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Viewpoint Issue 1 Summer Solstice 2015

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Volume 1 Issue 1 Summer Solstice 2015 Perspectives on what's shaping the business of health care for independent practices
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  • INTERPRETATIONS OF WHAT'S SHAPING THE HEALTH CARE INDUSTRY FOR INDEPENDENT PRACTICES

    WORLD HEALTH CARE CONGRESS 2015 Industry Innovations and Impact - What You Need To Know About The Evolution of Health Care in 2015

    PROVIDERS BECOME INSURERSAs New Models of Insurance Emerge, What Does That Mean For Providers?

    MEDICARE LEGISLATIVE UPDATE SGR Repeal, CHIP Reauthorization, and PIMA

    HOSPITAL-INSURER DISPUTESThings May Get Even Uglier

    IN MEMORIAMA Sad Goodbye to One of Pediatric's Fiercest Allies: Lynn Cramer

    SUMMER SOLSTICE 2015 PERSPECTIVES ON THE BUSINESS OF HEALTH CARE

    HUMAN RESOURCESWhy You Need To Update Your Employee Handbook Now

  • 29Big Impacts

    WORLD HEALTH CARE CONGRESS: Verden Group CEO Susanne Madden recently attended the 12th Annual World Health Care Congress. In this exclusive Verden Group Q& A, Susanne talks about health care innovations and their impact.

    MEDICARE LEGISLATIVE UPDATE: SGR Repeal, CHIP Reauthorization, and PIMA.

    Congress recently passed the 'Medicare Access and CHIP Reauthorization Act.' Jose Lopez breaks down what it all means for your practice.

    CONTENTS5

    Industry News

    Managing Multiple Priorities, Projects & Deadlines in a Busy Medical Practice

    Learning to manage stress caused by the multiple demands on your time will allow you to run your day, instead of your day running you.

    11

    Legal Notes Hospital-insurer disputes: Are things about to get ugly?

    High-profile disputes between health systems and insurers made headlines in recent months. Sumita Saxena, JD, cuts through the legalese to tell you what you need to know.

    16Pro Tips

    4

    Welcome Why a magazine offering perspective on the business of health care? Things are more complicated than ever, but with that complexity comes opportunity. CEO Susanne Madden explains why we felt compelled to deliver transparent interpretations of the health care industry to private practice.

    8BalanceJuggling the demands of work and family, while still making time for play and relaxation, is a constant struggle for most of us. But try we must. At The Verden Group, we encourage each other to rest often, to indulge the creative side and to have some fun whenever we can.

    Volume 1, Issue 1 - SUMMER SOLSTICE EDITION 2015

  • 3From city to city, coast to coast, we are on the move. Get details on the key events and conferences we're taking in this Fall that you don't want to miss.

    Frontlines brings you success stories from our clients, in their own words. In this edition, we talk to Ken Fenchel, Chief Operating Officer about their newly formed South Carolina Pediatric Alliance.

    28Events

    Payer News is our take on what's happening with payers and what you need to know now. This edition we discuss how the market is quickly evolving to attract new models of health insurance, and providers are becoming the new insurers.

    24

    Payer News

    26Frontlines

    Whether we heard it at the water cooler or on the conference trail, Overheard brings you snippets from conversations about the hottest topics in health care.

    28Overheard

    A tribute to our colleague and friend, the unforgettable Lynn Cramer. One of a kind, both personally and professionally, Lynn will be so very missed by so many.

    The features, columns and articles in this first issue of ViewPoint were written and edited by the team at The Verden Group. Our colleague, Kim Engler helped us pull it all together and to make sure that we were delivering our best, in our own voices, and from our shared vision. Watch this space in future issues to see some other familiar faces from the health care industry as we invite our colleagues and friends to contribute to our pages.

    FEATURED CONTRIBUTORS

    22

    HR Matters A well drafted employee handbook can be a huge asset to your practice. Help your practice stay ahead of the curve and out of legal trouble by making sure your handbook is up to date!

    Missed a blog post or tweet? Connect provides a quick recap of what you missed from all our media streams. Didn't know that we blogged, 'booked and tweeted? Join us online!

    20Connect

    25

    In Memoriam

    Heidi Hallett Jose Lopez Susanne Madden Sumita Saxena Kim Engler

    29Roll Call

    Taking a minute to congratulate all of our clients who worked so hard to achieve NCQA's PCMH Recognition so far this year.

  • 4? WELCOME ?Welcome to our inaugural edition of ViewPoint!

    We felt compelled to create a magazine that provides you, our clients and colleagues, with an industry perspective that helps you to make sense of the forces impacting your practice today. Thanks to the Affordable Care Act, things are more complicated than ever. But with that complexity comes opportunity; opportunity that I believe is best seized by physicians themselves if we are to realize more effective and consistent delivery of health care and retain physician independence in this country.

    ViewPoint is our contribution to that vision - to deliver transparent interpretations of the health care industry to independent practices so that you can better understand the who, how and why of what is going on, and how you can help to shape these evolving models as they develop. What you don't know can hurt you, so our goal is to keep you informed on the issues that matter.

    Our first edition would not be complete without a sincere thanks to The Independent Pediatrician, a publication that inspired us to round out the perspective by contributing our interpretation of the industry forces shaping the next era in the business of US health care.

    We hope you'll enjoy the news, tips and content shared in these pages and we'd love to hear your stories and perspective from the front lines too. Combining industry with practice helps to achieve a very clear viewpoint indeed!

    SUSANNE MADDEN | PRESIDENT & CEO

  • 5? INDUSTRY NEWS ?

    WORLD HEALTH CARE CONGRESS: an interview with The Verden Group CEO, Susanne Madden

    Susanne recently attended the 12th Annual World Health Care Congress (WHCC) held in Washington, D.C. in March. The World Health Care Congress convenes decision makers from several sectors of health care to discuss what's new and happening in the industry and what changes to expect in the coming year.

    What were the major themes discussed at the World Health Care Congress (WHCC)? SM: There was plenty of discussion focused on the impact of the Affordable Care Act (ACA), public and private exchanges, payer and provider consolidation, new approaches to value-based payment models, and some novel partnerships with the true potential to move the dial on care coordination and delivery. With five tracks running simultaneously, it was hard to keep up with everything!

    There were a number of Chief Executives from private payers on the panels. What was their assessment of the Insurance Landscape?

    SM: With 30% of the market now on public and private exchanges, the overarching view was that the consumer, not health care providers, will drive the market into the future. Consumers are looking for convenience and cost containment and third parties are scrambling to bring innovations and technology to the market that will meet those needs.

    What are some of the innovative ways technology will be used to provide better patient care and decrease costs?

    SM: There was significant discussion that the 'virtualization' of health care will allow limited resources to be spread across more lives. Examples of this include using fewer physicians across multiple locations, using clinicians in international places (e.g. reading x-rays) for round-the-clock delivery of services, smartphone integration, and the advent of consumer technology devices to meet patient needs, such as ?disease kits? for patient self-management.

    You can find more information about the WHCC, including interviews with

    the panelists, here.

  • 6How are employers responding to these changes in the health care environment?

    SM: Caesars CEO, Gary Loveman offered up a good example. Caesars provided health care incentives to their employees including lowering the share of premium costs, providing access to health care services at work, helping them take advantage of improved diagnostics, and providing off-hour telemedicine and access. The result? Health care costs for their employees have fallen by double-digits over the last few years and their employees are healthier even though they are older on average than the general population.

    What were some of the drawbacks of the ACA now that it has been fully implemented?

    SM: The biggest flaw of the ACA is the high deductibles and the emergence of narrow networks to contain costs for the Payers. And anyone that didn?t think narrow networks were about controlling costs can now stand corrected! Consumers were not properly educated on the designs of these plans and providers were not aware of the cost being passed along to the patient and in the form of lower payment rates for them. But with these changes there comes an interest in redefining exactly what health care insurance is supposed to be. As the market evolves, Steve Forbes (Chairman and Editor-in-Chief, Forbes Media) believes that ?real insurance? such as catastrophic coverage policies will be available in the future. I certainly applaud that!

    What are some of the ways payers are looking to contain these costs?

    SM: With the advent of the exchanges, consumers are the new purchasers and they are demanding pricing transparency from Payers and providers. This is forcing change not only in premium rates but also in payments. The Health Care Cost Institute (HCCI) sees change coming to provider payments as being ?premium rates paid to high quality providers? and the rest getting paid less for poorer outcomes. I've been saying that for years thanks to the work we do with Patient Centered Medical Home - it is only a matter of time before we reach a tipping point there and PCMH (and PCSP for that matter) become the 'new' standard. The rest will be facing a pay cut. This pricing transparency creates more risk for Payers too as they will be under pressure to price according to market (see the HCCI health care cost tool at www.guroo.com). Interestingly, Payers have started implementing this transformation by investing more in primary care and controlling the rising cost of specialty care.

    ?Healthcare is ten times more complex than Defense. Change is hard? people have legitimate differences. You have to persist, but cheerful persistence gets you much further. Listen, learn,

    help and lead others. Appreciate what they have to say.? Newt Gingrich,

    World Health Care Congress 2015

  • 7In what ways are Payers implementing this transformation with primary care providers?

    SM: Risk is being transferred from payers to providers but in the form of ?technical risk? (what you do) but not ?population risk? (high cost conditions). Payers understand that payment has to change and while they have 'big data' on things like encounters, medication and admissions, they need better data on outcomes to get a more complete understanding of what to invest in and what will be sustainable rates in the future. Providers must also recognize the consumer driven movement toward retail delivery of care. Retail is only just getting started in health care and I don't just mean the emergence of urgent care centers. Convenience, access and on-demand care is where the market is heading and we are helping our clients to get there by building services, access and processes to help meet the demand.

    What resources are available from Payers to help primary care providers with the transition to Value-Based Design?

    SM: Some Payers offer case managers to work with provider offices to help them meet benchmarks and rewarding them with enhanced payments, per-member-per-month care coordination fees and upside bonuses. What most of our clients don't fully understand - yet - is that primary care is influencing everything. Payers want providers who make data-driven decisions about who they refer to, why, and what it costs to do so. Pediatricians and primary care providers need to demand more for themselves; they are the cornerstones of care and are becoming a scarce commodity.

    What are Payers doing with regard to adapting to new Value-Based Designs within their networks?

    SM: Here are some examples: Blue Cross Blue Shield North Carolina (BCBSNC) has totally changed focus and rebranded to become the 'health value team'. Medical policy, redesign, and network management (contracting) falls under that team. They?re making the shift from ?high Payer accountability? to ?high Provider accountability? through Accountable Care Organizations (ACOs). It is necessary to bring providers into the equation and match providers to their capabilities by starting slowly and gaining traction as they help build infrastructure. They can?t implement any more ?bundling logic? because that is a manual payment process and they are moving to real-time claims adjudication. Long-term investment trumps short-term implementation in these new models.

    Humana?s Managed Services Organization (MSO) has a range of contracting arrangements with primary care providers (Fee for Service, Pay for Performance, and Risk-based). They realized that in order to achieve a higher quality of care they couldn't just push or share risk with providers; they needed to be rewarded ?upside' and not penalized when targets are hard to meet initially. They are getting into the ACO game too; Humana?s newest company, Transcend, intends to work with ?service organizations? to create Accountable Care Organizations.

    What are the market forces that will most greatly impact the future of health care?

    SM: Risk sharing, quality outcomes, emerging technologies, and the consumer-driven retail marketplace are the sustaining issues that are reforming health care today and they?ll continue to do so over the next 3 to 5 years.

    WHAT YOU NEED TO KNOWInsurers and Wearable Technologies: Trends, Attitudes, and Projections Accenture recently released their annual Technology Vision for Insurance report. Here are some of the key findings from the survey:

    - 63% of respondents believe that wearable technologies will be adopted broadly by the insurance industry - Almost one-third said they are already using wearables to engage customers, employees or partners - 73% of insurers said that providing a personalized customer experience is one of their top three priorities - Half claim to already see a positive return from their investment in personalized technologies - 75% believe the next generation of platforms will be led by insurance players, not technology companies - Half (51%) said they plan to partner with major digital technology and cloud platform leaders

  • 8THE ART OF BALANCE

    We all need balance. Juggling the demands of work and family, while still making time for play and relaxation, is a constant struggle for most of us. But try we must, for it is essential to our health and well-being to give equal attention to all parts of ourselves and in doing so, we hope to achieve the best in ourselves and to inspire others.

    Here at Verden we have a talented staff who are exceptionally multi-talented too. We encourage each other to rest often, to indulge the creative side and to come together to have some fun whenever we can. For example, while attending a recent conference in New Jersey, some of our team were able to turn a business trip into a weekend retreat at the beach, family included! Achieving personal balance within ourselves, and as a team, helps to ground us and realize our shared goal of bringing our best and fostering excellence in all that we do. We encourage our clients to do the same ? rest often, play regularly, and above all, enjoy the work that consumes so many hours of our day. Throughout this issue you will find pictures of nature taken by our team. These images remind us of the ever-changing landscape of the health care industry, inspire us to adapt to and growing in the midst of that constant change, and fortify us to work with the current, not against it, to deliver our most comprehensive business advice to your practice.

    In this and further issues of View Point Magazine, we will explore these changing themes in detail to bring you the industry perspective you need to balance the daily demands of your practice with an understanding of the larger forces at work that are shaping the market in which you do business. Who knows, perhaps we might even bring a little balance to your creative side too.

  • 9MEDICARE LEGISLATIVE UPDATE: SGR Repeal, CHIP Reauthor izat ion, and PIMA

    On April 14, 2105 Congress overwhelmingly passed the ?Medicare Access and CHIP Reauthorization Act?. This bill permanently eliminates the flawed Medicare sustainable growth rate formula (SGR) and replaces it with a more stable Medicare payment system, implementing a 0.5 percent rate increase starting in July 2015, with an additional annual 0.5 percent rate increase each January thereafter through 2019.

    The bipartisan legislation substantially supports the much-needed transition from the current volume-driven fee-for-service (FFS) to a value-based system that rewards quality of care. The new reimbursement formula has been publicly endorsed by a number of medical associations including the American Medical Association, the American Academy of Pediatrics, the American College of Cardiology, the American Congress of Obstetricians and Gynecologists, and the Association of American Medical Colleges.

    The bill also extends the Children?s Health Insurance Program (CHIP) for two years. CHIP provides low-cost health coverage to children in families that earn too much money to qualify for Medicaid, commonly referred to as the ?working poor.' Each state offers CHIP coverage, and works closely with its state Medicaid program. In some states, CHIP covers parents and pregnant women. Since its beginning 17 years ago, CHIP has worked with Medicaid to cut the child uninsured rate in half.

    Unlike many private insurance plans, which are based on the health needs of adults, CHIP offers insurance with age-appropriate benefits. CHIP plans also provide access to child-specific pediatric subspecialists and surgical specialists.

    Jose Lopez | Senior Consultant

    ? BIG IMPACTS ?

  • 10

    The bill also contains a set of Medicare fraud measures known as the Protecting the Integrity of Medicare Act 2015 (PIMA) including:

    - Further delay enforcement of the so-called Medicare ?two midnight rule? (stays lasting less than two midnights must be treated and billed as outpatient service) for inpatient admissions until September 20, 2015;

    - Loosen existing restrictions on gainsharing with physicians, thereby permitting providers to give bonuses to doctors for reduced costs on services which were not medically necessary;

    - Permit the Department of the Treasury to impose major levies of up to 100 percent on tax delinquent Medicare service providers;

    - Require CMS to stop using Social Security numbers on Medicare beneficiary cards; - Modify the face-to-face encounter requirement for durable medical equipment to permit nurse practitioners and

    physician assistants to perform the encounter if allowable under state law.

    Finally, the bill extends the Teaching Health Center Graduate Medical Education Program that provides care to patients in underserved areas by training primary care physicians in community-based settings and it also extends funding for Community Health Centers for two years.

    Insurers and Wearable Technologies: Trends, Att itudes, and Project ions Accenture recent ly released their annual Technology Vision for Insurance report . Here are some key findings from the survey:

    - 63% of respondents believe that wearable technologies will be adopted broadly by the insurance industry - Almost one- third said they are already using wearables to engage customers, employees or partners. - 73% of insurers said that providing a personalized customer exper ience is one of their top three pr ior it ies - Half claim to already see a posit ive return from their investment in personalized technologies - 75% believe the next generat ion of plat forms will be led by insurance players, not technology companies - Half (51%) said they plan to partner with major digital technology and cloud plat form leaders

    WHAT YOU NEED TO KNOWWhat does this legislation mean for my practice?

    - Instead of the SGR-mandated across-the-board 21 percent fee cut, overall; providers' fees will increase 0.5 percent this year and every year through 2019.

    - CMS?s current efforts to improve quality of care through electronic health records and performance reporting will be replaced by a new Merit-based Incentive Payment (MIP) program.

    - Policymakers will begin developing alternative payment models for patient care. Be sure to pay attention to the proposals that will be forthcoming, participate in discussions to ensure they are in your patients? best interests, and support professional associations and other advocates who are representing you.

    For claims that were submitted in April prior to this legislation, there was a temporary hold but this should have little practical impact on Medicare remittances. As always, providers are strongly encouraged to bill their usual and customary fees rather than the fee schedule amount.

  • 11

    Hospit al-Insurer disputes may get even uglier

    A recent article by Becker's, excerpted here, discussed several high-profile disputes between health systems and insurers that have impacted consumers and providers dramatically.

    Failed negotiations between UnitedHealthcare and Carolinas HealthCare made headlines in February. That same month, it was announced that a 20-year relationship between Humana and the University of Chicago Medicine would come to an end April 1, affecting approximately 1,750 patients. Rush University Medical Center was also involved in heated insurer negotiations, as Blue Cross & Blue Shield of Ill inois notified 65 medical groups they would receive reduced reimbursement if they referred BCBS HMO patients to Rush.

    But one of the most controversial and longest-running provider-payer disagreements is between Pittsburgh-based UPMC (provider and insurer) and the Blue Cross Blue Shield health insurer Highmark. The contract dispute was such a big deal that the government had to intervene with Pennsylvania lawmakers drafting legislation that would force UPMC and Highmark to work together. Finally, last June, the two organizations executed a consent decree and put a five-year transition plan into place. However, even with the consent decree governing their post-contract relationship, UPMC and Highmark have continued to skirmish over contract language. The saga continues.

    Sometimes new agreements can only be reached once relationships have ended altogether. In November 2014, Atlanta-based Grady Health System left the Blue Cross Blue Shield of Georgia network. At that time, Grady Health System executives claimed the health insurer paid it 70 percent less than other hospitals in the state. However, Blue Cross Blue Shield of Georgia claimed the system was seeking reimbursement higher than inflation. The parties continued to negotiate even after Grady Health System left the network, and the organizations agreed on a new contract in late March.

    Sumita Saxena, JD | Legal Consultant

    ? LEGAL NOTES ?

  • 12

    Contract negotiations between providers and payers are a normal part of doing business, but there are many new factors influencing these talks, including price transparency and the increasing role consumers are playing in health care. Even with the transition to more value-based care, it is likely these disputes will continue to occur.

    There are several factors causing more disagreements between providers and Payers. The economics of health care is complex and costs are always trending higher; this cost pressure is contributing to more contentious negotiations between providers and payers.

    "It comes down to employers, the government and consumers wanting more value," said Ben Isgur, director of PwC's Health Research Institute to Becker?s recently. To provide that value, payers and providers are trying to reign in costs but that is hard to do when both sides are looking for profit increases.

    The greater importance of cost for all parties has resulted in more transparency in the health care industry, and by allowing for comparison, transparency is also playing a significant role in these disagreements.

    "Consumers want more transparency," Mr. Isgur said. PwC's consumer surveys show about 43 percent of consumers want an online pricing experience, and many providers are responding to that demand. When that information is available to the public, there is increased pressure on systems to put together more competitive pricing.

    It would appear that this increased transparency can also have a positive influence on payer-provider relationships and lead to more productive negotiations. "One of the things we believe might happen is it will allow insurers and systems to enter into more value-added relationships, such as [accountable care organizations]," according to Julie Coffman, partner with Bain & Company's health care practice, who spoke to Becker?s.

    The tremendous amount of consolidation happening in the industry is triggering more negotiations and with it, a greater number of provider-payer disputes. "One of the benefits of consolidation is growth, and with growth comes purchasing power around pricing," said Rick Judy, principal of PwC's Health Industries Advisory practice, when asked by Becker?s.

    Why worry about what hospitals are doing with their payer contracts? Be careful you don't end up in the middle of a dispute.

    A client became very concerned when their admitting hospital dropped a large managed medicaid plan that accounted for 30% of the practice's business. With no hospital to admit these patients to, the practice had to decide if it needed to help thousands of patients switch plans right away or to attempt to intervene with the hospital.

    It worked out in the end, but the potential for a serious impact to the practice was significant. . .

    WHAT YOU NEED TO KNOW

    "It comes down to employers, the government and consumers want ing more value"

    Ben Isgur, Director

    PwC's Health Research Institute

    What is dr iving an increase in t hese disputes?

  • 13

    Payers are looking for networks of care that can provide the total quality experience and take care of patients in a variety of settings, and standalone facilities are feeling the squeeze. So having a robust 'internal network' is critical to holding on to provider leverage in the market.

    "Forming more clinically integrated networks over time is going to be necessary for standalone organizations to have the right negotiating stance," says Ms. Coffman.

    The pressures are also taking a toll on many community-based hospitals, especially those in dense urban markets. In February, Horizon Blue Cross Blue Shield of New Jersey announced Christ Hospital in Jersey City had terminated its contract with the insurer. In its announcement, the insurer said the contract was canceled because it "could not agree to the demands for rate increases made by Christ Hospital." Christ Hospital is part of CarePoint Health, which operates three of the six hospitals in densely populated Hudson County. Ten percent of Hudson County's population was uninsured in 2014, according to data from Enroll America. That number is slightly below the national average calculated by Gallup in the fourth quarter of 2014. A large percentage of the county's population is also on Medicaid or in need of charity care.

    CarePoint CEO Dennis Kelly told Becker?s, "Payers look at the marketplace and there aren't a lot of reasons for them to get a favorable contract, because there aren't a lot of people with private insurance to serve." He sees this as a significant problem.

    "The urban community providers are at risk. We've got to be able to negotiate contracts," Mr. Kelly says. "Unless the insurance companies recognize that the insurance rates need to be adjusted to the individual markets that systems operate in, safety-nets aren't going to be able to stay open."

    Rate increases are the center of heated negotiations between payers and providers in a fee-for-service world, and those types of disagreements might occur less often when dealing with value-based contracts.

    However, even if the subject matter of the disagreements changes when negotiating a value-based contract, there is still plenty for providers and payers to argue about. For instance, they have to agree on which quality metrics to use to determine bonuses or penalties and work out the details of shared savings agreements.

    Providers have a lot on the line when negotiating these contracts, with nearly 33 percent of healthcare providers expecting value-based contracting to negatively impact their organizations' bottom lines, according to a 2014 KPMG survey.

    Some organizat ions are harder hit t han others

    Will shif t ing t o value-based cont ract ing make for easier negot iat ions?

  • 14

    It's important for providers to use data in making their case to payers when negotiating value-based contracts. They can use data, such as hospital payment data and cost data, to perform a financial analysis for use when negotiating. Using the financial analysis, providers can determine where they "can afford to give a little, to get the contract elements more important" to them, according to The Advisory Board Company. At Verden, we approach provider negotiations in the same way.

    In addition to negotiation pressures, these new contracts require providers to meet the challenges presented in value-based contracts to make payers want to negotiate. "What we've determined is that payers are more willing to engage with providers that already have some experience with managing risk and can demonstrate the ability to reduce costs of care while maintaining high-quality outcomes," wrote the authors of the report.

    It is important to remember that negotiations between payers and providers are standard business practice, and even when a contract is terminated it doesn't mean the relationship between the parties is over. Many times, negotiations still continue.

    For instance, Carolinas HealthCare and UnitedHealthcare were unable to reach a new agreement before their contract expired Feb. 28, leaving 12 hospitals and a number of physician offices out-of-network for UnitedHealthcare members. However, a UnitedHealthcare spokesperson, Tracey Lempner, told Becker?s the two organizations are still involved in negotiations and "continue to meet regularly." She says, "Our goal has always been to have CHS continue its participation in our network."

    The same goes for University of Chicago Medicine and Humana. Although no agreement has been reached, a Humana spokesperson, Cathryn Donaldson, was quoted by Becker?s as saying, "Humana remains open to negotiating a new agreement that aligns with our members' need for affordable healthcare coverage."

    The personal nature of these disputes, along with the back-and-forth blame that often accompanies these disagreements, attracts media attention. Like the dispute between Grady Health System and Blue Cross and Blue Shield of Georgia, many providers and payers pass blame about why negotiations aren't successful.

    Providers have a lot on the

    line when negotiating these contracts, with nearly 33

    percent of health care providers expecting value-based

    contracting to negatively impact their organizations'

    bottom lines.

    Aren't negot iat ions always t his way?

  • 15

    Each party wants to paint the other as the 'bad guy'. For instance, Carolinas HealthCare and UnitedHealthcare provided conflicting accounts after their dispute. The health insurer began telling its members they would be considered out-of-network at Carolinas HealthCare hospitals and would pay more to use those facilities once the contract expired. Meanwhile, a system spokeswoman told the Charlotte Observer that Carolinas HealthCare decided to extend temporary waivers to UnitedHealthcare members so they would be billed as though they were in-network.

    Failed contract negotiations between providers and payers make headlines and disrupt patients, but these types of disputes are commonplace in other industries.

    "These disagreements may seem more radical in the health care industry because of the relationship that people have with their physicians," says Ms. Coffman, "whereas in other industries it is less of a personal nature."

    These disputes are also part of health care taking on more traditional market functions, experts say. "Ultimately, those market dynamics are going to be helpful for the industry," Mr. Judy told Becker's. While we don't disagree with Mr. Judy's assessment of the market, we are concerned about how this impact providers, particularly those that remain independent of big hospital systems.

    WHAT YOU NEED TO KNOWThe market is moving swiftly from a fee-for-service based one to a value-based economy. All of the markets players need to understand that we have shifted into a 'big data' era. Payers are measuring performance and setting the goals, but providers need to be the ones helping to create the new standards of care.

    With change comes upheaval and opportunity. Opportunities are being presented in the form of mergers, partnerships, risk-sharing and delivery design. It is essential to understand how you are being 'graded', ranked and viewed by payers, and essential to have the tools that allow you assess your data better than they can.

    Networks will get narrower, the hospital you admit to today may fall out with your largest payer tomorrow, so understand your market and its forces as clearly as possible so you can react to potential threats and opportunities as the market shakes itself out over the next couple of years.

  • 16

    No matter what your role or position, demands on your time have never been greater and will only increase in the future as reporting requirements, payment methodologies, and delivery of care models continue to evolve. In this article you'll find several methods you can use to gain more control over your time, tasks, and priorities. Learning to manage stress caused by the multiple demands on your time will allow you to run your day, instead of your day running you!

    Always start with ?Why??

    When thinking about how you will approach a new project or task, always ask ?why?? before you begin. Asking why allows us to question the necessity of a project, how it fits in with the organization?s core values, and to prioritize the project based on its value and desired outcome. On an individual level, understanding ?Why?? prompts the Reticular Activating System (RAS) in our brains. The RAS works with the visual parts of our brain to filter out information from external sources and focus the brain on one particular fact, detail, or thought, getting us interested and motivated in the task at hand. Over time, as the RAS is repeatedly activated and reconditioned, new neural patterns are created, fostering creativity.

    For these reasons, it is vital when starting a project that all members of a team understand the why and will actively support and participate in the assigned tasks.

    Managing Mult iple Pr ior it ies, Project s & Deadlines in a Busy Medical Provider Set t ing

    ? PRO TIPS ?

    Jose Lopez | Senior Consultant

  • 17

    Paired ComparisonPaired Comparison is a process for simplifying decisions or judgments that involves comparing options or entities in pairs and judging which element of the pair is preferred or has the greater amount of some other measurable property. The process is popular because paired comparisons are easy for people to make.

    The questions can be presented as pictorial scales, with numbers assigned to qualitative judgments to represent strength of opinion. Among other applications, paired comparison is used as a method for assessing preferences, assigning probabilities, voting and ranking decision options. This method is popular for group decisions as it easily incorporates individual preferences into a group whole.

    Set SMART Goals There are five characteristics of effective SMART goals: Specific, Measurable, Achievable, Realistic, and Time-Specific. By defining your goals in the SMART format, you are setting transparent expectations for yourself and members of your team. Every goal you set must meet each of these guidelines.

    Prioritize Tasks There are a number of techniques available to prioritize tasks. Below are three common techniques: Paired Comparison, Deadline/Payoff, and Eisenhower Quadrants. Once you determine which works best, use it consistently to prioritize and manage all your projects and tasks in order to meet deadlines.

    S

    AR

    T

    M

    Specific or Significant

    Measurable or Meaningful

    Attainable or Action Oriented

    Relevant or Rewarding

    Time-Bound or Trackable

  • 18

    "What is important is seldom urgent, and what is urgent is seldom important." - Dwight D. Eisenhower

    Delegate The greatest time-saver for most people is creative and effective delegation. To achieve results through delegation, you must think through your decision, consider possible training needs, clearly define the task/project for the people you delegate to, continue to supply resources and support, allow for maximum flexibility, and follow up. Proper delegation and teamwork is crucial to the success of the Patient Centered Medical Home (PCMH), as the team provides care based on the needs of the patient by fulfil l ing their assigned roles. Staff must be properly trained and feel empowered to be able to meet and exceed expectations.

    Eisenhower Quadrants Eisenhower Quadrants are so-called because they were used by President Eisenhower; however you may be familiar with them thanks to the popularization by Stephen Covey. Here tasks are evaluated using the criteria Important/Not Important and Urgent/Not Urgent, and then placed in different 'quadrants' within a matrix. Tasks are then handled based on the quadrant they are place in:

    - Important/Urgent quadrants are done immediately and personally (e.g., crises, deadlines, problems) - Important/Not Urgent quadrants get an end date and are done personally (e.g., relationships, recreation) - Unimportant/Urgent quadrants are delegated (e.g., interruptions, meetings, activities) - Unimportant/Not Urgent quadrants are dropped (e.g., time wasters, activities, trivia)

    If you consistently struggle to complete tasks, keep a time log for a couple weeks to identify time wasters. Most likely these are activities from the Not Important/Not Urgent Quadrant that are easy to fall prey to, such as TV, Social Media, etc. If the interruptions are from the Important/Urgent Quadrant, focus on Important/Non Urgent Quadrant activities that will reduce emergencies in the future.

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    Stay Organized There are a number of electronic calendar software applications (e.g., Microsoft Outlook, Google, Priority Matrix which utilizes Eisenhower Quadrants, etc.) that you can use that are also compatible with a smartphone to keep you organized and on task.

    The key is to find one you are comfortable with and then commit to use it in the following manner:

    - Plan for the week, not by the day. Always start Monday morning by dedicating time to plan your weekly schedule. If your calendar has the capability, organize activities by color coding them by project/category to give you a better visual layout of how you will spend your time.

    - Block off all times in your calendar using estimated times. Include personal activities breaks or you will never get to them. Treat these blocked off times as if it were a meeting with your most important client: you!

    - As the day and week progresses, adjust your calendar accordingly. The calendar is simply a tool or method to help you achieve your goals, it is not an end in itself.

    - The average person uses 13 different methods to control and manage their time.

    - The average person gets 1 interruption every 8 minutes, or approximately 7 an hour, or 50-60 per day. The average interruption takes 5 minutes, totaling about 4 hours or 50% of the average workday. 80% of those interruptions are typically rated as "little value" or "no value" creating approximately 3 hours of wasted time per day.

    - 20% of the average workday is spent on "crucial" and "important" things, while 80% of the average workday is spent on things that have "little value" or "no value".

    - Taking 5 minutes per day, 5 days per week to improve one?s job will create 1,200 little improvements to a job over a 5 year period.

    - It almost always takes twice as long to complete a task as what we originally thought it would take.

    - A project tends to expand with the time allocated for it. If you give yourself one thing to do, it will take all day. If you give yourself two things to do, you get them both done. If you give yourself a dozen things to do, you may not get 12 done, but you?ll get 7 or 8 completed.

    - Delegation is an unlimited method to multiply time for achieving results.

    - "If you always do what you?ve always done, you always get what you?ve always got." To change our output, we must change our input.

    Credit: Dr. Donald E. Wetmore

    WHAT YOU NEED TO KNOW

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    PCPCC Reports Positive Outcomes of PCMH Initiatives

    The Patient-Centered Primary Care Collaborative (PCPCC) recently released evidence from primary care PCMH initiatives taking place in both public and private markets across the country. The results are encouraging and demonstrate the PCMH?s positive impact on reducing cost and unnecessary health care utilization. Read more here.

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

    Providers are now responsible for any data breaches at their practices, and we are hearing about more every day. What can you do to protect your practice? Read more here.

    New HCPCS Modifiers Define Subsets of the 59 Modifier

    As of January 1, 2015 the Centers for Medicare and Medicaid Services (CMS) established four new Healthcare Common Procedure Coding System (HCPCS) modifiers to define subsets of the -59 modifier. Read more here.

    TVG BLOG TVG MEDIA STREAMS

    We decided to add a little video to Facebook to introduce our new magazine. You can view it, and other posts, here.

    You can also find us posting out snippets, links and news on Twitter from time to time here.

    Does the ?Doc Fix? Bill Help Telemedicine and Telehealth? In a word, yes. The Verden Group's Sumita Saxena explains how and what it means for your practice, here.

    Connect with all our social streams herewww.theverdengroup.com/connect/ verden-media/

    - CONNECT-

  • 21

    Welcome to our very first issue of ViewPoint magazine! Each issue will deliver our take on the latest news and developments from the health care industry, tips and success stories from our clients, blog recaps and reports from the conference trail.

    ViewPoint will also contain professional development ideas and engaging interviews and articles on everything from legal matters to practice management, and PCMH recognition.

    Want to stay connected and be the first to know all the latest news?

    Visit www.theverdengroup.com and click on CONNECT at the top of any page on our site. With just one click you're connected to all of The Verden Group's social media feeds. LinkedIn, facebook, and twitter plus a whole lot more.

    The TVG team will keep you up to date on events, conferences and training sessions that your practice needs to know about.

    Policy Search is the only search tool available that allows you to look up commercial healthcare insurance company policies, easily and immediately.

    No more searching insurance company websites for medical policies. No more chasing reps to get answers. Know how an insurer?s competitors are covering services and use that information to forge policy change.

    Get what you need, when you need it. INSTANTLY.

    The Verden Group, founded January 2007 by Susanne Madden, is a visionary consulting firm focused on shaping the landscape of advocacy by empowering medical practices to navigate through the increasingly complex business of healthcare, and to advocate on their own behalf to insurers and regulators.

    The Verden Group, delivers expert services and advice to meet needs across your practice. From contract management to social media management, start ups to super groups, PMCH to research studies, we are your Partner In Practice.To learn more about our services visit www.theverdengroup.com

    Subscribe to ViewPoint to stay on top of all our news and views on the business of health care.

    Using a smart phone or tablet? Just scan the QR code to subscribe now, or visit www.TheVerdenGroup.com

    www.TheVerdenGroup.com

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    ? HR MATTERS ?

    Many organizations issue an employee handbook, an official document that covers their policies on everything from computer use to vacation time. As new technologies and business-related laws take hold in the office, human resources departments must update those policies to reflect the most current trends.

    But this is easier said than done. A new survey by HR compliance resource XpertHR found that, although the majority of businesses (78 percent) have made revisions to their handbooks within the last two years, the biggest challenge for 41 percent is continuing to keep their handbooks up-to-date with an ever-changing workplace and workforce. The challenges of keeping up with a changing workforce, new laws and just getting employees to read the handbooks are not new, yet addressing evolving workplace issues is complex.

    Though it may be a difficult task, it's an important one: updating your handbook to include emerging laws and trends, even if they haven't affected your practice yet, will help head off any confusion among employees should a situation arise. Staying ahead of the curve can also help your business stay out of legal trouble.

    The first step in the process is to understand what changes may have taken place in federal, state and local laws since you last revised or issued your handbook. This can be challenging for employers to navigate as changes are not always consistent between federal and state levels. The laws also vary state-by-state. For example, some states, such as California, have recently enacted a Paid Sick Leave law effective July 1, 2015 which requires essentially all employers to provide a certain number of paid sick leave days per year to all eligible employees. It is critical, then, to examine your current Paid Time Off or Sick Leave policy to ensure it is compliant with the new law.

    Why You Need To Update Your Employee Handbook Now

    Sumita Saxena, JD | Legal Consultant

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    Another area of concern for employers are policies prohibiting employees from engaging in conduct or speech which would be construed as negative towards the employer, or violating confidentiality. For example, policies such as ?Be respectful to the company, other employees, patients, and vendors.? or ?Never publish or disclose the Employer?s or another?s confidential or other proprietary information. Never publish or report on conversations that are meant to be private or internal to the Employer.? have been ruled as illegal by the National Labor Relations Board (NLRB). The NLRB reasoned that such policies were too broad and thus unlawfully interfered with the employee?s rights to discuss the terms and conditions of their employment and to participate in concerted activity to improve such conditions of their work. The NLRB has been aggressively cracking down on this area and employers should be careful when drafting such policies to avoid being overly broad as to prohibit protected activity.

    Other important issues to address are at-will employment, cell phone use, dress code, compensation and benefits, and leaves of absences. One of the most important things to remember is that your handbook needs to reflect the way you do business. If you write a policy, be prepared to enforce the policy ? whether it is a policy setting limits or a policy supporting goals. You need your handbook be a true reflection of your business.

    You also need to decide what tone you want your handbook to take. Many handbooks are written from the negative "shall not" perspective. Some of the most effective manuals, however, are those written from a positive perspective. Employees need to know what kind of behavior will cause problems, such as excessive absences, but the policy doesn't have to be written focusing on the punishment.

    Some of the most effective manuals are those written from a positive perspective.

    A carefully drafted employee handbook can be a tremendous asset to your practice. It protects you from liability in the complex interplay between federal, state and local laws, while offering clear and concise guidelines for all employees to follow, which, in turn, results in a productive and efficient workplace.

    WHAT YOU NEED TO KNOW

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    -PAYER NEWS -

    Providers become Insurers

    WHAT YOU NEED TO KNOW

    The market is quickly evolving to attract new models of health insurance.

    North Shore-Long Island Jewish (LIJ) Health System in New York has been busy building a new insurer, called 'CareConnect', covering Long Island, Westchester, N.Y. and the northernmost New York City borough, the Bronx and up into Connecticut via a partnership with Yale-New Haven, with plans to expand into New Jersey.

    In a recent article in Health Plan Week, Patrick Connole interviewed Alan Murray, president and CEO of CareConnect. According to Mr. Murray, the CareConnect business plan is to offer consumers a very select provider network designed to coordinate care to raise quality and lower costs. ?We went to very specific facilities that had a level of integration and asked them if they wanted to be part of the same thing as North Shore-LIJ was for CareConnect. In order to come in, they had to agree to the financial incentives, give access to their medical directors and clinical staff, and allow us to make appointments for their members."

    Enrollment has been robust, with expectations being 40,000 at the end of 2015 up from 21,000 currently.

    The genesis of CareConnect came from the Affordable Care Act (ACA), with its public exchanges allowing access to new members and a new delivery system. ?The ACA was the catalyst for allowing us to get into the market. Before 2014 there were really only the very large national carriers and a couple of very large regional carriers in this market,? Murray says. ?There was tremendous consolidation, and distribution of the products was through a broker and general agent channel, which in essence had become very accustomed to dealing with only those major companies. So any new companies that wanted to break through would obviously have the sizable financial investment, but the major barrier in essence was how the hell do you sell your products. If you can?t break that distribution channel, then you can have the best ideas and strategies in the world, but you are not actually going to be able to sell. That obviously changed dramatically in 2012,? he adds.

    While many large hospital systems have had their own 'tiered networks' ? that is, specific networks of providers that their own employees would use ? for decades, offering health insurance to consumers outside of the hospital walls and partnering up with other organizations is new territory. It will be interesting to see what other large provider organizations follow suit.

    Susanne Madden | CEO

    It may not be long before your local health care system gets into the insurance game. Evaluate any proposed contracts very carefully, particularly when it comes to rates and financial incentives. If the rates are lower than most of your commercial plans, it may not make sense to join. Also be wary of too much risk, look for upside bonuses rather than penalties. And make sure that incentives can actually be achieved; it's not a bonus if you can never reach the set metrics.

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    It was with tremendous regret that we learned of the passing of Lynn Cramer, - the Mighty Lynn! - and our sincere condolences go out to her family and many friends.

    Professionally, Lynn was one of pediatric's fiercest allies. She ran an exceptionally tight ship as the Administrative Partner of Eden Park Pediatrics in Lancaster, PA, and shared freely all of her pearls of wisdom, routinely inviting others to come on site and learn about the latest idea that she had implemented.

    Lynn was a Pediatric RN and was an enormous contributor to the pediatrician community, sharing her vast knowledge with her colleagues and presenting at numerous conferences. She was also an elected member of the American Academy of Pediatrics Pediatric Practice Managers Alliance (PPMA) and a very active affiliate member of the Section on Administration and Practice Management (SOAPM). Lynn loved to travel, dance, share advice, learn new things she truly enjoy life to the fullest . . . she was simply an inspiration. She was open, honest and forthright and was also a generous soul with her time, her ideas, her efforts, and her kindness. She was truly one of a kind and will leave an enormous hole in so many people?s lives, both professionally and personally.

    Lynn, you will be so very missed . . .

    In Memoriam: Lynn Cramer

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    ? FRONTLINES ?

    Earlier this year, two pediatric practices in Columbia, South Carolina - Palmetto Pediatrics and Sandhills Pediatrics - decided to come together as one integrated 'super group'. Both groups were sizable with 17 and 18 pediatricians in each respectively. For decades they had been competitors but changes in the health care environment in Columbia, and across the region, brought them together to collaborate. In doing so, they have begun to realize big cost savings, have been able to build on their already great delivery of high quality pediatric care and hold their own against market players that have brought pressure on local practices to merge, sell or sign less-than-favorable agreements with them.

    We got a chance to speak with Ken Fenchel, COO, of the newly formed South Carolina Pediatric Alliance and asked him a couple of questions about the integration. Here's what he had to say.

    HH: Ken, there were obviously very compelling reasons to create this new group, particularly as your practices had been competitors. What do you see as the most tangible benefits coming out of the integration?

    KF: We expected to be able to reap economies of scale and were able to do so, in some cases substantially. Savings in areas such as malpractice coverage, supplies, vaccines and so on were realized but there were also some valuable benefits achieved that have been unexpected. Our corporate structure is more robust, we have better governance, our merged billing team is more effective than when we were two separate entities, and we have been able to take the best practices from each and apply them across the organization.

    HH: It sounds like you have managed to create tangible, successful outcomes in a very short period of time. Digging a little deeper on this, what have been the most positive aspects?

    KF: Well, these practices were competitors for decades, but we were able to see the commonality between us and build on that. Being two of the best pediatric groups in the area already, becoming allies has created a strong partnership for doing what we now collectively do best - providing the highest quality of care delivered through our medical home model.

    HH: Bringing together two large groups while preserving each one's independence must have presented significant challenges. What was the biggest change or challenge you had to overcome?

    KF: Merging our business cultures. Clinically we operated very similarly but from a business perspective there were significant differences in our day-to-day operations. My advice to others that are setting about building a Practice-Without-Walls is to allow for some time for team building

    An Interview with Ken Fenchel: Lessons Learned in Forming a Super Group

    Heidi Hallett | Director of Communications

  • 27

    between the organizations, for both staff and physicians. I think the transition would have been easier if we had the time to do some cross-practice team building, maybe having employees work at other locations, nurse-to-nurse, physician-to-physician and so on. Being able to see each other's operations before coming together may have facilitated and fostered a better understanding of each other's perspectives.

    Additionally, our accounting systems were different so it was a challenge to switch from one method to another. So I would say for practices to make sure that they compare their accounting methods beforehand and then adequately prepare for a short period (say, 90 days) in which to transition to a new one.

    HH: I believe you and your team managed to put this integration together in just four months? It seems like you achieved an almost impossible time line! I suspect that in order to do so, there were some things that you had to leave undone. Is there anything you would do differently if you could do it again?

    KF: That's right, Heidi, we did this in four short months. We had a good legal framework to work with and some assistance from our accountants and your group to help put it together, but our team moved mountains to get this done. I think it is easy to underestimate the amount of work to be done until you are actually in the trenches doing it. You could say that while this was not a 'shot gun wedding' it certainly was a 'race for the alter'. Four months left little time for preplanning so if I had it to do over, that is where I would focus and foster more up-front collaboration and team building.

    HH: I'm sure folks are curious to hear what were your most and least valuable outcomes or lesson learned from this process. Can you speak to that?

    KF: I think the most valuable outcome for us was in terms of economic savings. We saved hundreds on health insurance per employee, realized a 10% saving on our medical supplies, formed a buying group for vaccines and saved another 5% and improved our rebate amounts, and reduced banking fees substantially. In all, our savings will be close to a quarter million dollars this year. In terms of quality, and that's always been the big focus for us; our collaboration has improved care, ensured that all our locations are NCQA PCMH Recognized and operating as high-functioning medical homes, improved our HEDIS measures and data collection, and we are on track to fully implement Bright Futures protocols across the organization.

    It's not all good news, of course. The least valuable lesson learned was the underestimation of the time and stress involved to pull it all off. Our team has more grey hair now than ever but we are very pleased with where we are at currently and look forward to growing the organization across the state in the future.

    HH: Ken, thanks for speaking with us and we wish you all the very best for continuing success in the future!

  • 28

    July 21st, San Francisco

    www.pcc.com/users-conference

    EVENTSPCC?S USERS' CONFERENCE

    - PCMH 1-Day Workshop- New Practice Models- New Payment Models

    October 9-11, San Francisco

    www.pcmhcongress.com/home

    October 1, Sugarland, Texas

    www.txpeds.org/annual-meeting

    2015 PCMH CONGRESS

    - How to Set Up & Manage PCMH/PCSP Projects

    TEXAS PEDIATRIC SOCIETY

    - How Does Your Practice Score with Payers & Why You Need to Know

    OVERHEARDat The Verden Group

    "From 5% of the patient population to just ONE person..."Jose couldn't quite believe what he heard on a recent 'update call' from CMS regarding changes to the Meaningful Use rules. Of particular interest for practice's attesting for Stage 2 in 2015, the regulations around meaningful use 2 on 'view, download, transmit' (VDT) of personal data will likely change dramatically, and in this case, the requirement will drop from 5% of the practice population to just 1 patient needing to VDT. . .

    For more information on all the upcoming events and conferences visit: www.TheVerdenGroup.com

  • 29

    ROLL CALL!

    - STEPPING STONES, NY - PALM BEACH PEDIATRICS, FL - PEDIATRIC PARTNERS, FL - MC ALLEN PEDIATRICS, TX - KINDERCARE PEDIATRICS, NY - VILLAGE PEDIATRICS, CT - ELLICOTT CITY PEDIATRICS, MD - DAWSON PEDIATRICS, GA - PEDIATRIC ASSOCIATES OF MT CARMEL, OH - UNION PEDIATRICS, KY - CATHERINE SCRENCI, MD, NY - CAPITAL AREA PEDIATRICS, VA - CAROLINA PEDS OF WILMINGTON, NC - WILLIAMSBURG PEDIATRICS, NY - EASTERN CAROLINA PEDIATRICS, SC - PALMETTO PEDIATRICS, SC - PEDIATRIC ASSOC. OF BROOKLYN, NY - ONE PEDIATRICS, KY - THE PEDIATRIC GROUP, VA

    For more information about how Patient Centered Solutions (a division of The Verden Group) helps practices transition through NCQA's PCMH and PCSP programs, go here.

    We would l ike t o congratulate t he following client s t hat have at t ained t heir Nat ional Commit t ee of Qualit y Assurance (NCQA) Pat ient Centered Medical Home (PCMH) status so far t his year. We salute all of your hard work and dedicat ion!

  • 30

    VIEW POINT

    WWW.THEVERDENGROUP.COM

    ViewPoint is a seasonal publication, distributed digitally The Verden Group 2015Publisher: Susanne Madden | Editorial Manager: Jose Lopez | Editor and Production Manager: Heidi Hallett

    Contributors: Susanne Madden, Jose Lopez, Heidi Hallett, Sumita Saxena, Kim Engler Photography by: Susanne Madden, Jose Lopez, Heidi Hallett

of 30/30
I NTERPRETATI ONS OF WHAT'S SHAPI NG THE HEALTH CARE I NDUSTRY FOR I NDEPENDENT PRACTI CES WORLD HEALTH CARE CONGRESS 2015 Industry Innovations and Impact - What You Need To Know About The Evolution of Health Care in 2015 PROVI DERS BECOME I NSURERS As New Models of Insurance Emerge, What Does That Mean For Providers? MEDI CARE LEGI SLATI VE UPDATE SGR Repeal, CHIP Reauthorization, and PIMA HOSPI TAL-I NSURER DI SPUTES Things May Get Even Uglier IN MEMORIAM A Sad Goodbye to One of Pediatric's Fiercest Allies: Lynn Cramer SUMMER SOLSTICE 2015 PERSPECTI VES ON THE BUSI NESS OF HEALTH CARE HUMAN RESOURCES Why You Need To Update Your Employee Handbook Now
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