Riding the Blue Wave

Healthcare on the Legislative Docket We need to rally as one strong voice

The elections are over and now the real work begins, the collective work of the WCMS Government Affairs Commission (GAC), CCMS GAC, and NSMA GAC in conjunction with local and state PACs accurately assessed the outcomes of the elections with contributions and endorsements in all but one race throughout the state. For the first time in twenty years we have a Democrat Governor, Senate and House with Keith Pickard’s seat being contested possibly yielding a supermajority, although doubtfully needed.

We wholly expect this year to be another major healthcare session, as they all are now. Last session a bill passed, but ultimately vetoed by Governor Sandoval, that would have been very unfavorable to physicians seeking payment for services rendered provided to patients out of network (balance billing). This exact bill, virtually verbatim, has already been submitted as a bill draft request (BDR) for this session.

The leadership of WCMS and CCMS who are actively involved in the executive leadership of the NSMA have been meeting monthly with executive leaders of the Nevada Hospital Association (NHA) for over a year as part of a joint NSMA/NHA Balance Billing Task Force defining collaborative principles, attending legislative working groups and educating legislators about the linkage to network adequacy and contractual implications, reviewing model bill drafts and creating our own draft language, and strengthening ties for other important future collaborations.

Speaking of which, another serious threat facing healthcare providers in Nevada is tort reform. While most of us view this as a constant nagging concern, please be warned. The threat is now real. It might not come up until next session, but this will be part of the blue wave agenda. It is public record that the Nevada trial lawyer PAC gave large contributions to Governor-elect Sisolak’s campaign, among many other prominent government leaders. So, my friends, Keep Our Doctors In Nevada (KODIN) will almost certainly be challenged.

Sorry for the doom and gloom, but fear drives action and I am pleading with you to act. If you have read this far, then you are interested in the future of the practice of medicine in Nevada. Here is my plea. Make it your goal to recruit just one new member this year, maybe someone new to your practice, new to the hospital lounge, new referrer you discuss cases with, someone you think would like the stimulation and engagement. If not for political purposes, then for social gatherings and friendship, and if that doesn’t work use guilt. How could they not want to support their colleagues, people they depend upon every day, people they take themselves and their loved ones to see when they are sick? We need numbers. Sure, we need money, but more importantly we need to show unity. We need to be able to sit at the table and say we are here representing over three quarters of the physicians and this will not work. For anyone who nay-says the organization, please let them know that AB474, the Governor’s opioid law, was slated to be much more restrictive and that through the very hard work of our leaders was made workable. Furthermore, it has been sculpted in regulations and is set for revisions to be made more reasonable to physician practice patterns and workflow. This unfortunate, but necessary societal checkpoint, has been developed with input from our leadership. If we were not at the table, it would have been much, much worse. Just look to some of the other states in our Union (Kentucky limits opioids to a three-day supply) If we do not grow in number, demonstrate collective unity in public healthcare policy, then medicine and our patients in Nevada will suffer.

Sierra Neurosurgery Group’s Delegate Scholarship

Sierra Neurosurgery Group has established a special scholarship fund to support WCMS’ student and resident delegates to the NSMA annual meeting. The scholarships are awarded to University of Nevada Reno Scholl of Medicine student and resident to cover their registration and travel costs.

This sponsorship is aimed at enriching mentorship and the need for medicine and public health advocacy. The first recipients attended the NSMA Annual Meeting held Sept. 28-30 in Henderson. The recipients are: Neha Agrawal, student delegate, Class of 2021; Alex Cabrera, student alternate delegate, Class of 2021, and Chris Clifford, resident delegate, Class of 2018.

Sierra Neurosurgery Group embraces the mission of WCMS that quality care is essential for all Nevadans.

Contractual Relationships

Contractual relationships impact almost every aspect of a physician’s practice and merit a reminder of a few factors to keep in mind while considering entering such a relationship.

Who are the Parties to the Contract?

A simple question but a very necessary one. Are contracting in your individual capacity or through your professional entity? Is it more appropriate for the contract to be with your professional corporation for legal or tax purposes? Some contracts, such as an employment agreement, will typically be with an individual, but in many other cases a professional entity may be the better option.
As to the other party, who are you contracting with? Are you really entering into a contract with a local entity or their corporate parent entity? This could have an impact on issues such as how willing the entity is to negotiate modifications to the contract or what governing law applies.

Speaking of Governing Law….

Clause such as “governing law” are typically buried those clauses often referenced as the “boiler plate” of a contract. While it may be tempting to skip over these provisions when reviewing a contract, these clauses can have significant implications. Clauses such as governing law (what state’s law governs the provisions/interpretation of the contract) or jurisdiction can be problematic for the unsuspecting. Do you really want to have to file suit in New Jersey if you need to take legal action to enforce a contract or seek damages? Pay attention to these small details when reviewing a contract.

Know When to Walk Away

Does the contract you are considering open you up to unknown liabilities? What are your rights under the contract? How can you terminate it if need be and what potential penalties might you incur by doing so? Is the contract legally accurate? If you are reviewing a template document that was last revised in the prior decade, you should ensure that the terms all comply with current laws.

Know what your potential deal breakers are. Always keep in mind that unless your legal representative drafted the agreement, there may (and probably are) provisions that are more favorable to the other party. While some parties may be willing to negotiate terms, if the other party is resolutely set against any modifications, give serious thought as to whether you can live with the contract as is or if it’s best to leave it and walk away.

Ms. Beggs, principal of the Law Offices of Lyn E. Beggs, PLLC, focuses her practice primarily on assisting clients with administrative and professional licensing board matters in addition to representing healthcare providers on a variety of issues. Ms. Beggs may be reached at 775-432-1918 or at [email protected]. This article does not constitute legal advice and should not be considered a substitute for retaining counsel for advisement in legal matter.

One Students Journey

Can you guess what two words strike fear into the hearts of second year medical students? Prostate exam? Nope. Brainstem nuclei? No, already learned them. Cumulative final? Please, we are old pros at this point.

Step One? Bingo.

Our first of three licensing exams, passing the United States Medical Licensing Examination Step 1 is essential to progressing in our education. Scores range between 300 and 0, with most students scoring between 260 and 155, where 194 is considered passing. Thankfully, UNR Med prepares us well and the vast majority of students pass on their first try. While I know that my classmates and I will all be grateful to pass, excelling on Step 1 is essential to matching at a desired residency. And once you have passed Step 1, you can never take it again to try for a higher score. One test, one day, one time only defines us. Thus, it is not too surprising that we second year medical students compulsively reach for our study guides when we hear “Step 1” echo through our classroom.

One test one day will indeed define us, just as one patient interaction one day may define us, or define that patient’s life, for better or for worse. The high stakes will not end with this exam. People usually approach this test with fear, but I think it is time to change that.

Training in Aikido, a Japanese martial art, I used to have exams in front of a live audience of my peers. My teacher would call out the technique in Japanese and I would have to perform it on a grown man who was hurling a punch at me. I was nervous during my first exam. I got flustered and started to get sloppy in my techniques—which is pretty obvious when you are girl in her early teens trying to throw a grown man.
My sensei saw my nerves and paused my exam. He told me, “Do not think of this as a test. You know this material. Think of it as a demonstration.” That simple perspective shift increased my confidence and I have tried to use that frame on exams since.

So here is my call to action. Let’s not fear exams, but instead embrace the opportunity to demonstrate the wealth of knowledge we worked so hard to learn in the first two years of medical school.

WCMS 2nd Annual End of Summer Celebration

Thank You Sponsors!

Recruiting Volunteer Community Physicians

Our Commitment to Diversity

A culture of diversity, equity and inclusion is vital to the success of the University of Nevada, Reno School of Medicine as we train the next generation of physicians and health care professionals.

We are not creating, supporting and enhancing a culture of diversity, equity and inclusion because it is a trending topic, or a topical statement of the moment. A diverse culture is one of our most defining values, because it is who we are and what we do.

We strive to become a better school of medicine of greater breadth and depth and to achieve the highest level of excellence in education, patient care and research. We strive to drive innovation and becoming an employer of choice because of our culture and values.

Training a more diverse and culturally competent workforce will meet the needs of an increasingly diverse patient population, and address disparities and inequities in health. Asking research questions that are broader, more important, of higher impact and address the critical issue of health care disparities will lead to a higher quality of medical care. Breaking down stereotypical thinking and biases, challenging assumptions and broadening perspectives makes us accessible to patients and learners, and more comfortable with the breadth of human experiences beyond our own.
The profession of medicine is inextricably linked to diversity in all its forms and cannot escape its responsibility to care for a diverse population. Disease and suffering know no boundaries, whether characterized by differences in race, ethnicity, gender orientation, income, disability or any other human trait, yet patients with these characteristics fare less well in our current health care system. Disease processes are at one and the same time blind to all differences and entirely influenced by these differences. Disease and suffering lead us all to a state of human vulnerability that is in many ways the same for all, and in other ways unique to each person.

As physicians, scientists and health care professionals, we take seriously our training responsibilities to address the clinical implications of diversity. We need to embrace and understand the breadth of humanness to be as expert as possible in curing and caring.

It is for all of these reasons that UNR Med’s mission makes unequivocally clear our responsibility as an institution to improve the health and well-being of all Nevadans and their communities through an “institutional culture of respect, compassion and diversity.”

Through our Office of Diversity and Inclusion, with senior leadership from Dr. Nicole Jacobs, our Associate Dean for Diversity and Inclusion, a culture of diversity and inclusion is promoted through a wide range of initiatives, policies and programming. For example, all members of a faculty search committee are trained in awareness of the impact of implicit bias; we require faculty candidates to describe how they will contribute to our diverse culture and values; our admissions process for medical students takes a holistic approach to evaluating applicants, including their approach to a diverse health care workforce and patient population; we host difficult and revealing conversations during monthly Diversity Dialogues; and many of our leaders, faculty and staff members are actively engaged in ongoing diversity and inclusion training.

We are all aware of recent incidents, both local and national, that are hurtful, harmful and hateful. There will no doubt be more in the future. The commitment of UNR Med to a diverse and inclusive culture is our small contribution to changing the larger culture that leads to these events, a small pebble whose ripples we hope will spread this change to the world around us. We have made great progress, but have much yet to go.

I will defend and support UNR Med’s culture of diversity, equity and inclusion with all my energy, for as long as it is my responsibility. It is, in fact, my responsibility for as long as I am part of UNR Med, in whatever role, as it is for all members of UNR Med.

Looking to Our Future

As you are receiving this issue, I am participating in the NSMA Annual Meeting and House of Delegates. It is an opportunity to have in depth discussions with my colleagues about the future of healthcare and the practice of medicine. As delegates we discuss at length more than a dozen resolutions submitted by members that address potential legislative issues, public health concerns and the future of medicine.

Resolution topics range from protections that enable physicians to make the best care decisions without undue influence from the management of the corporations that employ them to a statewide vaccine program and revisions to the opioid law. As we accept, revise or reject resolutions, we are setting the foundation for our legislative focus and the direction WCMS should consider when planning our priorities for the new year.

While the 2019 legislative session has yet to open, NSMA is collaborating with our lobbyists, The Perkins Group, to monitor the intense work already in progress on more than 500 BDRs, bill draft requests, being discussed in committees. Catherin O’Mara, NSMA’s executive director, tells me that about 20% of the BDRs are relevant to healthcare and the practice medicine. This means she’s spending long days in meetings on our behalf.

We know that not all 500+ BDRs will become bills. But, we do know that we play a key role in influencing their content and intent. A perfect example is AB474, known as the opioid law. The resulting legislation and regulations are quite different from the original draft. We’ve worked in concert with Nevada State Board of Medical Examiners and the Nevada State Board of Pharmacy to tone down the language and resulting implementation of the regulations. This is an ongoing endeavor.

This coming legislative session, we know that balance billing and tort reform will definitely be huge issues. NSMA has formed an alliance with the Nevada Hospital Association to collaborate in our shared values for patient care and fair wages for services provided. We are up against powerful legislators and a powerful payor force but working together we believe we can pool our resources to achieve our best possible result. The Nevada Justice Association, the trial lawyer PAC, has made significant contributions this election cycle. There is no pre-term agreement in place, and we strongly believe that KODIN is at risk. By now you should be seriously concerned for the financial livelihood of your profession in Nevada. This affects all doctors, whether in private practice or an employed physician. We need you. NSMA needs you. And NEMPAC needs you.

The other aspect of the delegates’ work sets direction for policies and initiatives to be created and implemented by NSMA, WCMS and CCMS. For example, as WCMS revises its strategic plan and 2019 budget, we’ll be reviewing the adopted resolutions to determine how we allocate resources, both human and financial. For example, we may decide to devote resources to consumer education about a public health issue. We’re already discussing future CME programming with the UNR Reno School of Medicine based on 2018 resolutions. We’ll continue these discussions in 2019.

This is important work for the profession. But, also it is a great professional development opportunity for me as I participate in discussions of topics that don’t touch my specialty directly every day but certainly often have an impact in indirect ways.

As you plan for 2019, please think about becoming more active, if you are not at present. I’ll say it again—we need your opinions, ideas and expectations.

Stay tuned as we plan for 2019 and share with you the future direction of the WCMS.

CME Program: Physician Burnout to Esprit de Corps!

Friday, October 12, 5:30pm UNR’s Joe Crowley Student Union

The Northern Nevada Physician Wellness Coalition is hosting it’s first CME program addressing physician burnout. It will be held Friday, Oct. 12, at UNR’s Joe Crowley Student Union. The evening begins at 5:30 with refreshments and networking. The lecture begins at 6:30 p.m. To register: contact Sherri Rice, [email protected].

Guest lecturer Stephen Swensen, M.D., MMM, FACR, is medical director for professionalism and peer support at Intermountain Healthcare, Salt Lake City. Professor Swensen is a recognized, well-published expert in leadership and professional burnout. He is a senior fellow of the Institute for Healthcare Improvement where he co-leads their Joy in Work Initiative. He works as a theme leader and member of the NEJM Catalyst Board. For 35 years, he served patients at the Mayo Clinic as a practicing physician, director for leadership and organization development where he co-led professional burnout work and as director for quality.

This program provides 1.5 CME credit towards the Nevada State Board of Medical Examiners’ requirement for two hours of training during each licensure period related to ethics, pain management, or addiction care.

About Northern Nevada Physician Wellness Coalition

The non-profit (501c3) Northern Nevada Physician Wellness Coalition (NNPWC) is the first such alliance of its kind. To the best of our knowledge, no previous physician wellness initiative has ever been Physician Led, independent, compassionate to the needs of local physicians and medical students, while also proactively looking to confront the root causes of the worsening epidemic of physician burnout, depression, and suicide.

We are led by dedicated group of mostly-physician board directors and key advisors from all the major sectors of health care in northern Nevada. With this team, and the help of our community stakeholders and community-at-large, we are poised to raise much-needed awareness regarding this dilemma, become a confidential resource for our local physicians, and ultimately serve as the new paradigm for approaching physician un-wellness nationwide.