Spring Medical Conferences Takeaways...
By BECKY GILLETTE
AR Medical Society, AR Nurse Practitioners Association and ARMGMA offer Education, Networking & Support
Editor's note: This spring has been a busy and productive time for medical associations in Arkansas. Annual meetings have been held for the Arkansas Medical Society, the Arkansas Nurse Practitioners Association and the Arkansas Medical Group Management Association that provided opportunities for participants to network, learn and advocate for their professions. Arkansas Medical News attended all three meetings and is pleased to bring you highlights.
The recent session of the Arkansas Legislature was one of the most challenging ever, said AMS Director of Legislative Affairs, H. Scott Smith, JD.
"We had our hands full, both from the sheer volume of bills we were working and from the intensity of controversy surrounding some of the bills," Smith said. "Scope of practice bills are always difficult and keep us busy during any legislative session, but this year there was no letting up. It seemed as though the votes just kept coming, back-to-back-to-back, without much time to breathe between the votes."
Despite being time consuming, Smith said most of their legislative efforts turned out well. One major loss was that optometrists can now perform surgery.
"That was a bad bill," Smith said. "We fought it, but we lost. We did have good resolution regarding almost all of the scope of practice bills. There were a number of Advanced Practice Registered Nurse bills that didn't pass. There were some Certified Registered Nurse Anesthetist bills that didn't pass."
Telemedicine is an issue AMS has been dealing with for the past three sessions now. One of the telemedicine companies was trying to pass a bill that would allow a physician-patient relationship to be established just over the phone.
"We think that is a bad idea," Smith said. "That bill failed. We also worked with the Arkansas Hospital Association and helped pass a bill that pertains to basic fairness in contracting. Then, we also got a bill passed prohibiting a requirement for prior authorization for medication assistance treatment for opioid addiction. When you are dealing with opioid addiction, there are some medicines that help. The bill prohibits insurance companies and government programs, like Medicaid, from creating a hurdle for physicians to access FDA-approved medications for opioid addiction. It also requires at least one of those medications to be on the lowest cost tier that is available."
Also speaking at the AMS meeting was Kevin O'Dwyer, General Counsel, Arkansas State Medical Board (ASMB), which has a Pain Management Committee that tracks doctors who are overprescribing opioids and other controlled substances and meets with the ones who are nearing the threshold of "gross negligence" in order to discuss the issue.
"What the board has been doing is sending doctors with complaints about over prescribing, but who don't quite meet the threshold of gross negligence and ignorant malpractice, to the Pain Management Committee," O'Dwyer said. "We decided to start sending the people who might not have been in violation to the Pain Management Committee in hopes of educating them and hopefully preventing a future problem."
One red flag for physicians who may be overprescribing is if they have patients who travel long distances to see the physician. A cash-only clinic raises suspicion. O'Dwyer said another issue that might raise concern is if the physician is in a specialty that should not be writing a high number of pain medicine prescriptions. These red flags are not necessarily indicative of a violation.
If the state's Prescription Drug Monitoring Program indicates a certain physician is one of the top prescribers in the state or in hisher specialty, that might start an investigation. And law enforcement agencies are getting more aggressive with their investigations in order to stop the opioid problem.
"It is a balancing act for all of us," O'Dwyer said. "We don't want to swing so far the other way that it hurts patients. Doctors need to read the Medical Practice Act and follow that. Document the justification. There need to be details in their record regarding the justification for the prescription. That is really what we are looking for."
Justin C. King, Assistant Special Agent in Charge, Little Rock District Office, U.S. Department of Justice, Drug Enforcement Administration, said some medical professionals don't understand how overprescribing of opioids can lead to people becoming addicted and then turning to more dangerous substances such as heroin and fentanyl.
"People find a place where a doctor is not as diligent about prescribing," King said. "They put the doctors in a position doctors aren't prepared for because doctors expect their patients to be honest. Not everyone on pain pills is an addict, but we see a high percentage of heroin addicts who start out with pain pills. Doctors start to say 'No,' or people can't afford the pills, and we see them moving over to getting heroin."
A problem with purchasing heroin is that it can be cut with fentanyl, which is a lot cheaper to produce than heroin and even more dangerous.
"It is all about the drug traffickers making money," King said. "That polydrug organizations are also controlling meth and cocaine. They want to get as many people dependent on their products as possible. We see a lot of counterfeit opioid pills produced in clandestine labs in Mexico. People may think they are getting a diverted pharmaceutical, but it might be pure fentanyl."
King said there has been a significant increase in the availability of heroin, cocaine and methamphetamine. Today's methamphetamine is even stronger and more potent.
King said the medical community has a great opportunity to engage with and educate their patients.
"You're talking about a trusted profession of people who know the hazards and dangers of prescription drugs," King said. "They should know their patients, and if they don't, they should ask questions. Doctors should ask, 'Do you think you are becoming addicted to these pills?' Arkansas is the second highest opioid prescribing state. We all have to do more. It is important to partner with the medical community to educate and protect the population."
King said they are excited the medical community is having these conversations with law enforcement.
"We want to be partners with the medical community for Arkansas to lower prescribing rates," he said.
ANPA President Julie Ponder, APRN, who is an ER nurse practitioner at Arkansas Heart Hospital, said this is the fourth year for their annual conference and they feel it was definitely another great success.
Julie Ponder speaking to the Arkansas Nurse Practitioner Association.
"We were able to give not only general Continuing Education (CE) contact hours, but also offer pharmaceutical CE hours," Ponder said. "So, we were able to give more CE hours than originally expected. That was exciting for us. Another thing is every year we have strived for 200 attendees and finally did that this year with 202 in attendance. As an association, we have grown to a membership of 410. That was another accomplishment for us with our association being only four years old. We are a newer association for all NPs, and this conference was an opportunity to bring us all together to educate and network with one another."
Ponder said they were disappointed legislation to remove requirements that NPs have a collaborative practice agreement with physicians failed to pass. They got farther than in the past, but it failed by one vote to get out of an Arkansas House committee.
Ponder said removing the collaborative practice agreement would increase access to care for many individuals, especially because Arkansas is so rural.
"In some counties there is only one physician and multiple nurse practitioners who could help to meet that shortage," Ponder said. "NPs feel like in rural areas we can help with primary care coverage. There are not enough physicians out there to provide care to these Medicaid recipients. Should NPs be primary care providers? We're here and we can help fill the gap."
During the committee hearings, a doctor from Hot Springs made the statement that dog trainers at Petco require more training hours than NPs. That is not true.
"NPs complete a four-year bachelor's education program with clinical hours, and then have clinical experience hours," Ponder said. "The Arkansas Board of Nursing requires 2,000 RN experience hours before a NP is licensed. NPs must complete a Master or Doctorate level education program with classroom and precepted NP practice hours before applying for NP license. We are very safe in our practice and know when to refer patients for specialist care. We don't work outside of our knowledge and ability."
The keynote speaker at the conference was Family Nurse Practitioner Margaret Fitzgerald, DNP, president, Fitzgerald Health Education Associates, LLC, who has published eight books and hundreds of articles. Fitzgerald said NPs should be provided more autonomy so they can provide care in areas that are underserved.
"Legislation needs to be updated to be more reflective of contemporary NP practices," Fitzgerald said. "There are 26 states where NPs have full practice authority that allows them to expand their services to underserved populations."
Nurses often are seen by patients as being particularly empathetic and understanding.
"We are socialized from the beginning of nursing education to provide that high touch, high emotional connection type of care," Fitzgerald said. "It is not to say other disciplines are not so socialized, but that is really, really at the core of our education."
Fitzgerald has been asked if NPs are trying to replace physicians.
"No, we are not," she said. "In this great country there are so many people who live in healthcare underserved communities or can't get adequate care because of financial, language and cultural barriers. Everyone in this nation deserves to be well served by the healthcare community. NPs are trying to take a bigger piece of pie, but there are plenty of pieces of pie. We work collaboratively with physicians and others in the profession. That will continue as NPs to work to achieve full practice authority."
There can be incredible collaboration between MDs and NPs. Fitzgerald gives as an example a MD and NP who practice in urology. When the MD is in the OR doing what he does best, the surgical part, the NP is back in the office evaluating patients who will likely be surgical candidates at some point. One day the urologist is in the OR doing surgery, and the NP calls him and says, 'Mr. X is in the ER and has a kidney stone. I've seen him, done the diagnosis, and booked him for surgery after you finish this case."
Fitzgerald said in that case, the patient who needed an emergent surgical procedure got to the OR an hour earlier because of the collaboration. The patient avoided another hour of suffering pain and the surgeon's time was used more efficiently.
The major topics at the MGMA Spring Annual Conference included patient experience, burnout and wellness, healthcare marketing, healthcare fraud and IT security.
AMGMA President Diana McDaniel, who is also Vice President of Operations at Arkansas Children's NWA Hospital, said one of the best parts of the conference was seeing the interaction between their members as they discussed how they are handling challenges.
"I heard numerous conversations about PASSE (Provider-Led Arkansas Shared Savings Entity), recently passed state legislation and marketing strategies," McDaniel said. "Hearing those conversations lends itself to one of the hottest topics requested for this year: wellness and burnout. Our members are overwhelmed with the rapid changes coming with the business of healthcare and are also concerned about the burnout of physicians at their practices. With the high cost of turnover, they are looking for ways to bring a sense of balance to their practice. Wendy Ward, PhD, a UAMS psychologist, led a great session on finding your wellness gaps and developing strategies for better balance."
McDaniel said patient experience seems to be a topic every year as healthcare administrators are hungry for tools to use when teaching their staff about best practices when interacting with patients and families.
A group of Arkansas MGMA members takes a break from meetings.
"We had two sessions on experience at this year's conference, one by Jim Bryant, Chick-Fil-A operator, and another by Stephen Dickens of SVMIC," McDaniel said. "There is a strong desire from our membership to stay on top of fresh ideas and approaches to customer service in the healthcare setting. Sharing ideas about what is working well and what is not working well is one of the benefits of attending the conference."
McDaniel said being part of MGMA allows insight into how different policies and business challenges are handled by rural, private, academic, and non-profit healthcare setting. The membership networking lends to resources for managing the healthcare business pace.
"The state conference is a great setting to find professional colleagues dealing with the same challenges," she said.
Participants also heard from Drew Voytal, Associate Director, Government Affairs, for the national MGMA. Voytal said beginning this year, physician practices have new reimbursement opportunities for communications-based services, including telephone interactions and patient-submitted photos.
"These services offer more flexibility to physician practices because CMS determined that these services are not considered to be Medicare telehealth services and therefore not subject to the restrictive statutory rule on originating site limitations and rural geographic requirements," Voytal said. "The first new code is for 'virtual check-ins' (HCPCS code G2012), which is defined as a brief communication technology-based service by a physician or other qualified health care professional who can report evaluation and management services to established patients."
The second new code is for use of storage and forwarding technology (HCPCS code G2010) for the remote evaluation of recorded video and/or images submitted by an established patient including interpretation and follow-up with patients within 24 hours. Voytal said the new virtual-care codes indicate that CMS is finally recognizing group practices for the work they do outside of traditional office visits, though beneficiary cost-sharing obligations may create frustrating collections situations.
"MGMA sees these new codes as a step in the right direction since they offer physician groups more options in providing services to their patients," Voytal said. "However, one of the top advocacy priorities for the association is for Congress to amend current law to remove site restrictions for Medicare telemedicine payment. This greater flexibility would allow physician groups freedom to offer the right kind of care to their patients."
Voytal said as the leading voice for medical group practices in the country, MGMA remains committed to advocacy in 2019 that pushes for regulatory relief for group practices that participate in federal healthcare programs.
"It is the position of the association that the federal government needs to reduce excessive and arbitrary mandates and one-size-fits-all regulations that impede health care innovation while supporting high quality, cost effective care delivery," Voytal said. "More specifically, MGMA advocates for a simpler, more streamlined MIPS program that rewards outcomes, fair payment for medical groups that treat complex patients, an overall reduction in prior authorization requirements, and added flexibility to Medicare telehealth rules."
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