AMB APPOINTS NEW EXEC DIRECTOR: The Arizona Medical Board has appointed Patricia McSorley as executive director. Ms. McSorley has been employed by the Arizona Medical Board since 2005. For more than eight years, she managed the Investigations Department. On two occasions, she has been asked by the Board, and has served, as the Acting Interim Executive Director. Ms. McSorley holds a Juris Doctorate from Brooklyn Law School. Previously, she served as the Assistant Commissioner for the Bureau of Investigations and Trials with the New York City Fire Department. On February 26, the Board's Executive Director Committee appointed her as the Executive Director of the Arizona Medical Board and the Arizona Regulatory Board of Physician Assistants.
SCOTUS SETS TROUBLING PRECENDENT: In the case of North Carolina Board of Dental Examiners v. Federal Trade Commission, the U.S. Supreme Court ruled that the dental regulatory board illegally suppressed competition when it issued an edict against non-dentists offering teeth-whitening services. In effect, the ruling sets a precedent that state boards can be sued for antitrust. As it is common practice for regulatory boards to consist mostly of members of the profession, the case was of interest to physicians. The American Medical Association (AMA) had filed an amicus brief in support of North Carolina Board of Dental Examiners. There are serious concerns that this ruling could blur the line on determining whether certain medical procedures might be inappropriately undertaken by non-physicians, as dissent from the regulatory board of professionals can now be interpreted as an antitrust issue rather than a patient safety issue. The Arizona Medical Board has 12 members; it requires that four be non-physicians, one of which must be a licensed practical or professional nurse. The implications of this case for Arizona are both unclear and of concern.
LEGISLATIVE WEEK SIX: On Wednesday, Governor Doug Ducey wasted little time in putting his signature on SB 1149, only the second bill to reach him this session. It clears the physician licensing backlog at the Arizona Medical Board (AMB) which had affected many practices' ability to bring on new physician hires and stymied the license renewals of current AZ doctors. As amended, SB 1149 does three things: (1) rectifies the interpretation problems with the fingerprinting and criminal background check requirements added into law last session; (2) retroactively removes the requirement for fingerprinting of physicians at the time of license renewal (so this requirement will only apply to new license applicants); and, (3) requires the AMB to refund fees collected from physicians for background checks during their license renewals.
ArMA's legislation to stop spurious and burdensome licensing board complaints against physicians who perform independent medical exams (IMEs), SB 1290, garnered the full support of the AZ Senate yesterday, passing on third reading by a unanimous 29-0 vote.
Likewise, SB 1370, the bill sponsored by Sen. John Kavanagh to make compliance improvements to the state's controlled substance prescription monitoring program (CSPMP) came through Senate Committee of the Whole with ease. The bill now heads to third reading in the Senate, early next week.
CDC RECOGNIZES ARIZONA DESIGNATED EBOLA CENTER: This week, the Centers for Disease Control and Prevention (CDC) identified Maricopa Integrated Health System and University of Arizona Health Network as two of the 55 Ebola Treatment Centers in the United States. These two systems had already been designated Infectious Disease Treatment Centers of Excellence by the Governor's Council on Infectious Disease Preparedness and Response in fall of 2014. The Council was formed in response to concerns during the Ebola outbreak of 2014. CDC has posted a brand new list of all designated facilities and determined, because more than 80% of returning travelers from West Africa are within 200 miles from a designated treatment center, they will no longer be adding additional centers to their list. The plan and support from the Council allowed the Arizona facilities to be visited early by the CDC Rapid Ebola Preparedness Team and meet the requirements under a very short time period.
ARIZONA ADHS / VACCINE NEWS: ADHS Immunization Program Office released the latest edition of Arizona Vaccine News today. The publication provides an overview of vaccine news, new literature and resources. This edition covers topics in pertussis, measles and influenza, and recommendations for pneumococcal immunization of patients over 65 years of age, as well as CMS policy on Medicare payments. The edition also includes information on the efficacy of a new dengue vaccine.
CMS SHIFTING MEDICARE PAYMENT MODELS: The Department of Health and Human Services (HHS) has announced goals and timelines for Medicare related to quality and the use of alternative methods of healthcare delivery. By 2016, HHS intends that 30 percent of Medicare fee-for-service payments will tie to alternative payment models, such as Accountable Care Organizations (ACOs) and bundled payments, and 85 percent will be based on quality. These percentages will increase to 50% and 90%, respectively, by 2018. The HHS goals are intended to increase value and promote care coordination across the healthcare continuum by focusing on three areas:
- Payment incentives - rewarding value and care coordination, rather than volume and duplication of care
- Care delivery improvement and innovation - supporting providers to find ways to coordinate and integrate care with an emphasis on prevention and wellness
- Sharing information - creating more transparency on cost and the quality of health care; using electronic health information to inform care; and having the most recent scientific evidence available to help providers in clinical decision making.
HHS plans to work with state Medicaid agencies, private payers, providers, and others to expand alternative payment models into their programs. For additional information, visit the HHS website.
LEGISLATIVE WEEK FIVE: Licensing: Two very important AMB bills SB 1149 by Sen. Kelli Ward and HB 2521 by Rep. Heather Carter are being supported through fast tracking. These bills, which have been on converging paths in their respective legislative bodies, make critically needed quick-fixes to get the AMB back on the right track and relieve the licensing logjam, both for renewals and new licenses. As now amended, the bills do three things: (1) rectify the narrow interpretation problems with the fingerprinting and criminal background check requirements added last session; (2) retroactively remove the requirement for fingerprinting of physicians at the time of license renewal (so the requirement will only apply to new license applicants); and, (3) require the AMB to refund fees collected from physicians for fingerprinting during their license renewals. They both contain emergency enactment clauses, so if they receive 3/4 of the votes in both bodies of the Legislature, they will become effective as soon as the Governor signs them.
SB 1149 was rushed through the Senate this week, passing 28-0 (much more than a 3/4 vote). HB 2521 was for a short time held in House Rules, but late Thursday the House passed HB 2521 in COW and then (needing to send only one of the two bills to the Governor) swapped it with identical SB 1149, which it passed 58-0. In other words, the Legislature clearly heard our message on the need for these AMB "quick fixes" and everyone voted yes on this legislation! SB 1149 will now be transmitted to Governor Ducey, and we expect he will promptly sign this bill into law.
CSPMP: Another bill of importance to us is, SB 1370, which deals with checking the state's controlled substances prescription monitoring program (CSPMP). This bill, by Sen. John Kavanagh of Scottsdale, successfully came through Senate Health & Human Services on Wednesday, 7-0, and will be up in Rules on Monday. SB 1370 is one of two Senate bills on that topic this year (the other was Sen. Ward's SB 1031). ArMA advocate Steve Barclay worked effectively on both bills early in the session with other stakeholders to find an acceptable compromise with the two bill sponsors and remove some difficult language mandating the use of the CSPMP by physicians and other prescribers before writing prescriptions. Reporting by pharmacists when filling prescriptions for controlled substances is already mandatory. Sen. Ward ultimately agreed to give way to Sen. Kavanagh's SB 1370. So we now have a supportable bill by all concerned.
During the last weeks stakeholders helped modify SB 1370 into a bill that creates a more of a seamless, behind-the-scenes approach by the licensing boards to getting all prescribers holding DEA numbers registered with the monitoring program without further affirmative steps on the prescribers' part. The objective is to remove the obstacles to voluntary use of the program by all licensed prescribers, and then encourage (but not require) better use of the CSPMP. A pilot being run by the AZ Pharmacy Board to educate prescribers and give them useful feedback on their prescribing patterns should help with that part (so far the pilot is working well and it's to be rolled out in Maricopa and Pima Counties later this year). We appreciate the willingness of Senators Kavanagh and Ward to listen to ArMA's suggestions for improving compliance in a voluntary fashion -- if we can achieve a greater level of voluntary use of the CSPMP, we can avoid a future legislative mandate on physicians to do so.
Independent Medical Exam: The "IME" bill, SB 1290, has been successfully guided through the Senate Commerce Committee. This bill, to protect physicians from harassing licensing board complaints for merely performing an independent medical exam (IME) in a workers comp case, has been brought forward by ArMA and Copper Point Mutual Insurance, the state's largest comp carrier. Mr. Barclay provided the committee testimony - aided by very persuasive documentation from Carol Peairs, MD and Mike Powers, MD - and the bill passed handily on a 7-1 vote. It will now be considered in Rules.
Peer Review: An important measure to improve existing law protecting health care quality assurance (aka peer review) activities from disclosure (ARS Sections 36-2401 through 2403) was passed through House Health this week too, 5-0. This bill, which helps ensure that the sharing of the peer review data between entities won't waive the non-disclosure privilege, emerged via a "strike-everything" amendment to HB 2556 (a bill on a different topic). The sponsor of the striker amendment (and the underlying bill) is our new Vice Chair of Health, Rep. Gina Cobb, from Kingman, who is a practicing dentist.
MEASLES PROTOCAL: Measles is a highly contagious, acute viral illness which can cause severe health complications, including pneumonia, encephalitis, and death. It is transmitted by contact with an infected person through coughing and sneezing; infected people are contagious from four days before their rash starts through four days afterwards. After an infected person leaves a location, the virus remains viable for up to two hours on surfaces and in the air. Measles begins with fever (101 degrees F or higher), red, watery eyes, cough and coryza (runny nose). This is followed by a maculopapular rash (red, raised, and blotchy). The rash begins on the head at the hairline and moves down the trunk to the lower extremities. The rash may last for 5-6 days and turn brownish. Symptoms typically appear 7-12 days after exposure to measles but may take up to 21 days. A person with measles is considered to be contagious four (4) days before rash onset (generally one day prior to fever) through the fourth day after rash onset. Evidence of immunity for healthcare workers consists of two documented doses of MMR vaccine or positive serology or physician documented infection with measles. For those with one vaccine, they may receive a second and return to work. For those born prior to 1957, a single documented dose of vaccine or positive serology is sufficient unless we develop an outbreak in our community, in which case two doses of vaccine would be recommended for all ages.
All clinicians are strongly urged to:
- Ensure you are immune to measles. If a measles exposure occurs in a healthcare setting, healthcare workers without adequate evidence of immunity will be excluded from work for 21 days following the exposure or until the healthcare worker can provide evidence of immunity to measles.
- Review and ensure documented immunity to measles for ALL healthcare workers. This includes ancillary staff such as office staff, dietary, housekeeping, maintenance, vendors and volunteers - anyone who may share airspace in your facility with a patient. If such documentation does not exist, we recommend vaccination over serologic evaluation.
- Consider measles in your differential diagnosis for all patients with a consistent prodrome and exposure or ANY rash illness.
- Report all suspect cases to your infection control department and/or Pima County Health Department (http://webcms.pima.gov/cms/One.aspx?portalId=169&pageId=185804).
- Place surgical masks and signs at all healthcare entrances alerting anyone with cough, runny nose, red eyes, fever OR a rash illness to wear a mask BEFORE they enter the hospital/facility. These patients should tell the receptionist about their symptoms and be evaluated by a healthcare provider before they remove the mask. Ask visitors to postpone their visits to hospitalized patients until symptoms have resolved.
- Implement airborne isolation protocols for all patients with rash illness (i.e. possible measles) presenting for healthcare until an alternate firm diagnosis is made. If airborne isolation is not available, place the patient in a private room with the door closed and place a surgical mask on the patient.
ADHS has compiled extensive information for clinicians as well as the general public at www.azdhs.gov/measles/. ADHS has also updated its measles clinician fact sheet and it is available for download here.
THE LEGISLATURE WEEK FOUR: We are very pleased to report SB 1040, a dangerous bill to allow chiropractors to seek an advance certification as part of their licenses to be allowed to prescribe four drugs: two NSAIDs (ibuprofen and naproxyn) and two muscle relaxants (cyclobenzaprine and methocarbomol), has been stopped! The bill was sponsored by Senator Nancy Barto, who as Chair of Senate Health was in a powerful position in terms of pushing her bill through that very committee.
Tucson’s Ray Woosley, MD PhD, wowed the committee with his heartfelt, impactful testimony on the dangers of allowing untrained, unqualified providers to prescribe these potentially dangerous drugs. Dr. Woosley, as many of you know, is the founding President and Chairman of the Board for CredibleMeds Worldwide, a non-profit organization dedicated to safe use of medications. He is the quintessential expert on clinical pharmacology.
This is a very gratifying considering the bill posed a threat to the integrity of the sunrise process required of scope of practice expansions, and most importantly, to patient health and safety. We’ll stay on guard and be ready should the bill resurface in Health or another legislative committee.
IMEs: Working in tandem with Copper Point Mutual (the former State Comp Fund), ArMA has a helpful bill teed up to address an annoying problem: the filing of licensing board complaints against doctors for the sole reason that they perform "IMEs" (independent medical exams) on injured claimants in workers comp cases. The complaints are being filed by claimants for harassment and intimidation purposes, to cause a chilling effect on doctors so they won't do more IMEs. SB 1290, sponsored by our friend (and doctor) Sen. Kelli Ward, will help fix this problem. The bill comes up for its first committee hearing on Monday afternoon.
AHCCCS CUTS: A fact sheet packet about the impact of proposed AHCCCS provider reimbursement cuts has been created and will be shared with our legislators. The packet includes an overview of the findings from the AHCCCS provider survey ArMA conducted several weeks ago. The packet can be viewed here.
THE LEGISLATURE WEEK THREE: The week at the Capitol began with a large meeting of stakeholders from both the health professions and their regulatory bodies, plus Senators Kavanagh and Ward, to discuss the proposed improvements to and streamlining of the prescription drug monitoring program (PDMP). At first the regulatory boards seemed reluctant to agree. They didn't like the bill draft that essentially told them to "work things out" to make for a more seamless process of registering licensees automatically for the PDMP and not making them jump through added hoops to access it and renew their registrations. But then Sen. Kavanagh and Sen. Ward walked in, and let's just say the mood changed a lot...so, we now have a game plan moving forward that, once implemented, should help clear the barriers to voluntary compliance by all types of DEA-license-holding prescribers with the PDMP. Bear in mind, though, that the Legislature will be watching how we all do, and if there isn't continued increase in terms of checking the PDMP before prescribing class II drugs, then we may face a mandate to use the PDMP in a few years.
On Tuesday, the House Health Committee heard brief testimony from the Arizona Medical Board (AMB) and then quickly approved the House version of the AMB "quick fix" bill, HB 2521, by a 6-0 vote. The bill, and its mirror image bill in the Senate (SB 1149), does two critical things: fixes the physician background check snag with the FBI, and retroactively gets rid of the fingerprinting requirement for renewals (in other words, it will apply only to new applicants). The bills also contain emergency enactment clauses, so they can take effect faster (if they both secure a 3/4 vote).
House Health Chair Heather Carter said HB 2521 was one of the most important bills her committee would consider this session. The next afternoon, the Senate Health Committee unanimously approved the counterpart bill, SB 1149. The sponsor of SB 1149, Sen. Kelli Ward, announced that she intends to offer an amendment on the Senate floor to require the AMB to issue refunds to licensees who paid fees for fingerprinting that will not be necessary with the passage of these bills. While the bills both have to be considered in Rules and then go to the full House or Senate.
Last week ArMA's advocate Steve Barclay and our allies at the Arizona Osteopathic Medical Association (AOMA) and Arizona Chapter of the American Academy of Pediatrics (AzAAP) were asked to meet with Senator Nancy Barto and representatives of the Arizona Association of Chiropractic (AAC) to discuss the Senator's bill for the AAC, SB 1040. This bill would give prescribing privileges to chiropractors -- after yet-to-be-defined added educational and rotational prerequisites -- for four drugs: ibuprofen, naproxen, methocarbomol, and cyclobenzaphrine. Even more troubling, however, is that SB 1040 was never approved through the "sunrise" process by the legislative Committee of Reference (COR). Their application for these prescribing privileges was rejected in 2013 by the COR (on a 4-3 vote against), and last fall the AAC elected not to apply again through the sunrise process. Instead, they are trying to do an end-run on the sunrise process and avoid having their drug prescribing proposal rejected again by the COR.
Unfortunately, Sen. Barto believes that the AAC has met the spirit of the sunrise process (if not the letter). She's pushing their bill forward over our objections and those of AOMA and AzAAP, and we will have to try to stop her bill in Senate Health next week. Steve and his colleagues will be putting on a full court press to do that, arguing both against the end-run around the sunrise process and the lack of valid science to support allowing even limited prescribing privileges to chiropractors.
MEASLES IN ARIZONA: There are currently SEVEN confirmed cases of measles in Arizona, with >1,000 exposures in the community and at four healthcare facilities in Maricopa, Pinal, and Gila counties. Pima County has NO confirmed cases. Recommendations for providers:
- Isolate patients presenting with a febrile rash illness and evaluate for measles
- Immunocompromised patients may not have rash or present with atypical rash
- IMMEDIATELY consult with your local health department for suspected measles cases
- Collect NP (Dacron) swabs & urine for PCR and serum for IgM serology on suspected cases
- Ensure patients and staff are up to date on MMR vaccine and other vaccinations.
HHS SHIFTS REIMBURSEMENTS FROM VOLUME TO VALUE: HHS has set a goal of tying 30 percent of traditional, or fee-for-service, Medicare payments to quality or value through alternative payment models, such as Accountable Care Organizations (ACOs) or bundled payment arrangements by the end of 2016, and tying 50 percent of payments to these models by the end of 2018. HHS also set a goal of tying 85 percent of all traditional Medicare payments to quality or value by 2016 and 90 percent by 2018 through programs such as the Hospital Value Based Purchasing and the Hospital Readmissions Reduction Programs. This is the first time in the history of the Medicare program that HHS has set explicit goals for alternative payment models and value-based payments. To make these goals scalable beyond Medicare, Secretary Burwell also announced the creation of a Health Care Payment Learning and Action Network. Through the Learning and Action Network, HHS will work with private payers, employers, consumers, providers, states and state Medicaid programs, and other partners to expand alternative payment models into their programs. HHS will intensify its work with states and private payers to support adoption of alternative payments models through their own aligned work, sometimes even exceeding the goals set for Medicare. The Network will hold its first meeting in March 2015, and more details will be announced in the near future.
ACA UPDATE: This week, the federal government filed its brief responding to the challengers in the King v. Burwell lawsuit, which claims the Affordable Care Act (ACA) language does not allow for subsidies to be available to people in states on the federal exchange. The brief argues that the "text, structure, design, and history" of the law indicates its intent to make subsidies available regardless of who sets up the exchanges; in addition, the brief argues that the challengers' reading of the law transforms the subsidy structure into a "threat" and therefore disrespects "state sovereignty."
This tax season marks the first time families will be asked to answer basic questions regarding their health insurance on their tax returns. Most consumers just need to check a box to indicate they have coverage, but those with Marketplace coverage will receive a new form in the mail, Form 1095-A, that they will use to reconcile their upfront financial assistance. In the coming weeks, tools and resources will be made available for those tax filers who have health coverage through the Marketplaces, those seeking an exemption, and those looking for information about the fee for those who could afford to purchase health coverage but chose not to.
ADHS HEALTH ADVISORY: The Arizona Department of Health Services reports that 40 patients have had adverse events associated with Wallcur's simulated IV saline solution, Practi-0.9% sodium chloride solution and it is associated with various adverse events, hospitalization and 1 death in Florida, Georgia, Idaho, Louisiana, North Carolina, New York, and Colorado. No deaths or adverse events have been reported in Arizona at this time. These products are not sterile and should not be injected in humans or animals. Clinicians and office staff are encouraged to take steps to ensure IV solution simulation products are removed from office inventory to eliminate the possible injection of Wallcur simulated products into patients. If you suspect that any Wallcur training IV products have been administered to patients please contact FDA's MedWatch program online or at 1-800-332-1088. FDA recommendations and guidance can be located here. If you have any questions or concerns you may contact Arizona Department of Health Services HAI Program at 602-376-3676 or Eugene.Livar@azdhs.gov.
IRS, TAX RETURN SCAM UPDATE: In 2014, a number of physicians nationwide found themselves victims of a tax-filing scam. ArMA worked with the FBI, IRS and Secret Service to locate and assist any ArMA members impacted by the scam. In order to allow those who were affected by the scam to file electronically in the future, all reported victims will be provided with a special individual pin number that will allow you to again file electronically. The IRS has updated us that all those reporting a scam have received a PIN so that they can file electronically. If you have not yet received your PIN, contact your local IRS office.
SEVERAL SCOPE OF PRACTICE EXPANSIONS DEFEATED: The Arizona Medical Association announced last week that two scope of practice expansion Sunrise applications had been withdrawn by their sponsors. The Sunrise Process is unique to Arizona and was lobbied into place by ArMA many years ago in order to minimize the lack of scientific presentations that were occurring at the legislature over medical scope of practice expansion requests as well as requests for new licensure. Non-physician groups were finding legislative sponsors to introduce licensure or scope expansion bills, and hearings were taking place where little or no scientific justification was presented as to the rationale or qualifications of the group seeking these changes. The Sunrise Process established a requirement that any group seeking certification or an expansion in its scope needed to notify the legislature of their request prior to the session convening, and a bi-cameral group, Sunrise Committee of Reference (COR), was established to hear testimony as to the need for the expansion or certification, and qualifications of the group seeking the changes. The COR then issues a report indicating support or lack thereof for the application. The findings report and recommendation of the COR is very influential as to whether or not the group goes forward with its legislative request and the ultimate legislative outcome.
Recently the Arizona Naturopathic Medical Association notified the legislature they were withdrawing their request to be authorized to prescribe Schedule II drugs. ArMA, PCMS, MCMS and others have been intense in our opposition, and we had provided legislators with medical, scientific facts from a renowned physician expert explaining the danger this presented to patients. It became clear our opposition was convincing and we had the votes to stop it. The naturopaths opted to withdraw the application rather than sustain a significant loss. A thank you goes out to Ray Woosley, MD, PhD, University of Arizona faculty and pharmacology expert, who provided irrefutable information on the danger this presented. Also of significance was the withdrawal of the Arizona Pharmacy Association's application to allow pharmacists to immunize children ages 6-17 without a physician's prescription. ArMA, the Arizona Chapter of the American Academy of Pediatrics (AzAAP), and the Arizona Academy of Family Physicians (AzAFP) collaborated to oppose this request which would have shattered a key element of physician oversight with young children. The pharmacists, who we should point out are generally supportive of our issues, realized the validity of our concerns and decided to withdraw their request. In all, this is a very good ending to actions we feel would have compromised patient care, in some cases to a dangerous degree. Both are clear, working examples of how critical it is for medicine to advocate for patient safety, during the legislative session and throughout the year.
NEW MEDICARE PAY CUTS SCHEDULED IN 2015: Physicians have until December 31 to decide whether they will be participating or nonparticipating physicians in the Medicare program next year. In addition to the annual threat of a steep payment cut as a result of the sustainable growth rate (SGR) formula, another factor for physicians to consider in making the decision this time around is that 2015 will be the first year that the Centers for Medicare & Medicaid Services (CMS) will impose penalties under the value-based modifier (VBM) program. According to CMS, 1,010 groups of 100 or more eligible professionals will see payment adjustments from the VBM in 2015. More than 300 of these groups will face Medicare payment cuts of 1 percent, while a few others will see cuts of 0.5 percent. Only 16 groups will receive bonuses of an amount yet unknown. Other penalties that will be applied in 2015 based on 2013 performance-including those tied to quality reporting, meaningful use and ePrescribing-will decrease the limiting charge amounts that nonparticipating physicians can bill to patients for unassigned claims. The VBM penalties and bonuses, however, will not apply to unassigned claims so that means practices facing a VBM penalty next year could avoid the penalty by choosing the nonparticipating physician status option. As described in the AMA guide to Medicare participation options, the Medicare payment schedule for nonparticipating physicians is set 5 percent below the participating physician payment schedule. At the same time, nonparticipating physicians can bill patients for 15 percent above that lower payment schedule amount. While participating physicians agree to accept assignment for all Medicare claims, nonparticipating physicians can decide whether to accept assignment on a claim-by-claim basis. This year, 96.6 percent of physicians are participating. Physicians who want to become nonparticipating in 2015 must send a letter to their Medicare contractor postmarked before January 1 to terminate their participation agreement for the coming year. (Source: AMA Advocacy Update, 12/04/2014)
ADHS RELEASES OPIOID PRESCRIBING GUIDLEINES: The Division of Public Health Services at the Arizona Department of Health Services has released the final version of the state’s Opioid Prescribing Guidelines. They are the result of input and expertise of practitioners from across the state representing professional associations, health plans, academic institutions, federal health care providers and others.
The objective of the guidelines is to balance the appropriate treatment of pain with approaches to more safely prescribe opioids and complements other statewide “best practice” guidelines for Emergency Department Controlled Substance Prescribing and Dispensing Controlled Substances.
An important next step to encourage use of the Arizona Opioid Prescribing Guidelines is training that will help prescribers implement Arizona’s guidelines. The University of Arizona is in the process of putting together free, online training that is expected to be available in January. We will notify you when the training is available.
TEN (10) MEDICARE PAYMENT REVISIONS IMPORTANT TO YOU: Without a doubt you haven't read through the nearly 1,200 pages that makes up the 2015 Medicare Physician Fee Schedule final rule released Oct. 31 and published Thursday in the Federal Register. Here are the 10 top payment policy changes discussed in this humongous document that you need to know about.
- The sustainable growth rate (SGR) formula calls for a 21.2 percent cut to physician payments, effective April 1.
- Continuing medical education (CME) will not be reported under the Physician Payments Sunshine Act.
- Proposed penalties under the value-based payment modifier (VBM) will be scaled back.
- The Physician Quality Reporting System (PQRS) becomes a penalty-only program next year.
- The Physician Compare website will continue to expand-but not as much as planned.
- Chronic care management services will be supported by a monthly payment.
- Four services now are eligible for telehealth payment.
- Surgical global periods will change from 10- and 90-day periods to 0-day periods.
- There are 350 CPT codes identified as new, revised or potentially misvalued-318 of these changes were based on physician input.
The timeline for submitting new codes and revaluations of services will shift. The deadline for receiving all code and value recommendations for the following year's payment policies will be February to allow more time for public comment.
You can read more about these and other components of next year's Medicare payment policies by viewing the complete AMA Wire post.
FLU ALERT: The Arizona Department of Health Services and the Pima County Health Department have confirmed the first influenza case in Arizona for the 2014-2015 influenza season. A child with no recent travel was diagnosed with influenza A (H3) by PCR at the Arizona State Public Health Laboratory.
We strongly recommend vaccinating your patients and staff against influenza throughout the flu season. All eligible individuals aged 6 months or older should be vaccinated.
Please remind your patients the best way to prevent flu and other respiratory diseases, include:
- Get vaccinated against the flu,
- Wash hands often,
- Avoid touching your face with unwashed hands,
- Cover your cough and sneezes,
- Clean and disinfect surfaces frequently,
- Avoid close contact with sick people, and
- Stay at home if you are sick
For questions regarding the 2014-2015 flu vaccine, you can call your local health agency or the Arizona Immunization Program Office at (602) 364-3630.
For a list of influenza vaccine clinics please go to www.StopTheSpreadAZ.org. This year's national influenza vaccine recommendations are available at www.cdc.gov/flu/protect/vaccine/index.htm or www.cdc.gov/vaccines/hcp/acip-recs/index.html.
CDC OFFERS UP NEW ALGORITHM FOR MANAGEMENT OF POTENTIAL EBOLA PATIENTS: Dr. Francisco Garcia, director and chief medical officer for the Pima County Health Department, has asked that we post the attached algorithm for our membership. This is the protocol being followed by the health department for first responders, hospitals and clinics. To review go to: http://www.cdc.gov/vhf/ebola/pdf/ed-algorithm-management-patients-possible-ebola.pdf
CDC ISSUES REVISED INTERIM U.S. GUIDANCE FOR MONITORING AND MOVEMENT OF PERSONS WITH POTENTIAL EBOLA VIRUS EXPOSURE (Issued October 28, 2014):
The Centers for Disease Control and Prevention (CDC) issued revised Interim U.S. Guidance for Monitoring and Movement of Persons with Ebola Virus Exposure. This guidance provides new information public health authorities and other partners can use to determine appropriate public health actions based on Ebola exposure risk factors and clinical presentation. It also includes criteria for monitoring exposed people and for when movement restrictions may be needed.
In determining the right approach, we have put the health and safety of Americans first and foremost, and our deliberations have been informed by our most knowledgeable and experienced public health and homeland security professionals. As with everything we have done to respond to the threat of Ebola both at home and abroad, we have been guided by the best science available.
Coordinated public health actions are essential to stop and reverse the spread of Ebola virus. CDC announced last week that public health authorities will begin active post-arrival monitoring of travelers whose travel originates in Liberia, Sierra Leone, or Guinea and arrive at one of the five airports in the United States doing enhanced screening. The revised interim guidance released today is intended to guide state and local health officials with decisions about managing the movement of individuals being monitored, including travelers from the countries with widespread transmission and others who may have been exposed in the United States.
Active post-arrival monitoring means that travelers without febrile illness or symptoms consistent with Ebola will be contacted daily by state and local health departments for 21 days from the date of their departure from Liberia, Sierra Leone, or Guinea. Six states (New York, Pennsylvania, Maryland, Virginia, New Jersey, and Georgia), where approximately 70% of incoming travelers are headed, will start active monitoring today, with the remainder of the states starting in the days following.
This guidance also outlines appropriate public health actions for those individuals classified as “some risk.” These include health care workers who are providing direct care to Ebola patients in West Africa or others, such as observers, who enter an Ebola treatment area where Ebola patients are being cared for. Additional precautions, such as direct active monitoring, are recommended for those classified as “some risk.” In addition, the guidance recommends public health authorities determine on an individualized case-by-case basis whether additional restrictions, such as controlled movement, workplace exclusions, or restrictions on other activities, are appropriate. This daily health consultation will give additional confidence to the community that a returning health care worker is asymptomatic and therefore not contagious.
Returning health care workers should be treated with dignity and respect. They, along with our civilian and military personnel in the region, are working tirelessly on the frontlines against Ebola, and their success is what ultimately will enable us to eliminate the threat of additional domestic Ebola cases. We must not prevent or unduly discourage them from undertaking this indispensable and selfless work.
Guidance for returning health care workers from West Africa should be distinguished from health care workers providing care for Ebola patients in the United States. There are important differences between providing care or performing public health tasks in Africa versus in a U.S. hospital. A U.S. hospital provides a more controlled setting than a field hospital in West Africa. A U.S. healthcare worker would be able to anticipate most procedures that would put them at risk of exposure and wear additional personal protective equipment as recommended. In some places in Africa, the same may not be true and workers may not have the ability to prepare for potential exposures.
This guidance is interim guidance and could be updated or changed as new information becomes available.
CDC ANNOUNCES ACTIVE POST-ARRIVAL MONITORING FOR TRAVELERS FROM IMPACTED COUNTRIES: The Centers for Disease Control and Prevention (CDC) announced that public health authorities will begin active post-arrival monitoring of travelers whose travel originates in Liberia, Sierra Leone, or Guinea. These travelers are now arriving to the United States at one of five airports where entry screening is being conducted by Customs and Border Protection and CDC. Active post-arrival monitoring means that travelers without febrile illness or symptoms consistent with Ebola will be followed up daily by state and local health departments for 21 days from the date of their departure from West Africa. Six states (New York, Pennsylvania, Maryland, Virginia, New Jersey, and Georgia), where approximately 70% of incoming travelers are headed, have already taken steps to plan and implement active post-arrival monitoring which will begin on Monday, October 27. Active post-arrival monitoring will begin in the remaining states in the days following. CDC is providing assistance with active post-arrival monitoring to state and local health departments, including information on travelers arriving in their states, and upon request, technical support, consultation and funding.
Active post-arrival monitoring is an approach in which state and local health officials maintain daily contact with all travelers from the three affected countries for the entire 21 days following their last possible date of exposure to Ebola virus. Twenty-one days is the longest time it can take from the time a person is infected with Ebola until that person has symptoms of Ebola.
Specifically, state and local authorities will require travelers to report the following information daily: their temperature and the presence or absence of other Ebola symptoms such as headache, joint and muscle aches, weakness, diarrhea, vomiting, stomach pain, lack of appetite, or abnormal bleeding; and their intent to travel in-state or out-of-state. In the event a traveler does not report in, state or local public health officials will take immediate steps to locate the individual to ensure that active monitoring continues on a daily basis.
In addition, travelers will receive a CARE (Check And Report Ebola) kit at the airport that contains a tracking log and pictorial description of symptoms, a thermometer, guidance for how to monitor with thermometer, a wallet card on who to contact if they have symptoms and that they can present to a health care provider, and a health advisory infographic on monitoring health for three weeks.
Active monitoring establishes daily contact between public health officials and travelers from the affected region. In the event a traveler begins to show symptoms, public health officials will implement an isolation and evaluation plan following appropriate protocols to limit exposure, and direct the individual to a local hospital that has been trained to receive potential Ebola patients.
Post arrival monitoring is an added safeguard that complements the existing exit screening protocols, which require all outbound passengers from the affected West African countries to be screened for fever, Ebola symptoms, and contact with Ebola and enhanced screening protocols at the five U.S. airports that will now receive all travelers from the affected countries. All three of these nations have asked for, and continue to receive, CDC assistance implementing exit screening.
All the latest information on Ebola is here: http://www.cdc.gov/vhf/ebola/
ADHS URGES HEALTHCARE FACILITIES DEVELOP AN EBOLA PREPARATION AND RESPONSE PLAN: Ebola has arrived in the United States. It is imperative that every practitioner, infection preventionist, clinic and health department is prepared to identify, isolate and manage suspected and confirmed cases of Ebola.
To assist with outpatient clinic preparation, the Arizona Department of Health Services has created an Ebola Outpatient Clinic Toolkit. This toolkit provides concise checklists, planning templates, screening guidelines and posters for clinics to use in building a practical and feasible Ebola Preparation and Response Plan.
The Arizona Department of Health Services strongly urges every healthcare facility to develop an Ebola Preparation and Response Plan. The key to Ebola control in Arizona relies on the training and response of each and every facility.
To begin, the following actions can be performed immediately.
- Appoint 1-2 individuals to be responsible for receiving and distributing Arizona Ebola communications
- Complete the Outpatient Clinic Checklist for Ebola Preparedness to assess readiness.
- Implement a facility specific screening protocol for Ebola virus.
- Schedule a tabletop exercise or drill for the management of an Ebola patient.
As the situation is continually evolving, Arizona's Ebola toolkits and website will be updated frequently. Interim questions should be directed to local health departments or to the Office of Infectious Disease Services at the Arizona Department of Health Services at (602) 364-3676.
AZ COURTS DO NOT SEE TREATING PHYSICIANS AS EXPERTS: ArMA, PCMS and MCMS all have been involved in numerous defenses of attempts by plaintiffs' personal injury attorneys to dismantle our legislative tort success. We report on this periodically as we have had numerous important successes, including a decision at the State Supreme Court keeping in place our qualifications of expert witness statute. Most recently, we petitioned to reverse a court rule that has more practical financial implications. In summary, the Court of Appeals ruled in Sanchez v. Gama that treating physicians are not considered experts and thus are only entitled to $12.00 per day for providing a deposition or testifying at trial, plus $.20 per mile for travel, one way. Accordingly, if a doctor receives a subpoena for a deposition or to testify at trial and is the treating physician in the suit, under the Court of Appeals' decision, they are not entitled to compensation for time out of the office. However, if the doctor has been retained as an expert witness in the suit, pursuant to Rule 26(b)(4)(C) of the Arizona Rules of Civil Procedure, the party noticing the deposition must pay the doctor "a reasonable fee." Because the Arizona Supreme Court denied the rule change petition to provide compensation for treating physicians, and because the Arizona Supreme Court denied the Petition for Review of the Sanchez decision, the Arizona Court of Appeals' decision in Sanchez still governs this issue. This is unfortunate news for those called into the Arizona court system as treating physicians.
HYDROCODONE RECLASSIFICATION: If you prescribe hydrocodone combination products, prescribing these medications to the patients who need them to alleviate pain just became more complicated. A new rule from the Drug Enforcement Administration (DEA) taking effect Oct. 6 reclassifies hydrocodone combination products as Schedule II controlled substances, prohibiting refills and establishing other restrictions that will require major changes to prescribing practices. Here are six key points you need to know so you can take appropriate action over the next few weeks:
1. Refills aren't allowed for prescriptions that are written beginning Oct. 6. Be prepared to issue new hard-copy or electronic prescriptions for patients. Note that eScripts can only be used if state law permits and the prescriber is certified to ePrescribe Schedule II substances. Pharmacies also must be certified to accept eScripts for controlled substances.
2. Prescriptions issued before Oct. 6 won't necessarily qualify for refills; plan to issue new ones. Although the DEA rule allows refills of prescriptions issued before Oct. 6 until April 8, 2015, other factors could prevent patients from getting those refills. Several states have published notices that they will treat hydrocodone combination product prescriptions issued before Oct. 6 in the same way they will handle prescriptions issued after the rule's implementation date. In addition, any state laws that are more stringent than the DEA rule will govern refills. Meanwhile, some pharmacy quality and safety processes may not allow refills for prescriptions issued before Oct. 6, and some health insurers will not pay for those refills.
3. Prescriptions can't be called in or faxed. Make sure to plan ahead for any patients who may need refills. The new rule prohibits pharmacies from filling prescriptions delivered over the phone or via fax, so you'll need to issue written scripts. The only exception to this rule is emergency treatment, which would allow physicians to call in a limited quantity of the medication to cover the emergency period only. Pharmacies are required to report prescribers to the DEA if they make such a request and do not give the pharmacy a written prescription within seven days.
4. Allied health professionals might not be able to write prescriptions for these drugs going forward. Check your state's restrictions around Schedule II substances to confirm whether any non-physician members of your team who have prescriptive authority will be able to continue issuing prescriptions for hydrocodone combination products. You may need to modify your collaborative practice agreements accordingly.
5. Multiple prescriptions may be issued at one time under certain circumstances. The new rule does allow a patient to receive prescriptions that would total a 90-day supply, if the prescriber has determined it is appropriate to see the patient only once every 90 days. Each prescription must include written instructions that specify the earliest date it may be filled. In addition to sound medical judgment and established medical standards, make sure to base your practice's policy on issuing multiple prescriptions on relevant federal and state laws.
6. Patients should be notified of the new requirements and processes. Make sure your patients understand that their new prescriptions will not be refilled and are aware of the procedures they will need to follow going forward.
We have warned the DEA about the potential unintended consequences of reclassifying hydrocodone combination products since the agency made the proposal early last year. Eliminating phoned-in prescriptions and refills could make it difficult for some patients to get the pain relief they need, especially patients in nursing homes and those with persistent pain and disabilities. The rule is published in the Federal Register.
ADHS HEALTH NOTICE / ENTEROVIRUS D68 ASSOCIATED WITH SEVERE RESPIRATORY ILLNESS IN CHILDREN: In late August, the Centers for Disease Control and Prevention (CDC) was notified by two states of an increase in children hospitalized with severe respiratory illness. Enterovirus D68 (EV-D68) was identified in many of these patients. There are now several other states reporting increases in admissions for severe respiratory illness. It is possible that these are also associated with EV-D68. EV-D68 appears to spread via close contact (e.g., saliva, sputum, feces) with infected individuals. Currently, there is no vaccine to prevent EV-D68 and no specific antiviral treatment recommended. However, patients can help protect themselves and others from respiratory illnesses by:
- avoiding close contact with people who are sick;
- avoiding touching eyes, nose, and mouth with unwashed hands;
- washing hands often with soap and water, especially after changing diapers;
- cleaning/disinfecting frequently touched surfaces, such as toys and doorknobs, especially if someone is sick;
- ensuring vaccinations, including the influenza vaccine, are up to date.
Clinicians should be aware of EV-D68 as one of many causes of viral respiratory disease and should report clusters of unexplained respiratory illness to the Pima County Health Department. Please refer to this MMWR for more detailed information.
FSMB RELEASES MODEL LEGISLATION FOR CREATING MULTISTATE COMPACT SYSTEM: In a move to facilitate the growth of telemedicine and speed increased healthcare access to residents in rural areas, the Federation of State Medical Boards has released model legislation that could be used to create a multistate agreement, or "compact" system, under which physicians who are licensed in one state can use a streamlined process to be quickly licensed in another. The Wyoming State Board of Medicine spearheaded the effort; Executive Director Kevin Bohnenblust said states like his are accustomed to interstate compacts. The model legislation calls for at least seven states to participate in the compact and with participating states to have representatives on a governing commission. Once enough states have joined the effort, participating states would share credential and disciplinary information on physicians licensed by their states with other states so they could quickly issue their own licenses without collecting the usual load of paperwork normally required. Read more at Modern Healthcare.
DEA TO ALLOW RETURN OF UNUSED PRESCRIPTIONS TO PHARMACIES AND HOSPITALS: The abuse of prescription medications has been termed a "public health crisis." In an effort to address the nation's growing prescription drug abuse problem, the U.S. Drug Enforcement Administration (DEA) announced this week that it will allow hospitals, clinics and pharmacies to collect unused prescription drugs. Effective next month, the DEA's new regulation will also provide residents at long-term health facilities with the option of turning in unused prescription drugs on-site. Under the new regulation, patients and their relatives will also be allowed to mail unused prescription drugs to an authorized collector using packages to be made available at pharmacies and other locations, like libraries and senior centers. Read more here. Further information on drug disposal as well as the final published rule is available at the DEA website.
HEALTHCARE DATA BREACHES INCREASING: The recent theft of 4.5 million medical records by hackers highlights one undeniable truth about healthcare data: it's valuable, and people want it. Identity thieves can sell patient information to be used for obtaining free medical care or to file bogus insurance claims. Since federal reporting requirements kicked in, the U.S.
Department of Health and Human Services' (HHS) database of major breach reports (those affecting 500 people or more) has tracked 944 incidents affecting personal information from about 30.1 million people. A majority of those records are tied to theft (17.4 million people), followed by data loss (7.2 million people), hacking (3.6 million), and unauthorized access accounts (1.9 million people). There are also many more incidents of smaller-scale breaches. In 2012, HHS received 21,194 reports of smaller breaches affecting 165,135 people, according to the department's most recent report to Congress. Healthcare data has seemingly become increasingly targeted, accounting for 43% of major data breaches reported in 2013, according to the Identity Theft Resource Center. That's the first time the healthcare sector topped the group's annual list, and it's on the same pace for 2014. Read more here: https://www.magnetmail.net/actions/email_web_version.cfm?recipient_id=1450658731&message_id=5994069&user_id=PIAA&group_id=1210335&jobid=21166378
AHCCCS CLARIFIES NEW REQUIREMENT FOR SAM COVERAGE: Physicians have asked AHCCCS to offer clarification of their new requirement regarding insurance coverage for Sexual Abuse and Molestation (SAM). According officials, SAM is discretionary.
MICA-insureds can find a newsbrief that notes, subject to the terms of the policy, MICA’s medical professional liability insurance policy provides for defense of an insured when faced with these kinds of claims. For non-MICA policy holders, check with your carrier about coverage but don’t be pressured into purchasing coverage that you already have, or may not need.
ADHS RELEASES INFECTIOUS DISEASES MANAUAL: The Arizona Department of Health Services recently released “An Introduction to Arizona’s Infectious Diseases” manual. To view the new guide click here: http://www.scribd.com/doc/236048552/Arizona-Dept-of-Health-Physician-Manual?secret_password=J281p3z1rxz2HUEL24tS
IOM REPORT STIRS GME FUNDING CONTROVERSY: The federal government, mostly via the Medicare program, currently provides more than $11 billion per year in payments to support graduate medical education (GME), the training of doctors who have graduated medical school. Most of these funds go to the hospitals that sponsor interns and residents. States, through the Medicaid program, contribute nearly another $4 billion annually. But there is little data on how those funds are spent and how well they contribute to the preparation of a medical workforce needed for the 21st century. This week saw the release of a report from an expert panel by the Institutes of Medicine (IOM) that recommended a complete overhaul of the way government pays for the training of physicians. The five major recommendations the committee made were:
- Medicare should maintain its GME support but should be replaced in phases by a new payment system.
- A GME policy council should be created in the Office of the Secretary of Health and Human Services, as well as a GME Center within the Centers for Medicare and Medicaid Services.
- The single Medicare GME fund should be divided into two parts: an Operational Fund to support residency training positions that are currently approved and a Transformation Fund to develop and test new GME programs.
- Medicare should make a single payment to GME programs based on a national, geographically adjusted, per-resident amount.
- Medicaid funding for GME should remain at the discretion of individual states.
The Association of American Medical Colleges issued sharp criticism of the report, stating that the recommendations threaten the viability of excellent training programs. The panel did not recommend lifting the current cap on residency slots currently supported by Medicare which were established with the 1997 Balanced Budget Act.
PHYSICIANS SHIFTING TO EMPLOYMENT RATHER THAN PRIVATE PRACTICE: Jackson Healthcare this week released the findings of a survey on physician practice environment, workload and patient access. A total of 1,527 physicians across the nation completed the survey this spring. When comparing previous survey results, this year's findings noted that the percentage of hospital-employed primary care physicians doubled from 10 percent in 2012 to 20 percent in 2014. The number of primary care physicians with an ownership stake in a single-specialty practice decreased from 12 percent in 2012 to 7 percent in 2014. When responding to why they chose employment, overall, the lifestyle that employment offers is the underlying factor driving physician preference. The number of physicians taking call in 2012 (77 percent) dropped to 57 percent in 2014. Eighty-five percent of physician practices reported accepting new Medicare patients. Sixty percent reported accepting new Medicaid patients. Survey details here: http://www.jacksonhealthcare.com/media-room/articles/physician-trends/physician-data-on-practice-environment-workload-and-patient-access.aspx
PHYSICIANS CHALLENGED BY ACA PLANS: A new study released by the Medical Group Management Association (MGMA) surveyed 728 practices representing 40,000 physicians in 46 states during April 2014. Almost 80% of the medical groups reported their practice is participating with new health insurance products sold on the ACA exchanges, and over 90% of these practices have already seen patients with this coverage. These practices report that verification processes were more difficult and lengthy than with commercial plans. Nearly 60% of respondents indicated that it is more difficult to verify patient eligibility, obtain cost-sharing or network information, or get information about the plan's provider network, in order to facilitate referrals. For practices not participating with ACA insurance exchange product, 48.1% cited concerns about assuming financial liability during a 90-day grace period for ACA exchange enrollees. For practices that chose to participate with ACA insurance exchange products, 57.6% cited remaining competitive in the local market as the reason for doing so. Almost half of respondents reported they have been unable to provide covered services to exchange patients because their practice is out of the patient's network. About 36.6% of respondents indicated that average payment rates for ACA exchange insurers were equal to payment rates from traditional commercial and traditional Medicare contracts; 32% indicated that average payment rates were somewhat lower. The American Medical Association (AMA) has created a physician practice resource page for grace period information. Resources include model language and sample letter forms for notifying patients.
WEBSITE OFFERS ACCESS TO CLINICAL TRIALS: Participating in vital health-related research to help improve or saves lives has gotten easier, thanks to a new website that features the clinical trials at the Arizona Health Sciences Center. The new Clinical Research Studies website facilitates access to research studies at the University of Arizona for the general public and for researchers recruiting people to their studies. The UA Clinical Research Studies website is searchable by health topic and makes access to information about the studies easy to find. The studies are listed by disease area and in laymen's terms for ease of navigation and understanding, and more in-depth medical information also is included for both UA and community health-care providers. Currently, there are over 100 UA studies focusing on a variety of diseases. The studies are led by nationally renowned researchers who are working to identify new cancer therapies, treatments for heart disease, asthma and lung disease, depression, Alzheimer's disease, Parkinson's disease, diabetes, and to find innovative uses for technology in health care.
ICD-10 CODING: The requirement to use the ICD-10 coding system has been extended to Oct. 1, 2015, however if your practice hasn’t developed an implementation plan these resource sites can assist.
Online ICD-10 Guide: http://www.cms.gov/Medicare/Coding/ICD10/ICD-10ImplementationTimelines.html
Introduction to ICD-10: http://www.cms.gov/Medicare/Coding/ICD10/ProviderResources.html
Basics for Small and Rural Practices: http://www.cms.gov/Medicare/Coding/ICD10/Medicare-Fee-for-Service-Provider-Resources.html
AMA’s What You Need to Know for the Upcoming Transition to ICD-10: http://www.azmed.org/ckfinder/userfiles/files/icd-10-transition.pdf
AMA’s Your 12-Step Transition Plan for ICD-10: http://www.azmed.org/ckfinder/userfiles/files/AMA_icd-10-action-plan-12-step-transition.pdf
PCMS / FAVORITE STAFFING SERVICE: If you need staffing, contact Favorite our affiliate medical staffing service. Favorite provides a full range of services including direct hire, contract, temp- to-perm, permanent placement and “just –in-time” per diem. Special rates are given to member physicians. Call Amy Erbe at 319-5766. She is anxious to assist.
WALK-WITH-A-DOC: The Society is teaming with the Arizona Chapter of the American College of Physicians (ACP) to host and provide physician leaders for the monthly Walk-With-A-Doc outings. Walkers sign in at the ramada east of Swan Bridge on the south bank.PCMS physicians are encouraged to urge patients to participate in the program. Each walk begins with a brief discussion on a health topic and includes a one- or two-mile walk on level ground. Please contact Dennis Carey at 795-7985 or email@example.com with questions. There is one more walk scheduled for 2013. It's on December 14. In 2014 walks will be held on January 11, February 8, March 8, April 12, September 13, October 11, November 8 and December 13. They begin at 8 a.m.