IT is “of the highest importance.” “The trick now is to make sure we have programs that talk to each other,” he said.

Petersen also agreed that health IT is a “high priority” for Wyoming and said the question really illustrates what Wyoming needs to do overall with technology. “Our whole future relies on being on the cutting edge,” she said. Specifi cally regarding health IT, she said the state “very much has to take a leadership role, and it will take money.”

Simpson noted his support for health IT in legislation he sponsored three years ago and pledged to continue helping hospitals and physicians to expand health IT. “It’s a wonderful opportunity for you and your patients,” he said, “but I also understand how it can burden you.”

Docs & patients, pilot projectThe candidates quickly followed Meyer’s lead in decisively answering “no” to a question whether it would be “appropriate for the state government to legislate or infl uence what takes place between physicians and their patients?” That relationship is “sacred,” several said.

All six candidates also were unanimous in their support for a health pilot project approved by the Legislature earlier this year, Healthy Frontiers. The demonstration project is intended to create a model for health insurance and preventive health care services designed to hold down costs, decrease utilization and keep Wyoming residents healthier.

Micheli said the project addresses a very critical problem in the state, and “as a state, we need to stand up and give it a shot.”

Petersen said the pilot project is “innovative” and was created by Wyoming

people for Wyoming. She also praised its emphasis on preventive care and patient co-pays, ensuring that they “have a little more skin in the game.”

Simpson supported the bill in the 2010 session and said, “It’s targeted and it should work well. It’s got great possibilities, and it is a fi ne example of what states can do.”Gosar said, “Creative solutions are what we need. I’m a big believer in personal responsibility.”

Mead called it a “great project” and a model for “what we should be doing.”

Meyer, answering last, quipped, “I share their love.”

“There is no reason why Wyoming should not be a leader in health-care reform,” she added, calling the pilot project a small step that “could help us emerge as a leader.”

Comprehensive careThe fi nal question asked candidates what, if any, should be the state’s role in supporting comprehensive patient care in Wyoming, such as dental care and critical access hospitals and trauma care. It stumped some of the candidates but gave them an opportunity to reiterate their support for a strong health-care system.“I confess that I’m not able to easily answer this question,” said Petersen, the fi rst to answer, “but the state has to be nimble and supportive of our doctors. I think that training and philosophical support of the medical community is at the core of what the state should be doing.”

Simpson said the Legislature has been struggling with comprehensive patient care for decades. “The state does have a role in supporting comprehensive patient care because those hospitals can’t carry it themselves, and we are treating those who are least able to help themselves or pay for that type of care,” he said. He also said the state should continue supporting the fi ve-state WWAMI medical education program

and continue to look at utilizing primary care physicians to monitor total care for their patients.

Gosar said he thinks the state can help health practitioners avoid “death by a thousand cuts” when routine makes a job less fresh and desirable, and he also suggested possible state support for air service for patients.

Mead said, “The state is involved in comprehensive health care, it’s a question of degree and how well we are doing. Good health care in Wyoming is not just a quality of life issue, it’s an economic issue.” He also said the state needs to lead in establishing electronic health records.

Meyer said she sees medical care “kind of coming full circle again,” with primary care physicians using the concept of medical homes and monitoring the total health of their patients. “People don’t expect to get a heart transplant in Thermopolis, Wyoming,” she said, “but they expect access to some level of care that incorporates a look at themselves. Telemedicine will absolutely leverage these efforts.”

Micheli, the fi nal speaker of the morning, said the state’s greatest role in supporting medicine is in support for telemedicine. “I think Wyoming could be a leader in promoting telemedicine,” he said. “I think we have wonderful opportunities to do that.”

The fi eld will be narrowed to two on Aug. 17. WM

Dennis E. Curran is publisher of the Wyoming Business Report, where a story about the WMS candidate forum appeared in the July issue. He can be reached at [email protected] or 307 638-3200.

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W y o m i n g m e d i c a l s T U d e n T s a closer look By: Jonathan Green

Tyler Quest wants to be a doctor. That may be the easy part. Quest also wants an excellent education at a top-notch school. He wants to avoid fi nding himself in a student loan hole mea-sured by dollars into six fi gures. He wants very much to help lower health care costs in his native Wyoming without lowering the quality of care. Elise Lowe also wants to be a doctor. Wit-ness her eight years on ski patrol, her EMT certifi cation and a fortnight spent translating for a doctor in Honduras. Like Quest, Lowe is interested in quality educa-tion supported by small class sizes. “I love the Rocky Moun-tain West,” she says, and would like to prac-tice medicine in Wyoming. Money – read “cost” – is also important, but her goals are “much greater than just the fi nancial aspect.” What to do?The University of Washington’s School of Medicine (UWSOM) seemed a good place to start. “The School of Medicine consis-tently ranks as the number one primary

care medical school by US News & World Report, and in the top ten research medical schools,” Quest notes. “Consistent” might be an understatement: Washington has held the top spot for 16 consecutive years. A good start indeed. But what about pay-ing for that world-class education? Enter WWAMI. An alliance of universi-ties in Washington, Wyoming, Alaska,

Montana and Idaho, the program gives students like Quest and Lowe a chance to study at UWSOM and at home. Wyoming students spend their fi rst year of medical school at Laramie, their second in Se-attle and two more years at clinical sites throughout the region.

Lowe and Quest will pay $12,000 a year for four years of medical school through the program, while the University of Wyo-ming will loan them the difference be-tween that price and what UWSOM would charge them as non-resident students. That difference was about $145,000 in 2009, according to a WWAMI fact-sheet. If Quest and Lowe return to Wyoming af-ter receiving their MDs and practice here

for three years, UW will forgive the loan. Good school? Check. Affordable? Check. A chance to return to, and help, Wyoming? Check.

elIse lOWe “I have wanted to be a doctor for as long as I can remember,” Elise Lowe says. “Growing up in the mountains of Wyo-ming” – Lowe is from Sheridan – “I developed a love of the outdoors as well.” Even with her under-graduate, let alone med school and residency, studies still years ahead, Lowe dove into the fi eld. She says ski patrolling

is “the perfect combination” of her dual loves of medicine and the outdoors. “It gave me an introduction to patient care and affi rmed my desire to be a physician,” Lowe says. “I took the course during my sophomore year of high school and patrolled for the next eight years until

By: Jonathan Green

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around wyoming WM

medical school.”Lowe says patrolling the slopes will continue to be a passion for her; she plans to return after she earns her MD. She is appreciative of the exposure to medicine the work offered her. “Patrolling opened doors to me,” she says, including a chance to shadow docs in the ER and riding in ambulances on occasion. Those ride-alongs propelled Lowe into her next medical foray. “I loved emergency medicine and got my EMT license as soon as I turned 18,” she says. She has since helped transport psychiatric patients via non-emergent air ambulance, volunteered at the Missoula County, Mont., Search and Rescue and worked for the Missoula city ambulance. There was also the two week period in Honduras, in 2007, where Lowe says she was inspired “seeing the large public health impact of small, well orga-nized programs and infrastructure.” Lowe’s varied palate of experience fore-

shadows her ambiguity over which path to take toward her MD. “While I greatly appreciate my experiences in emergency medicine, my focus has gradually shifted more to public health. I have not decided on a specialty yet, but I am interested in infectious disease, epidemiology and system-wide solutions to common medical problems.” Regardless of which specialty she chooses, because of her shared medical and out-doors interests, WWAMI has long been “a natural choice for me,” Lowe says. “The support we get through the program is much greater than just the financial aspect,” she says. “The small class size allows us to have access to our extremely qualified and motivated faculty. We are provided with all kinds of resources and supported in all aspects of our education.” Lowe is currently fulfilling the research requirement of her MD working on a

state-sponsored telepsychiatry pilot project from Sheridan. This fall, she begins her second year of medical school in Seattle.

Tyler QuesT

Tyler Quest, like Lowe, has long been attracted to medicine. “I attended the Uni-versity of Wyoming for my undergraduate studies and basically wanted to attend medical school for most of my life (with a few other thoughts from time to time).” Quest agrees with Lowe that the variety and quality of opportunity in the WWAMI program was a big factor in his decision to enroll. “What many people don’t know is that Wyoming actually has first year medi-cal students being educated at the Univer-sity of Wyoming each year.” “Out of (the WWAMI participating) states, Washington is the only one with a four-year medical program, and therefore a need was identified to give students from the other four states an opportunity to have



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a more ‘in-state’ experience.”Quest, also preparing to begin his second year of medical school this autumn, points out the number of prospects he will have to choose from in his third and fourth years. “Students spend their time doing clinical rotations in various fields. (We) have the op-portunity to complete these clinical years both at a large medical institution such as the University of Washington, as well as at several different towns and hospitals out in the five state region.” Perhaps auguring his own future plans, Quest continues, “Often students spend part of their (clinical) years in Seattle, then move to a state like Wyoming and do a rotation, then Alaska, et cetera. “This allows for students to learn in a large hospital with many students and physicians, as well as practice in a small, rural town, which might only have one physician and you.” “Many people also do not realize that students are allowed to do their residency training anywhere in the world before coming back to work in Wyoming. I greatly look forward to spending some time in Seattle and someday returning to practice in Wyo-ming to help care for its population.” Quest is not a circumstantial benefactor of WWAMI, but shaping

up as one of its biggest boosters. “I learned about WWAMI at a lunch meeting former students sponsored during my freshman year of college, and have been amazed by it since.” “I believe in the mission of WWAMI, to bring physicians back to the state. This not only reduces health care costs in the state, but also allows for a happier and healthier population with physicians that have received the finest of training.” Program execution also weighed on Quest’s mind in choosing the WWAMI route. “A first year medical school class of 16 students allows for a great deal of one-on-one instruction and creates an extremely close knit group of colleagues that can depend on one another for the rest of their life and career.” “Wyoming WWAMI is especially unique in that it allows stu-dents to be paired with a physician preceptor in a one-on-one setting once a week throughout the year.” With classes set to resume soon, Quest is looking forward to Seattle and is gracious for his experiences in Laramie. “I had a great time my first year and am very thankful for the experiences, faculty, staff and students.” WM

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Negotiating Reimbursement In A Payor Contract

Not Mission Impossible, And You Should Choose to Accept It.

Negotiating or renegotiating a payor con-tract for your medical practice can be one of the most important steps you can make toward improving the practice’s financial health. In the current healthcare reim-bursement environment, physicians may (justifiably) feel that their medical prac-tice’s financial viability is being threat-ened. Most medical practices are finding a larger percentage of the fees they receive is fixed. There is little (or no) room for fee flexibility with Medicare and Medicaid, combined with the ever present threat (and reality) of cuts to the Medicare Physician Fee Schedule. As national economic chal-lenges mount, health care providers find themselves with a greater percentage of un-insured, underinsured or “no pay” patients. Physician practices need to look hard at the financial areas over which they have some control, and try to maximize those areas. One of these areas, whether you feel it or not, is fee reimbursement.

Prelude: Physician, Heal Thyself.Medical practice reimbursement is a hydra, the multi-headed beast of myth. It encom-passes financial issues, community service issues, and patient access issues. Any of these issues is worth writing an article on. However, this article focuses on addressing the financial implications of deciding to, and following through on, renegotiating a commercial payor contract.

Reimbursement is an area that many phy-sicians overlook when determining how to improve their practice’s financial health. Reimbursement rates are often taken as a “given” by physicians. That those rates

could (and should) be negotiated does not occur to them. Even if the practice feels it is not being reimbursed fairly by a particu-lar payor, many physicians would prefer to concentrate on improving financial areas of the practice in which they feel comfortable than renegotiate. Negotiation implies con-frontation, which is not only uncomfort-able, it goes against many physician’s basic natures. Conflict is rarely part of the heal-ing process in which physicians are trained. Likewise, negotiation implies haggling to some physicians, which is distasteful and clearly not why they got into medicine in the first place. Thus, many physicians, whether consciously or unconsciously, al-low the reimbursement levels in their payor agreements to stagnate or worse, decline. However, looking at your practice’s reim-bursement levels is one of the best ways to ensure you have the healthiest practice possible.

Step One: Deciding To Renegotiate. The first decision is one that is usually tak-en as a given by health care providers, but it is one of the most important: Should your practice have a preferred provider agree-ment with a specific payor? Becoming a “preferred provider” or “in network” for a payor means that, in return for agreeing to the reimbursement rates offered by a pay-or, the payor agrees to give you access to patients that you may not otherwise have. Patients, by and large, will usually go to a “preferred provider” for their payor over an “out of network” provider. There can be many reasons for this; the payor may require the patient to pay more of the cost of treatment out-of-pocket if provided by

an “out-of-network” provider, or the payor may do a good job of promoting its net-work of providers. Therefore, there is usu-ally some advantage to being a “preferred provider” for a particular payor.

The “Preferred Provider”: What’s the advantage?Many practices want to be “preferred pro-viders” for payors, fearing exclusion pa-tient sources if they are not. However, it is worth recognizing that agreeing to be a preferred provider means agreeing to the payor’s reimbursement schedules, and thus giving up some measure of autonomy in your practice. In making this decision, you should give thought to the following:

• How many patients in your market area are covered by this particular payor?

• How many providers in your special-ty area already have preferred provid-er contracts with this payor?

• What other health entities (i.e. hospi-tals, surgical centers, DME compa-nies) have preferred provider agree-ments with a particular payor?

• If you decide not to be a preferred provider, are there significant admin-istrative and billing challenges for your practice if you treat patients that see you “out-of-network”?

• Do you have the capacity in your practice, in terms of volume, to han-dle the additional patients that may come with being a preferred provider, and if the answer is “maybe”, do the reimbursement rates you will receive justify the added cost of treating

legal WM


James (Jim) DobbynPhysician Practice Management Healthcare Services

Nick Healey, JDDray, Thomson & Dyekman, PC

Step Two: Review The Payor Agreement. If you’ve decided that your practice should be a “preferred provider” with a particular payor, the next step is to review and under-stand the terms of that relationship, includ-ing the reimbursement levels. These are set out in the provider agreement that you (should) have with the payor. With an exist-ing payor relationship, pull out your current agreement and make sure you understand the terms you have in place. If you are es-tablishing a new “preferred provider” rela-tionship with the payor, ask for a copy of the payor’s standard plan agreement. This may or may not include a proposed fee schedule, but will give you the standard “boiler plate” from which to start.

How long is it, and can I get out?If you have a current agreement, start with determining the “term and termination” provisions of the contract. This will control how long the contract is in effect and when (and if) you can renegotiate. Some contracts can be very restrictive as to your time frame for re-negotiating. Typically, the “term and termination” provisions are viewed as “boil-erplate” and thus either unimportant or not able to be changed anyway, and so not worth being concerned with. However, ignore the “boilerplate” at your peril! Some of the most important parts of the contract can be “boilerplate”. This does not mean, though, that they are (a) not important or (b) unable to be changed.

The contract language probably does not al-low you to renegotiate reimbursement levels whenever you want. However, it may allow you to renegotiate at specific intervals (ie. an-nually). If the agreement does not give you any reasonable options for renegotiation, you may have to go to the payor and ask to discuss renegotiation. Some payors will be cooperative and work with you on renegoti-ating reimbursement levels. After all, it does not help payors to have networks full of physicians that harbor a grudge against the payor. Other payors may be more restric-tive. If so, check to see when the agreement expires. If it does not expire soon, and you want to renegotiate, you may be forced to move into the termination process to rene-gotiate. Check the agreement’s termination

provision to see if you can terminate the agreement prior to its expiration. Most pay-or agreements have some type of “without cause” termination provision, meaning that either party can simply terminate the agree-ment without either party having done any-thing wrong. Many such agreements require that you give written notice (such as 90 days) before terminating the agreement, although the timing and notice requirements may be complicated and the termination option may only be able to be exercised at specific times. You should consult with your legal advisor before terminating the agreement, as there are potential downsides to termination that should be considered. However, if you have gone through the analysis above with respect to whether you need to be a “preferred pro-vider”, then you will be in a good position to know whether the potential benefits are worth the potential downsides.

Step Three: Make Contact With the PayorOnce you understand the various terms of the existing contract or standard contract, it is time to meet with the payor’s representa-tive.

At the initial meeting with the payor repre-sentative, be prepared to discuss the changes in the terms of the agreement you are look-ing for. These should include:

1. How the practice will be reimbursed for services rendered;

2. How much the practice will be reim-bursed for services;

3. Opportunities for periodic review of the reimbursement levels;

4. What services are covered;5. The term of the agreement and the

termination clauses;6. Possible “special project” arrange-

ments you may like to see with the payor.

How the practice is reimbursed for services can be as important as how much. Some payors like to use fee schedules that they’ve developed, and may try to insist on using those in the agreement. While this may seem like a small issue, using the payor’s fee schedule takes control away from you on ad-justing fees and gives it to the payor. Other

payors will propose a percentage multiple of the Medicare fee for a particular service. In theory, it may sound good to receive 130% or 140% of Medicare’s fee schedule; how-ever, no physician needs reminding that Medicare’s fee schedule is under constant as-sault from Congress, and that Medicare rates are typically lower than many commercial payers. The best option for many practices, therefore, is to negotiate to be reimbursed at a multiple of your own fee schedule. This gives you more control over your fees. Re-view your own existing fee schedule and make adjustments before meeting with the payor.

Once you have determined the best pay-ment methodology for your practice, you need to determine what you will accept for reimbursement. Typically, the basis for re-imbursement will be a specific fee for each current procedural terminology (CPT) code. Make sure you use the same CPT codes used by Medicare (resource based relative value scale (RBRVS)), which is the stan-dard with most medical practices. There are other companies who attach different rela-tive value scale (RVS) values to CPT codes, such as Ingenix, which is favored by some payors. However, using different RVS scales will make the process of comparing data with the payor extremely difficult, and you will probably come out worse off compared to the payor.

Step 4: The Cost of a Pound of FleshGenerally, the fees you request should be rea-sonable for the services you provide. Your fee schedule, by CPT code, should reflect the maximum fee level you charge patients for specific services. Those fees should be determined by examining the market, your position in the market, the demand for your services, and the cost of services you pro-vide. As discussed above, practices are re-ceiving more and more pressure from fixed revenue sources in reimbursement. When working with payors, you should examine the entire mix of fees you receive and how that impacts the overall practice reimbursement, and remember that payors are competitors that should be competing with each other. Therefore, one strategy is to look at trying to develop parity between payors in terms of


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what you are reimbursed for the same CPT codes.

Legal Note: Don’t seek reimbursement information from physicians in your community to determine what you should charge.

When trying to determine what is reason-able to accept as reimbursement, you may be tempted to simply call colleagues at other medical practices in your community and ask what arrangements they have with the par-ticular payor you’re negotiating with. After all, they are likely your friends and colleagues, and the payor has the information in any case, since it contracts with all of you. RE-SIST THE TEMPTATION! Other phy-sicians may be your friends and colleagues, but they are also, from a legal perspective, your competitors. Sharing price informa-tion between competitors can be viewed as the first step to price-fixing among competi-tors, which is unlawful under both state and federal anti-trust law. Moreover, the Federal Trade Commission, responsible for enforc-ing the federal anti-trust laws, has actively enforced those laws in the Rocky Moun-tain Region in recent years among physician groups sharing pricing information and at-tempting to negotiate reimbursement rates as a group. In two recent examples, the FTC entered into consent decrees (essen-tially official settlement agreements) with two Colorado independent practice associa-tions (IPA’s) the Boulder Valley Independent Practice Association (IPA), in 2008, and the Roaring Fork Valley Physicians IPA in 2010, to stop those physician groups from shar-ing pricing information among independent physician practices and engaging in collective negotiations with payors. Also, don’t assume that the FTC will not set its sights on Wyo-ming. While the Boulder Valley IPA oper-ated in Boulder, a fairly major metropolitan area, the Roaring Fork Valley IPA operated in Glenwood Springs, Colorado, which is not so different from many towns and cities in Wyoming. Therefore, it is clearly better to avoid sharing such information, or seeking it from others. The better course of action is to obtain such information from national or regional surveys, if possible.

Once you have established your fee struc-

ture, the next step is to consider what level of reimbursement you will accept from a payor under that fee schedule. Although the ultimate goal may be to receive full (100%) reimbursement of your fee schedule, that’s probably unlikely. The proportion you ac-cept is ultimately up to you; however, 90% of your fee schedule, if it is reasonable and you have taken care to prepare it according to the steps outlined above, is not unreason-able.

Also, payors may have different levels of flexibility on different CPT codes, so be aware of the volume of your business that is being generated by specific CPT codes. It is not uncommon for 80% of a practice’s vol-ume to be concentrated in 20% of the total number of CPT codes used in the practice. For instance, a primary care practice prob-ably generates a significant amount of its volume and income from CPT codes 99213, 99214, 99203, and 99204. In a surgical prac-tice, most of the volume and income is con-centrated with 10 to 15 CPT codes. If you are unable to obtain the target percentage of your fee schedule that you hoped for with the payor, consider focusing on the CPT codes you use the most. Although most plans try to keep the formulas for reimbursement sim-ple, and would prefer not to negotiate differ-ent reimbursement percentages for different CPT codes, it is an option to suggest in ne-gotiations. Again, the factors above need to be examined in determining what to suggest. You should also require contractual language that gives you flexibility in adjusting your fee schedule from time to time, such as every six months or annually. The payor may want to cap the percentage by which fees can be ad-justed in this time period, or may want con-tractual language locking you in to the term of the contract. However, your goal should be obtaining the greatest flexibility for fee adjustment. The ideal situation is to be fairly reimbursed for your services without mak-ing you an outlier compared to other simi-lar practices. Remember, in most cases, the payor has the same (or even greater options) to terminate the relationship, with or without cause, as you have. It is not advisable to be on a payor’s radar screen because your reim-bursement levels are unreasonable. Payors want to have preferred providers in their net-works, which makes them more attractive to

potential clients, and just like the providers, payors have motivations other than simply the fee schedule. Most payors are willing to work with a practice if the practice is reason-able in its requests.

While this article has focused on preparing to negotiate payor agreements, the payor’s response, and the course and conduct of negotiations with the payor once that prepa-ration and initial meeting have happened, is unpredictable. However, if you have pre-pared as set out above, and considered all the issues discussed above, you should be much better prepared than you would otherwise be to handle whatever surprises come your way.

Conclusion: It’s In Your Hands!As you can tell, negotiating or re-negotiating a payor agreement can be very challenging and requires a strong understanding of your practice’s economics, your marketplace, the contract language and how it achieves the practice’s goals. However, the best advice that can be given, at this point, is that you are not powerless in your relationship with a payor. Nor do you have to be a bully, shout or scream in order to be able to negotiate ef-fectively. Think about your practice’s goals, how those can be achieved and be willing to request specific language and commitments in payor agreements. You are entering a partnership of sorts with the payor, and the best partnerships are founded on expecta-tions and commitments that are fair, clearly stated and understood by both sides. You therefore want as much clarity as possible in the relationship, which is documented in your payor agreement. The payor also wants (and probably needs you) as a provider to un-derstand the relationship and wants the least amount of confusion about your respective roles and responsibilities possible. The end-game of this process is for you, as a provider, to be compensated fairly for the services you provide and not to have payor contractual is-sues interfere with the patient/physician re-lationship. Although that is a simple goal, it is not an easy one to accomplish. However, with the preparation and forethought set out above, it is possible, and you’ll be the better off for having done it. WM


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recognition WM

Nick Morris, MD of Powell was selected by the Wyoming Medical Society as the recipient of the 2010 Community Service Award. This award is presented each year to Wyoming’s top physician in recogni-tion of their contributions to Wyoming communities, honoring the physician for time and personal sacrifi ce for the benefi t of the community.

Dr. Morris is a beloved member of the Powell community and has been nothing but a beacon of honesty and integrity. In a letter of support for Dr. Mor-ris’ nomination, Powell physi-cian, Michael Tracy, MD wrote, “Dr. Morris is incredibly em-pathic and is truly the epitome of a ‘small-town’ surgeon. He has a deep commitment to his patients, and he responds with grace in all situations from trau-ma calls to being asked a ques-tion in the check-out line in the grocery store.” He has served the community in many leadership roles, including serving as the Chief of Staff at Powell Hospital, Past Hospital Board Member, and Board member of a local philanthropic foundation.

He is well respected by his patients and peers across the Bighorn Basin and the referral hospitals in Billings. Dr. Morris has consis-tently received positive feedback as a teacher of medical students through the WWAMI program.

Former students have commented on how they benefi ted from his knowledge base, professional demeanor, and work ethic years af-ter their rotations with Dr. Morris. A former WWAMI student from Wyoming, Dr. Nathan Rieb, has moved to Powell to be the community’s general surgeon starting in September 2010. Dr. Morris will remain in the area in a mentorship role as he retires and Dr. Rieb begins his career in Powell.

In addition to dedicating efforts toward the care of Powell patients, Dr. Morris has committed countless hours to the citizens of the Powell area through his work with the Heart Mountain Volunteer Medical Clinic, a free clinic in Powell that will celebrate its 2nd anniversary in early July. He has clearly always gone the extra mile to provide quality services to the citizens of Powell. “Nick Morris, MD is a tireless advocate for his patients and his com-munity. The Powell medical community is fortunate to include him in our ranks,” said Robert L. Chandler, MD of Dr. Morris. Students at many levels of education have been encouraged by Dr.

Morris to play a role in the opera-tion of the clinic. High school and college students alike have learned by shadowing. A Pow-ell High School graduate who is pursuing her advanced prac-tice nursing degree spent sev-eral weeks at the clinic. Bryn Parker, a third year medical student in the WWAMI pro-gram, spent every Tuesday night of her fi ve month rotation in Powell volunteering at the clinic. Dr. Morris has created an atmosphere that will shape the future of healthcare in a

positive fashion.

Dr. Morris has practiced medicine in Wyoming since 1991. He received his undergraduate degree from Pennsylvania State Uni-versity and later completed his medical school training at Temple University Medical School in Philadelphia, PA. Dr. Morris com-pleted his internship at Dartmouth Affi liated Hospi-tals in Hanover, NH and fi nished his medical training with a gen-eral surgery residency at Episcopal Hospital (Temple University affi liate). Dr. Morris shares his joys with his wife Madelyn and their four children Trish, Sherry, Chris and Matt. He has a new kayak and plans to do more fi shing and paddling out of reach of his cell phone. WM

Left to right: Nick Morris, MD, Bryn Parker, Mike Tracy, MD, Mark Wurzel, MD


cover storyWM

interview skills. “Four years ago we barely had 10 qualifi ed applicants. This year, we had 16, plus 11 on the alternate list who were just as good,” Dr. Hillman said. In fact, he said, the Wyoming Legislature will be asked to expand funding to 20 students.

The WWAMI arrangement depends on the continued good will of the Legislature. “Of all the things I’ve seen the Legislature do for 30 years, there’s been more bang for the buck with WWAMI than with anything else I’ve seen,” Dr. Hillman said. “This is much more cost effective than $20 million to start a medical school.”

In fact, the Legislature did consider a proposal by the University of Wyoming in 1978 to fund a medical school, to respond to the chronic shortage of rural health care. Fifteen state senators con-cluded the state lacked the money and population to support a medical school, and they effectively blocked the funding. The idea died with that session.

Soon after, the Legislature created the UW Family Practice Resi-dency Program clinics in Cheyenne and Casper, with the aim of attracting newly graduated family physicians to a residency pro-gram and then to practice in Wyoming. In the 1980s, as Wyoming headed into its own recession, some legislators argued for the clin-ics’ demise because they didn’t make economic sense. But they survived, largely on the merit of providing health care to an under-served, poor population in the two cities.

State Sen. Charles Scott of Casper, who has served in the Leg-islature since 1979 and is chair of the Senate Labor, Health and Social Services Committee, remembers those legislative fi ghts as being motivated at least somewhat by regional rivalries. Sen. Scott considers the family practice centers an important piece of Wyo-ming’s effort to attract primary care physicians – wherever they are grown.

WWAMI has begun using the UW Family Practice center in Chey-enne for clerkships in family practice, and students who serve their post-graduate residencies there have their repayment obligation re-duced from three to two years. The UW Family Practice center in Casper is an essential part of primary care for the state’s second-largest city, Scott said, and now it operates jointly with the feder-ally funded community health center.

The Legislature previously used the Western Interstate Commis-sion for Higher Education program (WICHE) to help Wyoming students attend medical school. Lawmakers continue to help pay tuition for other health care programs, but state funding for physi-cians is focused on WWAMI. The high rate of success for bringing Wyoming doctors back to Wyoming and the ranking of the Uni-versity of Washington’s medical school as number one for primary

care (and number two in research funding) make convincing argu-ments for continued legislative support for WWAMI, Dr. Hillman said.

He said the WICHE program had just 4-5 students a year, with only a 23 percent return rate.

Wyoming also tried a contract program to send a handful of stu-dents each year to medical school at the University of Utah and to Creighton University in Omaha. That did have a payback provi-sion, but it lacked the rural orientation, and the return rate was about 45 percent, Dr. Hillman said.

For a brief time in 1999, a proposal by New York millionaire Rob-ert Ross to build a campus in Casper for a Carribbean-based unac-credited for-profi t medical school had support from the governor and several lawmakers in Wyoming.

The shortage of physicians in Wyoming is chronic. Scott, Hillman and others point to the peculiar nature of rural practice, the pe-culiar Medicare reimbursement formula that short-changes rural providers and the failure of medical liability insurance reform as possible contributors to the shortage. Meanwhile, the average age of physicians in Wyoming is 51, and about 20 percent plan to retire within the next fi ve years.

Back in the early 1990s, the alarm over the shortage seemed to get renewed attention in Wyoming. It was the dean of the newly-formed College of Health Sciences at the University of Wyoming who took the fi rst steps toward WWAMI, Curran recalled. Dean Martha Williams assembled the healthcare stakeholders in Wyo-ming, and together they looked at the University of Washington and the program as it was working with Alaska, Montana and Ida-ho – making it WAMI (with one “W”). “Of course they all raved about how wonderful it was.”

The Wyoming Medical Society and UW drafted an agreement and built support among legislators, hospitals and policy-makers around the state to join the program. The Wyoming Legislature ap-proved the funding in 1996. Wyoming began the program with 10 students in 1997, later expanding to 16.

Dr. Hillman said WWAMI administrators and faculty are con-stantly reviewing the curriculum and working on im-provements, includ-ing increasing the class size from 16 to 20. “We’re try-ing to develop the program so it em-phasizes the needs of Wyoming,” he

interview skills. “Four years ago we barely had 10 qualifi ed applicants. This year, we had 16, plus 11 on the alternate list who were just as good,” Dr. Hillman said. In fact, he said, the Wyoming Legislature will be asked to expand funding to 20 students.Paul Johnson, MD ~ WWAMI Graduate

Jackson Sullivan ~ Future medical student... or pilot


said. One push is to make a seamless program for primary care and family medicine, so a student would start out at the University of Wyoming and perhaps get early admission to a family medicine residency in Wyoming. Another push is to increase graduate medi-cal education -- residencies – in Wyoming, which is difficult with such a small population.

“Our goal is to prepare quality physicians from Wyoming who want to come back to Wyoming in every specialty, family medi-cine through neurosurgery, because we need all of those.” WM


cover story WM

In 1978, as now, Wyoming struggled with the lack of doctors, and the Wyoming Leg-islature seemed to like the idea of the Uni-versity of Wyoming creating its own com-prehensive medical school and facilities. At least the House of Representatives liked it and included it in a section of the state budget bill that funded UW, but that’s as far as it got. The Senate Appropriations Committee de-leted medical school funding, and that’s how the bill came to the floor for debate. In the 30-member Senate, 15 lawmak-ers were resolutely against the idea. They feared the cost of a medical school in poor economic times (which occurred 10 years later). “I think it would have broken the state,” says Dick Sadler of Casper, 81, who was one of two Democrats who voted with 13 Republicans to oppose funding. They also doubted the students in such a sparse-ly-populated state would get experience with the number and variety of diseases necessary for a good medical education. Those 15 approved removal of funding, and they outvoted the other 14 senators on

the floor. Sen. Rex Arney, a Sheridan at-torney, was in the chair for Committee of the Whole that day and didn’t vote. A 15-15 stalemate defeated every attempt to restore the funding or keep $690,000 for medical school staff and planners for one year. “We couldn’t get off the 15-15 vote,” Sadler said. Arney remembers three House-Senate con-ference committees that met without suc-cess, and the Legislature adjourned with no budget for the University of Wyoming for the next two years. Ninety days later, Gov. Ed Herschler, who had supported the med-ical school idea, called the lawmakers back for a special session to pass a UW budget. The medical school funding was gone from the bill. Sadler said the 15 opponents never formed an official block, but for this special session they issued a joint statement, addressed to House Speaker Nels Smith, to make sure everyone understood the score:

Because of a rumor that a new medical school proposal would be acceptable to one or more members of the 15 senators

opposed to a medical school, we feel it is critical that we inform you and members of the House that we will not support any compromise resulting from this special ses-sion that will leave the door ajar, thus post-poning a decision on behalf of the people of Wyoming for another year. Specifically, we will not vote for an additional year’s funding to retain medical school staff and planners. We take this opportunity to for-ward to you this statement, and the realities of the situation with sincere hopes we can avoid an unfortunate re-enactment of the deadlock of the House and Senate as was experienced in the recent budget session. Regards,(Signed by each of the 15)

That was that. Sadler thinks at least some supporters were acting out of loyalty to UW. Meanwhile, he said, “I didn’t think we could afford it, and I wasn’t about to change my mind.” He does recall feeling bad, however, when he got up to speak against the medical school proposal, with his family physician being the “doctor of the day” and present in the Senate chambers. WM

The Beginning of Wyoming’s medical school sTory

By: Marguerite Herman


national perspectivesWM

3. Integration and consolidation of ser-vices were accelerating well in ad-vance of the federal law as a means of economic survival. Physicians are mi-grating into integrated systems, more often than not as employees, hospitals are buying up physicians and smaller hospitals, especially the now capped physician investor hospitals, at fi re sale prices, and the plans continue to eye each other as prospective owners. Market share is acquired, not won through vigorous competition.

4. EHRs are still due by 2015, and the meaningful use criteria have been of-fi cially modifi ed and adopted. Under most scenarios, growing adoption will facilitate the other structural require-ments in reimbursement and account-ability (code for ‘recovery audits’)

5. Congressional makeover notwith-standing, most analysts see the Re-publican pushback, however substan-tial, as sub- threshold-- not enough votes to overcome a veto. That renders some reversible aspects problematic, as timelines outrun congressional of-fi ce terms. The polling trends also suggest the emergence of a political center as more categories of voters understand the personal benefi ts, fi re-walling in some districts a partisan surge. The legal challenges are consid-ered long shots by many constitutional experts, who note an unbroken string of Supreme Court decisions sustaining the Congress’ authority to regulate ac-tivities that have a substantial effect on interstate commerce, including medi-cal care, and like Social Security taxes, Congress can require the purchase of health insurance then tax those who do not in order to cover those costs.

Thesis II: Service Integration and its Iterations: The incubating payment realignments are by design intended to encourage if not compel the integration and subsequent coordination of services, since the incen-tive payments only accrue in those settings that can prove up evidence based, coordi-nated care, demonstrable outcomes, and

all its incumbent effi ciencies. The federal policy engineers demonstrably don’t intend for every physician to be retrofi tted into a Mayo, Kaiser, or Geisinger system. In ad-dition to substantial fi nancial incentives for primary care services, medical homes, and restoring that pipeline, the law contem-plates the semi-organized consolidation of smaller practices in Accountable Care Or-ganizations. Whether they are the fi rewall to protect that endangered species of small and solo group practice or yet another rein-vention of the clinic-without-walls, ACOs have the full force of federal law behind them. It enjoys considerable grassroots in-terest (Colorado is rolling Medicaid ACOs over the next 18 months) but is still an un-tested model outside a few settings other than the large networks, like the unique community-wide collaboration in Grand Junction that includes the community hos-pital and a highly regarded non profi t HMO

Thesis III: Executive Branch Triple Threat or Play? In what outgoing CBO director Peter Orsag called ‘the largest yielding of sovereignty from the Congress since the creation of the Federal Reserve’, the Congress handed off to the executive branch three federal sub-agencies real time authority to alter every day practice: The Independent Payment Advisory Board (IPAB) , the Patient Cen-tered Outcome Research Institute (PCO-RI), and the Center for Medicaid/Medicare Innovation (CMI). Here’s a cocktail nap-kin sketch of their powers. It ‘aint rocket surgery’ as a colleague is fond of saying, to contemplate how these three change the entire game. 1. IPAB: Beginning in January 2014,

each year that Medicare’s per capita costs exceed a certain threshold, the IPAB will develop and propose poli-cies for reducing this infl ation. The secretary of HHS must institute the policies unless Congress enacts alter-native policies leading to equivalent savings.

2. PCORI: will publish research fi nd-ings and any limitations, as well as what further research may be needed, in a manner useful to clinicians, pa-

tients and the general public in making health care decisions as to what ser-vices and procedures are more or less ‘comparatively effective’:• Such fi ndings may not include

practice guidelines, coverage recommendations, or payment or policy recommendations. There is no requirement that the fi nd-ings communicated to the public be consistent with U.S. Food and Drug Administration approved la-beling of regulated products.

• Federal payers are not prohibited from using research fi ndings to in-form payment, coverage and treat-ment decisions. However, com-parative research fi ndings alone may not be used to deny coverage.

3. Center for Medicaid/Medicare In-novation is mandated to : • “test innovative payment and ser-

vice delivery models to reduce program expenditures under the applicable titles (Medicare and Medicaid) while preserving or enhancing the quality of care fur-nished to individuals under such titles.”[7]

• The enabling law instructs the HHS Secretary, in selecting pay-ment and service delivery models, to “give preference to models that also improve the coordination, quality and effi ciency” of care for Medicare benefi ciaries, Medicaid benefi ciaries, and dual eligibles.[8] The law also allows the Sec-retary to test models within geo-graphic areas.

Thesis IV: Physicians Coming off the Bench? Organized physician infl uence on the congressional effort has to this point been marginal or at best symbolic for the most common of political circumstances: They are sharply divided within their ranks. When not just lying low to avoid friendly fi re, Physician organizations have been vocal, if not visceral in their opinions on pivotal elements of the Act(s) , and thus incapable of supporting the legislation


national perspectives WM

with any politically relevant unity. Con-sequently, physicians in the form of orga-nized medicine are perceived on the Hill as also incapable of enforcing hostile votes drawn from the lengthy and conten-tious congressional debate. To be fair, even a unifi ed front, which is usually limited to galvanizing issues like malpractice reform or managed care disputes, would have to overcome the extreme partisan pressures on their respective congressional delegations, notwithstanding the fact those delegations typically enjoy close if not always cordial relations with their state medical societ-ies. With the laws on the books and now in the byzantine maze of federal and state agencies, the rules of engagement are very different. One former high ranking federal offi cial (and now with a prominent DC law fi rm) observed recently, ‘the docs weren’t really in the game because larger forces were at work… and other than the AMA and AAFP endorsements, most of them were wrapped around spe-cifi c sub-issues…now is the time they should come off the bench and work with their delegations on the hundreds of insider plays developing at the agen-cy level.’ His point was, whether the substance is fecal matter or liquid gold, it all fl ows downhill to the states for implementation, and the state medical organizations would be well suited to fully engage their members, given their local standing and infl uence within their local and political communities.’

Thesis V: Getting RAC’d. Political veterans of health care budget wars all understand that the fi rst place the government looks for ‘savings’ in the system is fraud. Long before health system issues were a gleam in Speaker Pelosi’s eye, The (2003) congress au-thorized as part of the Medicare Mod-ernization Act the creation of Recovery Audit Contractors, with, for once, a fi tting acronym, RAC. RACs use pro-prietary software programs to identify potential payment errors in such areas as duplicate payments, fi scal intermedi-aries’ mistakes, medical necessity and coding. RACs also conduct medical

record reviews, and by law can extrapolate from random audits their fi ndings across all claims in any given year. The penalties are stiff, and have the additional leverage of threatening criminal prosecution.

HHS estimates, citing CBO fi gures, that the return on investment by Congress in anti-fraud efforts is 17:1. Secretary Sebe-lius announced in her report to Congress this winter a federal task force, Health-care Fraud Prevention and Action Team, or HEAT, which says it all while bending the rules of federal health care acronyms: “HEAT is an unprecedented partnership that brings together high-level leaders from both departments so that we can share in-formation, spot trends, coordinate strategy,

and develop new fraud prevention tools.”

Sic transit Gloria the presumption of inno-cence. In my experience, the government investigators won’t leave your home with-out a scalp, and the rules heavily favor their position. It is a target rich environment, and they are well equipped to go hunt-ing—loaded for bear, as my father would say. WM

offi cial (and now with a prominent DC offi cial (and now with a prominent DC law fi rm) observed recently, ‘the docs law fi rm) observed recently, ‘the docs weren’t really in the game because weren’t really in the game because larger forces were at work… and other larger forces were at work… and other than the AMA and AAFP endorsements, than the AMA and AAFP endorsements, most of them were wrapped around spe-most of them were wrapped around spe-cifi c sub-issues…now is the time they cifi c sub-issues…now is the time they should come off the bench and work should come off the bench and work with their delegations on the hundreds with their delegations on the hundreds of insider plays developing at the agen-of insider plays developing at the agen-cy level.’ His point was, whether the cy level.’ His point was, whether the substance is fecal matter or liquid gold, substance is fecal matter or liquid gold, it all fl ows downhill to the states for it all fl ows downhill to the states for implementation, and the state medical implementation, and the state medical organizations would be well suited to organizations would be well suited to fully engage their members, given their fully engage their members, given their local standing and infl uence within their local standing and infl uence within their

Political veterans of health care budget Political veterans of health care budget wars all understand that the fi rst place wars all understand that the fi rst place the government looks for ‘savings’ in the government looks for ‘savings’ in the system is fraud. Long before health the system is fraud. Long before health system issues were a gleam in Speaker system issues were a gleam in Speaker Pelosi’s eye, The (2003) congress au-Pelosi’s eye, The (2003) congress au-thorized as part of the Medicare Mod-thorized as part of the Medicare Mod-ernization Act the creation of Recovery ernization Act the creation of Recovery Audit Contractors, with, for once, a Audit Contractors, with, for once, a fi tting acronym, RAC. RACs use pro-fi tting acronym, RAC. RACs use pro-prietary software programs to identify prietary software programs to identify potential payment errors in such areas potential payment errors in such areas as duplicate payments, fi scal intermedi-as duplicate payments, fi scal intermedi-aries’ mistakes, medical necessity and aries’ mistakes, medical necessity and coding. RACs also conduct medical coding. RACs also conduct medical


national perspectivesWM

Health Reform: Now What? Some wild guesses and irresponsible speculation:

By: Kimble Ross

As Yogi Berra famously said, ‘the future ain’t what it used to be.’ Here’s a dozen- plus less than scientific guesses at scenarios that follow from these factors, drawn from ongoing conversations with analysts, think tankers, health lawyers of considerable experience, economists, politicians, medical society leaders and advocates, and the usual arm chair opinion suspects.

1. Tighter networks enforced by commercial plans to control costs, since other means of offsetting through risk aversion and underwriting have been barred. Plans’ payment methodologies will more closely track, even mirror Medicare policies.

2. Collusion between some plans and some hospitals to control those networks; the term ‘bilateral oligopoly’ will be googled by more health writers and physicians, who will also be able to distinguish between a monopoly and a monopsony.

3. Legislation by litigation—the disenfranchised will seek relief from the courts, and the support of their medical or-ganizations— which will also generate legislative scrutiny of current anti trust laws, state and federal, and in some jurisdictions realign some plaintiff attorney, physicians-as-plaintiff relationships.

4. Increased friction in some hospital-medical staff settings as administrators control bundled payments, employ more physicians, and cut deals with payors to maintain networks.

5. More migration of marginal practices into employed settings.

6. More divisions and internal pressures on organized medicine; strange alliances emerge as employed physicians seek advocates, some plans collaborate with integrated groups, some hospitals do the same.

7. Softening of corporate practice or related restrictions on the hiring and firing of physicians. Full employment for labor lawyers with enough health policy savvy.

8. ACOs growth, incentives notwithstanding, will run hot and cold. Most significant variable is the presence or ab-sence of physician leadership in those communities.

9. Increased pressure by RNPs, PAs, other professions to expand scope of practice, which in turn raises militancy of primary care phyisician organizations; FPs will press medical educators to fill more slots and generate internal conflicts among the specialties on campus.

10. As more comparative effectiveness research comes on line, along with other payor ‘evidence-based payment poli-cies, more litigation will arise over standard of care, and increasingly pit manufacturer and physician prescriber defendants against each other.

11. The CER movement may also draw manufacturers and prescribers closer; formulary gaming or manipulating by a payer or PBM may draw, for example the PhRMAs and physicians closer on clinical questions of medical necessity versus cost cutting efficiency, especially when the liability for therapeutic failure or toxicity falls on the prescribing physician.

12. Fee for service as currently configured joins unaligned solo and small group practices in a slow spiral into obscurity (or concierge/cash practice).

13. With many more voters covered, political tensions may realign less along insured/uninsured class warfare lines and more toward age discrimination fronts—Medicare beneficiaries versus Medicaid/SCHIP versus commercial sector--the young invincibles mandated to buy coverage or pay a penalty, versus the boomers now acquiring chronic conditions.

Wyoming Primary Care Association For assistance, please contact Kristy Hazelton: 2005 Warren Avenue ∙ Cheyenne, WY 82001 (307) 632‐5743 ext. 10 ∙ Fax: (307) 638‐6103

[email protected] ∙ www.wypca.org

Services Available Support/promote Wyoming Health Centers Support the expansion of affordable health care services

across Wyoming Improve access to medical, dental and mental health

services Provide training and technical assistance on rural health

issues Provide grant writing assistance

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Dear Editor,

My heartiest congratulations to Dr. Rob Monger, Editor, and to Ms. Sheila Bush, WMS Executive Director, on the publication of the new WMS magazine.

It is a beautiful publication, with articles of interest for all Wyoming doctors, and the general population also.

This achievement has come about only after long hours of thought, consideration, and hard work.

Thank you for your efforts, and congratulations on this new endeavor. I wish you and the WMS Magazine a long and successful run.

~Reed Shafer, MDWMS Past President

a note from our readers...

to your healthWM

CHILDHOOD AND ADOLESCENT OBESITYFACING REALITY AND MEETING THE CHALLENGES

Col. W. Joseph Horam, MD, FAAP

The incidence of childhood obesity in the United States was 5% in 1963 and has risen to 17% in 2004 with some studies estimating as high as 33% of all youth with either overweight or obese status. This represents an epidemic of grand proportions. (1,6) In general, overweight and obese children will worsen as adults. Obesity threatens the health of today’s children to such an extent that for the fi rst time in over the past century of United States history the current generation may have a shorter lifespan than previous generations. (2) Societal values and behaviors have created an environment of sedentary activity, energy dense foods, reliance on sugar-sweetened beverages, increasing devotion to television/computers/video games, larger food portions and dependence on motor vehicle transportation all leading to an imbalance of energy consumption for our youth.

The measurement of body mass index (BMI) from the calculation of weight in kg divided by height in meters squared provides an accurate quantitative value for total body fat. The Centers for Disease Control has the broadest population studies to develop percentile graphs for BMIs for the span of 2 years through adulthood located at www.cdc.gov/growthcharts.Accepted defi nitions for overweight persons are a BMI range of 85%tile to 94%tile and obesity of 95%tile and above. Super obesity is defi ned at the 99%tile threshold. (3, 4, 5) The BMI may be overestimated for high weight muscular individuals and underestimates risk for Asians.

COMOrBIDITy

The impact on the general health and welfare for children and adolescents with weight pathology is signifi cant and no

longer thought to primarily manifest as adult disease. Type 2 diabetes mellitus has increased tenfold over the past two decades. Hepatic steatatosis with nonalcoholic fatty liver changes was unrecognized before 1980 and can be found in 1:3 obese youth. The psycho emotional toll has contributed to escalating problems with depression, anxiety, impaired body image and eating disorders. Metabolic syndrome with hyperglycemia, hypertension, dyslipidemia and increased risk factors for cardiovascular disease now exists.

Obese children have three times the incidence of hypertension. Children with obesity have a greater incidence of obstructive sleep apnea syndrome. Other considerations include polycystic ovary disease, pseudotumor cerebri, cholelithiasis, musculoskeletal joint disease and dermatologic conditions. Recent studies following accidental deaths have documented greater atherosclerotic vascular disease in youngsters with known elevated serum lipid levels. Standards now exist for elevated cholesterol and triglyceride levels over 2 years of age with recommendations for treatment including dietary modifi cations and medications to include the use of bile resins and statins. The

American Academy of Pediatrics advocates fasting lipid screening for all children over 2 years of age with a positive family history of early heart disease, dyslipidemia or risk factors to include obesity, hypertension and type 2 DM.(6,7,8,9,10)

ClINICAl eVAluATION

The evaluation begins with an offi ce based approach that provides an annual screen for BMI measurement after 2 years of age. It is important to recognize risk factors for weight problems. Family history of fi rst degree relatives and genetic predisposition is highly predictive of a child’s risk for subsequent development of overweight or obesity problems. Genetic studies with separated identical twins clearly favors genetics (70%) over environmental factors (30%) as the major infl uences for weight profi les in the absence of medical disease states. Infrequently diagnosis of primary medical conditions may cause obesity. These include Cushing’s syndrome, psuedotumor cerebri, hypothalamic disturbance, pharmaceuticals such as atypical antipsychotics, polycystic ovary disease, pseudohypoparathyroidism and genetic syndromes such as Prader-Willi Syndrome. Disorders of hypothyroidism are actually an uncommon cause of obesity, but are frequently attributed as a cause of weight disturbance. A child with normal height growth would not be a candidate for hypothyroidism. A comprehensive history also includes dietary habits, physical activities, review of systems, social history including family activities, peer relations and activities, school status and a comprehensive exam. The history and physical should incorporate the above mentioned comorbidity concerns. (1, 3, 5)

“For the fi rst time in over the past century of United States history the current generation may have a shorter lifespan than previous generations.”


to your health WM

lABOrATOry AND TesTING Basic recommendations include a fasting lipid panel, fasting glucose with chemistry panel and an AST/ALT. Additional tests depending on clinical concern includes a chromosome analysis, fasting insulin level, 2 hour glucose tolerance test, thyroid function, serum amylase and GGT. Pulmonary function tests and sleep polysomnograpy studies may be considered for sleep or respiratory symptoms. An ECG is indicated for hypertension. Endocrine and genetic consults are benefi cial referrals for special testing requirements. Radiologic evaluations of the hips and knees for slipped capital femoral epiphysis, Legg-Perthes disease and Blount’s disease are advisable when clinically indicated.(1, 4, 5)

TreATMeNT AND PreVeNTION

Randomized and controlled studies simply do not exist for evidence based treatment for the management of overweight and obese children. An Expert Committee comprised of the AMA, Health Resources and Service Administration and CDC have made a careful analysis of existing data to merit their collective support of the following 4 stages of treatment/prevention recommendations:

Stage 1 Prevention Plus

• Eat a minimum of 5 servings of fruits and vegetables per day

• Avoid all sugar sweetened beverages

• Limit juice to less than 6 oz under 6 years and 12 oz over 6 years

• TV/computer/video games screen time less than 2 hrs per day

• No TV in bedroom

• Physical activity over one hour per day

• Increase home meals

• Fast food no more than once per week

• Do not skip breakfast

• Assess the family culture and motivation to change

Stage 2 Structured Weight Management• Dietician consult with planned meals/

snacks and balanced macronutrients (fat/carbohydrate/protein)

• TV screen time less than one hour

• supervised physical activity

• monitor compliance with a logbook

Stage 3 Comprehensive MultidisciplinaryIncludes above stages and team with a provider, dietician, counselor and exercise trainer. Increase behavior modifi cation and visits with a school, hospital or community based program.

Stage 4 Tertiary Care: Academic medical center with consultant team of specialists and research capability that incorporates treatment protocols for severe obesity over 95-99%tile. Includes use of medications and bariatric surgery.

In principle, improvements not seen within 3-6 months in any given stage of treatment should move up to the next stage. A reasonable goal is 1 pound weight loss per month under 11 years and up to 2 pounds per week over 11 years. Caloric restricted diets require dietician and provider supervision. Diets should be rich in calcium, low in saturated fat and limit energy dense foods. Recommendations for children under 2 years of age incorporates exclusive breast feeding to 6 months of age, use of low fat milk after one year of age and avoid excess fruit juice. (2, 4, 5,7,11)

PAyMeNT FOr MeDICAl serVICes

The American Academy of Pediatrics has issued fact sheets for obesity coding at www.aap.org/healthtopics/overweight.cfmA complete discussion of this topic is the subject of “Paying for Obesity: A Changing Landscape” per reference 12. WM(Original Article published in the Kosovo Medical Newsletter, US Army Camp Bondsteel Medical Falcon Task Force, October 2009. Dr. Horam is a Pediatrician with the Cheyenne Children’s Clinic at Cheyenne Regional Medical Center and serves as a military physician with the Wyoming Army National Guard.)

References

1. Barlow EB: Expert Committee Recommendations for Obesity. Pediatrics 2007; 120: S164-S192

2. Davis MM: Recommendations for Prevention of Childhood Obesity. Pediatrics 2007; 120: S229-253

3. Klish WJ: Clinical Evaluation of the Obese Child and Adolescent. Up To Date 2009; Online 17.2

4. Krebs NF: Assessment of Child and Adolescent Overweight and Obesity. Pediatrics 2007; 120: S193-S228

5. Schneider MB: Obesity in Children and Adolescents. Pediatrics in Review 2005; 26: 155-162

6. Ludwig DS: Childhood Obesity-The Shape of Things to Come. NEJM 2007; 357: 2325-2327

7. Daniels SR: Lipid Screening and Cardiovascular Health in Childhood. Pediatrics 2008; 122: 198-2008

8. Ferranti S: Storm over Statins-The Controversy Surrounding Pharmacologic Treatment of Children. NEJM 2008; 359: 1309-1312

9. Cowell KM: Type 2 Diabetes Mellitus. Pediatrics in Review 2008; 29: 289-292

10. Klish WJ: Comorbidities and Complications of Obesity in Children and Adolescents. Up To Date 2009; Online 17.2

11. Spear BA: Recommendations for Treatment of Childhood and Adolescent Overweight and Obesity. Pediatrics 2007; 120: S254-S288

12. Simpson LA: Paying for Obesity: A Changing Landscape. Pediatrics 2009; 123: S301-S307

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