MEDICINE

Advancing the healthcare dialogue in Wyoming communities

wyoming

Volume 1. Number 2.

WWAMI 101
Election 2010
Gubernatorial
Candidates &
Health Care

Childhood and
Adolescent Obesity Growing
OurOwn
a publication of the WYOMING MEDICAL SOCIETY AUGUST 2010
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WM
content

Cover photo: Jesse Sullivan of

Freckle Photography. Featuring
Left to Right: Paul Johnson, MD,
community p9 Beth Thielen, Derek Nevins, MD, &
Five-year-old Jackson Sullivan
2010
cover story Growing Our Own
p10
Gubernatorial Wyoming WWAMI and Our Next Generation of Doctors
Candidates
Marguerite Herman
talk to the issues of health
care in our state and
what they will do to help
Wyoming’s future.
national perspectives
p12
Dennis E. Curran

Health Reform
The Fallout from the Congressional Shout-out

Kimble Ross

Around Wyoming Legal Corner To Your Health

P16 P19 P30

Jonathan Green offers a closer
look at Wyoming WWAMI
students. Learn about the
students’ journeys in selecting
medicine, choosing the University
of Wyoming and the University
of Washington to become part of
Wyoming’s medical future.
Dray, Thomson & Dyekman, PC
attorney Nick Healey, JD, and
James (Jim) Dobbyn educate pro-
viders about “Negotiating Reim-
bursement In A Payor Contract.”
Wyoming Pediatrician and
Former President of the American
Academy of Pediatrics State
Chapter, W. Joseph Horam, MD,
speaks to the issues of “Childhood
and Adolescent Obesity.”
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 MEDICINE
wyoming
from The
August 2010
ediTor
By: Robert Monger, MD
The Wyoming Medical Society (WMS) is the premier Chief Editor
membership organization dedicated to promoting the
interests of Wyoming physicians and physician assistants Not many doctors practice Residency Programs in Casper
through advocacy, education and member services. medicine in Wyoming. and Cheyenne, the state has been
WYOMING MEDICINE (ISSN-2154-1681) is published With a total of about 1000 able to recruit a number of great
bi-annually by WMS at 122 East 17th Street, Cheyenne, physicians practicing in the state, physicians to our state.
Wyoming 82001. Contact WMS at (307) 635-2424 or Wyoming has the smallest number
sheila@wyomed.org of doctors of any of the 50 states.
I would like to take this opportunity
Perhaps more telling is the fact
to thank the four individuals who
that even for our small population
volunteered to be on our cover:
we have one of the lowest numbers Listed from left
to right, Dr. Paul
“Wyoming has the Johnson, Beth
WYOMING MEDICAL SOCIETY LEADERSHIP Thielen, Dr.
smallest number of Derek Nevins,
President Gerrie Gardner, DO
Vice President Cynthia Casey, MD practicing doctors of and old
five-year-
Jackson
Secretary/Treasurer Michael Tracy, MD any of the 50 states.” Sullivan.
Past President Reed Shafer, MD
AMA Delegate Robert Monger, MD All four were
AMA Alt. Delegate Stephen Brown, MD of physicians per 100,000 people: good sports about being cover
Executive Director Sheila Bush according to 2007 data from the models and very generous with
MAGAZINE EDITORIAL BOARD American Medical Association their time. Thanks also to the
Wyoming is 47th in the country in Governor’s mansion in Cheyenne
Chief Editor Robert Monger, MD number of physicians per capita. for letting us use their beautiful
Publisher Sheila Bush grounds for the photo shoot.
Member Steve Bahmer What can be done to recruit
Member Dennis Curran doctors to come to Wyoming? Dr. Johnson and Dr. Nevins are
Member Wendy Curran Our cover story in this edition examples of the WWAMI program
Member Dennis Ellis of WYOMING MEDICINE at its best. Both completed their
Member Pennie Hunt is about one of the truly great first year of medical school in
Subscriptions programs Wyoming has going for Laramie and then went on to
To subscribe to WYOMING MEDICINE, write to it: the WWAMI medical education finish their other three years of
WMS Department of Communications, P.O. Box 4009, program. medical school at the University
Cheyenne, WY 82003. Subscriptions are $10 per year. of Washington.
Through the WWAMI program,
Articles published in WYOMING MEDICINE represent Wyoming students have the Dr. Johnson is originally from
the opinions of the authors and do not necessarily reflect opportunity to attend medical Laramie, Wyoming. After
the policy or views of the Wyoming Medical Society. school and then return to Wyoming graduating from medical school
The editor reserves the right to review and to accept or after they finish medical school and and completing an ENT residency
reject commentary and advertising deemed inappropriate. residency to pay back their school at Columbia University he
Publication of an advertisement is not to be considered debt. The WWAMI program also returned to a serve Wyoming at a
an endorsement by the Wyoming Medical Society of the allows students from other states private practice in Cheyenne.
product or service involved. WYOMING MEDICINE is to spend time in Wyoming as part
printed by Print By Request, Cheyenne, Wyoming. of their medical education. Dr. Nevins is originally from
Wheatland and is now a second
Postmaster: Because of programs like year resident at the University
Send address changes to Wyoming Medical Society, WWAMI, as well as the University of Wyoming Family Medicine
P.O. Box 4009, Cheyenne, WY 82003. of Wyoming Family Medicine Residency in Cheyenne. Hopefully

6 wyoming medicine August 2010

 from the editor WM

he will choose to stay in Wyoming after he completes his residency No matter who you decide to support in this year’s election, please
training. remember that we owe a debt of gratitude to all the candidates who
are running for elected office. Each one of these individuals spends
Beth Thielen is a M.D. /Ph.D. WWAMI student at the University many months away from their families traveling around the state,
of Washington. She is originally from Minnesota and is currently in the public eye, just for the opportunity to possibly become a
completing her 3rd year family public servant. Thanks to the six candidates
medicine clerkship at the residency we review in our story for making the time to
program in Cheyenne; she will return attend the WMS forum, and thanks to all of
to Wyoming next spring for a surgery
clerkship in Casper. Prior to her
“The WWAMI program is the candidates running for office this year for
your willingness to serve Wyoming.
participation in the WWAMI program more than just a one-way
Beth had never been to Wyoming.
street.” Congratulations to Nick Morris, M.D.,
a fine physician from Powell, Wyoming,
Beth is a good example of how the who is the winner of this year’s Wyoming
WWAMI program is more than just a Medical Society Community Service Award.
one-way street for Wyoming students The award is presented each year at the WMS
to go out of state to medical school. Annual Meeting, and you can read about
Through Wyoming’s participation in the WWAMI program, Dr. Morris’ many accomplishments in this edition of Wyoming
medical students and residents from other parts of the country Medicine. Nominations for the 2011 Community Service Award
have the opportunity to come to Wyoming for part of their medical will be taken by the WMS next spring, so start thinking now about
school or residency training. Hopefully some of them will fall in who you might want to nominate.
love with our great state and return here to practice someday.
We at WYOMING MEDICINE would like to hear from you! If
Wyoming voters have many options to choose from this year you have any questions, or suggestions about how we can make
for governor, and in another story in this issue we profile six of the magazine better, please email us at WMmagazine@wyomed.
the candidates. All six participated in a candidate forum at the org.
Wyoming Medical Society Annual Meeting at Jackson Lake
Lodge in June, and our article highlights some of their thoughts Thank you for reading Wyoming Medicine. WM
about health care issues.

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7 wyoming medicine January 2010


2010 gUBernaTorial elecTion
Can Wyoming’s Next Governor Heal Health-care Pains?
Will Wyoming’s next governor be a help
or a hindrance, a leader or a laggard, in
supporting quality medical and health care
in the state during the coming four years?
The answer appears to be positive, judging
from a recent Wyoming Medical Society
forum.
While sometimes short on specifics, all six
major candidates for governor say they are
committed to making quality health care a
continuing top priority in Wyoming. Some
even are championing another run at tort
reform.
And all of them are hoping for support
from the state’s medical community as
they square off in the Aug. 17 primary
election to determine the Republican and
Democratic nominees.
The top contenders -- Republicans Matt
Mead, Rita Meyer, Ron Micheli and Colin
Simpson and Democrats Pete Gosar and
Leslie Petersen – were invited to answer
questions about health care at an early-
morning candidate forum at the WMS
annual meeting in Grand Teton National
Park June 12.
Meet the candidates
Mead, a Cheyenne
attorney and rancher, is
a former U.S. attorney
and the grandson of the
late Gov. and U.S. Sen.
Clifford P. Hansen of
Jackson.
Meyer is completing her
first term as state auditor,
the state’s payroll officer.
She is a retired Wyoming
Air National Guard colonel
with combat command
experience in Kuwait and
community WM
By: Dennis E. Curran
Afghanistan and was chief of staff for Gov. making his third bid for the Republican
Jim Geringer. nomination: and Tom Ubben, a Kinder
Morgan employee from Laramie.
Micheli is a fourth-
generation Wyoming The other Democrats are Al Hamburg,
rancher from Fort Bridger a retired house painter from Torrington
in Uinta County. He served making his 17th bid for state or federal
16 years in the Wyoming elected office; Rex Wilde, a cabinet
House of Representatives manufacturing company employee from
and headed the Wyoming Cheyenne; and Chris L. Zachary, a
Department of Agriculture retired federal and state psychiatrist from
under Geringer. Cheyenne.
Simpson, a Cody lawyer, Scope of practice
has served 12 years in From the very first question, the candidates
the Wyoming House were quick to show their general support for
of Representatives and the medical community. The first question
was speaker the last two involved scope of practice, and candidates
years. He is the son of were asked specifically whether they would
former U.S. Sen. Alan K. support so-called “sunrise” legislation to
Simpson. require at least a year to study proposals to
allow various health-care professionals to
Gosar, a Laramie expand their practices.
businessman and pilot for
the Wyoming Aeronautics Gosar said he thinks it is important to health-
Division, is a political care consumers that they have confidence
newcomer but is actively in their providers, and he said he thinks
campaigning and has name discussions about professional standards
recognition as a University of are important. He also used his opening
Wyoming football standout answer to emphasize the importance of
two decades ago. good health care in general. “When wealth
is lost, nothing is lost,” he said. “But when
Petersen, a retired Jackson real estate broker, health is lost, something is lost.”
was state Democratic Party
chair until she entered the Mead spoke more directly to the sunrise
governor’s race. A longtime question, stressing the importance of giving
conservation lobbyist, she as much notice as possible when discussing
served for six years as a scope of practice issues to “avoid last-
Teton County commissioner minute consequences.” “Too often, you get
and ran unsuccessfully for in a rush to pass legislation, and too often
secretary of state in 1982. you get unintended consequences,” he said.
The other Republican candidates are Alan Meyer, married to a dentist, recalled
Kousoulos, a Wyoming Department of battles over allowing expanded practice by
Transportation employee from Cody; denturists and declared that “patient safety
John Self, a retired Sheridan businessman is always paramount.”
Continued on page 14
August 2010 wyoming medicine 9
 Growing
Wyoming
Our Own in
By: Marguerite Herman
“Grow your own” has become the conventional wisdom in Wyo-
ming’s efforts to recruit and retain physicians. By all indications,
the state has found the solution in the WWAMI program. After 13
years, it has a stellar performance record in its mission to supply
Wyoming’s rural residents with primary care and specialty physi-
cians.
“It has vastly exceeded my greatest expectations,” said Wendy
Curran, who was the deputy director of the Wyoming Medical So-
ciety when the program began. “We believed if we got close to 50
percent return rate for the students, we would be wildly success-
ful.” In fact, about 70 percent of the Wyoming students who attend
medical school under the WWAMI program are coming back to
the state to practice.
The name represents the five states that participate in the same
contract program with the University of Washington to prepare
physicians to practice in a rural setting: Washington, Wyoming,
Alaska, Montana and Idaho.
The keys to success of WWAMI (pronounced “whammy”) are the
focus on rural medicine - for Wyoming residents - paid for by the
state - with an obligation to come back and practice in the state
or repay the some $150,000 Wyoming has spent to send them to
medical school, with interest. Another key element is students’
preparation at the University of Wyoming before going to Seattle.
The obvious beneficiaries of
WWAMI are the medical stu-
dents and the Wyoming folks
who can find the medical
care they need, if not in their
hometown then in a commu-
nity close by. Other benefi-
ciaries are the hospitals Derek Nevins, MD ~ Resident
and clinics who hire these talented young physicians, the
University of Wyoming and the entire community of health care
providers in the state. So continuing support for WWAMI comes
from the Wyoming Medical Society and the Wyoming Hospital
Association and of course the Wyoming Legislature, which ap-
propriates money every two years to send Wyoming students to
medical school.
Here Is THe “GrOWING yOur OWN” sCeNArIO IN WyOMING:
A high school student is interested in health sciences. A guidance
counselor encourages the student to check out the WWAMI pro-
gram and talk to Assistant WWAMI Dean Matt McEchron, PhD,
at the University of Wyoming.
The student (who is a certified resident of Wyoming and might
be from Casper or Alpine or Saratoga) completes a pre-med un-
dergraduate degree program at the University of Wyoming or any
other college. The student applies to the University of Washington
School of Medicine. (WWAMI helps the student prepare for the
Medical College Aptitude Test and polish interviewing skills.)
The student is interviewed by the WWAMI Admissions Commit-
tee in hopes of securing one of 16 slots for the Wyoming WWAMI
class.
Once admitted, the student takes the first year of medical school
in Laramie. Then the student has the option of participating in a
four-week Rural/Underserved Opportunities Program (RUOP) ex-
perience throughout the WWAMI region. Wyoming has 14 RUOP
sites. So the Wyoming student we are following might spend a
month with Don Kirk, MD, in Thayne or Larry Kirven, MD, in
Buffalo or 12 other locations. The student then heads to Seattle to
complete the second year of medical school.

During the third and fourth years, this student may rotate through
all five WWAMI states and complete required and elective clerk-
ship rotations with the following extra options:
• Apply to be one of 12 students from each WWAMI class of
200 to spend 20 weeks of the third year in one rural commu-
nity. This is the WWAMI Rural Integrated Training Experi-
ence (WRITE), with rotations in family medicine, internal
medicine, pediatrics and psychiatry. The student also com-
pletes an elective rotation. The WRITE sites in Wyoming
are in Powell and Lander.
• Apply for one of four Wyoming Rural Clinical Experience
spots. If selected, the student will complete four or more of
their six required third-year clerkships in Wyoming
After the four years of medical school it is time to complete a resi-
dency in a specialty and look for employment back in Wyoming.
After graduation from residency, the WWAMI physician returns to
Wyoming to practice medicine for three years, comfortable with
the practice of medicine in a rural environment, and wants to stay
for the long term.
And that is how it is playing out.
Richard Hillman, MD, is the clinical dean for WWAMI in Wyo-
ming. He is a member of the WWAMI “team” for all the clinical
activities in Wyoming. (The WWAMI team includes the Univer-
sity of Washington, University of Wyoming, Wyoming Medical
Society and Wyoming Hospital Association). Dr. Hillman has the
critically important job of finding clinical sites for the third and
fourth year clerkships in Wyoming.
“We’re looking for quality physicians in their practice and in their
professionalism. They must be willing to teach and work with stu-
dents as a team,” Dr. Hillman said. “Part of the problem is these
physicians are so busy, they just can’t work with students.”
For the physician mentors, the rewards are huge, Dr. Hillman said.
In addition to a small stipend, they get faculty status at the Univer-
sity of Washington, and they have Internet access to its first-class
research library. Plus, the University of Washington brings them to
Seattle once a year for continuing medical education.
cover story WM
Curran, who is the health policy analyst for Wyoming Gov. Dave
Freudenthal, said she has seen this connection of mentors to the
top-rated University of Washington medical school have the effect
of retaining rural doctors in Wyoming. “Instead of just sitting in
your office in Buffalo, you make sure your skills are up to date,
and you’re working with brilliant young minds,” she said. The ex-
perience invigorates the doctor with a fresh perspective and con-
nections with the cutting edge of his or her area of practice.
And there’s more. Dr. Hillman said the WWAMI students who are
in Wyoming for the RUOP experi-
ence present a great recruiting op-
portunity for hospitals and doctors.
“You don’t have to spend $100,000
recruiting for unknown physicians,”
he said. About 300 students rotate
through Wyoming for 4-6 weeks
each year. “The communities, hospi-
tals and doctors need to take advan-
tage of that and recruit them when
they’re here,” he said. “This is a great Beth Thielen ~ WWAMI Student
opportunity we’re missing right now.” The WWAMI program is
relatively new in Wyoming, just 13 years old, and we’re still learn-
ing how to put all this together for the best for our state.
“It’s a lot better than recruiting doctors for Wyoming whom no-
body wants,” he said.
A sign that the Wyoming program has reached a level of maturity
is the participation of WWAMI alumni in recruiting and mentor-
ing current students. The doctors who have been “grown” are now
cultivating future Wyoming physicians, for instance WWAMI grad
Blaine Ruby, MD, who was a preceptor for rural surgery in Buf-
falo 2009-2010. Adam Peters, MD, of Cody, Gentian Scheer, MD,
and Justin Hopkins, MD, in Lander hosted students for the RUOP
experience in 2009.
Another sign is the quality of students we are sending to Wash-
ington. The University of Wyoming has sharpened its pre-med
and first year programs, and other WWAMI team members have
helped students with clinical experience, MCAT preparation and
Continued on page 24

Now that the multiple federal health system
‘reform’ deeds are done, the blogosphere
and journals are flush with prognoses from
cynics, polemicists, and optimists, left,
right and centrist, on what’s next. Don’t
expect a consensus in your professional
lifetime. This kind of creative disrup-
tion transcends anything physicians have
experienced since Medicare was birthed
in 1965, or perhaps even when Abraham
Flexner produced his book-length, seminal
report in 1910.
This article maintains that unless you are
a closeted policy wonk, there is little rea-
son to wring your hands over esoteric and
out-of-your-immediate-reach concepts like
insurance exchanges, long-term health in-
surance and other risk pools, still pending
federal transfers to buttress Medicaid or
SCHIP, or even the tough federal over-
sights of the health plans, especially when
the earth is moving in multiple directions
under your feet. The following proposes
five practice-specific, game changing the-
ses and offers some brief discussion on
their underlying logic—all rebuttable and
subject to contradiction—that they are ar-
guably the more influential factors at the
exam room level in this phone-book thick
body of federal law:
Thesis I: Forget Repeal - Get Real:
Really more a caveat than an independent
variable in this grand lab experiment: Re-
versing what’s been done is problematic at
best, given the time lines and institutional
and legal barriers. There will undoubtedly
be revisions and course corrections, but the
general policy direction won’t change.
12 wyoming medicine August 2010
The falloUT
congressional shoUT-oUT:
The Downstream Flushing Effects of
What Congress Did, and Didn’t Do
Thesis II: Integrate or Die: The macro
trend in Horizontal and Vertical Integra-
tion—and its alter ego, consolidation—will
accelerate, given the powerful incentives to
come together (or starve out of network).
Does small group and solo practice go the
way of the brontosaurus?
Thesis III: Triple Threat in the Execu-
tive Branch: Congress did a triple play
handoff (to mix sports metaphors) to the
agency side, creating three distinct entities
that can, and will make unilateral decisions
about who, where, and when to pay for ser-
vices without having to seek Congressional
permission.
Thesis IV: Coming off the Bench? Phy-
sicians have been mostly on the sidelines
in this game by their disparate views, leav-
ing the major players on the field—hospital
systems, payers, employers, and others on
the capital-intensive side of the ledger to
influence the next iterations. And therein
lies their opportunity.
Thesis V: Providers Will Get RAC’d: An
unprecedented consolidation of effort and
resources by the feds to ‘recover’ fraudu-
lent services or simply overpayments will
round up the usual suspects, then shotgun
the whole herd and separate the sheep from
the goats post mortem. Call it , ‘leave no
outlier behind.’
Following that batting order, here is a little
more elaboration on the game changers
within that medical practice context.
Thesis I: Forget Repeal - Get Real:
It’s not just that those horses have stam-
from The
By: Kimble Ross
peded out of the barn—Congress has been
known to reverse itself. However, there are
considerable political barriers and econom-
ic realities this go-round:
1. Payment realignments, the most sig-
nificant inspiration among practice
variable catalysts, were proceeding
with or without changes in federal law.
The SGR debacle, now in its 7th year,
is an unsustainable trend, a collision
course with physicians that sooner, not
later, get a phase-in treatment. It is not
driving system reform, but rather is
chasing it, if for no other reason than
because the patches continue to enable
an expiring payment methodology.
2. Medicare’s pilots along the array of
‘quality/value’ options such as episod-
ic payment, value based purchasing,
pay for performance, and in-patient
service bundling-- are on the precipice
of widespread adoption. Commercial
payors are quick to adhere to those
policies, making any federal change
private-sector-metastatic. Think of
Never Events as the market adaptive
model. In the fall of 2008, Medicare
came up with six ‘never events’ they
would not reimburse, and within
weeks the commercial payors said
‘me too’, followed by several hospi-
tal systems. One system, Geisinger,
raised the ante by guaranteeing some
treatment episodes. AHIP has reported
considerable interest among the plans
to retool all contracts to an RBRVS
methodology, and most contracts al-
ready include a clause hinging Medi-
care reimbursement changes to their
provider fee schedules.
Continued on page 26
 Inaction vs
In actIon
:

ss The Litigation Center of the American Medical

Association and the State Medical Societies
is committed to protecting doctors and upholding the
highest standards of patient care.

In courtrooms across America, we are achieving legal

victories that preserve the rights of physicians, promote
public health and protect the integrity of the profession.

Whether we are challenging managed care

organizations’ payment practices or preserving the
autonomy of the hospital medical staff, one thing
remains constant: The Litigation Center is an active
force fighting for physicians’ rights.

Learn more on how The Litigation Center can help you:

www.ama-assn.org/go/litigationcenter

Membership in the American Medical Association

and the Wyoming Medical Society makes the work
of The Litigation Center possible.
Join or renew your memberships today.

www.ama-assn.org www.wyomed.org
WM
community
Continued from page 9
“This should be a process that includes
proper credentialing, education, and
training for all professionals,” she said,
calling for plenty of notice when scope of
practice issues are discussed.
Micheli said it’s important that “we do
everything we can to make sure we have
quality people” treating patients. “It’s
incumbent on all of us to make sure
people out there are qualified to provide
these services.” However, Micheli noted
that as a 16-year veteran of the Wyoming
Legislature, he was not sure how the
legislative logistics would allow for a one-
year notification period.
Petersen
agreed the
sunrise
concept
“is a grand
idea” and
said she
certainly
is for
appropriate
credentialing of all health-care
practitioners, but she noted that “few things
fly through the Legislature” anyway. “I can
see where it would be very advantageous,
but in actuality I would think it’s unlikely,”
she said.
Simpson noted he has dealt with “quite a
few scope of practice issues” during his
legislative tenure, and he said he wants
to continue working with WMS on those
issues, because “patient safety is very
important.” But he said a one-year notice
requirement is “probably unrealistic.”
New look at tort reform?
The six candidates were less in agreement
over alternatives to achieving meaningful
medical liability reform in Wyoming,
but they all appeared open minded to
discussing alternatives.
Wyoming’s medical liability laws do not
limit damages for non-economic losses,
14 wyoming medicine August 2010
such as pain and suffering, and doctors
contend that this lack of “caps” is causing
rates for medical liability insurance to
soar out of control in Wyoming. All six
neighboring states allow caps on damages,
and all have lower liability insurance rates.
Wyoming voters in 2004 narrowly rejected
a proposed constitutional amendment that
would have allowed the Legislature to
impose caps, and two candidates - Micheli
and Meyer - urged the doctors to take up
the battle again because they believe the
political climate has changed.
“I would encourage you not to give up on
this, and I would hope that the Wyoming
Medical Society would not back off on this
issue,” Micheli said. “I believe you cannot
have a meaningful discussion about health-
care reform without a discussion about tort
reform.”
Meyer termed herself “a vocal advocate
for tort reform” and charged that medical
liability concerns “continue upward
pressure on the cost of health care.”
“It will not resolve all of our health care
issues, but it is part of the equation,” she
said. “We are surrounded, as you know, by
other states that have initiated tort reform,
and it’s working in those states.”
Review Panel alternative?
Mead said he hopes recent efforts to
strengthen the state’s Medical Review
Panel will help limit frivolous lawsuits and
avoid rising costs, but he said he views
tort reform as a “critical issue” because of
the importance of quality health care for
Wyoming residents and the importance
of quality health care in economic
development and physician recruitment.
Simpson, viewed by many doctors as a
tort reform opponent, said he voted for
the legislation in 2004 and is “open to
conversations and negotiations” about
the issue, though he emphasized he also
believes “very strongly in personal rights
and the right of a jury trial” and believes
the amount of the cap suggested in 2004 --
$300,000 -- is “too low.”
Petersen said she is “somewhat open” to
caps on damages if they are high enough.
She said she isn’t sure what the amount
should be, but “I certainly do not think
that $300,000 is high enough.” She also
said she was not sure it has been “clearly
articulated” how caps would stabilize or
reduce medical costs, but “overall, I have
a very open mind on the question, and I
appreciate your comments and wisdom.”
Gosar said he looks at the issue as a patient
and health consumer and thinks that “a
common sense approach” is needed. “You
have the world you would like, and you
have the world you have,” he said. “The
people of Wyoming rejected health care
reform…. The Medical Review Panel
seems to me a common sense approach….
(that could avoid going to court and
encouraging people) to sit across the table
and talk.”
Health IT hot topic
All six candidates voiced support for
expanded use of information technology
in health and medicine, though they were
a little short on how to pay for it. “This
is an opportunity for Wyoming, not only to
help people but also to increase jobs,” said
Gosar. “I think that’s the future … and can
make your jobs (as doctors) easier.”
Mead agreed, calling health IT “vital” to
Wyoming. But he stressed that the state
must provide for uniformity in electronic
medical records. “We cannot have multiple
systems,” he said. “The state has to take
charge on this. The state has to provide real
leadership on this so we’re all on the same
page.”
Meyer followed, saying the call for state
leadership is fine, but the “big, big gorilla on
the backs of health-care providers is who’s
going to pay for it.” Some federal stimulus
dollars are available, but they won’t be
enough, she warned, “and there are vendors
out there just waiting to snooker you.”

Micheli, noting that former Gov. Jim
Geringer was way ahead of his time in
connecting communities with information
technology, said health IT is “of the highest
importance.” “The trick now is to make
sure we have programs that talk to each
other,” he said.
Petersen also agreed that health IT is a
“high priority” for Wyoming and said the
question really illustrates what Wyoming
needs to do overall with technology. “Our
whole future relies on being on the cutting
edge,” she said. Specifically regarding
health IT, she said the state “very much has
to take a leadership role, and it will take
money.”
Simpson noted his support for health IT in
legislation he sponsored three years ago
and pledged to continue helping hospitals
and physicians to expand health IT. “It’s
a wonderful opportunity for you and your
patients,” he said, “but I also understand
how it can burden you.”
Docs & patients, pilot project
The candidates quickly followed Meyer’s
lead in decisively answering “no” to a
question whether it would be “appropriate
for the state government to legislate
or influence what takes place between
physicians and their patients?” That
relationship is “sacred,” several said.
All six candidates also were unanimous
in their support for a health pilot project
approved by the Legislature earlier this
year, Healthy Frontiers. The demonstration
project is intended to create a model for
health insurance and preventive health
care services designed to hold down costs,
decrease utilization and keep Wyoming
residents healthier.
Micheli said the project addresses a very
critical problem in the state, and “as a state,
we need to stand up and give it a shot.”
Petersen said the pilot project is
“innovative” and was created by Wyoming
people for Wyoming. She also praised its
emphasis on preventive care and patient
co-pays, ensuring that they “have a little
more skin in the game.”
Simpson supported the bill in the 2010
session and said, “It’s targeted and it should
work well. It’s got great possibilities, and
it is a fine example of what states can do.”
Gosar said, “Creative solutions are what
we need. I’m a big believer in personal
responsibility.”
Mead called it a “great project” and a model
for “what we should be doing.”
Meyer, answering last, quipped, “I share
their love.”
“There is no reason why Wyoming should
not be a leader in health-care reform,” she
added, calling the pilot project a small step
that “could help us emerge as a leader.”
Comprehensive care
The final question asked candidates what, if
any, should be the state’s role in supporting
comprehensive patient care in Wyoming,
such as dental care and critical access
hospitals and trauma care. It stumped
some of the candidates but gave them an
opportunity to reiterate their support for a
strong health-care system.
“I confess that I’m not able to easily answer
this question,” said Petersen, the first to
answer, “but the state has to be nimble
and supportive of our doctors. I think that
training and philosophical support of the
medical community is at the core of what
the state should be doing.”
Simpson said the Legislature has been
struggling with comprehensive patient
care for decades. “The state does have a
role in supporting comprehensive patient
care because those hospitals can’t carry it
themselves, and we are treating those who
are least able to help themselves or pay for
that type of care,” he said. He also said the
state should continue supporting the five-
state WWAMI medical education program
community WM
and
continue
to look at
utilizing
primary
care
physicians
to monitor
total care for their patients.
Gosar said he thinks the state can help
health practitioners avoid “death by a
thousand cuts” when routine makes a
job less fresh and desirable, and he also
suggested possible state support for air
service for patients.
Mead said, “The state is involved in
comprehensive health care, it’s a question
of degree and how well we are doing.
Good health care in Wyoming is not just
a quality of life issue, it’s an economic
issue.” He also said the state needs to lead
in establishing electronic health records.
Meyer said she sees medical care “kind of
coming full circle again,” with primary care
physicians using the concept of medical
homes and monitoring the total health of
their patients. “People don’t expect to get a
heart transplant in Thermopolis, Wyoming,”
she said, “but they expect access to some
level of care that incorporates a look at
themselves. Telemedicine will absolutely
leverage these efforts.”
Micheli, the final speaker of the morning,
said the state’s greatest role in supporting
medicine is in support for telemedicine.
“I think Wyoming could be a leader in
promoting telemedicine,” he said. “I think
we have wonderful opportunities to do
that.”
The field will be narrowed to two on Aug.
17. WM
Dennis E. Curran is publisher of the
Wyoming Business Report, where a story
about the WMS candidate forum appeared
in the July issue. He can be reached at
dcurran@wyoming.com or 307 638-3200.
August 2010 wyoming medicine 15
 Wyoming medical sTUdenTs
a closer look By: Jonathan Green

Tyler Quest wants to be a doctor. That may care medical school by US News & World Lowe and Quest will pay $12,000 a year
be the easy part. Report, and in the top ten research medical for four years of medical school through
schools,” Quest notes. “Consistent” might the program, while the University of Wyo-
Quest also wants an excellent education be an understatement: Washington has ming will loan them the difference be-
at a top-notch school. He wants to avoid held the top spot for 16 consecutive years. tween that price and what UWSOM would
finding himself in a student loan hole mea- charge them as non-resident students. That
sured by dollars into six figures. He wants A good start indeed. But what about pay- difference was about $145,000 in 2009,
very much to help lower health care costs ing for that world-class education? according to a WWAMI fact-sheet.
in his native Wyoming without lowering
the quality of care. Enter WWAMI. An alliance of universi- If Quest and Lowe return to Wyoming af-
ties in Washington, Wyoming, Alaska, ter receiving their MDs and practice here
Elise Lowe also for three years, UW will
wants to be a forgive the loan.
doctor. Wit-
ness her eight Good school? Check.
years on ski Affordable? Check. A
patrol, her EMT chance to return to, and
certification help, Wyoming? Check.
and a fortnight
spent translating elIse lOWe
for a doctor in “I have wanted to be a
Honduras. Like doctor for as long as I
Quest, Lowe can remember,” Elise
is interested in Lowe says. “Growing up
quality educa- in the mountains of Wyo-
tion supported ming” – Lowe is from
by small class Sheridan – “I developed
sizes. “I love the a love of the outdoors as
Rocky Moun- well.”
tain West,” she
says, and would Even with her under-
like to prac- graduate, let alone med
tice medicine school and residency,
in Wyoming. studies still years ahead,
Money – read Lowe dove into the field.
“cost” – is also She says ski patrolling
important, but her goals are “much greater Montana and Idaho, the program gives is “the perfect combination” of her dual
than just the financial aspect.” students like Quest and Lowe a chance to loves of medicine and the outdoors.
study at UWSOM and at home. Wyoming
What to do? students spend their first year of medical “It gave me an introduction to patient care
The University of Washington’s School of school at Laramie, their second in Se- and affirmed my desire to be a physician,”
Medicine (UWSOM) seemed a good place attle and two more years at clinical sites Lowe says. “I took the course during
to start. “The School of Medicine consis- throughout the region. my sophomore year of high school and
tently ranks as the number one primary patrolled for the next eight years until

16 wyoming medicine August 2010

 around wyoming WM

medical school.”
Lowe says patrolling the slopes will
continue to be a passion for her; she plans
to return after she earns her MD. She is
appreciative of the exposure to medicine
the work offered her. “Patrolling opened
doors to me,” she says, including a chance
to shadow docs in the ER and riding in
n ambulances on occasion.
Those ride-alongs propelled Lowe into her
next medical foray. “I loved emergency
medicine and got my EMT license as soon
as I turned 18,” she says. She has since
helped transport psychiatric patients via
non-emergent air ambulance, volunteered
at the Missoula County, Mont., Search and
Rescue and worked for the Missoula city
ambulance. There was also the two week
period in Honduras, in 2007, where Lowe
says she was inspired “seeing the large
public health impact of small, well orga-
nized programs and infrastructure.”
Lowe’s varied palate of experience fore-
shadows her ambiguity over which path
to take toward her MD. “While I greatly
appreciate my experiences in emergency
medicine, my focus has gradually shifted
more to public health. I have not decided
on a specialty yet, but I am interested
in infectious disease, epidemiology and
system-wide solutions to common medical
problems.”
Regardless of which specialty she chooses,
because of her shared medical and out-
doors interests, WWAMI has long been “a
natural choice for me,” Lowe says.
“The support we get through the program
is much greater than just the financial
aspect,” she says. “The small class size
allows us to have access to our extremely
qualified and motivated faculty. We are
provided with all kinds of resources and
supported in all aspects of our education.”
Lowe is currently fulfilling the research
requirement of her MD working on a
state-sponsored telepsychiatry pilot project
from Sheridan. This fall, she begins her
second year of medical school in Seattle.
Tyler Quest
Tyler Quest, like Lowe, has long been
attracted to medicine. “I attended the Uni-
versity of Wyoming for my undergraduate
studies and basically wanted to attend
medical school for most of my life (with a
few other thoughts from time to time).”
Quest agrees with Lowe that the variety
and quality of opportunity in the WWAMI
program was a big factor in his decision to
enroll. “What many people don’t know is
that Wyoming actually has first year medi-
cal students being educated at the Univer-
sity of Wyoming each year.”
“Out of (the WWAMI participating) states,
Washington is the only one with a four-
year medical program, and therefore a
need was identified to give students from
the other four states an opportunity to have

Continued on page 18

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WM
around wyoming
Continued from page 17
a more ‘in-state’ experience.”
Quest, also preparing to begin his second year of medical school
this autumn, points out the number of prospects he will have to
choose from in his third and fourth years. “Students spend their
time doing clinical rotations in various fields. (We) have the op-
portunity to complete these clinical years both at a large medical
institution such as the University of Washington, as well as at
several different towns and hospitals out in the five state region.”
Perhaps auguring his own future plans, Quest continues, “Often
students spend part of their (clinical) years in Seattle, then move
to a state like Wyoming and do a rotation, then Alaska, et cetera.
“This allows for students to learn in a large hospital with many
students and physicians, as well as practice in a small, rural town,
which might only have one physician and you.”
“Many people also do not realize that students are allowed to do
their residency training anywhere in the world before coming
back to work in Wyoming. I greatly look forward to spending
some time in Seattle and someday returning to practice in Wyo-
ming to help care for its population.”
Quest is not a circumstantial benefactor of WWAMI, but shaping
18 wyoming medicine August 2010
up as one of its biggest boosters. “I learned about WWAMI at a
lunch meeting former students sponsored during my freshman
year of college, and have been amazed by it since.”
“I believe in the mission of WWAMI, to bring physicians back to
the state. This not only reduces health care costs in the state, but
also allows for a happier and healthier population with physicians
that have received the finest of training.”
Program execution also weighed on Quest’s mind in choosing the
WWAMI route. “A first year medical school class of 16 students
allows for a great deal of one-on-one instruction and creates an
extremely close knit group of colleagues that can depend on one
another for the rest of their life and career.”
“Wyoming WWAMI is especially unique in that it allows stu-
dents to be paired with a physician preceptor in a one-on-one
setting once a week throughout the year.”
With classes set to resume soon, Quest is looking forward to
Seattle and is gracious for his experiences in Laramie. “I had a
great time my first year and am very thankful for the experiences,
faculty, staff and students.” WM

Negotiating Reimbursement
In A Payor Contract
Not Mission Impossible, And You Should Choose to Accept It.
James (Jim) Dobbyn
Physician Practice Management Healthcare Services
Negotiating or renegotiating a payor con-
tract for your medical practice can be one
of the most important steps you can make
toward improving the practice’s financial
health. In the current healthcare reim-
bursement environment, physicians may
(justifiably) feel that their medical prac-
tice’s financial viability is being threat-
ened. Most medical practices are finding a
larger percentage of the fees they receive
is fixed. There is little (or no) room for fee
flexibility with Medicare and Medicaid,
combined with the ever present threat (and
reality) of cuts to the Medicare Physician
Fee Schedule. As national economic chal-
lenges mount, health care providers find
themselves with a greater percentage of un-
insured, underinsured or “no pay” patients.
Physician practices need to look hard at the
financial areas over which they have some
control, and try to maximize those areas.
One of these areas, whether you feel it or
not, is fee reimbursement.
Prelude: Physician, Heal Thyself.
Medical practice reimbursement is a hydra,
the multi-headed beast of myth. It encom-
passes financial issues, community service
issues, and patient access issues. Any of
these issues is worth writing an article on.
However, this article focuses on addressing
the financial implications of deciding to,
and following through on, renegotiating a
commercial payor contract.
Reimbursement is an area that many phy-
sicians overlook when determining how to
improve their practice’s financial health.
Reimbursement rates are often taken as a
“given” by physicians. That those rates
could (and should) be negotiated does not
occur to them. Even if the practice feels it
is not being reimbursed fairly by a particu-
lar payor, many physicians would prefer to
concentrate on improving financial areas of
the practice in which they feel comfortable
than renegotiate. Negotiation implies con-
frontation, which is not only uncomfort-
able, it goes against many physician’s basic
natures. Conflict is rarely part of the heal-
ing process in which physicians are trained.
Likewise, negotiation implies haggling to
some physicians, which is distasteful and
clearly not why they got into medicine
in the first place. Thus, many physicians,
whether consciously or unconsciously, al-
low the reimbursement levels in their payor
agreements to stagnate or worse, decline.
However, looking at your practice’s reim-
bursement levels is one of the best ways
to ensure you have the healthiest practice
possible.
Step One: Deciding To Renegotiate.
The first decision is one that is usually tak-
en as a given by health care providers, but
it is one of the most important: Should your
practice have a preferred provider agree-
ment with a specific payor? Becoming a
“preferred provider” or “in network” for a
payor means that, in return for agreeing to
the reimbursement rates offered by a pay-
or, the payor agrees to give you access to
patients that you may not otherwise have.
Patients, by and large, will usually go to a
“preferred provider” for their payor over
an “out of network” provider. There can
be many reasons for this; the payor may
require the patient to pay more of the cost
of treatment out-of-pocket if provided by
legal WM
Nick Healey, JD
Dray, Thomson & Dyekman, PC
an “out-of-network” provider, or the payor
may do a good job of promoting its net-
work of providers. Therefore, there is usu-
ally some advantage to being a “preferred
provider” for a particular payor.
The “Preferred Provider”:
What’s the advantage?
Many practices want to be “preferred pro-
viders” for payors, fearing exclusion pa-
tient sources if they are not. However, it
is worth recognizing that agreeing to be a
preferred provider means agreeing to the
payor’s reimbursement schedules, and thus
giving up some measure of autonomy in
your practice. In making this decision, you
should give thought to the following:
• How many patients in your market
area are covered by this particular
payor?
• How many providers in your special-
ty area already have preferred provid-
er contracts with this payor?
• What other health entities (i.e. hospi-
tals, surgical centers, DME compa-
nies) have preferred provider agree-
ments with a particular payor?
• If you decide not to be a preferred
provider, are there significant admin-
istrative and billing challenges for
your practice if you treat patients that
see you “out-of-network”?
• Do you have the capacity in your
practice, in terms of volume, to han-
dle the additional patients that may
come with being a preferred provider,
and if the answer is “maybe”, do the
reimbursement rates you will receive
justify the added cost of treating
Continued on page 20
August 2010 wyoming medicine 19
WM
legal
Continued from page 19
Step Two: Review The Payor
Agreement.
If you’ve decided that your practice should
be a “preferred provider” with a particular
payor, the next step is to review and under-
stand the terms of that relationship, includ-
ing the reimbursement levels. These are
set out in the provider agreement that you
(should) have with the payor. With an exist-
ing payor relationship, pull out your current
agreement and make sure you understand
the terms you have in place. If you are es-
tablishing a new “preferred provider” rela-
tionship with the payor, ask for a copy of the
payor’s standard plan agreement. This may
or may not include a proposed fee schedule,
but will give you the standard “boiler plate”
from which to start.
How long is it, and can I get out?
If you have a current agreement, start with
determining the “term and termination”
provisions of the contract. This will control
how long the contract is in effect and when
(and if) you can renegotiate. Some contracts
can be very restrictive as to your time frame
for re-negotiating. Typically, the “term and
termination” provisions are viewed as “boil-
erplate” and thus either unimportant or not
able to be changed anyway, and so not worth
being concerned with. However, ignore the
“boilerplate” at your peril! Some of the
most important parts of the contract can be
“boilerplate”. This does not mean, though,
that they are (a) not important or (b) unable
to be changed.
The contract language probably does not al-
low you to renegotiate reimbursement levels
whenever you want. However, it may allow
you to renegotiate at specific intervals (ie. an-
nually). If the agreement does not give you
any reasonable options for renegotiation,
you may have to go to the payor and ask to
discuss renegotiation. Some payors will be
cooperative and work with you on renegoti-
ating reimbursement levels. After all, it does
not help payors to have networks full of
physicians that harbor a grudge against the
payor. Other payors may be more restric-
tive. If so, check to see when the agreement
expires. If it does not expire soon, and you
want to renegotiate, you may be forced to
move into the termination process to rene-
gotiate. Check the agreement’s termination
20 wyoming medicine August 2010
provision to see if you can terminate the
agreement prior to its expiration. Most pay-
or agreements have some type of “without
cause” termination provision, meaning that
either party can simply terminate the agree-
ment without either party having done any-
thing wrong. Many such agreements require
that you give written notice (such as 90 days)
before terminating the agreement, although
the timing and notice requirements may be
complicated and the termination option may
only be able to be exercised at specific times.
You should consult with your legal advisor
before terminating the agreement, as there
are potential downsides to termination that
should be considered. However, if you have
gone through the analysis above with respect
to whether you need to be a “preferred pro-
vider”, then you will be in a good position
to know whether the potential benefits are
worth the potential downsides.
Step Three: Make Contact
With the Payor
Once you understand the various terms of
the existing contract or standard contract, it
is time to meet with the payor’s representa-
tive.
At the initial meeting with the payor repre-
sentative, be prepared to discuss the changes
in the terms of the agreement you are look-
ing for. These should include:
1. How the practice will be reimbursed
for services rendered;
2. How much the practice will be reim-
bursed for services;
3. Opportunities for periodic review of
the reimbursement levels;
4. What services are covered;
5. The term of the agreement and the
termination clauses;
6. Possible “special project” arrange-
ments you may like to see with the
payor.
How the practice is reimbursed for services
can be as important as how much. Some
payors like to use fee schedules that they’ve
developed, and may try to insist on using
those in the agreement. While this may
seem like a small issue, using the payor’s fee
schedule takes control away from you on ad-
justing fees and gives it to the payor. Other
payors will propose a percentage multiple of
the Medicare fee for a particular service. In
theory, it may sound good to receive 130%
or 140% of Medicare’s fee schedule; how-
ever, no physician needs reminding that
Medicare’s fee schedule is under constant as-
sault from Congress, and that Medicare rates
are typically lower than many commercial
payers. The best option for many practices,
therefore, is to negotiate to be reimbursed at
a multiple of your own fee schedule. This
gives you more control over your fees. Re-
view your own existing fee schedule and
make adjustments before meeting with the
payor.
Once you have determined the best pay-
ment methodology for your practice, you
need to determine what you will accept for
reimbursement. Typically, the basis for re-
imbursement will be a specific fee for each
current procedural terminology (CPT) code.
Make sure you use the same CPT codes
used by Medicare (resource based relative
value scale (RBRVS)), which is the stan-
dard with most medical practices. There are
other companies who attach different rela-
tive value scale (RVS) values to CPT codes,
such as Ingenix, which is favored by some
payors. However, using different RVS scales
will make the process of comparing data
with the payor extremely difficult, and you
will probably come out worse off compared
to the payor.
Step 4: The Cost of a Pound
of Flesh
Generally, the fees you request should be rea-
sonable for the services you provide. Your
fee schedule, by CPT code, should reflect
the maximum fee level you charge patients
for specific services. Those fees should be
determined by examining the market, your
position in the market, the demand for your
services, and the cost of services you pro-
vide. As discussed above, practices are re-
ceiving more and more pressure from fixed
revenue sources in reimbursement. When
working with payors, you should examine the
entire mix of fees you receive and how that
impacts the overall practice reimbursement,
and remember that payors are competitors
that should be competing with each other.
Therefore, one strategy is to look at trying
to develop parity between payors in terms of

what you are reimbursed for the same CPT
codes.
Legal Note:
Don’t seek reimbursement information from
physicians in your community to determine
what you should charge. cept is ultimately up to you; however, 90%
When trying to determine what is reason-
able to accept as reimbursement, you may
be tempted to simply call colleagues at other
medical practices in your community and ask
what arrangements they have with the par-
ticular payor you’re negotiating with. After
all, they are likely your friends and colleagues,
and the payor has the information in any
case, since it contracts with all of you. RE-
SIST THE TEMPTATION! Other phy-
sicians may be your friends and colleagues,
but they are also, from a legal perspective,
your competitors. Sharing price informa-
tion between competitors can be viewed as
the first step to price-fixing among competi-
tors, which is unlawful under both state and
federal anti-trust law. Moreover, the Federal
Trade Commission, responsible for enforc-
ing the federal anti-trust laws, has actively
enforced those laws in the Rocky Moun-
tain Region in recent years among physician
groups sharing pricing information and at-
tempting to negotiate reimbursement rates
as a group. In two recent examples, the
FTC entered into consent decrees (essen-
tially official settlement agreements) with
two Colorado independent practice associa-
tions (IPA’s) the Boulder Valley Independent
Practice Association (IPA), in 2008, and the
Roaring Fork Valley Physicians IPA in 2010,
to stop those physician groups from shar-
ing pricing information among independent
physician practices and engaging in collective
negotiations with payors. Also, don’t assume
that the FTC will not set its sights on Wyo-
ming. While the Boulder Valley IPA oper-
ated in Boulder, a fairly major metropolitan
area, the Roaring Fork Valley IPA operated
in Glenwood Springs, Colorado, which is not
so different from many towns and cities in
Wyoming. Therefore, it is clearly better to
avoid sharing such information, or seeking it
from others. The better course of action is
to obtain such information from national or
regional surveys, if possible.
Once you have established your fee struc-
ture, the next step is to consider what level
of reimbursement you will accept from a
payor under that fee schedule. Although the
ultimate goal may be to receive full (100%)
reimbursement of your fee schedule, that’s
probably unlikely. The proportion you ac-
of your fee schedule, if it is reasonable and
you have taken care to prepare it according
to the steps outlined above, is not unreason-
able.
Also, payors may have different levels of
flexibility on different CPT codes, so be
aware of the volume of your business that is
being generated by specific CPT codes. It is
not uncommon for 80% of a practice’s vol-
ume to be concentrated in 20% of the total
number of CPT codes used in the practice.
For instance, a primary care practice prob-
ably generates a significant amount of its
volume and income from CPT codes 99213,
99214, 99203, and 99204. In a surgical prac-
tice, most of the volume and income is con-
centrated with 10 to 15 CPT codes. If you
are unable to obtain the target percentage of
your fee schedule that you hoped for with the
payor, consider focusing on the CPT codes
you use the most. Although most plans try
to keep the formulas for reimbursement sim-
ple, and would prefer not to negotiate differ-
ent reimbursement percentages for different
CPT codes, it is an option to suggest in ne-
gotiations. Again, the factors above need to
be examined in determining what to suggest.
You should also require contractual language
that gives you flexibility in adjusting your fee
schedule from time to time, such as every six
months or annually. The payor may want to
cap the percentage by which fees can be ad-
justed in this time period, or may want con-
tractual language locking you in to the term
of the contract. However, your goal should
be obtaining the greatest flexibility for fee
adjustment. The ideal situation is to be fairly
reimbursed for your services without mak-
ing you an outlier compared to other simi-
lar practices. Remember, in most cases, the
payor has the same (or even greater options)
to terminate the relationship, with or without
cause, as you have. It is not advisable to be
on a payor’s radar screen because your reim-
bursement levels are unreasonable. Payors
want to have preferred providers in their net-
works, which makes them more attractive to
legal WM
potential clients, and just like the providers,
payors have motivations other than simply
the fee schedule. Most payors are willing to
work with a practice if the practice is reason-
able in its requests.
While this article has focused on preparing
to negotiate payor agreements, the payor’s
response, and the course and conduct of
negotiations with the payor once that prepa-
ration and initial meeting have happened, is
unpredictable. However, if you have pre-
pared as set out above, and considered all the
issues discussed above, you should be much
better prepared than you would otherwise be
to handle whatever surprises come your way.
Conclusion: It’s In Your Hands!
As you can tell, negotiating or re-negotiating
a payor agreement can be very challenging
and requires a strong understanding of your
practice’s economics, your marketplace, the
contract language and how it achieves the
practice’s goals. However, the best advice
that can be given, at this point, is that you
are not powerless in your relationship with a
payor. Nor do you have to be a bully, shout
or scream in order to be able to negotiate ef-
fectively. Think about your practice’s goals,
how those can be achieved and be willing to
request specific language and commitments
in payor agreements. You are entering a
partnership of sorts with the payor, and the
best partnerships are founded on expecta-
tions and commitments that are fair, clearly
stated and understood by both sides. You
therefore want as much clarity as possible
in the relationship, which is documented in
your payor agreement. The payor also wants
(and probably needs you) as a provider to un-
derstand the relationship and wants the least
amount of confusion about your respective
roles and responsibilities possible. The end-
game of this process is for you, as a provider,
to be compensated fairly for the services you
provide and not to have payor contractual is-
sues interfere with the patient/physician re-
lationship. Although that is a simple goal, it
is not an easy one to accomplish. However,
with the preparation and forethought set out
above, it is possible, and you’ll be the better
off for having done it. WM
August 2010 wyoming medicine 21
 recognition WM

Nick Morris, MD of Powell was selected In addition to dedicating efforts toward the care of Powell patients,
by the Wyoming Medical Society as the Dr. Morris has committed countless hours to the citizens of the
recipient of the 2010 Community Service Powell area through his work with the Heart Mountain Volunteer
Award. This award is presented each year Medical Clinic, a free clinic in Powell that will celebrate its 2nd
to Wyoming’s top physician in recogni- anniversary in early July. He has clearly always gone the extra
tion of their contributions to Wyoming mile to provide quality services to the citizens of Powell. “Nick
communities, honoring the physician for Morris, MD is a tireless advocate for his patients and his com-
time and personal sacrifice for the benefit munity. The Powell medical community is fortunate to include
of the community. him in our ranks,” said Robert L. Chandler, MD of Dr. Morris.
Students at many levels of education have been encouraged by Dr.
Dr. Morris is a beloved member Morris to play a role in the opera-
of the Powell community and tion of the clinic. High school
has been nothing but a beacon and college students alike have
of honesty and integrity. In a learned by shadowing. A Pow-
letter of support for Dr. Mor- ell High School graduate who
ris’ nomination, Powell physi- is pursuing her advanced prac-
cian, Michael Tracy, MD wrote, tice nursing degree spent sev-
“Dr. Morris is incredibly em- eral weeks at the clinic. Bryn
pathic and is truly the epitome Parker, a third year medical
of a ‘small-town’ surgeon. He student in the WWAMI pro-
has a deep commitment to his gram, spent every Tuesday
patients, and he responds with night of her five month rotation
grace in all situations from trau- in Powell volunteering at the
ma calls to being asked a ques- clinic. Dr. Morris has created
tion in the check-out line in the an atmosphere that will shape
grocery store.” He has served Left to right: Nick Morris, MD, Bryn Parker, Mike Tracy, MD, Mark Wurzel, MD the future of healthcare in a
the community in many positive fashion.
leadership roles, including serving as the Chief of Staff at Powell
Hospital, Past Hospital Board Member, and Board member of a Dr. Morris has practiced medicine in Wyoming since 1991. He
local philanthropic foundation. received his undergraduate degree from Pennsylvania State Uni-
versity and later completed his medical school training at Temple
He is well respected by his patients and peers across the Bighorn University Medical School in Philadelphia, PA. Dr. Morris com-
Basin and the referral hospitals in Billings. Dr. Morris has consis- pleted his internship at
tently received positive feedback as a teacher of medical students Dartmouth Affiliated Hospi-
through the WWAMI program. tals in Hanover, NH and finished his medical training with a gen-
eral surgery residency at Episcopal Hospital (Temple University
Former students have commented on how they benefited from his affiliate). Dr. Morris shares his joys with his wife Madelyn and
knowledge base, professional demeanor, and work ethic years af- their four children Trish, Sherry, Chris and Matt. He has a new
ter their rotations with Dr. Morris. A former WWAMI student kayak and plans to do more fishing and paddling out of reach of
from Wyoming, Dr. Nathan Rieb, has moved to Powell to be the his cell phone. WM
community’s general surgeon starting in September 2010. Dr.
Morris will remain in the area in a mentorship role as he retires
and Dr. Rieb begins his career in Powell.

August 2010 wyoming medicine 23

 WM
cover story
Continued from page 11
interview skills. “Four years ago we
barely had 10 qualified applicants.
This year, we had 16, plus 11 on
the alternate list who were just as
good,” Dr. Hillman said. In fact, he
said, the Wyoming
Legislature will be asked to expand
Paul Johnson, MD ~ WWAMI Graduate funding to 20 students.
The WWAMI arrangement depends on the continued good will of
the Legislature. “Of all the things I’ve seen the Legislature do for
30 years, there’s been more bang for the buck with WWAMI than
with anything else I’ve seen,” Dr. Hillman said. “This is much
more cost effective than $20 million to start a medical school.”
In fact, the Legislature did consider a proposal by the University
of Wyoming in 1978 to fund a medical school, to respond to the
chronic shortage of rural health care. Fifteen state senators con-
cluded the state lacked the money and population to support a
medical school, and they effectively blocked the funding. The idea
died with that session.
Soon after, the Legislature created the UW Family Practice Resi-
dency Program clinics in Cheyenne and Casper, with the aim of
attracting newly graduated family physicians to a residency pro-
gram and then to practice in Wyoming. In the 1980s, as Wyoming
headed into its own recession, some legislators argued for the clin-
ics’ demise because they didn’t make economic sense. But they
survived, largely on the merit of providing health care to an under-
served, poor population in the two cities.
State Sen. Charles Scott of Casper, who has served in the Leg-
islature since 1979 and is chair of the Senate Labor, Health and
Social Services Committee, remembers those legislative fights as
being motivated at least somewhat by regional rivalries. Sen. Scott
considers the family practice centers an important piece of Wyo-
ming’s effort to attract primary care physicians – wherever they
are grown.
WWAMI has begun using the UW Family Practice center in Chey-
enne for clerkships in family practice, and students who serve their
post-graduate residencies there have their repayment obligation re-
duced from three to two years. The UW Family Practice center in
Casper is an essential part of primary care for the state’s second-
largest city, Scott said, and now it operates jointly with the feder-
ally funded community health center.
The Legislature previously used the Western Interstate Commis-
sion for Higher Education program (WICHE) to help Wyoming
students attend medical school. Lawmakers continue to help pay
tuition for other health care programs, but state funding for physi-
cians is focused on WWAMI. The high rate of success for bringing
Wyoming doctors back to Wyoming and the ranking of the Uni-
versity of Washington’s medical school as number one for primary
24 wyoming medicine August 2010
care (and number two in research funding) make convincing argu-
ments for continued legislative support for WWAMI, Dr. Hillman
said.
He said the WICHE program had just 4-5 students a year, with
only a 23 percent return rate.
Wyoming also tried a contract program to send a handful of stu-
dents each year to medical school at the University of Utah and to
Creighton University in Omaha. That did have a payback provi-
sion, but it lacked the rural orientation, and the return rate was
about 45 percent, Dr. Hillman said.
For a brief time in 1999, a proposal by New York millionaire Rob-
ert Ross to build a campus in Casper for a Carribbean-based unac-
credited for-profit medical school had support from the governor
and several lawmakers in Wyoming.
The shortage of physicians in Wyoming is chronic. Scott, Hillman
and others point to the peculiar nature of rural practice, the pe-
culiar Medicare reimbursement formula that short-changes rural
providers and the failure of medical liability insurance reform as
possible contributors to the shortage. Meanwhile, the average age
of physicians in Wyoming is 51, and about 20 percent plan to retire
within the next five years.
Back in the early 1990s, the alarm over the shortage seemed to
get renewed attention in Wyoming. It was the dean of the newly-
formed College of Health Sciences at the University of Wyoming
who took the first steps toward WWAMI, Curran recalled. Dean
Martha Williams assembled the healthcare stakeholders in Wyo-
ming, and together they looked at the University of Washington
and the program as it was working with Alaska, Montana and Ida-
ho – making it WAMI (with one “W”). “Of course they all raved
about how wonderful it was.”
The Wyoming Medical Society and UW drafted an agreement
and built support among legislators, hospitals and policy-makers
around the state to join the program. The Wyoming Legislature ap-
proved the funding in 1996. Wyoming began the program with 10
students in 1997, later expanding to 16.
Dr. Hillman said WWAMI administrators and faculty are con-
stantly reviewing
the curriculum and
working on im-
provements, includ-
ing increasing the
class size from 16
to 20. “We’re try-
ing to develop the
program so it em-
phasizes the needs
of Wyoming,” he
Jackson Sullivan ~ Future medical student... or pilot
 cover story WM

said. One push is to make a seamless program for primary care “Our goal is to prepare quality physicians from Wyoming who
and family medicine, so a student would start out at the University want to come back to Wyoming in every specialty, family medi-
of Wyoming and perhaps get early admission to a family medicine cine through neurosurgery, because we need all of those.” WM
residency in Wyoming. Another push is to increase graduate medi-
cal education -- residencies – in Wyoming, which is difficult with
such a small population.

The Beginning of Wyoming’s

Medical School Story
By: Marguerite Herman

In 1978, as now, Wyoming struggled with
the lack of doctors, and the Wyoming Leg-
islature seemed to like the idea of the Uni-
versity of Wyoming creating its own com-
prehensive medical school and facilities.
At least the House of Representatives liked
it and included it in a section of the state
budget bill that funded UW, but that’s as
far as it got.
The Senate Appropriations Committee de-
leted medical school funding, and that’s
how the bill came to the floor for debate.
In the 30-member Senate, 15 lawmak-
ers were resolutely against the idea. They
feared the cost of a medical school in poor
economic times (which occurred 10 years
later). “I think it would have broken the
state,” says Dick Sadler of Casper, 81, who
was one of two Democrats who voted with
13 Republicans to oppose funding. They
also doubted the students in such a sparse-
ly-populated state would get experience
with the number and variety of diseases
necessary for a good medical education.
Those 15 approved removal of funding,
and they outvoted the other 14 senators on
the floor. Sen. Rex Arney, a Sheridan at-
torney, was in the chair for Committee of
the Whole that day and didn’t vote. A 15-15
stalemate defeated every attempt to restore
the funding or keep $690,000 for medical
school staff and planners for one year. “We
couldn’t get off the 15-15 vote,” Sadler
said.
Arney remembers three House-Senate con-
ference committees that met without suc-
cess, and the Legislature adjourned with no
budget for the University of Wyoming for
the next two years. Ninety days later, Gov.
Ed Herschler, who had supported the med-
ical school idea, called the lawmakers back
for a special session to pass a UW budget.
The medical school funding was gone from
the bill.
Sadler said the 15 opponents never formed
an official block, but for this special session
they issued a joint statement, addressed to
House Speaker Nels Smith, to make sure
everyone understood the score:
Because of a rumor that a new medical
school proposal would be acceptable to
one or more members of the 15 senators
opposed to a medical school, we feel it is
critical that we inform you and members
of the House that we will not support any
compromise resulting from this special ses-
sion that will leave the door ajar, thus post-
poning a decision on behalf of the people
of Wyoming for another year. Specifically,
we will not vote for an additional year’s
funding to retain medical school staff and
planners. We take this opportunity to for-
ward to you this statement, and the realities
of the situation with sincere hopes we can
avoid an unfortunate re-enactment of the
deadlock of the House and Senate as was
experienced in the recent budget session.
Regards,
(Signed by each of the 15)
That was that.
Sadler thinks at least some supporters were
acting out of loyalty to UW. Meanwhile,
he said, “I didn’t think we could afford it,
and I wasn’t about to change my mind.” He
does recall feeling bad, however, when he
got up to speak against the medical school
proposal, with his family physician being
the “doctor of the day” and present in the
Senate chambers. WM

August 2010 wyoming medicine 25

WM
national perspectives
Continued from page 12
3. Integration and consolidation of ser-
vices were accelerating well in ad-
vance of the federal law as a means of
economic survival. Physicians are mi-
grating into integrated systems, more
often than not as employees, hospitals
are buying up physicians and smaller
hospitals, especially the now capped
physician investor hospitals, at fire
sale prices, and the plans continue to
eye each other as prospective owners.
Market share is acquired, not won
through vigorous competition.
4. EHRs are still due by 2015, and the
meaningful use criteria have been of-
ficially modified and adopted. Under
most scenarios, growing adoption will
facilitate the other structural require-
ments in reimbursement and account-
ability (code for ‘recovery audits’)
5. Congressional makeover notwith-
standing, most analysts see the Re-
publican pushback, however substan-
tial, as sub- threshold-- not enough
votes to overcome a veto. That renders
some reversible aspects problematic,
as timelines outrun congressional of-
fice terms. The polling trends also
suggest the emergence of a political
center as more categories of voters
understand the personal benefits, fire-
walling in some districts a partisan
surge. The legal challenges are consid-
ered long shots by many constitutional
experts, who note an unbroken string
of Supreme Court decisions sustaining
the Congress’ authority to regulate ac-
tivities that have a substantial effect on
interstate commerce, including medi-
cal care, and like Social Security taxes,
Congress can require the purchase of
health insurance then tax those who do
not in order to cover those costs.
Thesis II: Service Integration and its
Iterations:
The incubating payment realignments are
by design intended to encourage if not
compel the integration and subsequent
coordination of services, since the incen-
tive payments only accrue in those settings
that can prove up evidence based, coordi-
nated care, demonstrable outcomes, and
26 wyoming medicine August 2010
all its incumbent efficiencies. The federal
policy engineers demonstrably don’t intend
for every physician to be retrofitted into a
Mayo, Kaiser, or Geisinger system. In ad-
dition to substantial financial incentives
for primary care services, medical homes,
and restoring that pipeline, the law contem-
plates the semi-organized consolidation of
smaller practices in Accountable Care Or-
ganizations. Whether they are the firewall
to protect that endangered species of small
and solo group practice or yet another rein-
vention of the clinic-without-walls, ACOs
have the full force of federal law behind
them. It enjoys considerable grassroots in-
terest (Colorado is rolling Medicaid ACOs
over the next 18 months) but is still an un-
tested model outside a few settings other
than the large networks, like the unique
community-wide collaboration in Grand
Junction that includes the community hos-
pital and a highly regarded non profit HMO
Thesis III: Executive Branch Triple
Threat or Play?
In what outgoing CBO director Peter Orsag
called ‘the largest yielding of sovereignty
from the Congress since the creation of the
Federal Reserve’, the Congress handed off
to the executive branch three federal sub-
agencies real time authority to alter every
day practice: The Independent Payment
Advisory Board (IPAB) , the Patient Cen-
tered Outcome Research Institute (PCO-
RI), and the Center for Medicaid/Medicare
Innovation (CMI). Here’s a cocktail nap-
kin sketch of their powers. It ‘aint rocket
surgery’ as a colleague is fond of saying,
to contemplate how these three change the
entire game.
1. IPAB: Beginning in January 2014,
each year that Medicare’s per capita
costs exceed a certain threshold, the
IPAB will develop and propose poli-
cies for reducing this inflation. The
secretary of HHS must institute the
policies unless Congress enacts alter-
native policies leading to equivalent
savings.
2. PCORI: will publish research find-
ings and any limitations, as well as
what further research may be needed,
in a manner useful to clinicians, pa-
tients and the general public in making
health care decisions as to what ser-
vices and procedures are more or less
‘comparatively effective’:
• Such findings may not include
practice guidelines, coverage
recommendations, or payment or
policy recommendations. There
is no requirement that the find-
ings communicated to the public
be consistent with U.S. Food and
Drug Administration approved la-
beling of regulated products.
• Federal payers are not prohibited
from using research findings to in-
form payment, coverage and treat-
ment decisions. However, com-
parative research findings alone
may not be used to deny coverage.
3. Center for Medicaid/Medicare In-
novation is mandated to :
• “test innovative payment and ser-
vice delivery models to reduce
program expenditures under the
applicable titles (Medicare and
Medicaid) while preserving or
enhancing the quality of care fur-
nished to individuals under such
titles.”[7]
• The enabling law instructs the
HHS Secretary, in selecting pay-
ment and service delivery models,
to “give preference to models that
also improve the coordination,
quality and efficiency” of care for
Medicare beneficiaries, Medicaid
beneficiaries, and dual eligibles.
[8] The law also allows the Sec-
retary to test models within geo-
graphic areas.
Thesis IV: Physicians Coming off the
Bench?
Organized physician influence on the
congressional effort has to this point been
marginal or at best symbolic for the most
common of political circumstances: They
are sharply divided within their ranks.
When not just lying low to avoid friendly
fire, Physician organizations have been
vocal, if not visceral in their opinions on
pivotal elements of the Act(s) , and thus
incapable of supporting the legislation
 national perspectives WM

with any politically relevant unity. Con- record reviews, and by law can extrapolate and develop new fraud prevention tools.”
sequently, physicians in the form of orga- from random audits their findings across all
nized medicine are perceived on the Hill claims in any given year. The penalties are Sic transit Gloria the presumption of inno-
as also incapable of enforcing hostile stiff, and have the additional leverage of cence. In my experience, the government
votes drawn from the lengthy and conten- threatening criminal prosecution. investigators won’t leave your home with-
tious congressional debate. To be fair, even out a scalp, and the rules heavily favor their
a unified front, which is usually limited to HHS estimates, citing CBO figures, that position. It is a target rich environment,
galvanizing issues like malpractice reform the return on investment by Congress in and they are well equipped to go hunt-
or managed care disputes, would have to anti-fraud efforts is 17:1. Secretary Sebe- ing—loaded for bear, as my father would
overcome the extreme partisan pressures on lius announced in her report to Congress say. WM
their respective congressional delegations, this winter a federal task force, Health-
notwithstanding the fact those delegations care Fraud Prevention and Action Team,
typically enjoy close if not always cordial or HEAT, which says it all while bending
relations with their state medical societ- the rules of federal health care acronyms:
ies. With the laws on the books and now “HEAT is an unprecedented partnership
in the byzantine maze of federal and state that brings together high-level leaders from
agencies, the rules of engagement are very both departments so that we can share in-
different. One former high ranking federal formation, spot trends, coordinate strategy,
official (and now with a prominent DC
law firm) observed recently, ‘the docs
weren’t really in the game because
larger forces were at work… and other
than the AMA and AAFP endorsements,
most of them were wrapped around spe-
cific sub-issues…now is the time they
should come off the bench and work
with their delegations on the hundreds
of insider plays developing at the agen-
cy level.’ His point was, whether the
substance is fecal matter or liquid gold,
it all flows downhill to the states for
implementation, and the state medical
organizations would be well suited to
fully engage their members, given their
local standing and influence within their
local and political communities.’

Thesis V: Getting RAC’d.

Political veterans of health care budget
wars all understand that the first place
the government looks for ‘savings’ in
the system is fraud. Long before health
system issues were a gleam in Speaker
Pelosi’s eye, The (2003) congress au-
thorized as part of the Medicare Mod-
ernization Act the creation of Recovery
Audit Contractors, with, for once, a
fitting acronym, RAC. RACs use pro-
prietary software programs to identify
potential payment errors in such areas
as duplicate payments, fiscal intermedi-
aries’ mistakes, medical necessity and
coding. RACs also conduct medical
WM
national perspectives
Health Reform: Now What?
Some wild guesses and irresponsible speculation:
By: Kimble Ross

As Yogi Berra famously said, ‘the future ain’t what it used to be.’ Here’s a dozen- plus less than scientific guesses
at scenarios that follow from these factors, drawn from ongoing conversations with analysts, think tankers, health
lawyers of considerable experience, economists, politicians, medical society leaders and advocates, and the usual
arm chair opinion suspects.

1. Tighter networks enforced by commercial plans to control costs, since other means of offsetting through risk
aversion and underwriting have been barred. Plans’ payment methodologies will more closely track, even mirror
Medicare policies.

2. Collusion between some plans and some hospitals to control those networks; the term ‘bilateral oligopoly’ will
be googled by more health writers and physicians, who will also be able to distinguish between a monopoly and a
monopsony.

3. Legislation by litigation—the disenfranchised will seek relief from the courts, and the support of their medical or-
ganizations— which will also generate legislative scrutiny of current anti trust laws, state and federal, and in some
jurisdictions realign some plaintiff attorney, physicians-as-plaintiff relationships.

4. Increased friction in some hospital-medical staff settings as administrators control bundled payments, employ more
physicians, and cut deals with payors to maintain networks.

5. More migration of marginal practices into employed settings.

6. More divisions and internal pressures on organized medicine; strange alliances emerge as employed physicians
seek advocates, some plans collaborate with integrated groups, some hospitals do the same.

7. Softening of corporate practice or related restrictions on the hiring and firing of physicians. Full employment for
labor lawyers with enough health policy savvy.

8. ACOs growth, incentives notwithstanding, will run hot and cold. Most significant variable is the presence or ab-
sence of physician leadership in those communities.

9. Increased pressure by RNPs, PAs, other professions to expand scope of practice, which in turn raises militancy
of primary care phyisician organizations; FPs will press medical educators to fill more slots and generate internal
conflicts among the specialties on campus.

10. As more comparative effectiveness research comes on line, along with other payor ‘evidence-based payment poli-
cies, more litigation will arise over standard of care, and increasingly pit manufacturer and physician prescriber
defendants against each other.

11. The CER movement may also draw manufacturers and prescribers closer; formulary gaming or manipulating
by a payer or PBM may draw, for example the PhRMAs and physicians closer on clinical questions of medical
necessity versus cost cutting efficiency, especially when the liability for therapeutic failure or toxicity falls on the
prescribing physician.

12. Fee for service as currently configured joins unaligned solo and small group practices in a slow spiral into obscurity
(or concierge/cash practice).

13. With many more voters covered, political tensions may realign less along insured/uninsured class warfare lines and
more toward age discrimination fronts—Medicare beneficiaries versus Medicaid/SCHIP versus commercial sector-
-the young invincibles mandated to buy coverage or pay a penalty, versus the boomers now acquiring chronic
conditions.
28 wyoming medicine August 2010
 a note from our readers...
Dear Editor,

My heartiest congratulations to
Dr. Rob Monger, Editor, and to
Ms. Sheila Bush, WMS Executive
Director, on the publication of the
new WMS magazine.

It is a beautiful publication, with

articles of interest for all Wyoming Services Available 
doctors, and the general population  Support/promote Wyoming Health Centers 
also.  Support the expansion of affordable health care services 
across Wyoming 
This achievement has come about  Improve access to medical, dental and mental health     
only after long hours of thought, services 
consideration, and hard work.  Provide training and technical assistance on rural health 
issues 
 Provide grant writing assistance 
Thank you for your efforts, and
congratulations on this new Wyoming Primary Care Association 
endeavor. I wish you and the WMS For assistance, please contact Kristy Hazelton: 
Magazine a long and successful run. 2005 Warren Avenue ∙ Cheyenne, WY 82001 
(307) 632‐5743 ext. 10 ∙ Fax: (307) 638‐6103 
~Reed Shafer, MD kristy@wypca.org ∙ www.wypca.org 
WMS Past President

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to your health
CHILDHOOD AND ADOLESCENT OBESITY
FACING REALITY AND MEETING THE CHALLENGES
Col. W. Joseph Horam, MD, FAAP
The incidence of childhood obesity in the
United States was 5% in 1963 and has risen
to 17% in 2004 with some studies estimating
as high as 33% of all youth with either
overweight or obese status. This represents
an epidemic of grand proportions. (1,6)
In general, overweight and obese children
will worsen as adults. Obesity threatens
the health of today’s children to such an
extent that for the first time in over the past
century of United States history the current
generation may have a shorter lifespan than
previous generations. (2) Societal values
and behaviors have created an environment
of sedentary activity, energy dense foods,
reliance on sugar-sweetened beverages,
increasing devotion to television/
computers/video games, larger food
portions and dependence on motor vehicle
transportation all leading to an imbalance
of energy consumption for our youth.
The measurement of body mass index
(BMI) from the calculation of weight in
kg divided by height in meters squared
provides an accurate quantitative value
for total body fat. The Centers for Disease
Control has the broadest population studies
to develop percentile graphs for BMIs
for the span of 2 years through adulthood
located at www.cdc.gov/growthcharts.
Accepted definitions for overweight
persons are a BMI range of 85%tile to
94%tile and obesity of 95%tile and above.
Super obesity is defined at the 99%tile
threshold. (3, 4, 5) The BMI may be
overestimated for high weight muscular
individuals and underestimates risk for
Asians.
COMOrBIDITy
The impact on the general health and
welfare for children and adolescents with
weight pathology is significant and no
30 wyoming medicine August 2010
longer thought to primarily manifest as
adult disease. Type 2 diabetes mellitus has
increased tenfold over the past two decades.
Hepatic steatatosis with nonalcoholic fatty
liver changes was unrecognized before
1980 and can be found in 1:3 obese youth.
The psycho emotional toll has contributed
to escalating problems with depression,
anxiety, impaired body image and eating
disorders. Metabolic syndrome with
hyperglycemia, hypertension, dyslipidemia
and increased risk factors for cardiovascular
disease now exists.
“For the first time in
over the past century of
United States history
the current generation
may have a shorter
lifespan than previous
generations.”
Obese children have three times the
incidence of hypertension. Children
with obesity have a greater incidence
of obstructive sleep apnea syndrome.
Other considerations include polycystic
ovary disease, pseudotumor cerebri,
cholelithiasis, musculoskeletal joint
disease and dermatologic conditions.
Recent studies following accidental deaths
have documented greater atherosclerotic
vascular disease in youngsters with known
elevated serum lipid levels. Standards
now exist for elevated cholesterol and
triglyceride levels over 2 years of age with
recommendations for treatment including
dietary modifications and medications to
include the use of bile resins and statins. The
American Academy of Pediatrics advocates
fasting lipid screening for all children over
2 years of age with a positive family history
of early heart disease, dyslipidemia or risk
factors to include obesity, hypertension and
type 2 DM.(6,7,8,9,10)
ClINICAl eVAluATION
The evaluation begins with an office based
approach that provides an annual screen for
BMI measurement after 2 years of age. It
is important to recognize risk factors for
weight problems. Family history of first
degree relatives and genetic predisposition
is highly predictive of a child’s risk for
subsequent development of overweight
or obesity problems. Genetic studies with
separated identical twins clearly favors
genetics (70%) over environmental factors
(30%) as the major influences for weight
profiles in the absence of medical disease
states. Infrequently diagnosis of primary
medical conditions may cause obesity.
These include Cushing’s syndrome,
psuedotumor cerebri, hypothalamic
disturbance, pharmaceuticals such as
atypical antipsychotics, polycystic ovary
disease, pseudohypoparathyroidism and
genetic syndromes such as Prader-Willi
Syndrome. Disorders of hypothyroidism
are actually an uncommon cause of obesity,
but are frequently attributed as a cause of
weight disturbance. A child with normal
height growth would not be a candidate
for hypothyroidism. A comprehensive
history also includes dietary habits,
physical activities, review of systems,
social history including family activities,
peer relations and activities, school status
and a comprehensive exam. The history
and physical should incorporate the above
mentioned comorbidity concerns. (1, 3, 5)
 to your health WM

lABOrATOry AND TesTING

Basic recommendations include a fasting
lipid panel, fasting glucose with chemistry
panel and an AST/ALT. Additional tests
depending on clinical concern includes
a chromosome analysis, fasting insulin
level, 2 hour glucose tolerance test,
thyroid function, serum amylase and
GGT. Pulmonary function tests and sleep
polysomnograpy studies may be considered
for sleep or respiratory symptoms. An ECG
is indicated for hypertension. Endocrine
and genetic consults are beneficial
referrals for special testing requirements.
Radiologic evaluations of the hips and
knees for slipped capital femoral epiphysis,
Legg-Perthes disease and Blount’s disease
are advisable when clinically indicated.(1,
4, 5)
TreATMeNT AND PreVeNTION
• Avoid all sugar sweetened
beverages
• Limit juice to less than 6 oz under 6
years and 12 oz over 6 years
• TV/computer/video games screen
time less than 2 hrs per day
• No TV in bedroom
• Physical activity over one hour per
day
• Increase home meals
• Fast food no more than once per
week
• Do not skip breakfast
• Assess the family culture and
motivation to change
Stage 2 Structured Weight Management
Stage 4 Tertiary Care:
Academic medical center with consultant
team of specialists and research capability
that incorporates treatment protocols for
severe obesity over 95-99%tile. Includes
use of medications and bariatric surgery.
In principle, improvements not seen within
3-6 months in any given stage of treatment
should move up to the next stage. A
reasonable goal is 1 pound weight loss per
month under 11 years and up to 2 pounds per
week over 11 years. Caloric restricted diets
require dietician and provider supervision.
Diets should be rich in calcium, low in
saturated fat and limit energy dense foods.
Recommendations for children under 2
years of age incorporates exclusive breast
feeding to 6 months of age, use of low fat
milk after one year of age and avoid excess
fruit juice. (2, 4, 5,7,11)

Randomized and controlled studies simply
do not exist for evidence based treatment
for the management of overweight and
obese children. An Expert Committee
comprised of the AMA, Health Resources
and Service Administration and CDC have
made a careful analysis of existing data
to merit their collective support of the
following 4 stages of treatment/prevention
recommendations:
Stage 1 Prevention Plus
• Eat a minimum of 5 servings of
fruits and vegetables per day
• Dietician consult with planned meals/
snacks and balanced macronutrients
(fat/carbohydrate/protein)
• TV screen time less than one hour
• supervised physical activity
• monitor compliance with a logbook
Stage 3 Comprehensive Multidisciplinary
Includes above stages and team with a
provider, dietician, counselor and exercise
trainer. Increase behavior modification and
visits with a school, hospital or community
based program.
PAyMeNT FOr MeDICAl serVICes
The American Academy of Pediatrics has
issued fact sheets for obesity coding at
www.aap.org/healthtopics/overweight.cfm
A complete discussion of this topic is the
subject of “Paying for Obesity: A Changing
Landscape” per reference 12. WM
(Original Article published in the Kosovo Medical
Newsletter, US Army Camp Bondsteel Medical
Falcon Task Force, October 2009. Dr. Horam is a
Pediatrician with the Cheyenne Children’s Clinic at
Cheyenne Regional Medical Center and serves as a
military physician with the Wyoming Army National
Guard.)

References
1. Barlow EB: Expert Committee Recommendations for Obesity. Pediatrics 2007; 120: S164-S192
2. Davis MM: Recommendations for Prevention of Childhood Obesity. Pediatrics 2007; 120: S229-253
3. Klish WJ: Clinical Evaluation of the Obese Child and Adolescent. Up To Date 2009; Online 17.2
4. Krebs NF: Assessment of Child and Adolescent Overweight and Obesity. Pediatrics 2007; 120: S193-S228
5. Schneider MB: Obesity in Children and Adolescents. Pediatrics in Review 2005; 26: 155-162
6. Ludwig DS: Childhood Obesity-The Shape of Things to Come. NEJM 2007; 357: 2325-2327
7. Daniels SR: Lipid Screening and Cardiovascular Health in Childhood. Pediatrics 2008; 122: 198-2008
8. Ferranti S: Storm over Statins-The Controversy Surrounding Pharmacologic Treatment of Children. NEJM 2008; 359: 1309-1312
9. Cowell KM: Type 2 Diabetes Mellitus. Pediatrics in Review 2008; 29: 289-292
10. Klish WJ: Comorbidities and Complications of Obesity in Children and Adolescents. Up To Date 2009; Online 17.2
11. Spear BA: Recommendations for Treatment of Childhood and Adolescent Overweight and Obesity. Pediatrics 2007; 120: S254-S288
12. Simpson LA: Paying for Obesity: A Changing Landscape. Pediatrics 2009; 123: S301-S307
WM
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