Mission: To promote, protect and improve the health of all

people in Florida.Judge

Enforce legislationDefine quality

LicenseCommunicate

The Board is a group of volunteers who are charged with upholding the Medical Practice Act for the State of

Florida.

Twelve physician members Three consumer members

All Members of the Board are appointed by the Governor and confirmed by the State Senate.

ACA – Perspective from a member of the Florida Board of MedicinePersonal view….not “formally” Personal view….not “formally”

representing the representing the Florida Board of MedicineFlorida Board of Medicine

Title XVII of the Social Security Act50% had Health InsuranceCost 3XMonthly premium Part B $3.00Projected expenditure: $238,000,000

August 14, 1987 The Resource-Based Relative Value Scale: Toward the Development of an Alternative Physician Payment System William C. Hsiao, PhD; Peter Braun, MD; Edmund R. Becker, PhD; Stephen R. Thomas, PhD

September 28, 1988Estimating Physicians' Work for a Resource-Based Relative-Value ScaleWilliam C. Hsiao, Ph.D., Peter Braun, M.D., Douwe Yntema, Ph.D., and Edmund R. Becker, Ph.D.

Healthcare Reform

7

The Facts and Nothing But the Facts(macro)

• In the year 2000, Medicare provided coverage to 43.3 million seniors

• The first baby boomers reached the age of Medicare eligibility in 2011 (2008 eligibility for Social Security)

• By 2030, the year the last baby boomers reach Medicare eligibility, the number of people covered by Medicare will balloon to 78 million. A change from 43 to 78 (81%)(81%)

“Folks, 10,000 10,000 people are going to turn 6565 every day for the next 20 years. Those of us who care about protecting the Medicare guarantee, we’re going to have to find a way to make some tough decisions.”

Senator Ron Wyden D-Oregon

12

If you don’t like change, you are going to like irrelevance even less

–Tom Peters

Shift HappensJim Feldman

Who Cares……..?

Economic Impact of the Patient Protection and Affordable Care Act

The New Alphabet SoupThe New Alphabet Soup

(PQRS)

Physician Quality Reporting Syste

m

(FFS) Fee for service

(PQRS)

Physician Quality Reporting System

(VBP)

Value based purchasin

g

(ACOs)

Accountable care organizations(P4P)

Pay for Performance

(PPACA) Patient Protection and Affordable Care Act of 2010

(HCERA) Health Care and Education Reconciliation Act of 2010

(together, the Healthcare Reform Law)

(IOASE)In-office ancillary services exception

(Stark Law)

(AKS)Anti-Kickback Statute

(IPAB)Independent Payment Advisory Board(PQRI)

Physician Quality Reporting Initiative

(QHP)Qualified Health Plan

(SH

OP)

Sm

all B

usin

ess

Hea

lth O

ption

s Pr

ogra

m”

1.) Provide health insurance for those who couldn’t afford it or were unable to obtain it through their employers; 2.) Reduce the overall cost of care, specifically Medicare. Accountable care organizations (ACOs) and other experimental payment models under Medicare,

Replacing “volume” with “value.” More will no longer be better. A major shift from the fee-for-service incentives Providers at risk for delivering quality care in the most cost effective manner possible.Tracking and rewarding quality. Physicians have been reporting on quality measures for years through Medicare’s Physicians’ Quality Reporting

System (PQRS). Hospital employment of physicians will continue to expand. A 2011 survey of hospital executives found that more than 70 percent intend to expand their physician employment to position

Affordable Care Act (ACA) 2010:

HCAHPS (Hospital Consumer Assessment of Healthcare Providers and Systems) survey

• First national, standardized, publicly reported survey of patients' perspectives of hospital care.

Goals: 1. Survey designed to produce data about patients' perspectives

of care that allow objective and meaningful comparisons of hospitals on topics that are important to consumers.

2. Public reporting of the survey results creates new incentives for hospitals to improve quality of care.

3. Public reporting serves to enhance accountability in health care by increasing transparency of the quality of hospital care provided in return for the public investment.

HCAHPS (Hospital Consumer Assessment of Healthcare Providers and Systems) Survey

The HCAHPS survey asks discharged patients 27 questions 27 questions about their recent hospital stay. •1818 core questions about critical aspects of patients' hospital experiences (communication with nurses and doctors, the responsiveness of hospital staff, the cleanliness and quietness of the hospital environment, pain management, communication about medicines, discharge information, overall rating of hospital, and would they recommend the hospital). •44 items to direct patients to relevant questions, •33 items to adjust for the mix of patients across hospitals,•22 items that support Congressionally-mandated reports

http://www.medicare.gov/hospitalcompare/results.aspx#cmprID=100286,100018,100012&loc=34134&lat=26.3398513&lng=-81.8333656

Value Based PurchasingHCAHPS Hospital Consumer Assessment of

Healthcare Providers and Systems SurveyQUESTIONS

Communication with NursesCommunication with DoctorsResponsiveness of Hospital StaffPain ManagementCommunication About MedicinesCleanliness and Quietness of Hospital EnvironmentDischarge InformationOverall Rating of Hospital

Patient satisfaction (30%) was NOT associated with performance on process measures (70%)

•Antibiotic prophylaxis, R = −0.216 [P = .24]; •Appropriate hair removal, R = −0.012 [P = .95]; •Foley catheter removal, R = −0.089 [P = .63]; •Deep vein thrombosis prophylaxis, R = 0.101 [P = .59]. •In addition, patient satisfaction was not associated with a hospital's overall safety culture score (R = 0.295 [P = .11]. No association between patient satisfaction and the individual culture domains of job satisfaction (R = 0.327 [P = .07], working conditions (R = 0.191 [P = .30]), or perceptions of management (R = 0.223 [P = .23] JAMA Surg. 2013

Major Elements of “Reform” that May Impact Board of Medicine

Why Maintenance of Licensure (MOL)?

State medical boards and the medical profession as a whole are facing increasing demand from the public and health policy makers for greater accountability and transparency.

• As medicine has become more complex and fast-evolving, the need for lifelong learning and skills maintenance has increased.

•This is part of a larger movement in the United States and internationally to improve health care quality, decrease medical errors and improve patient safety.

•The public has increased its focus and scrutiny on quality and safety issues in health care; consumers have become more empowered

and seek greater accountability and transparency in the health care system.

A process by which a licensed physician provides, as a condition of license renewal, evidence of participation in continuous professional development that:

• Is practice-relevant• Is informed by objective data

sources• Includes activities aimed at

improving performance in practice

What is Maintenance of Licensure (MOL)?

“State medical boards have a responsibility to the public to

ensure the ongoing competence of physicians seeking re-licensure.”

FSMB House of Delegates2004 Policy Statement

Reaffirmed 2013

• Support commitment to lifelong lifelong learninglearning, facilitate improvement in physician practice

• SMBs should establish MOL SMBs should establish MOL requirementsrequirements; should be administratively feasible, developed in collaboration with other stakeholders

• MOL should not compromise patient should not compromise patient care or create barrierscare or create barriers to physician practice

• Flexible infrastructure with variety of variety of optionsoptions for meeting requirements

• BalanceBalance transparency with privacy protection

MOL Guiding Principles(adopted 2008; modified 2010, reaffirmed 2012)

Component 3:Performance in

practice(How am I doing?)

Component 2:Assessment of

knowledge & skills (What do I need to

know?)

Component 1: Reflective self-

assessment(What improvements can

I make?)

3 major components of effective lifelong learning

MOL Framework(adopted by FSMB HOD in 2010)

COMPONENT 1:

Reflective self-assessment

• MOC/OCC• Self-review tests• Simulations• CME in practice area• Literature review

COMPONENT 2:

Assessment of

knowledge and skills

• Practice-relevant exams (MOC/OCC)• Procedural hospital privileging• Standardized patients• Computer-based case simulations• Patient/peer surveys• Observation of procedures

COMPONENT 3:

Performance in practice

• Performance improvement CME & projects (Surgical Care Improvement Project, Institute for Healthcare Improvement, Improving Performance in Practice, Healthcare Effectiveness Data and Information Set)

• MOC/OCC• AOA Bureau of Osteopathic Specialists’ Clinical Assessment Program• 360o evaluations• Analysis of practice data• CMS measures

MOL Framework / Recommended Tools

• There will notnot be a mandatory, secure, high stakes examination for MOL

• State medical boards will notnot require specialty board certification, nor MOC or OCC, as a condition for medical licensure

• MOL is notnot the same as MOC or OCC, though all value the concept of physician accountability and continued professional development

• Participation in MOC or OCC shouldshould substantially count, however, for any state’s MOL requirements

Four Important Points about MOL

Only Wine and Cheese Improve With Age……

Greenfield Adv Surg. 1999

Physiological processes of aging (1) Wear and tear: includes mechanical damage to structures that are only imperfectly repaired. (2) Programmed cell death : somatic cells are limited from the time of fertilization to only approximately six to 15 generations of mitoses. After that limit, further cell division is impossible, and injured or worn out cells no longer can be replaced. (3) Knowledge and experience remain for a long time.

First to go is strength, then eyesight, then dexterity, and finally cognition!

Knowledge, experience, and reputation can compensate for a long time. The declines are gradual. The surgeon and his or her colleagues may not notice the changes until the deficits become serious.

When Older Doctors Put Patients At Risk….

•20% of the nation’s physicians are over 65, (proportion will rise). Many are under increasing financial pressures that make them reluctant to retire. •The rate of disciplinary action was 6.6 percent for doctors out of medical school 40 years, compared with 1.3 percent for those out only 10 years. (Am J Med, 2005)•In complicated operations, patients’ mortality rates were higher when the surgeon was 60 or older, though there was no difference between younger and older doctors in routine operations. (Ann Surg, 2006)

When Older Doctors Put Patients At Risk….

National Patient Safety Foundation: “We need to be systematically and comprehensively evaluating physicians on some sort of periodic basis.”

They are being encouraged to do so voluntarily, but few do — less than 1 percent of the 69,000 so-called grandfathered members of the American Board of Internal Medicine, “re-certify”.

Patient advocates note that commercial pilots, who are also responsible for the safety of others, must retire at age 65 and must undergo physical and mental exams every six months starting at 40. American Journal of Medicine 2013

Physical Decline…..

Vision, hearing, motion, and dexterity as physical attributes of a surgeon that inevitably decline with age. Reaction time has been found to decline only slowly. • “Maximum strength is generally achieved during the third decade of life, with a 25% 25% loss of strength by age 6565 years. …• As we age, visual acuity and accommodation decrease in association with lens changes and pupillary shrinkage. Optimal performance requires…100% more [illumination] in workers older than 55 years”

Clin Orthop Relat Res. 2009

Cognitive Decline………

(1) The ability to focus attention(2) The ability to process and correlate

information (3) Native intelligence

are cognitive attributes of a surgeon that decline with age

“older surgeons were significantly less likely to perform immediate reconstruction (…Odds ratio = 5.18),

Clin Orthop Relat Res. 2009

The Aging Physician: Changes in Cognitive Processing and

Their Impact on Medical Practice

Academic Medicine 2002

Physician Review and Enhancement Program (PREP), (PREP), based at McMaster University•Current battery consists of

1) multiple-choice-question test of medical knowledge, 2) encounters with four standardized patients, (Skills

evaluated with the standardized-patient encounters include communication, diagnosis, and data gathering)

3) chart-stimulated recall (physician's own charts are reviewed and used as the basis for discussion between the assessors and the physician to test problem solving, patient-management skills, and record-keeping practices).

• Strong inverse relationship: Age/Performance which extends beyond a reduced tendency to assimilate new knowledge. ? Related to premature closure.

• Strong positive relationship between Age and Preliminary Diagnostic Accuracy

Cognitive functioning, retirement status, and age: results from the Cognitive Changes and Retirement among Senior

Surgeons study.

J Am Coll Surg. 2010

Computerized cognitive tasks measuring 1) visual sustained attention, 2) reaction time, and 3) visual learning and memory were administered to both practicing and retired surgeons •61% 61% of practicing senior surgeons performed within the range of the younger surgeons on all cognitive tasks. •78% 78% of practicing senior surgeons aged 60 to 64 performed within the range of the younger surgeons on all tasks compared with 38% 38% of practicing senior surgeons aged 70 and older. •45% 45% of retired senior surgeons performed within the range of the younger surgeons on all tasks. •NoNo senior surgeon performed below the younger surgeons on all 3 tasksall 3 tasks.

Remoteness of Education………Effect of age on surgeons, •Quantity of education

Gyn Onc Fellowship: 2 years 3 years 4 years•Remoteness of education

Meta analysis: 5959 articles . Not surgeon specific! 52% 52% reported all measures of quality of care declining with increasing physician years in practice. 7% 7% reported increasing quality of medical care with increasing years in practice.•Obsolescence of the content of the education

Molecular BiologyGeneticsMinimally Invasive surgery

Clin Orthop Relat Res. 2009

QUALITY OF INITIALQUALITY OF INITIALEDUCATIONEDUCATION

Experience versus Skill…………Related to the problem of remoteness of education is the •Need to maintain old skills •Develop new skills•Grow through experience Deterioration of purely physical skills begins near the end of the third decade of life (around age 28). Cognitive skills diminish later. Widely agreed that most surgeons reach their peak of overall performance around the second half of the fifth decade (45–50 years of age). Therefore, for more than two decades, growing experience can and does more than compensate for diminishing physical skills.

Clin Orthop Relat Res. 2009

Assuring Competence in Surgery…….In 1993, the American College of Surgeons Board of Governors’ Committee on Physicians’ Health was charged with the task of studying and making recommendations about the admittedly “controversial issue of credentialing the aging surgeon” This seemed to be a promising step in the right direction. However, a search of the literature has located no evidence of any publication of the results of this charge in the decade and a half since the committee was so charged.

National Resident Matching Program® (NRMP®) 2013

Estimated Physician Shortage 2020: 90,00-125,000Estimated Physician Shortage 2020: 90,00-125,000

• Match participation at an all-time high of 40,000, • 1,097 (2.7%) (2.7%) U.S. senior medical students did not

match in the first round (up from 815 last year: (up from 815 last year: 34%)34%)

• Students who did not match entered the NRMP’s Supplemental Offer and Acceptance Program (SOAP).

• By the end of Match Week, 528 U.S. M.D. graduates STILLSTILL did not have a residency position.

Perfect storm of unintended consequences.•Hopkins and University of Maryland shadowed “interns” at two over the course of almost 900 hours•Current interns spend the majoritymajority of their time in activities only indirectlyindirectly related to patient care, like reading patient charts, writing notes, entering orders, speaking with other team members and transporting patients. •The calculated amount of “intern” time spent face to face with patients,

8 minutes 8 minutes each day to each patient 12 percent 12 percent of their time.

For New Doctors, 8 Minutes Per Patient

J Gen Int Med 2013

Physicians Foundation: 2012Between 2008 and 2012,•Decrease in average number of hours physicians worked (57 hours/week to 53 [5.9%], [5.9%], •16.6% 16.6% fewer patients If the trend continues through 2016, it would equate to the loss of 44,25044,250 full-time physicians •2030 Surgeon Shortage:

9% 9% General Surgeons39% 39% Thoracic Surgeons

By incentivizing “the delivery of outpatient care through hospital-owned networks,” the ACA will directly lead to a reduction in physician productivity and also a loss of quality in care. Scott Gottlieb, MD, says industry estimates show that productivity falls by 25% (35% in the 90s) or more for physicians who work for hospitals or hospital-owned groups, “a consequence of the more fragmented, less accountable care that results from these schemes.” Continuity of care also declines, since a physician's responsibilities end when his shift is over. This results in reduced incentives for doctors to cover weekend calls, see patients in the ER, “squeeze in” an office visit, or take phone calls rather than turfing them to nurses. It also means physicians no longer take the time to give detailed sign-offs as they pass care of patients to other doctors who cover for them on nights, weekends and days off.

The Doctor Won't See You Now. He's Clocked Out ObamaCare is pushing physicians into becoming hospital

employees. The results aren't encouraging.

3/14/2013

Transition from Doctor-as-Entrepreneur to Doctor-as-Employee

MGMA-ACMPE survey (630,000): •Employed physicians work fewer hours per week than doctors in private practice•See 17% fewer patients (18 a day) than practice-owning doctors (22 a day). •20% of employed doctors work fewer than 40 hours a week, compared with 18% of physicians with an ownership stake in their practice. •> 60% of physicians younger than age 40 are employed by a hospital or other entity.

Majority of gynecologic oncologists (77%) (77%) continue to be salaried employees, this is significantly more than the 56% 56% who classified themselves as salaried employees in 2005 (p < .01).

The 2010 survey reveals movement toward a relatively younger age of gynecologic oncologists as well as growth in the number of women entering the field of gynecologic oncology. Gynecologic oncologists, on average, are 4747 years of age; relatively younger than in 2005 when the mean age was 5151 (p < .01). Twenty five percent (25%) (25%) completed their fellowship within the past five years compared to the 2005 survey where 15% 15% completed their fellowship within the previous five years. Women now represent 33% 33% of the gynecologic oncologists; up from 20% in 2005 (p < .01). The current percentage of female Candidates (35%) is significantly greater (p < .01) than male Candidates (15%).Among gynecologic oncologists over the age of 60, the majority (97%) are male and 3% are female compared to gynecologic oncologists 35 or younger where 40% are male and the majority (60%) are now female (p < .01).

Gynecologic oncologists plan to practice a total of 3131 years bringing the mean retirement age to 65mean retirement age to 65. . This does not differ from the 2005 survey, and remains higher than the reported total years in practice of 28 in the 1998 survey. Current gynecologic oncologists have been in practice a mean of 1313 years; significantly less than the mean of 1717 years reported in 2005 (p < .01). Importantly, responding gynecologic oncologists plan to remain in practice for an additional 18 18 years; significantly increased from 14 years reported in 2005 (p < .01).Male gynecologic oncologists have been in practice a mean of 15 years compared to a mean of 88 years for females (p < .01). MaleMale gynecologic oncologists plan to practice for a total of 32 yearstotal of 32 years, on average, compared to a mean of 29 years 29 years for female gynecologic female gynecologic oncologists (p < .01). Gynecologic oncologists over the age of 60 plan to practice a total of 36 years (p < .01) compared to all other age groups. MaleMale gynecologic oncologists plan to remain in practice for an additional 1616 years compared to an additional 2020 years for female female subspecialists (p < .01).

2010 SGO SurveyGender difference: 33% patients 28% operations

Rayburn Obstet Gynecol 2012

2010•33,624 general (ob-gyns) in the United States •5.0% of the total 661,400 physicians. •2.65 ob-gyns per 10,000 women and •5.39 ob-gyns per 10,000 reproductive-aged women. •Density of ob-gyns varied•Approximately half (1,550, 49%) of the 3,143 U.S. counties lacked a single ob-gyn, •10.1 million women (8.2% of all women) lived in those predominantly rural counties.

• Primary care doctors complete 21,70021,700 hours of education/training over 11 years

• NPs have 5,350 (25%) (25%) hours of training/ education during (5 to 7 years).

• Physician assistants average 22002200 hours (10%) (10%) of clinical training (26-month program)

• AMA backed the academy’s report, noting that 86% 86% of patients believe they benefit from a physician-led primary care team

Scope of Practice

AAFP

• Between January 2011 and December 2012, there were 1,7951,795 scope of practice related bills proposed in 54 states, territories or the District of Columbia, of which 349 have been adopted or enacted into law.

• As of April 1, 2013, there have been 178 178 scope of-practice related bills proposed in 38 states and the District of Columbia.

Scope of Practice Legislation

FTC on scope-of-practice billsYear: 2013State: ConnecticutSummary: A bill would remove a rule requiring advanced-practice nurses to have a collaborative practice arrangement with a physician before prescribing medications.FTC involvement: The agency wrote a letter to legislators in support of the proposal.Outcome: The bill did not pass out of committee this session, but could be revived later this year.

FTC on scope-of-practice billsYear: 2012State: KentuckySummary: A bill would remove a requirement that APRNs and physicians have a collaborative practice arrangement for APRNs to prescribe nonscheduled medications.FTC involvement: The FTC wrote a letter in support of the bill.Outcome: The bill failed.

Year: 2012State: LouisianaSummary: A bill would remove a requirement that APRNs and physicians have a collaborative practice arrangement for APRNs to prescribe nonscheduled medications.FTC involvement: The FTC wrote a letter recommending that the Louisiana Legislature lift the restriction on APRNs.Outcome: The bill failed.

FTC on scope-of-practice billsYear: 2012State: MissouriSummary: A bill would enable only physicians to treat pain through use of injections around the spine or spinal cord guided by imaging technology.FTC involvement: The FTC wrote a letter in opposition to the bill.Outcome: The bill passed.

Year: 2011State: TennesseeSummary: A bill would require that a physician directly supervise any advanced-practice nurse who provides pain management services in unlicensed health care facilities.FTC involvement: The FTC wrote a letter opposing the proposal.Outcome: The bill passed.

More Than Half the Population Not Wed to A Doctor

April 2013

Expanding the Role of Advanced Nurse Practitioners — Risks and Rewards

May 16, 2013

Iglehart N Engl J Med 2013

Association of American Medical Colleges estimates that by 2015 the nation will face a shortage of 62,100 physicians — 33,100 primary care practitioners and 29,000 other specialists

“The possibility of strengthening the largest component of the health care workforce — nurses — to become partners and leaders in improving the delivery of care and the health care system as a whole inspired the IOM to partner with the Robert Wood Johnson Foundation . . . in creating the [Robert Wood Johnson Foundation] Initiative on the Future of Nursing, at the IOM. In this partnership, the IOM and [the Robert Wood Johnson Foundation] were in agreement that accessible, high-quality care cannot be achieved without exceptional nursing care and leadership. By working together, the two organizations sought to bring more credibility and visibility to the topic than either could by working alone. The organizations merged staff and resources in an unprecedented partnership to explore challenges central to the future of the nursing profession”.

(18)(18)

• There have been 33 telemedicine bills introduced this year

• Common Types of State Telemedicine Legislation:– Direct regulation of telemedicine practice– Requirement of parity in reimbursement– Statements of commitment to further research and

development of telemedicine policies

Telemedicine Bills

From: Eliminating Waste in US Health Care

JAMA. 2012;307(14):1513-1516. doi:10.1001/jama.2012.362

The “wedges” model for US health care follows the approach based on the model by Pacala and Socolow. The solid black “business as usual” line depicts a current projection of health care spending, which is estimated to grow faster than the gross domestic product (GDP), increasing the percentage of GDP spent on health care; the dashed line depicts a more sustainable level of health care spending growth that matches GDP growth, fixing the percentage of GDP spent on health care at 2011 levels. Between these lines lies the “stabilization triangle”—the reduction in national health care expenditures needed to close the gap. The 6 colored regions filling the triangle show one possible set of spending reduction targets; each region represents health care expenditures as a percentage of GDP that could be eliminated by reduction of spending in that waste category over time.

6 categories of Medical waste—Overtreatment ($158 billion to $226 billion in 2011) Failures of care coordination ($25 billion to $45 billion in 2011), Failures in execution of care processes ($102 billion to $154 billion), Administrative complexity ($107 billion to $389 billion), Pricing failures ($84 billion to $178 billion), and Fraud and abuse ($82 billion to $272 billion)

Sum of the lowest available estimates >20% of total health care expenditures. Highest >36%.

Berwick JAMA. 2012

• Revoked Medicare billing privileges of 14,663 providers and suppliers over the past two years — (6,307 in prior 2 years)

• Recovered $14.9 billion in Medicare fraud money, due in large part to the 2010 ACA. The law allowed the government to analyze data to spot indications of fraud and stop paying providers.

• CMS reported in January that the system was saving $3 for every $1 spent in the first year.

• Last year, between 40,000 and 50,000 phone calls to the Medicare hotline were key to fraud investigations.

• Government estimates that about 8.6 percent of all Medicare Fee-For-Service (FFS) claim payments are improper

Policing of Medicare Fraud Explodes over Two Years

First ACA physician shield becomes lawAMEDNewsIN BRIEF — Posted May 13, 2013

     Georgia Gov. Nathan Deal on May 6 signed into law a measure that

protects doctors from civil liability for breaching federal health system reform requirements, the first statute of its kind.The Provider Shield Act, drafted from American Medical Association

model legislation, prevents health reform metrics from being used as evidence in liability cases. The measure states that payer guidelines and quality criteria under federal law shall not establish a legal basis for negligence or a standard of care for the purposes of determining medical liability.In a statement, AMA Board of Trustees member Patrice A. Harris, MD, commended Georgia lawmakers for enacting legal protections “for physicians engaged in quality and delivery improvement initiatives

• Those who aspire to master the “paradigm shift” and not simply master “another reimbursement model”.

• Robust information technology and monitoring/reporting capabilities will be required.

• Those who have track record of collaborating on patient care.• “Meaningful Users” of EHR and other clinical technologies will fair better.• Providers with a stable primary care patient base.• Providers that have standardized clinical processes and protocols.• Providers with aligned incentives.• Providers with strong governance and change management structures.

Transformation Agenda: Who Is Likely To Win

The Physicians Foundation Identifies Top Five Issues to Impact Physicians and Patients

in 20131. Ongoing uncertainty over PPACA2. Consolidation means “bigger.”

But is bigger better? 3. 12 months to 30 million4. Erosion of physician autonomy5. Growing administrative burdens

• Physician leadership • Physician-led care management • Quality monitoring • Patient information and data sharing

• Payor engagement ** See, D. Grauman, C. Graham and M. M. Johnson, 5 Pillars of Clinical Integration -

http://www.hfma.org/Templates/InteriorMaster.aspx?id=33692

What We Really Need To Be Talking About**

Departing Thought………Departing Thought………

The Coming Storm(Photo By Jonathan Knight©)