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  Mission : To promote, protect and improve the health of all people in Florida.   Judge Enforce legislation Define quality   License   Communicate.

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Presentation on theme: "  Mission : To promote, protect and improve the health of all people in Florida.   Judge Enforce legislation Define quality   License   Communicate."— Presentation transcript:

1   Mission : To promote, protect and improve the health of all people in Florida.   Judge Enforce legislation Define quality   License   Communicate

2 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.

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

4 Title XVII of the Social Security Act 50% had Health Insurance Cost 3X Monthly premium Part B $3.00 Projected expenditure: $238,000,000

5 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, 1988 Estimating Physicians' Work for a Resource-Based Relative-Value Scale William C. Hsiao, Ph.D., Peter Braun, M.D., Douwe Yntema, Ph.D., and Edmund R. Becker, Ph.D.

6 Healthcare Reform

7 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) (81%) 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%) 10, “Folks, 10,000 people are going to turn 65 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

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12 12 If you don’t like change, you are going to like irrelevance even less – Tom Peters Shi f t Happens Jim Feldman Who Cares……..?

13 Economic Impact of the Patient Protection and Affordable Care Act

14 The New Alphabet Soup (PQRS) Physician Quality Reporting System (FFS) Fee for service (PQRS) Physician Quality Reporting System (VBP) Value based purchasing (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 (SHOP) Small Business Health Options Program”

15 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 :

16 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.

17 HCAHPS (Hospital Consumer Assessment of Healthcare Providers and Systems) Survey 27 questions The HCAHPS survey asks discharged patients 27 questions about their recent hospital stay 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). 4 4 items to direct patients to relevant questions, 3 3 items to adjust for the mix of patients across hospitals, 2 2 items that support Congressionally-mandated reports

18 Value Based Purchasing HCAHPS Hospital Consumer Assessment of Healthcare Providers and Systems Survey QUESTIONS Communication with Nurses Communication with Doctors Responsiveness of Hospital Staff Pain Management Communication About Medicines Cleanliness and Quietness of Hospital Environment Discharge Information Overall 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 = [P =.59]. In addition, patient satisfaction was not associated with a hospital's overall safety culture score (R = [P =.11]. No association between patient satisfaction and the individual culture domains of job satisfaction (R = [P =.07], working conditions (R = [P =.30]), or perceptions of management (R = [P =.23] JAMA Surg. 2013

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

21 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.

22 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)?

23 “State medical boards have a responsibility to the public to ensure the ongoing competence of physicians seeking re-licensure.” FSMB House of Delegates 2004 Policy Statement Reaffirmed 2013

24 lifelong learning Support commitment to lifelong learning, facilitate improvement in physician practice SMBs should establish MOL requirements SMBs should establish MOL requirements; should be administratively feasible, developed in collaboration with other stakeholders should not compromise patient care or create barriers MOL should not compromise patient care or create barriers to physician practice variety of options Flexible infrastructure with variety of options for meeting requirements Balance Balance transparency with privacy protection MOL Guiding Principles (adopted 2008; modified 2010, reaffirmed 2012)

25 Component 3: Performance in practice (How am I doing?) 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)

26 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 360 o evaluations Analysis of practice data CMS measures MOL Framework / Recommended Tools

27 notThere will not be a mandatory, secure, high stakes examination for MOL notState medical boards will not require specialty board certification, nor MOC or OCC, as a condition for medical licensure notMOL is not the same as MOC or OCC, though all value the concept of physician accountability and continued professional development shouldParticipation in MOC or OCC should substantially count, however, for any state’s MOL requirements Four Important Points about MOL

28 Only Wine and Cheese Improve With Age…… Greenfield Adv Surg 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.

29 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)

30 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

31 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. 25% 65 “Maximum strength is generally achieved during the third decade of life, with a 25% loss of strength by age 65 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

32 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

33 The Aging Physician: Changes in Cognitive Processing and Their Impact on Medical Practice Academic Medicine 2002 (PREP), Physician Review and Enhancement Program (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

34 Cognitive functioning, retirement status, and age: results from the Cognitive Changes and Retirement among Senior Surgeons study. J Am Coll Surg 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% 38% 78% of practicing senior surgeons aged 60 to 64 performed within the range of the younger surgeons on all tasks compared with 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. No all 3 tasks No senior surgeon performed below the younger surgeons on all 3 tasks.

35 Remoteness of Education……… Effect of age on surgeons, Quantity of education Gyn Onc Fellowship: 2 years 3 years 4 years Remoteness of education 59 52% 7% Meta analysis: 59 articles. Not surgeon specific! 52% reported all measures of quality of care declining with increasing physician years in practice. 7% reported increasing quality of medical care with increasing years in practice. Obsolescence of the content of the education Molecular Biology Genetics Minimally Invasive surgery Clin Orthop Relat Res QUALITY OF INITIAL EDUCATION

36 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

37 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.

38 National Resident Matching Program® (NRMP®) 2013 Estimated Physician Shortage 2020: 90,00-125,000 Match participation at an all-time high of 40,000, (2.7%) (up from 815 last year: 34%) 1,097 (2.7%) U.S. senior medical students did not match in the first round (up from 815 last year: 34%) Students who did not match entered the NRMP’s Supplemental Offer and Acceptance Program (SOAP). STILL By the end of Match Week, 528 U.S. M.D. graduates STILL did not have a residency position.

39 Perfect storm of unintended consequences. Hopkins and University of Maryland shadowed “interns” at two over the course of almost 900 hours majority indirectly Current interns spend the majority of their time in activities only indirectly 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

40 Physicians Foundation: 2012 Between 2008 and 2012, [5.9%], Decrease in average number of hours physicians worked (57 hours/week to 53 [5.9%], 16.6% 16.6% fewer patients 44,250 If the trend continues through 2016, it would equate to the loss of 44,250 full-time physicians 2030 Surgeon Shortage: 9% 9% General Surgeons 39% 39% Thoracic Surgeons

41 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. 3/14/201 3

42 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. (77%) 56% Majority of gynecologic oncologists (77%) continue to be salaried employees, this is significantly more than the 56% who classified themselves as salaried employees in 2005 (p <.01).

43 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 47 years of age; relatively younger than in 2005 when the mean age was 51 (p <.01). (25%) 15%  Twenty five percent (25%) completed their fellowship within the past five years compared to the 2005 survey where 15% completed their fellowship within the previous five years. 33%  Women now represent 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).

44 31 mean retirement age to 65. Gynecologic oncologists plan to practice a total of 31 years bringing the mean 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 13 years; significantly less than the mean of 17 years reported in 2005 (p <.01). Importantly, responding gynecologic oncologists plan to remain in practice for an additional 18 years; significantly increased from 14 years reported in 2005 (p <.01). 8  Male gynecologic oncologists have been in practice a mean of 15 years compared to a mean of 8 years for females (p <.01).  Maletotal of 32 years 29 years female gynecologic  Male gynecologic oncologists plan to practice for a total of 32 years, on average, compared to a mean of 29 years for 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.  Male 1620female  Male gynecologic oncologists plan to remain in practice for an additional 16 years compared to an additional 20 years for female subspecialists (p <.01) SGO Survey Gender difference: 33% patients 28% operations

45 Rayburn Obstet Gynecol ,624 general (ob-gyns) in the United States 5.0% of the total 661,400 physicians 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.

46 21,700 Primary care doctors complete 21,700 hours of education/training over 11 years (25%) NPs have 5,350 (25%) hours of training/ education during (5 to 7 years) (10%) Physician assistants average 2200 hours (10%) of clinical training (26-month program) 86% AMA backed the academy’s report, noting that 86% of patients believe they benefit from a physician-led primary care team Scope of Practice AAFP

47 1,795Between January 2011 and December 2012, there were 1,795 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. 178As of April 1, 2013, there have been 178 scope of-practice related bills proposed in 38 states and the District of Columbia. Scope of Practice Legislation

48 FTC on scope-of-practice bills Year: 2013 State: Connecticut Summary: 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.

49 FTC on scope-of-practice bills Year: 2012 State: Kentucky Summary: 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: 2012 State: Louisiana Summary: 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.

50 FTC on scope-of-practice bills Year: 2012 State: Missouri Summary: 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: 2011 State: Tennessee Summary: 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.

51 More Than Half the Population Not Wed to A Doctor April 2013

52 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”.

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54 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

55 From: Eliminating Waste in US Health Care JAMA. 2012;307(14): doi: /jama 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.

56 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

57 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

58 First ACA physician shield becomes law AMEDNewsIN 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

59 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

60 The Physicians Foundation Identifies Top Five Issues to Impact Physicians and Patients in Ongoing uncertainty over PPACA 2.Consolidation means “bigger.” But is bigger better? 3.12 months to 30 million 4.Erosion of physician autonomy 5.Growing administrative burdens

61 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 - What We Really Need To Be Talking About**

62 Departing Thought………

63 The Coming Storm (Photo By Jonathan Knight©)


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