The Trump Effect on Mega-Mergers

In the latest issue of Verden ViewPoint we discussed the likely impact of proposed health insurance company mega mergers. It remains to be seen how the election of Donald Trump could affect the deals between Anthem & Cigna, and Aetna & Humana but it’s entirely possible that a Trump administration would be pro merger.

With the Anthem/Cigna deal already before the courts and the Aetna/Humana trial scheduled for December, it’s fairly safe to assume that decisions in both cases will be made before Trump is set to take office in January but that likely won’t be the end of it.

Conservative Republican Senator Jeff Sessions was recently nominated by Trump to be Attorney General, and while we can’t know how Sessions would deal with antitrust cases, we do know that Trump has said he wants less government regulation of business.

It’s not clear how Mr. Sessions would have the department handle antitrust cases, but Mr. Trump has previously said that he wants “deep cuts” to government regulation of business. It’s doubtful that the DOJ would drop the cases but it’s also entirely possible that the losing party will appeal and that’s where Trump’s influence may come into play. Where a Trump administration will stand on antitrust issues can’t really be known until key positions in Federal Trade Commission and Justice Department are made but it’s not far fetched to think a Trump administration will be more lenient in terms of a settlement favoring a big insurer.




Many State Medicaid Meaningful Use Attestations Delayed

For Medicare providers, the deadline to attest for the 2015 reporting period with CMS was March 11, 2016. However, due to recent revised requirements, many states have not yet established a 2016 deadline for providers to attest for the 2015 reporting period with their Medicaid EHR Incentive Program. If fact, many states are only accepting 2015 reporting period attestations for adopt, implement, or upgrade (AIU), and Meaningful use Modified Stage 2 attestations are not yet available.

If you are a Medicaid provider, visit your State Medicaid EHR Incentive web site and subscribe to their Listservs to be kept informed if attestations or deadlines have been or will be set.

Looking Ahead: Meaningful Use Stage 3 Requirements

By Jose Lopez, Senior Consultant, The Verden Group

In my recent blog on the proposed changes to Meaningful Use 2 requirements CMS recognized the barriers providers were facing in meeting the Meaningful Use Stage 2 requirements, and proposed a rule to simplify the Measures and Objectives for 2015 and beyond. CMS clearly heard the complaints from providers that meeting the measures were creating workflow issues. The Verden Group applauds these changes and hope they are approved in their entirety.

Let’s look forward now to what lies beyond meeting the revised Stage 2 requirements in 2015 and 2016, to Stage 3. Following a proposed “optional” year in 2017, all providers will report on the same streamlined definition of Meaningful Use at the Stage 3 level in 2018, regardless of prior participation.

CMS has come out with 8 tentative advanced use objectives for Stage 3 designed to align with national healthcare quality improvement efforts, and to promote interoperability and health information exchange which will focus on the triple aim of reducing costs, improving access and improving quality:

  1. Protect electronic health information
  2. e-Prescribing
  3. Clinical decision support
  4. Computerized provider order entry
  5. Patient electronic access to their data
  6. Coordination of care through patient engagement
  7. Health information exchange
  8. Public health reporting

The specific measures for each objective have yet to be defined but if you think the objectives look like Stage 2, then you would be correct. And as with Stage 2, the most challenging objectives appear to be those where the provider does not have direct control over their outcomes: patient engagement (patient use of portals and e-messaging), health information exchange (by states or other entities), and public health reporting (by states or other entities).

While CMS came under fire in 2014 following the fallout of providers being unable to meet Stage 2 requirements, it is vital that practices continue to advance their use of electronic health information. As Medicare and private payers continue their evolution from fee-for-service to pay-for-performance, data is being used to report on quality outcomes and to differentiate high performing practices to patients.

In closing, it is crucial that providers and provider associations provide feedback when CMS proposes rules for Stage 3 to ensure the data being required isn’t arbitrary (as was the case with Stage 2), but that it meets the intent of the HITECH Act to begin with: reducing costs, improving access, and improving quality.

In our next blog on Meaningful Use, we’ll discuss proper Meaningful Use Attestation documentation and the ugly truth no one wants to hear: CMS plans to audit one in every 20 meaningful use attesters.

The Verden Group has been working with an exciting new company, TruMed Systems, on their revolutionary new approach to vaccine storage and management.

They started by asking the question; how would you design a better vaccine storage and handling solution?

Running a vaccine ‘business’ is an essential yet very costly component of your primary care practice. A study conducted by The Verden Group in 2009 quantified the costs of vaccine storage and handling for averaged sized primary care practices (3 providers) and estimated the costs of handling, storage, wastage and missed billing at $16,000 annually.

TruMed Systems looked at the process of vaccine storage and handling and set out to find a better solution. Assembling a network of physicians, nurses, practice managers and vaccine industry experts, they set about designing AccuVaxTM a fully automated vaccine storage and handling solution. We happen to think it’s AWESOME.

We thought we’d share this latest white paper from TruMed – click here to read it and see what AccuVax can do, and how it may help transform your vaccine business.

Cyber Risk Insurance – Should you consider getting it for your practice?

By Sumita Saxena, Senior Consultant, The Verden Group

The cyber-attack on Anthem, which left 80 million customers and employees vulnerable to identity theft, has quickly elevated the question of whether to purchase cyber risk insurance to the forefront of discussion among healthcare providers. The attack will certainly impact the market of cyber security insurance for healthcare providers, payers and others. Small to medium-sized healthcare organizations that have not considered such coverage may do so now while insurers will be re-evaluating underwriting standards and likely premium levels in the wake of the Anthem attack.

Most policies provide broad coverage for what constitutes a privacy breach, whether it results from a hacker, unauthorized access by an internal rogue employee or a laptop that was lost or stolen. Coverage can be divided into two categories: first-party and third-party costs.

Typically first-party costs involve those direct costs related to responding to a privacy breach or security failure. Such costs include forensic investigation of the breach, legal advice to determine notification obligations, notification costs of communicating the breach, offering credit monitoring to customers or patients as a result, and loss of profits and extra expenses during time network is down (business interruption).

Generally third-party costs include legal defense, settlements or damages or judgments related to the breach, liability to banks for re-issuing credit cards, cost of responding to regulatory inquiries and regulatory fines and penalties. Optional coverage can encompass underwriting for cyber-extortion, where hackers access a network and demand a ransom in exchange for not stealing data (many companies would rather pay the ransom and make the problem go away).

Larger organizations are more likely to purchase coverage than smaller ones given their access to risk managers and in-house IT security. Smaller companies, like physician practices and local clinics, may not have access to such resources and may forego coverage as unnecessary or too expensive. Data breaches, however, are continuing to garner significant attention and some insurance experts have commented that more and more small and mid-sized organizations are actively seeking out this coverage. Premiums for a $1 million plan are generally $5,000 to $10,000 annually though the cost can vary based on several factors, including company revenue, cyber-risk management efforts and the coverage chosen.

The cost of insurance coverage and breach response is minimal, however, when compared to the legal and regulatory costs associated with a data breach, which depending on the size of the attack, can run into the millions and substantially impair a company’s profitability if the response is not adequate.

Any large, well-publicized breach such as the one that struck Anthem will affect the market for cyber security insurance, as noted by industry experts, by influencing coverage terms, increasing coverage prices and making underwriting requirements more stringent, especially for healthcare companies as the industry sees more large-scale breaches. In light of these changes, it is prudent to re-assess network security and adequacy of breach notification, and to consider cyber risk insurance as an additional safeguard against the substantial cost associated with data breaches.

Creating a Life Plan

by Susanne Madden

It’s been a while since any of us at Verden have taken the time to add a blog post. Things have been so very busy and the micro-blogging capabilities of Facebook and Twitter have distracted us from this space.

But this topic deserves a little more room. I spend a lot of time here at the Verden Group helping our clients plan for the future. Planning for growth of their practices, planning for succession and sales, planning for mergers or acquisitions – you name it, we help you plan for it.

Recently it struck me that while I am busy planning out the professional and business lives of my clients, I’ve been giving very little thought to my own life. It’s easy to get too busy, work more hours to meet obligations and to prevent being overwhelmed, and generally put life on hold in the process. Many entrepreneurs, executives and small business owners face the same issues. The problem is, most of us don’t pay enough attention until there are serious consequences. We face major fatigue. We burn out. Worst case, we face serious illness and have heart-attacks. . .

So, how is one suppose to manage a busy career and live life more fully, without ending up in the emergency room?  It comes back to planning.

Yesterday, I stumbled across an e-book titled ‘Creating Your Personal Life Plan’ by Michael Hyatt, that really appealed to me. While I have not yet carved out some precious time to implement the tools in the plan, reading through it has motivated me to get started, and has given me some sense of hope that things can be different, if only we can plan for it.

Now, Mr. Hyatt is certainly more religious than I, but don’t let that put you off. The principles seem sound and grounded, to me. And I’m a big believer in ‘process’ as a game-changer. Every time we work through a planning exercise with a client, it is the process of planning that facilitates the changes needed to improve, grow, learn.

It’s time I took my own advice and put myself through the process of planning for life.

You can find more information on the FREE e-book* here:

(*I have no affiliation or business interest with this person or his company)

“If we would only give, just once, the same amount of reflection to what we want to get out of life that we give to the question of what to do with a two weeks’ vacation, we would be startled at our false standards and the aimless procession of our busy days.”
Dorothy Canfield Fisher

Using Evidence-Based Medicine Resources

By Tiffany Lauria

Two recently released reports have brought to light an interesting point regarding evidence based medicine- that it may not be as widely used as thought, or should be.

In a retrospective cohort study of cases submitted to the National Cardiovascular Data Registry-ICD Registry[1] between January 1, 2006, and June 30, 2009, researchers found that out of 111,707 patients, 25,145 received implantable cardioverter-defibrillators (ICDs) that were not recommended by evidence-based guidelines. In other news, a study published in Arthritis Care & Research[2] highlights that physicians treating patients with osteoarthritis (OA) may not be adhering to the recommended guidelines and that clinical practice often diverges from the medical evidence.   

So why the big deal? Simply put, evidence-based medicine works, and not adhering to it on a routine basis puts patients at risk and continues to add increased costs to our already over-burdened system. The patients who had non-evidence based ICDs in the above referenced study experienced a 0.57% risk of in-hospital death, compared to 0.18% in the patients who received an implant following standard approved guidelines. The same group also had an increased risk of post-procedure complications. How does a physician go about explaining this situation to the family of a patient that passed away, despite having clear guidelines to follow?

Ultimately, our healthcare boils down to trusting in our provider’s clinical expertise. Granted, the clinical experience of our provider is often comprehensive and trustworthy-  caring for thousands of patients with the same problems over the years, does tend to make one qualified to judge what works and what doesn’t. However, clinical expertise is largely dependent on staying abreast of new techniques and updated guidelines. It requires that providers know what works and what doesn’t in the national and international population, not just in their patient base over their years of practice. And, while each of us personally may be comfortable with our physician’s clinical judgment, regardless of what the evidence suggests, it is undoubtedly dependent on the provider to justify any decision-making that varies from evidence-based proof.

I certainly don’t make the statement that EBM is in-fallible, or that in all cases it is the right way to go. It is possible to mis-use or over-use the guidelines to the patient’s detriment. Blindly following a ‘proved’ algorithm of care eliminates the very essence of personalized healthcare. All patients are entitled to care that considers the patient as a whole. The EBM guidelines for two different conditions may cancel each other out, or worse yet, do more damage than good. And the personal opinions and circumstances of your patients must be considered. After all, what good is evidence when it can’t (or won’t) be followed? So where clinician training, experience and judgment dovetail with the evidence is where you want your medical practice to be. Without this quadrant of care, the potential for good medicine is lacking.

We can look, however, to the mentioned studies for some ideas on why physicians may be thwarting the evidence. For example, in the ICD study, the number of non-evidence based implants was significantly different according to physician specialty and hospital. Therefore, it is reasonable to conclude that the practicing environment and specialty culture may have a large impact on a provider’s commitment to adhering to recognized guidelines. In addition, the extent in which a facility appropriately enables provider staff to maintain up-to-date knowledge of evidence-based guidelines, by the provision of educational and other resources, is likely to be largely diverse across organizations. As the old saying goes- he that is walking with wise ones, becomes wise. If providers surround themselves with an environment conducive to learning and a culture of evidence-based decision making, then using proven treatment guidelines will become their standard of care. Supplemented, of course, by their years of trusted judgment based on clinical experience in the patient arena.

As medical evidence increasingly becomes more accessible to the general population, providers will have additional reasons for ensuring that their clinical practice remains within the close confines of what has been proven and substantiated. With the advent of the internet, construction worker John Smith need only go to any number of medically oriented websites or patient forums to determine what tests and treatments are routinely prescribed and what is the ‘norm’ for a particular illness or condition. A particularly savvy patient, with persistent researching skills, may ultimately wind up uncovering the specifics of the national guidelines that pertain to their condition…and bring that in to face you, the provider, who may be doing otherwise.

Certainly, no one is advocating for cookie cutter medicine or a one-size-fits-all approach to healthcare. Clinical experience and a provider that is willing to step out of the box in their effort to best treat their patients are more than needed in today’s climate of increasingly complex conditions and new advances. However, the question of why evidence-based medicine is not common practice yet needs to be addressed by providers, facilities and regulators in order to determine the best means of integrating proven care strategies into everyday care. It shouldn’t take a health reform initiative to convince people that making decisions based on evidence, just plain works.

[1] Al-Khatib SM, et al.”Non–evidence-based ICD implantations in the United States” JAMA 2011; 305: 43-49. Retrieved from:

[2] David J. Hunter, Tuhina Neogi, and Marc C. Hochberg. “Quality of Osteoarthritis Management and the Need for Reform in the US.” Arthritis Care and Research; Published Online: June 25, 2010 (DOI: 10.1002/acr.20278); Print Issue Date: January 2011.

From A-B-C to C-A-B

by Tiffany Lauria

‘Look, Listen and Feel’ is a thing of the past….

After years of drilling ‘Look, Listen and Feel’ into first responders heads as step one of the basic CPR process, the American Heart Association has released their 2010 guidelines which changes the sequence of CPR steps from Airway-Breathing-Chest Compressions (ABC) to Chest Compressions-Airway-Breathing (CAB)[1] to emphasize the importance of minimizing delay in starting the chest compressions component of care. Included among the other 2010 recommendations is the total elimination of ‘Look, Listen and Feel’ from the steps. Interestingly, the AHA states that rescuers often find it difficult to open the airway and begin delivering breaths, so the change in sequence is expected to encourage more people to begin CPR immediately without hesitation.

This is actually quite a big change, considering the scope of re-training that needs to be accomplished across a spectrum of populations. From babysitters and school teachers to flight attendants and lifeguards, numerous people in varying professions will now need to be educated and certified on the 2010 changes.  Most importantly, of course, are the healthcare providers that perform this procedure, or stand ready to perform this procedure, routinely as part of their daily tasks. And don’t just think doctors and nurses, there are midwives and radiology technicians and physical therapists, etc. The list goes on.

The American Heart Association has always done a great job in reaching the public to broadcast a message of the importance of CPR training for lay people as well as healthcare workers. Everyone- moms, waitresses, bank tellers, construction workers- everyone may at one point be faced with a life or death crisis that affords them the opportunity to try and help. Still, most people today have never been educated on CPR outside of possibly a high school health class (where the thought of giving mouth-to-mouth to the dorky kid next to you was not much of an enticement to learning). The number of professions that are now requiring CPR training, and the numerous regulations regarding the presence of Automatic External Defibrillators, is an encouraging sign that the AHA is reaching the right sectors with timely information and vital instruction.

There are two steps that you and your facility should take now to prepare for the implementation of the new CPR recommendations.

Step one: Make sure your staff have heard of the changes

Believe it or not, as busy as healthcare workers are on the job, they are just as busy in their personal lives! Many of your staff may have not had a chance in the last week or two to jump online for a news fix or to read a newspaper or journal that updates on important industry topics. But, what they don’t know can hurt them and their patients, so include information on the updated regulations in your next facility newsletter or scheduled staff meeting. Also, be sure to assign department heads or managers the responsibility of informing all staff that changes have occurred and that they will need to be re-trained and certified. You may want to include information on the scientific rationale behind the new recommendations, adjusted for use by clinical, administrative or ancillary staff.

Step two: Construct your training plan to implement the new recommendations

This step is actually a staircase that encompasses-

  • Working with human resources to determine which departments and staff require certification and training and the dates when all personnel are due for training based on their past certifications (The AHA has not released guidelines or recommendations yet on whether previous certifications will be revoked early)
  • Working with your facility’s education department, local Red Cross or other corporate instructional agency to determine training options, such as on-site or off-site training, scheduling and learning materials
  • Project a reasonable budget, allowing for staff overtime and any scheduling changes that will be needed to allow staff to participate in training, and any program and material costs
  • Begin cycling all needed personnel through the selected training programs, updating their personnel files accordingly to reflect up-to-date certification. Prioritize training according to need- clinical staff, then administrative, and so on
  • It may be necessary to revise facility or practice clinical protocols or other protocols related to emergency procedures. Always keep your practice, facility and department Operating Procedures and Clinical Protocols up-to-date


How can you assist in the efforts to inform the public about the importance of CPR training while making it worthwhile to your practice? Keep current brochures from the local Red Cross or continuing education providers handy in your office and share them with patients and parents and caregivers of patients, especially caregivers of young children and older patients. During routine well exams or care appointments for chronic conditions, make it routine to ask if anyone in the household has been CPR certified and talk to them about the importance of CPR education in their personal lives. Consider reaching out to community instructors and offer them use of your waiting room or conference area for holding classes. This allows you to advertise the courses to the public, maximizing your exposure while bringing in potential patients into the practice.

The AHA has scheduled instructor training sessions for November 2010, so while instructors are gearing up to teach the new recommendations to the masses, use your time wisely and start planning now on how to best educate and train your staff in an organized and efficient way.

[1] The sequence has not changed for newborns. To review the full 2010 recommendations, visit:

Hospital Gone Mad?

by Tiffany Lauria

In a recent court document[1] , filed against Dimensions Health Corporation, Joseph and Felicia Ann Wheeler allege that while recovering from auto accident injuries at Prince George’s Hospital Center, Mr. Wheeler was misidentified as a female cancer patient 13 years his junior that was scheduled for chest tumor surgery. In the disturbing events that ensued, Mr. Wheeler’s complaint includes physical assault and battery, false imprisonment and infliction of emotional distress.

While the egregious complaint cannot be stated as fact until the matter is settled, a read through the actual complaint brings up multiple areas in which hospitals, indeed all facilities, could benefit by reviewing their operating procedures and more importantly, the extent that these procedures are followed. Two obvious areas of risk  highlighted by the complaint are as follows:

1. Patient Identification Protocols: From his first contact with clinical staff, right down to his interactions with hospital security, not only did staff neglect to check Mr. Wheeler’s ID bracelet, but upon checking and finding a female name, a nurse failed to exhibit common-sense and flag concern over the patient’s identity. A physician brought in to answer the patient’s questions was apparently upset over Mr. Wheeler’s ignorance of the surgical procedure and as a previous nurse did, failed to check Mr. Wheeler’s ID bracelet. The next time Mr. Wheeler states someone at the hospital checked his ID bracelet was following a period of alleged battery at the hands of hospital security.

Some things to consider when reviewing your organizational policies:

– Does your protocol contain enough checks and balances to ensure that the right identification bracelet is placed on the correct patient from the beginning?

– Are there mandatory sign off sheets or tick screens for clinical staff to mark identity checks completed with each interaction?

– Does your protocol also include physicians, obliging them to check patient identification with every patient interaction?

A proper identification protocol will include each of the aforementioned, as well as stated consequences for staff and physicians not performing up to task, the dates of training sessions completed on the importance of correct identification procedures, and proper procedures for following up on any concerns or deviations.

Remind your staff that common sense should always prevail, and the hospital would rather conduct an investigation into correct identity, than defend itself against allegations of misconduct or malpractice. Make that part of your organizational culture – safety comes first.

2. Incidence Response Protocols:

Mr. Wheeler indicates that as soon as he walked out of his exam room to leave the hospital, nursing staff began to argue with him and call for security. The two officers that responded, according to the allegations, immediately unleashed a barrage of physical abuse and verbal expletives in their attempt to hold the patient against his will in the hospital. This abuse subsequently continued through an interaction with the ranking Lieutenant, the apparent wrestling of a cell phone out of Mr. Wheeler’s hands as he attempted to call 911, and culminated in a hospital administrator begging Mr. Wheeler to stay and promising to provide Mr. Wheeler with a private room and any medications or pain killers that he requested.

One has to wonder about the sensitivity training provided to the security staff in dealing with patients, whether they are leaving against medical advice or truly combative. Regardless of whether your facility contracts out for security or hires in-house, it ultimately falls to you to ensure that all personnel have undergone extensive background checks and targeted training on dealing with your patients and their family members. At one point during the alleged physical abuse, Mrs. Wheeler was prohibited from being with her husband and told she could not enter into an elevator with her husband and the two security officers.

Incident training encompasses much more than security, however. Your Incidence Response Manual must be reviewed and updated annually, with revised versions of protocols and documentation logs, and emergency contact information for management and legal staff. A well-done manual is not only written with legal assistance, but final approval on all revisions must be approved by an attorney familiar with healthcare law. Staff training should include all clinical, administrative and ancillary personnel and it is highly recommended that drills be enacted for various situations.

Oh, and regarding the administrator offering patients any drugs or pain killers they want? One word- Don’t.

As Mr. Wheeler’s complaints play out in the judicial system, there will likely be some more points to be gleaned on how not to run hospital operations. In the end, it would benefit all facilities to take a good, hard look at what you have down on paper, and what really happens when things go awry.


A good day at Physician’s Practice LIVE

by Susanne Madden

Last Wednesday we participated in Physician’s Practice LIVE, a virtual conference for practices, for the second time this year. This second conference was even better than the last, with several presentations to listen to and five individual Ask the Expert hours, where attendees could pose questions and get advice.

The presentation session I was lucky enough to do was titled Session: “Advanced Tactics for Negotiating with Payers”. We had a great response to it, and the questions were excellent! You can listen to it here:

In the next couple of months we will be bringing you all kinds of interesting media via the Verden website. From hosted chats in our Thought Swap chat-room, to short podcasts of discussions overheard in the Verden office, to compilations of the most interesting industry news of the day, we hope to inform and enlighten our visitors daily.

Any ideas you have for our new site? Any topics you’d like to see posted here? Just let us know!