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MN310 WHAT TODAY’S HEALTHCARE LANDSCAPE MEANS TO YOUR PRACTICE ROBERT W. YELVERTON, MD APRIL 28, 2014 MCCORMICK PLACE LAKESIDE CENTER CHICAGO, ILLINOIS TABLE OF CONTENTS FACULTY ........................................................................................................................... iii COURSE OBJECTIVES ........................................................................................................ v SCHEDULE ....................................................................................................................... vii DISCLOSURE OF FACULTY AND INDUSTRY RELATIONSHIPS, ACCREDITATION, AND COGNATES .. ix INTRODUCTION .................................................................................................................. xi ROBERT W. YELVERTON, MD WHAT TODAY’S HEALTHCARE LANDSCAPE MEANS TO YOUR PRACTICE .................................. 1 ROBERT W. YELVERTON, MD DORIMAR SIVERIO-MINARDI, MPH, MBA EDUCATIONAL OPPORTUNITIES ......................................................................................... 44 COURSE DIRECTOR Robert W. Yelverton, MD Women’s Care Florida Tampa, Florida FACULTY Dorimar Siverio-Minardi, MPH, MBA Women’s Care Florida Tampa, Florida Course Objectives After attending this course, the practitioner should be able to: Acknowledge the current status of healthcare reform Acknowledge current challenges for ob/gyn medical practices o Clinical systems o IT o Reimbursement Identify current practice and reimbursement models Identify new trends and how they will impact the business model Discuss the impact of insurance exchanges Provide information on anticipated changes in office-based care to promote, enhance, and verify patient safety and quality WHAT TODAY’S HEALTHCARE LANDSCAPE MEANS TO YOUR PRACTICE APRIL 28, 2014 CHICAGO, ILLINOIS ROBERT W. YELVERTON, MD SCHEDULE MONDAY, APRIL 28, 2014 PM 2:00 Welcome, Introduction of Faculty, Review of Learning Objectives, Announcements Dr. Yelverton 2:15 4:30 The Current Status of Healthcare Reform Drs. Yelverton and Siverio-Minardi Current Challenges for Ob/Gyn Medical Practices Drs. Yelverton and Siverio-Minardi Current Practice and Reimbursement Models Drs. Yelverton and Siverio-Minardi SCOPE Certification Drs. Yelverton and Siverio-Minardi 4:50 5:00 Question-and-Answer Period Adjournment 3:00 4:00 Faculty and Participants DISCLOSURE OF FACULTY – INDUSTRY RELATIONSHIPS In accordance with College policy, planning committee members have signed a conflict of interest statement in which they have disclosed no financial interests or other relationships with industry relative to topics they will discuss at this program. All faculty members have signed a conflict of interest statement in which they have disclosed any financial interests or other relationships with industry relative to topics they will discuss at this program. At the beginning of the program, faculty members are expected to disclose any such information to participants. Such disclosure allows you to better evaluate the objectivity of the information presented in lectures. Please report on your evaluation any undisclosed conflict of interest you perceive. Thank you! College Committee on Continuing Medical Education ACCME ACCREDITATION The American College of Obstetricians and Gynecologists is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to provide continuing medical education for physicians. AMA PRA CATEGORY 1 CREDIT(S)™ OR COLLEGE COGNATE CREDIT AMA PRA CATEGORY 1 CREDIT(S)™ The American College of Obstetricians and Gynecologists designates this live activity for a maximum of 27 AMA PRA Category Credit(s)TM Physicians should only claim those credits commensurate with the extent of their participation in the activity. College Cognate Credit(s) The American College of Obstetricians and Gynecologists designates this live activity for a maximum of 27 College Cognate Credit(s) toward the Program for Continuing Professional Development for the Annual Clinical Meeting. The College has a reciprocity agreement with the AMA that allows AMA PRA Category 1 CreditsTM to be equivalent to College Cognate Credits. Please refer to the Annual Clinical Meeting Final Program for an additional breakdown of credits. MN310 WHAT TODAY’S HEALTHCARE LANDSCAPE MEANS TO YOUR PRACTICE APRIL 28, 2014 ROBERT W. YELVERTON, MD MCCORMICK PLACE LAKESIDE CENTER CHICAGO, ILLINOIS In accordance with ACOG policy, all planning committee members and faculty have declared any financial interests or other relationships with industry relative to topics they will discuss. This disclosure allows you to better evaluate the scientific objectivity of the information presented. ACCME ACCREDITATION AMA PRA CATEGORY 1 CREDIT(S)™ The American College of Obstetricians and Gynecologists designates this live activity for a maximum of 27 AMA PRA Category Credit(s)TM Physicians should only claim those credits commensurate with the extent of their participation in the activity. College Cognate Credit(s) The American College of Obstetricians and Gynecologists designates this live activity for a maximum of 27 College Cognate Credit(s) toward the Program for Continuing Professional Development for the Annual Clinical Meeting. The College has a reciprocity agreement with the AMA that allows AMA PRA Category 1 CreditsTM to be equivalent to College Cognate Credits. Please refer to the Annual Clinical Meeting Final Program for an additional breakdown of credits. Introduction of Speakers • Robert W. Yelverton, MD – Women’s Care Florida – Tampa, Florida • Dorimar Siverio-Minardi, MPH, MBA – Women’s Care Florida – Tampa, Florida • Robert W. Yelverton, MD –This speaker has relevant financial relationships with the following commercial interests: Speaker: Reckitt Benckiser. • Dorimar Siverio-Minardi, MPH, MBA – This speaker has no conflicts of interest to disclose relative to the contents of this presentation. Role of Course Director The course director is responsible for: • Selecting speakers. • Reviewing the lecture content. • Analyzing course content for potential conflicts of interest. Conflict of Interest • Circumstances reflect a conflict of interest when an individual has an opportunity to affect CME about products or services of a commercial interest with which he/she has a financial interest. www.accme.org If a Conflict of Interest is Determined, the Course Director will: • Resolve the issues pertaining to the conflict of interest prior to the educational meeting. • If a conflict of interest becomes apparent during the meeting, the Course Director will resolve this issue during the meeting. Evaluations A course evaluation can be submitted once the course has ended. Completion of the online evaluation is mandatory in order to receive CME credit for each course attended. To obtain an official certificate, click on the Print Certificate button AFTER completing evaluations for all courses attended. Any questions, contact College staff at [email protected]. + What Today’s Landscape Means to Your Practice ACOG - MN310 April 28, 2014 Robert W. Yelverton, MD, District XII Chair, Course Director Dorimar Siverio-Minardi, MPH, MBA + Conflicts of Interest The faculty of this course disclose no conflicts of interest + Contacts Robert W. Yelverton, MD The Yelverton Group LLC ACOG Chair District XII Florida Robert,[email protected] Dorimar Siverio-Minardi, MPH, MBA Women’s Care Florida, LLC [email protected] Agenda + Welcome Objectives Introduction Background Current – How We Got Here? Status of Healthcare Reform Insurance exchanges Current Challenges for OB/GYN Practices Reimbursement Information Management SCOPE Certification Questions + & Answers Objectives At the end of this presentation, participants should be able to: Describe the current status of healthcare reform and the impact of marketplace exchanges Identify current challenges for OB/GYN medical practices Discuss current practice and reimbursement models Discuss anticipated changes in office-based care to promote, enhance, and verify patient safety and quality How we got here? How we got here? How we got here? How we got here? How we got here? + How we got here? + Medicare Part B Expenditures per Service 13 Gulzar Natarajan, Dec. 2010 + Share of under-65 population with employer-sponsored insurance 20002011 Economic Policy Institute 2012 + 14 Towers Watson March 2014 + + Sources of health coverage for the under-65 population 2000, 2007, 2011 Economic Policy Institute 2013 18 + + Gaps in Current System No reward for outcomes/quality and cost savings Wide practice variation protocols Inadequate/inconsistent treatment plans Clinical Little data exchange hospital and physician Between payer and physician Between Limited focus on wellness, prevention and education Lack of incentives for patients to: Obtain preventive services Keep appointments Fill prescriptions Avoid high cost services (ER) + No Decrease in Decades in: Cerebral palsy Brachial Plexus Injury Maternal Preterm Mortality Birth Cesarean Delivery Rate Ranks 47th in Infant Mortality (2/3 is Perinatal Mortality) USA + Current Environment Health Care Reform Triple Aim Primary Care HEALTH CARE REFORM IS HERE Access WHAT’S A DOCTOR TO DO? Pay for Performance ACO Medical Home Bundled Payments Health Information Technology Hospital Physician Relations Meaningful Use + Simplifying Health Care (PPACA) It is about… Insurance changes mandate Individual Expanding Creation Medicaid of a Marketplace (Insurance Exchanges) + Healthcare Reform - PPACA For individual and small group coverage on or after 1/1/2014: Insurance Exchanges No preexisting conditions Guarantee issue Guarantee renewability Essential health benefits Out of pocket maximum limits Premium tax credits – available based on household income to assist in purchasing health insurance Healthcare Reform - PPACA + Essential Health Benefits: patient services Emergency services Hospitalization Mental health and substance use disorder services Rehabilitation services and devices Laboratory services Pediatric services, including oral and vision Preventive and wellness services and chronic disease management Maternity and newborn care Prescription drugs Ambulatory + PPACA – Woman’s Health Services 58% of women already have coverage Largest barrier to coverage is affordability + PPACA – Woman’s Health Services Preventive and wellness services effective” prevention services as defined by the U.S. Preventive Services Taskforce as an A or B rating Certain immunizations 1 annual well visit “highly Oral Contraceptives plan response: Coverage limitations (mostly generics), quantity limits & authorization requirements) Health + PPACA – Woman’s Health Services Maternity and newborn care benefit also for males Breastfeeding support Screening for HPV, STDs, gestational diabetes and domestic violence Support services like treatment for postpartum depression Essential + Healthcare Reform - Marketplace New entity intended to create more organized and competitive market for private health insurance Rules regarding the offering and pricing Information for consumers to better understand their options Covered services Cost sharing Mechanism Moving for electronic enrollment towards portability of insurance + Healthcare Reform - Marketplace Pros Expanded Cons coverage protection Consistent benefits Focus on price Eases enrollment process Future impact on insurance portability Consumer + Would it be a cheaper alternative? How will costs be managed? Potential adverse selection – mostly high-risk individuals will participate Higher Administrative costs 32 Accountable Care Organization Fairness in Profit Distribution 1. Performance 2. Equality 3. Systemic Disadvantage 4. Luck 5. Beyond Performance JAMA 3/14/14 + Healthcare Reform - Marketplace Individual Mandate M enrolled as of 2/1/2014 11.5% of those eligible Penalties start in 2014 3.3 Employer Penalty 2015 Mandate delayed to + Healthcare Reform – Marketplace Goals: Focus competition among plans on price and minimize a plans tendency to change benefits to attract healthier patients Reforming the insurance market Same essential benefits for all P G S Higher Premium B Lower Premium Metal levels are based on differences in cost-sharing and out-of-pocket expenses + Healthcare Reform – Marketplace Enrollment as of January 2014: P G S B 7% 13% 60% 20% Source: Assistant Secretary for Planning and Evaluation - Office of Health Policy + Healthcare Reform - Marketplace Source: Assistant Secretary for Planning and Evaluation - Office of Health Policy Healthcare Reform - Marketplace + Source: Assistant Secretary for Planning and Evaluation - Office of Health Policy + Healthcare Reform - PPACA Medicaid Expansion all under 65 with income up to 138% FPL Package includes essential health benefits Supreme Court decision that it is up to the states to implement Medicaid expansion As of January 2014 26 States – Implementing expansion 6 States - Open debate 19 States - Not moving forward Florida – Opted out 1.1 M would be eligible $51 B in funding over 10 years To + Healthcare Reform - PPACA Medicaid Expansion - Issues of the program Funding States will receive 100% federal funding for 2014 through 2016 95% federal financing in 2017 94% federal financing in 2018 93% federal financing in 2019 90% federal financing for 2020 and subsequent years Where are these funds coming from? More spending by the Medicaid population Access to care Transformation + Healthcare Reform - PPACA Medicaid Expansion - Pros for states programs More people will be covered State economic activity Protection for certain populations Mental health Funding How we got here? + Healthcare companies rethink their role 1. 2. 2014 Top Healthcare Issues Sutter Health in CA – HMO License Walgreens – New concept stores Start-ups being funded by corporate venture capital Adopted from Pricewaterhouse Coopers, LLC - Healthcare Research Institute + 2014 Top Healthcare Issues Employers using exchanges as a way to offer coverage 3. Increase in price transparency 4. $400 M towards start ups in the transparency business Employer steerage to more cost effective providers Healthcare is going mobile 5. Adopted from Pricewaterhouse Coopers, LLC - Healthcare Research Institute + 2014 Top Healthcare Issues Use of technology to define how medicine is practiced 6. Population health management Consumer insight on clinical trials 7. New ways of getting insight Pressure to be innovative 8. Kaiser Permanente Garfield Innovation Center 9. Medicaid Expansion 10. Pharmaceutical supply chain security Eliminating counterfeit medications in the drug supply chain Adopted from Pricewaterhouse Coopers, LLC - Healthcare Research Institute + Current Challenges - Reimbursement “Health industry organizations that don’t measure up on new metrics will be penalized” PwC Health Research Institute Employers are demanding performance Physicians will be: Paid for value/outcomes Penalized for not accomplishing value/outcomes 2015 – Medicare - Penalties scheduled to start for hospitals New Trends Will Change the Business Model + Focus on Quality & Value • • • • Payment Reform • Pay for value/outcomes • Providers bear more financial risk in order to attain savings with managing patients Aging Population • Larger percentage of hospital based comprise of Medicare patients, impacting reimbursement Medicaid Expansion Increase in insured population Demonstration of value Increased transparency More clinical and administrative standards Focus on primary care • Economic landscape • Health Reform – Increased enrollment • Will individual mandate increase number of insured? + Paid for Value Quality Satisfaction Cost Value = Q/C + Current Practice Models Independent Practice • Solo / Small • Large Group Hospital Owned • Physicians as employees Integrated Delivery System • Hospitals / Physicians / Other Ancillaries (Lab, Radiology) • Physicians as employees Patient Centered Medical Home ACO • Patient belongs to a physician managed home that coordinates integrated care • Independent multi-specialty / primary care focus group or hospital affiliated • Patient belongs to an ACO including physicians, hospitals and other providers that coordinate integrated care + Challenges – Reimbursement OB/GYN Traditional Payer Mix 9% Commercial 10% Medicaid & Medicare Other 81% Independent Practice Reimbursement Challenges + Fee for service Value = Q/C Rewards volume not value How are you going to get paid in the future? Can you accommodate those models? How do you maximize the model? Sustainable Growth Rate (SGR) Medicare fee schedule Reductions Shift on payer mix More Medicaid and Medicare Less fee for service / private insurance Competition - Alternatives available Hospital Employment (all specialties) + 5% Private Employee 42% 53% Source: American Medical Association 2013 Independent Contractor + Hospital Employment for OB/GYN + Employed Physicians Reimbursement Challenges Top 4 challenges (Medscape 2013) decision making authority Not being able to make hiring decisions Loss control over billing and charge coding New equipment and facilities requirement Administrator Employed Physicians Reimbursement Challenges + With salaries ranging between $465,000 to $715,000 (2010 MGMA), how do you make decisions? More emphasis on primary care specialties More emphasis on value not productivity with performance scorecards determining salary and bonuses Productivity Required to take roles in administration Is there compensation for this? Other – how are RVUs determine? considerations Contractual relationship + Sample Scorecard + Reimbursement Challenges Other Models Need for increased partnership Physicians & hospitals Physicians and health plans Patient centered medical home or ACO affiliation Capitation or shared savings model Less utilization and volume rewarded? Controlled access? Is quality being sacrificed? Transparency Patient Cost Estimators Narrow networks + Reimbursement Challenges Other Models Increased costs in administration a health plan to control cost Authorizations and referrals From Penalties For failure to meet government mandates eRx ICD-10 conversation payment Implementation issues Denied + Reimbursement Challenges Other Models Increase More Bad volume? are covered debt? patients paying their share? Are + Marketplace Reimbursement Challenges Marketplace Eligibility issues grace period Reimbursement issues Typically placed on lower paid networks Exclusion issues Narrow networks Increased administrative costs Authorizations, referrals & formularies 90-day + Challenges – Reimbursement The Future payments for services Episode of care - (providers paid to treat a specific condition over a period of time) Physician Quality Reporting System Shared savings programs Bundled + Challenges – Information Management Little data exchange hospital and physician Between payer and physician Between Lack of expertise and IT resources in practices Fractionated Immature Variety and volatile supplier market solutions of specialty-specific needs Perceived cost-barrier Requires behavior change for optimal workflow integration + Challenges – Information Management Electronic Health Record facilitates: Decision support Evidence-based medicine Order entry / sets Safety Alerts (ex. contraindications) Documentation Communication / coordination Remote connectivity Safety Issue – having information at point of decision Connectivity with other providers and hospitals + Challenges – Information Management Electronic Health Record are not being used to their full capacity Need for optimization Issues: Data entry Inability to exchange information Lack of support Lack of analytics expertise + Challenges – Information Management Does the support infrastructure exist? Does your organization have the necessary skills and capabilities? Necessary implementation roles? Have you identified any 3rd party vendors? Have you considered physician retention and relationships? Policies and procedures? Workflow changes? Rollout strategy? Training needs? Financial support? How would ROI be measured? What success benchmarks will be used? + Challenges – Information Management Lack of measurement Outcomes Cost Access Wait time Time to next available appointment No-show rate Cancellation rate + Challenges – Information Management Need or data to achieve incentives: Use Pay for Performance / Pay for Quality Accountable Care – Shared savings Patient centered medical home Population health / patient registries Chronic disease management Meaningful + Challenges – Information Management Meaningful Use – Stage 1 - Data Capture and Access way of capturing information Using information to track critical conditions Care coordination Quality measure reporting Patient engagement Standardized Issues: Adoption of clinical-evidence based guidelines System Data collection and analytics Reporting structure + Challenges – Information Management Meaningful Use – Stage 1 - Data Capture and Access Demographics Vital signs lists Problem eRx Medication list quality metrics (3) Clinical records Clinical summaries Clinical + Challenges – Information Management PQRS Breast cancer screening cancer screening Chlamydia screening Osteoporosis management Urinary incontinence Cervical Issues: Adoption Data of clinical-evidence based guidelines collection and analytics Reporting structure + Challenges – Information Management Lack Patient connectivity Laboratory results Registration Message on including requests for prescription refills and appointments Ask general questions to clinical and administrative staff Obtain education materials Pay their bill + Challenges – Information Management Smartphone Document PM A/P, apps image management and RCM (clearinghouse services plus) G/L, P/R Voice recognition Disease Nurse management registries call documentation Interactive practice web services and patient portals + Women Health Safety Certification for Outpatient Practice Excellence Program SCOPE + 73 Objectives At the end of this presentation, participants should be able to: Identify the components of safety and quality as it applies to ambulatory settings Discuss the process for Safety Certification for Outpatient Practice Excellence (SCOPE) ACOG Patient Safety and Quality Improvement + Focus on Office Safety: Part of a Long history of Safety and Quality initiatives in Ob/Gyn Begun under ACOG presidency of Dr. Douglas Kirkpatrick Response to increasing movement of surgical procedures into the office setting Presidential Task Force convened in 2008 ACOG Patient Safety and Quality Improvement + Release of Task Force Report ACOG Patient Safety and Quality Improvement + Areas Addressed Office Medical Director Time-outs Mock and checklists drills Policy and Procedure manual Anesthesia and ability to rescue Credentialing , privileging and accreditation ACOG Patient Safety and Quality Improvement + Office Surgery Checklist ACOG Patient Safety and Quality Improvement + Office Patient Safety Assessment (OPSA) OPSA workgroup formed April 2009 Create an evaluation tool for assessing patient safety in office-based women’s healthcare Recommend ways to collect data from ACOG Fellows OPSA self-assessment survey ACOG Patient Safety and Quality Improvement + Office Patient Safety Assessment (OPSA) The OPSA Workgroup: current office practice patient safety self assessments Developed an obstetrician-gynecologistspecific self assessment tool for the evaluation of office-based care Discussed how this assessment tool would be marketed and distributed among Fellows. Made recommendations concerning the collection of data and its use in benchmarking. Reviewed ACOG Patient Safety and Quality Improvement + OPSA Survey Results Approximately 80 responses received from February ‘10 through January ‘11 Included responses from all ACOG Districts The self-assessment survey is still available to Fellows to complete and analyzing 2011 now. Participants receive: report of practice responses, with comparisons to national results Recommendations for improving care with reference to ACOG and non-ACOG resources Customized ACOG Patient Safety and Quality Improvement + National Results Areas for possible improvement of surgical privileges and monitoring competency (41% compliance) Quarterly drills for emergency response to untoward events (39% compliance) Logging of dispensed medication samples (43% compliance) Tracking whether patients referred to other physicians were actually seen and a report received (43% compliance) Granting ACOG Patient Safety and Quality Improvement + Evolution Using what was learned both from the Presidential Task Force on Patient Safety in the Office Setting and the OPSA survey, the Safety Certification in Outpatient Practice Excellence for Women’s Health (SCOPE) was created. + Developed to evaluate and certify high-quality, safe women's health care processes in the outpatient setting. NOT JUST FOR outpatient surgery! ANY women’s health office setting. Two‐step process: Application with data submitted and Site Review to document Quality and safety measures in practice + ACOG ahead of the group! ACOG SCOPE: 1/9/2012 AMA “widespread patient safety problems in ambulatory care such as incorrect prescribing, misdiagnosis, and poor communication” NQF action to expand its serious-reportable events list to cover office-based settings + A CONGRESS activity (allows certifying function) Falls within Division of Women’s Health but crossover to Practice Application includes demographics similar to OPSA application WEBSITE: www.scopeforwomenshealth.org + SCOPE – What? Launched by ACOG Pilot Stage 2011 1st Women’s Health Focused Safety & Quality Certification Program Participation is Voluntary Assists OB-GYN’s in Instituting Processes Specific to their Individual Setting and Needs Gives Assurance to OB-GYN’s that their Ambulatory Setting is Operating in Line with Current Safety Criteria + SCOPE - Why? 70 Million OB-GYN Visits Occurring Each Year 30% Gynecological Surgeries now Preformed in the Office Setting Hysteroscopy, Transvaginal Tubal Sterilization, Global Endometrial Ablation, LEEP Adverse Office Incidents 10x More Likely to Occur in + SCOPE - How? Voluntary Specific for OB-GYN Office Practice Practices Request a Survey SCOPE Sends Request for Information of Practice Provider Information Written Policies and Procedure on Safety Measures & Procedures within Practice Characteristics + SCOPE - How? Submitted Site Information Reviewed Visit Follows Certification Suggestions + Opportunities for Improvement SCOPE - Why? Improves Office Safety & Quality by Verifying Gaps Allows ACOG to Set the Standard for Patient Safety in Women’s Health Will Highlight practice in Value Added Reimbursement Strategies Will provide personal practice recommendation letter to health and liability insurer on request. + SCOPE - Certifications Written Application Request Site Visit Post Site Visit Evaluation Report Full to Provide Documents on Certification Status Summary on Status of Safety Evaluation Opportunities + for Improvement SCOPE - General Standards Medical Written Director Appointed & Identified Safety Manual with Safety Goals Documented Safety Training for all Office Personnel On Going Safety Drills Quarterly Documentation of Regular Staff Meeting on Clinical Matters and Safety Scope of Practice Competency & Maintenance + SCOPE - Related to Medications Verbal Orders Repeated Back Double Confirmation of Patients Identity Double Check all Injections, Medications List Up “Do Not Use” Abbreviations to Date List of Medications + SCOPE Related to Medications E-Prescribing Accurate List of Allergies Double Identification of Patient before Injection or Immunization Drug Expiration Date Check Medical Sample Log SCOPE - Related to Office-based Surgery + Informed Pre-Op Consent Pregnancy Status Escort Driver Check List/ Time Out Written ASA Post-op Instructions Class 1 & 2 Only Equipment Staff Training Checklist Availability + Check Logs of Emergency Cart The Future OB-GYN Practice Flexible Less Design Waiting Room Check-in Replaced with Kiosks, Finger Scanned Ins. Patient Paged Silently from remote sight when care giver is ready to see patient Records System all Digital with connectivity to the remainder of integrated organization and beyond. + The Future OB-GYN Practice Virtual Office Visits/Telemedicine Technology Replacement Routine of the Routine Pelvic Exam ? Endovaginal Sonography for Wellness Exam? Same Day Diagnostic Sonography Design + of the Future Office The Future OB-GYN Practice Patient-Centric Same Day Appointment as standard option Evening and Weekend Hours Routine Remote Medicine E-mail; telemedicine Future of Hospitalists- Laborist + Contacts Robert W. Yelverton, MD The Yelverton Group LLC ACOG Chair District XII Florida Robert,[email protected] Dorimar Siverio-Minardi, MPH, MBA Women’s Care Florida, LLC [email protected] + Questions & Answers UPCOMING COLLEGE FREESTANDING POSTGRADUATE COURSES 2014 December 4-6 Update on Cervical Diseases Mark Spitzer, MD The Sheraton Times Square New York, New York December 11-13 Practical Obstetrics and Gynecology Patrick Duff, MD Hyatt Regency Chicago Chicago, Illinois