Published: October 11, 2013

Mack’s Earplugs

More from October 2013 – Vol. 32 No. 10

Dymista Pg. 1

Allegra

2014 Hospital Outpatient Prospective Payment and Ambulatory Surgical Center Payment Systems Proposed Rule

On July 8, the Centers for Medicare & Medicaid Services (CMS) released its 2014 proposed rule for the hospital outpatient prospective payment (OPPS) and ambulatory surgical center (ASC) payment systems. Below are a few important changes relevant to otolaryngology for CY 2014. A complete summary of the proposed rule can be found at http://www.entnet.org/Practice/CMS-News.cfm. Hospital Outpatient Prospective Payment System (OPPS) As members know, OPPS payments cover facility resources including equipment, supplies, and hospital staff, but do not pay for the services of physicians and non-physician practitioners who are paid separately under the Medicare Physician Fee Schedule (MPFS). All services under the OPPS are technical and are classified into groups called Ambulatory Payment Classifications (APCs). Services in each APC are grouped by clinically similar services that require the use of similar resources. A payment rate is established for each APC using two-year-old hospital claims data adjusted by individual hospitals cost-to-charge ratios. The APC national payment rates are adjusted for geographic cost differences, and payment rates and policies are updated annually through rulemaking. OPPS 2014 Proposed Payment Rates For CY 2014, CMS proposes a hospital outpatient department conversion factor rate increase of 1.8 percent. CMS has also proposed to continue the statutory -2 percent reduction in payments for hospitals that fail to meet the hospital outpatient quality reporting (OQR) requirements. See the summary link from paragraph one to access changes in reimbursement under the proposed rule for CY 2014 for the 100 most frequently billed ENT services in the OPPS setting. Updates Affecting OPPS Payments In CY 2014, CMS has proposed to continue the changes made in 2013 to base the relative weights on geometric mean costs rather than previously utilized median costs. It will continue to use these weights to set a cost-to-charge ratio within an APC to determine payment for services within an APC. In CY 2014, CMS proposes several significant changes to their methodology to calculate APC payments, including: Establishing comprehensive APCs for 38 device-dependent services and applying a single payment for the comprehensive service based on all OPPS payable charges on the claim Expanding the types of services that are packaged and not paid separately Replacing the current five levels of visit codes for the clinic with three new Level II HCPCS codes, which represent a single level of payment for each of the three visit types Changes to otolaryngology related to many of these policies are outlined below, however, members seeking additional information can access our full summary via the link above, which includes a complete list of APCs and changes to their payment rates. New Comprehensive APCs In an effort to improve accuracy and transparency of certain device-dependent procedures, CMS proposes 29 new comprehensive APCs to prospectively pay for the most costly device-dependent services. These APCs will replace 29 of the most costly device-dependent APCs. A comprehensive APC would be defined to include the provision of a primary service and all adjunctive services provided to support the delivery of the primary service. Under the proposal, the entire claim, including the primary service, would be associated with a single comprehensive service and all costs reported on the claim would be assigned to that service. The comprehensive APC would treat all individually reported codes as representing components of the comprehensive service and would make a single payment based on the cost of all individually reported codes, representing provision of the primary service, and all adjunctive services provided to support delivery of the primary service. CMS believes this will increase the accuracy of the payment for the comprehensive service and also increase the stability of the payment from year to year. CMS proposes to include packaged services and supplies; adjunctive services; devices, durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS); OPD services reported by therapy codes that are provided within the perioperative period of the primary service; hospital room and board revue centers; and hospital-administered drugs as part of these new comprehensive APCs. Payment for comprehensive APCs would be made for the largest comprehensive payment associated with the claim based on the listed CPT codes, however, all costs on the claim will be considered in ratesetting for the comprehensive APC. Of note, APC 0259, which includes CPT 69930 Implant Cochlear Device will be included as a comprehensive APC for CY 2014. Proposed New Packaging Policies for CY 2014 For CY 2014, CMS proposes to add the following five items and services to those that will be packaged under the OPPS. Drugs, biologicals, and radiopharmaceuticals that function as supplies when used in a diagnostic test or procedure Drugs and biologicals that function as supplies or devices when used in a surgical procedure Clinical diagnostic laboratory tests Procedures described by add-on codes Ancillary services (status indicator “X”) The packaging policies that influence otolaryngology are discussed in greater detail in our full summary; however, we note that items 2-5 on the list above capture at least one ENT service. Affected services include laryngology procedures, head and neck imaging services, audiology, and SLP services. Access the online summary for a full list of affected CPT codes and APCs by policy proposal. CMS also indicates it is considering a proposal for 2015 that would conditionally package all imaging services with any associated surgical procedures. Imaging services not provided with a surgical procedure would continue to either be separately paid according to a standard clinical APC or a composite APC. OPPS Payment for Hospital Outpatient Visits For CY 2014, CMS is proposing to replace the current five levels of visit codes describing clinic visits, Type A and Type B emergency department visits, and critical care services with three alphanumeric Level II HCPCS codes representing a single level of payment for three types of visits. CMS believes a policy that recognizes a single visit level for clinic visits, Type A ED visits, and Type B ED visits for payment under the OPPS is appropriate for several reasons, including: To incentivize hospitals to maximize efficiency Remove incentives of providing unnecessary services or expending unnecessary resources Reduce administrative burden Eliminate the need to distinguish between new and established patients Eliminate incentives to “upcode” patients whose visits don’t fall into a clear category Under this proposal, beginning in 2014, physicians and hospitals would begin using the coding structure displayed in the chart to report their visits in the OPPS setting. Supervision of Outpatient Therapeutic Services in CAHs and Small Rural Hospitals CMS proposed to end its non-enforcement policy requiring direct supervision of outpatient therapeutic services in CAHs and small rural hospitals. Thus, for years beginning with 2014, CAHs and small rural hospitals would have to comply with the CMS supervision policy, which requires direct supervision of therapeutic services except for those that CMS identifies as appropriate for general supervision, based on input from the Advisory Panel on Hospital Outpatient Payment (Advisory Panel). CMS believes it is appropriate to let this grace period expire to ensure the quality and safety of hospital and CAH outpatient therapeutic services provided by Medicare. Supervision for Observation Services CMS also clarified that for observation services, if the supervising physician or appropriate non-physician practitioner determines and documents in the medical record that the beneficiary is stable and may be transitioned to general supervision, general supervision may be furnished for the duration of the service. Medicare will not require an additional initiation period(s) of direct supervision during the service. CMS believes this clarification will assist hospitals in furnishing the required supervision of observation services without undue burden on their staff. Hospital Outpatient Quality Reporting (OQR) Program As established in previous rules, hospitals will continue to face a -2 percent reduction to their OPD fee schedule payments for failure to report on quality measures in the OQR Program in CY 2014. Program measures and details on timing and reporting periods can be accessed on the CMS Quality Net website at https://www.qualitynet.org/dcs/ContentServer?c=Page&pagename=QnetPublic%2FPage%2FQnetTier2&cid=1191255879384. For 2014 reporting, CMS proposes five new quality measures and removes two measures from the OQR program for CY 2016 payment. None of the five new measures are applicable to our specialty; however, one of the two measures proposed for deletion (Transition Record with Specified Elements Received by Discharged Patients) may have been reportable by ENTs. Ambulatory Surgical Centers CMS performs an annual review of the legislative history and regulatory policies regarding changes to the lists of codes and payment rates for covered surgical procedures and covered ancillary services in an Ambulatory Surgical Center (ASC) setting. Covered surgical procedures in the ASC setting are defined as procedures that would not be expected to pose a significant risk to the beneficiary’s safety when performed in an ASC and that would not be expected to require active medical monitoring and care at midnight following the procedure. ASC 2014 Proposed Payment Rates For CY 2014, CMS proposes a .9 percent increase to the ASC conversion factor. The table above reflects the major categories of procedures in the ASC setting, the amount paid to each of those settings in 2013, and the estimated percentage change in payments to those categories for 2014. Of note, otolaryngology procedures fall within several of the key categories, including Eye, Integumentary, Auditory, Lymphatic, etc. Ambulatory Surgical Center Quality Reporting Program (ASCQR) In 2012, CMS finalized the implementation of an ASC quality reporting program (ASCQR), which will begin with 2014 payment determination. Quality measures have been adopted for the calendar years 2014-2016. The measures can be found on the CMS Quality Net website previously referenced. CMS continues their proposal to apply a -2 percent payment reduction for ASCs that fail to properly report their quality data in CY 2014. Penalties will be applied in CY 2016 payments based on 2014 reporting.

Recent AMA Policy Changes Affecting Our Specialty

Liana Puscas, MD Chair, AAO-HNS Delegation to the AMA House of Delegates In June, the American Medical Association (AMA) conducted its annual House of Delegates meeting in Chicago. Below are some issues judged to be of increased interest to members of our Academy. Use of Patient Satisfaction Surveys in Determining Physician Payment. Patient satisfaction surveys are increasingly used for both marketing and regulatory purposes. However, spuriously negative surveys can be unfairly detrimental to a physician’s practice. The House of Delegates adopted policy that the AMA work with Centers for Medicare & Medicaid Services (CMS) and non-government payers to ensure that physician payment, when incorporating quality parameters, only consider measures that are under the direct control of the physician. Also, this new policy calls for such surveys to be used only as an adjunctive and not a determinative measure of physician quality for the purpose of physician payment. Scheduling of Hydrocodone. In response to indications from the FDA that it was considering rescheduling hydrocodone from schedule III to schedule II, the AMA adopted policy specifically asking the FDA to keep it as a medication on schedule III of the Controlled Substances Act. There was significant concern that reclassification would restrict access to this common pain medication since schedule II drugs require triplicates and refills are not allowed. Compatibility of EHR systems. The House of Delegates also voted that the AMA will seek legislation or regulation to require all electronic health record (EHR) vendors to utilize interoperable software technology to enable use of EHRs across healthcare delivery systems and community-based settings of care. This policy will result in improved patient care while making it the responsibility of the vendors to ensure interoperability rather than physicians. ICD-10. ICD-10 is scheduled for mandatory implementation by CMS on October 1, 2014. The Cutting Costly Codes Act of 2013 (H.R. 1701) has been introduced in Congress to repeal implementation of ICD-10. The AMA already has policy advocating for delay and repeal of ICD-10. However, should ICD-10 be implemented (or ICD-11 in its stead), the House of Delegates passed another resolution asking insurers for a two-year period in which physician payment would not be denied based on lack of specificity in ICD-10/11 coding. At the meeting, the AAO-HNS delegation consisted of Liana Puscas, MD, chair of the delegation, Michael S. Goldrich, MD, Robert Puchalski, MD, Shannon Pryor, MD, and David R. Nielsen, MD (Academy EVP/CEO and Alternate Delegate). Joy Trimmer, JD, senior director of Government Affairs, Jenna Kappel, director of Health Policy, and Joe Cody, Health Policy analyst, provided staff support. Also of note from this meeting, Dr. Puscas was elected to the AMA’s Council on Medical Education and Dr. Pryor was elected chair of the newly created Women Physicians Section. Prior to the meeting, Dr. Puchalski was elected secretary of AMPAC, the AMA’s political action committee. The next meeting of the AMA House of Delegates will take place November 16-19 in Fort Washington, MD. On the Frontlines: State Legislative Tracking AAO-HNS members are a key resource for tracking state legislation and helping to communicate to policymakers its influence on the specialty and patients. Join the growing team of AAO-HNS state trackers by signing up at govtaffairs@entnet.org to receive daily or weekly legislative tracking updates. If you identify legislation needing Academy action (e.g., letter, action alert, testimony), simply fill out the new online State Action Form at www.entnet.org/Advocacy. Follow Government Affairs on Twitter Do you want to be one of the first to know the status of healthcare bills moving through Congress? Follow the Government Affairs Twitter account @AAOHNSGovtAffrs. By following us, you can learn more about the issues affecting the specialty, including repeal of the flawed Sustainable Growth Rate (SGR) formula, medical liability reform, scope-of-practice battles, Graduate Medical Education (GME) funding, truth-in-advertising initiatives, and efforts to repeal the Independent Payment Advisory Board (IPAB). Not a fan of Twitter? You can also check the Government Affairs webpage for updates at http://www.entnet.org/Advocacy. ENT PAC, the political action committee of the AAO-HNS, financially supports federal Congressional candidates and incumbents who advance the issues important to otolaryngology–head and neck surgery. ENT PAC is a non-partisan, issue-driven entity that serves as your collective voice on Capitol Hill to increase the visibility of the specialty with key policymakers. To learn more about ENT PAC, visit our PAC website at www.entpac.org (log-in with your AAO-HNS ID and password).

Member Profile: Learning and Listening with Earl Singleton, MD

This is the first in an occasional Bulletin series profiling otolaryngologists in later stage and/or no-longer-active practice. The series allows us to hear about and learn from the history, experience, and legacy of those otolaryngologists who have paved the way for others. Dr. Singleton perfectly models an ideal of the “quiet giant” that was coupled with an amazing zest for learning and resulted in influence beyond his small community. His story came to the Bulletin as a result of the readership survey (to be fully reported in our December issue). Jeevan Ramakrishnan, MD, wrote, “My father-in-law recently retired after practicing otolaryngology for 50 years. He spent most of his career in private practice in a small town in north Texas. His story is fascinating.” Dr. Ramakrishnan concluded, “I think it [this and other such stories] might create … the opportunity to get to know one another a little better.” By M. Steele Brown Special to the Bulletin By all accounts, Earl F. Singleton, MD, was one heck of a country doc, but he would’ve been outstanding regardless of locale. A recently retired otolaryngologist-head and neck surgeon and Academy Life-Fellow who spent 39 years in a single specialty private practice in the North Texas border town of Wichita Falls, Dr. Singleton said he never planned to return to practice medicine in his hometown. “I came home to visit my mother and my sister—my dad had died when I was seven—and a doctor who had just opened his ENT practice after getting out of the [U.S.] Air Force at Sheppard Air Force Base there in town, asked me to join him,” Dr. Singleton said. “So he guaranteed me a salary for the first year and we opted to go to work together—thinking that if it worked out that’s great, and if it didn’t, it wouldn’t be a big deal because no anti-compete clauses were in effect. We ended up working together for nearly four decades, so I guess it worked out all right.” Family Ties Regardless of where he ended up, Dr. Singleton may have been genetically predisposed to practice medicine. “Both my dad and his younger brother, my uncle, were physicians,” Dr. Singleton said. “To get through school, they would take turns working and going to school—one would teach while the other one went to (medical) school and they would switch back-and-forth. My dad, who finished first, went into general practice, while my uncle eventually did his residency in ENT in Philadelphia.” “On top of that, my older brother, George Singleton, MD, started the ENT program at the University of Florida (Gainesville) in 1961,” he said. “So while the history only goes back one generation, you get four doctors out of that.” After finishing his undergraduate degree at Rice Institute (now RiceUniversity), Dr. Singleton went to medical school and surgical internship at the University of Texas Medical Branch in Galveston. “I went to medical school in Galveston because it was the only one that would have me, what with my graduating ‘laude-how-come’ from college,” he joked. “I absolutely loved medical school. My wife was pregnant and delivered our first child 36 hours after graduation. So, we decided to stay in Galveston and do a straight surgical internship.” From there, Dr. Singleton completed his year of general surgery at the University of Florida in Gainesville before moving to Boston to do his otolaryngology-head and neck surgery residency at HarvardUniversityMedicalSchool. He said that in medical school he waffled between plastic surgery and otolaryngology-head and neck surgery for a time, but eventually gravitated to otolaryngology because he loved the intricacy of the anatomy of the head and neck. “I thought that a lot of plastic surgery was burn surgery from my medical school exposure and I didn’t want to do that, but I eventually figured out that I could find everything I loved about plastic surgery in ENT,” Dr. Singleton said. “We went to the University of Florida (my wife is from Gainesville) for the year of general surgery and then finished my training in 1969 at the Massachusetts Eye and Ear Infirmary. Harvard was a wonderful training experience for him, with surgical giants such as Harold F. Schuknecht, MD; William Montgomery, MD; Richard Gacek, MD; and Charles Gross, MD, helping him to hone his craft. “He got a wide variety of experience,” according to Jeevan Ramakrishnan, MD, Singleton’s son-in-law and an otolaryngologist-head and neck surgeon in Raleigh, NC. “Harold F. Schuknecht personally taught him how to do stapes surgery.” Top Shelf Country Medicine After completing his residency, Dr. Singleton was in the USAF at Andrews AFB for two years and then was on staff at the University of Michigan for two years, under then-department chief Walter Work, MD, and alongside Roger Boles, MD, former chair of Otolaryngology—Head and Neck Surgery at the University of California, San Francisco, as well as Frank Ritter, MD. As a young attending surgeon at Michigan, he also had the privilege of teaching a veritable Who’s Who group of residents including Michael Johns, MD, the eventual chancellor of EmoryUniversity; Dale Rice, MD, University Southern California department chair and former DrexelUniversity chair of Otolaryngology-Head and Neck Surgery, Robert Sataloff, MD, among others. Then he decided to give up his promising career in academic medicine and open up shop back home in Texas. When they started the practice, Dr. Singleton and his partner were the only two “modern trained” ENTs in Wichita Falls. In a few years they added another associate and the three of them worked together for more than 30 years. “They were go-getters in terms of work and intellectually, so it was really fun,” Singleton said. “We focused mainly on the broad field of general ENT and added facial plastic surgery in there as time went by. We had some training in that field because of our work with the nose, but we also became active in terms of skin cancers, because in our area, there was nobody else doing plastic surgery of that type. “The general surgeons couldn’t do it as well as we did,” he said. “So we ended up working closely with the dermatologists in an office-surgical setting that saved everybody time, money and effort and probably risk, as we were able to do things in the office with minimal sedation. It just ended up being a really neat way to practice country medicine.” Ramakrishnan said that, considering his father-in-law’s expertise, it was more than that. “He didn’t just stick with what he was taught in medical school and residency, he continued to improve and learn,” Ramakrishnan said. “His patients just didn’t know how good a doctor he was and how lucky they were to have this top-notch doctor taking care of them.” Dr. Singleton, who retired to live in the mountains near Waynesville, NC, near his children and grandchildren, said that, as a “country doc,” the physician-patient relationship was an important part of practicing medicine. “That may be family heritage, you know, coming from a family of general practitioners, but I also think that I came through medical school at an extremely practical time, which was ideal for me,” Singleton said. “I always liked to know what people did [for a living]. For one thing, I could usually learn how I could do something better or different—be it fixing something at home or fixing somebody in the operating room—by listening to my patients.” “It helped that I could always extrapolate and figure it out as I went without necessarily having to be taught to do something,” he said. “I might have picked up a trick from a plumber or other field, on how to do something different and often better.” Dr. Singleton said that listening also helped him decide when not to do some things as well. “Those conversations usually gave me an insight as to what might be playing a role in what was going on, even if we are just talking about what they do for a living,” he said. “I think as a part of that, I got to know my patients and their family dynamics. “And I’m not trying to be a psychiatrist, but I think that there are psychological aspects to so many ailments, even including the common cold at times, and I think some of those issues have always played a role in how I treated patients and lent me a degree of understanding that formed how I practiced. I found that many times, just telling somebody that their response was normal was very helpful.” Dr. Singleton said the isolated location of Wichita Falls—roughly 150 miles south of Oklahoma City, Okla. and 130 miles west of Dallas—and some really good timing contributed to his amazing experience. “There were no plastic surgeons, neurologists, pulmonologists, gastroenterologists, oncologists or other specialties that overlapped with general ENT,” he said. “We did everything we were trained to do and then some. You had to learn how to problem-solve and make it happen; and it was amazing if you went a day without learning something.” “There was one neurosurgeon in town when I got there who I was able to work with very closely, and I started doing pituitaries with him,” he said. “To bring that kind of thing in to a town of 100,000 people part way between Dallas and Amarillo was pretty extraordinary. Looking back, I feel like we had as many resources as anybody around [in the field] and more opportunity than a lot, I’d like to think. “One has to remember that this story began in the day when we used head mirrors for exams, tomography was the new thing and CT’s, MRI’s, flexible scopes and many of lab tests, antibiotics etc. were not around yet. It was truly a fun and great time to have practiced medicine when we pretty well kept up with all the changes and expertise.” They had a group that expanded to five ENT doctors that continues to serve that community and otolaryngology-head and neck surgery well. Dr. Singleton feels one of the important things is that we flourish when we are happy. For us to be happy, we must create and seek well as much as we can—this includes family, office and hospital staff, and patients as well as in our other associates and acquaintances. As we often ask our patients “How are you doing?” It’s important to also ask that of our families, staff, and associates. It certainly lets them know that we care, which adds to their happiness and it is often returned several fold to you, the physician.

Optum: An Academy Advantage Partner—A Proactive Treatment Plan Addressing ICD-10-CM “Code Z56.5”*

According to the most recent ICD-10-CM/PCS implementation timeline released by the Centers for Medicare & Medicaid Services (CMS), small, medium, and large practices should already have conducted high-level training on ICD-10-CM for clinicians and coders. To stay on track with the timeline, those practices should currently be testing clinical documentation, coding practices, software, and billing, with October 2013 as the time for practices to begin testing claim transactions with business partners. January 1–April 1, 2014, is the designated time to review coder and clinician preparation with detailed ICD-10-CM coding training. There will be no further delays, and the implementation date is firmly October 1, 2014, for all healthcare providers. For the otolaryngologist, this new generation of coding will facilitate the capture of much greater specificity and clinical information, resulting in increased sensitivity when refining diagnosis grouping and establishing reimbursement methodologies. Plus, better coded data improves clinical decision making and outcomes measurement. While the challenges of coding with ICD-10-CM for otolaryngology are perhaps less significant than for other specialties, they still exist. So what are the steps you can take now to avoid the condition described by ICD-10-CM code Z56.5?* Step 1: Relax, most of the significant changes: code expansion, coding guidance, coding instruction, and classification axes have, for the most part, left the most commonly assigned codes in otolaryngology unscathed. That’s not to imply that solid coding training and preparation can be ignored. Coding training and documentation improvements are necessary to achieve coding compliance. What is important is that this advantage of fewer changes provides a head start in several ways. First, the historical ICD-9-CM coded data will be more easily mapped to ICD-10-CM and will continue to provide valuable data. Second, documentation improvement necessary for coding will not be a giant leap. Third, coding training can be focused, and risks associated with delayed claim submission and denials can be avoided. Step 2: Initiate the action plan for real-time coding training. Appoint an ICD-10-CM coding trainer to take the lead in this action plan. Identify a critical subset of ICD-9-CM codes based on utilization/reimbursement assessment. Code the subset of diagnoses using ICD-10-CM. Mapping can assist in this task as long as it is used in combination with code set knowledge, anatomy and physiology fundamentals, and proper coding practices. Identify any differences in clinical concepts, classification axes, coding practices, and terminology for the specific subset of codes. Assess and implement documentation improvement and coding practices concerning the identified coding differences required for accurate code assignment. Focus ICD-10-CM training based on the code utilization subset including the clinical concepts, classification axes, coding practices, and terminology challenges for the subset of codes. Assess skill levels after training and institute periodic refresher training and coding issue discussions. Step 3: Address these coding/documentation issues challenges. Aftercare versus subsequent encounter: Aftercare visit codes cover situations when the initial treatment of a disease has been performed and the patient requires continued care during the healing or recovery phase or for the long-term consequences of the disease. Subsequent encounter codes cover encounters after the patient has received active treatment for the injury and is receiving routine care for that injury. Laterality: right, left, and bilateral options Asthma: mild intermittent, mild persistent, moderate persistent, and severe persistent classification Recurrent versus nonrecurrent episodes of infections Step 4: Create a work environment that embraces a positive attitude toward change, and thus avoid unnecessary stressors associated with a change as fundamental as a new coding classification system. Taking the steps outlined above will provide a solid foundation for transitioning to ICD-10-CM and avoid the condition described by Z56.5. *Z56.5 Uncongenial work environment (Difficult conditions at work)

From the Diversity Committee: LGBTIQ (Lesbian, Gay, Bisexual, Transgender, Intersex, Questioning) HEALTH EQUITY

Phyllis B. Bouvier, MD Editor’s Note: Dr. Bouvier has just received the Arnold P. Gold Foundation Award for Humanism in Medicine during our annual meeting. She is also a committee member of both our Diversity Committee and that of the National Medical Assocication. She is Co-Director of Diversity for Kaiser Permanente, CO, and author of Kaiser Permanente’s, “Handbook on Culturally Competent Care. Our increasingly diverse healthcare consumer market is demanding concrete evidence of our ability to provide high quality, cost-effective care. This can only be possible by delivering culturally competent care, care that depends on our ability to acknowledge and understand cultural diversity in the clinical setting, demonstrate respect of the patient’s health beliefs and practices, and which values cross-cultural communication and collaboration. Health equity is the attainment of the highest level of health for all people, and when inequities exist, they result in health disparities for individuals, communities, and global societies. In the U.S., about 9 million people (3.5 percent) identify as “lesbian, gay, or bisexual” (LGB), but about 19 million in the U.S. (8.2 percent) have acknowledged engaging in same-sex sexual behavior. About .3 percent identify as “transgender,” that is, a person whose gender identity (the sense of whether you are male or female) may not be the same as one’s physical birth sex. “Transsexual” is a subset of transgendered. This population has so much gender dysphoria that hormone therapy or surgery is used to make the body genitally congruent with the gender identity. “Intersex” describes the condition in which one is born with external genitalia and/or internal reproductive or sexual anatomy that may not fit the typical definitions of male or female. The number of intersex individuals is estimated to be one in 2,000 newborns each year in the U.S. “Q” refers to someone who is questioning what his or her sexual orientation or gender identity is. The term “queer” may be used by many LGBT youth in the U.S. as a prideful and empowering term, but may have negative connotations depending on the social environment. Sexual behavior may be fluid throughout life, and self-identity may be as well. Sexual orientation (our emotional and physical attraction to others of a particular sex) is only a part of someone’s identity. The LGBTI population is made up of individual heterogeneous groups that include all races, ethnicities, age, socioeconomic status, education, disability or veteran statuses, etc., with distinct health risks, experiences, and care needs. Major barriers to the provision of culturally competent care for the LGBTI patient are: A patient’s sexual identity may be invisible to the physician. Patients are often unwilling to self-identify because of fear of discrimination through historically negative interactions with healthcare institutions and providers. Until recently in parts of the U.S., certain aspects of an individual’s sexuality were illegal. Before 1973 homosexuality was listed as an illness or pathological condition by the American Psychiatric Association. There is often a delay in seeking healthcare. Issues of confidentiality are especially important in the healthcare setting since unintentional “outing” can have significant consequences on social and work status. An additional dilemma for providers involves patients who are minors, since parents would ordinarily be able to review the medical record. A physician’s biases, either implicit (unconscious) or explicit (conscious), may affect the quality of the interaction. This includes: homophobia (fear of same-gender sexuality); transphobia (fear/hatred of transgendered individuals); and heterosexism (the belief that heterosexuality is the only form of sexuality). Both heterosexual and the homosexual communities often shun bisexuals. Bisexuality is frequently seen as a nonentity—a transitional phase from heterosexuality to homosexuality or vice-versa and/or as denial that one is actually homosexual. Social stigmatization is still prevalent. In the clinical setting, avoid the use of the term “straight” to identify heterosexuals, as it may imply to the LGBTI patient that anything other than straight is “twisted.” There is limited epidemiological research and lack of provider knowledge of specific LGBTI healthcare issues. Invisibility makes it difficult to accrue demographic data that can help identify needs and expectations of this population. What little is known indicates severe disparities for this population. Alcoholism/binge drinking is prevalent and persists with age. Added stresses of being without full legal protection and lack of societal supports for relationships often leads to increased depression and suicide risk. Lesbians have predicted increased risks of breast and ovarian cancer. Transgendered patients may be at increased risk for HIV/AIDS, but remember that sexual behavior and not sexual orientation causes the disease. Transexuals in transition may be more complicated to provide care for with the onset of the Electronic Medical Record. Some transgendered may be living as the opposite sex for one year before surgery has been completed, and they will still require the preventive care of their birth sex. For example, a female transitioning to a male (FTM) still requires a pap test; a MTF will still need a prostate exam. Not surprisingly, the lab thinks there is an error with the test ordered. Intimate partner violence exists. Batterers can be misidentified as victims and treated as such by police and healthcare providers. We must strive to make healthcare an inclusive and safe environment for all. 2014 Committee Applications Opens November 1 Want to get more involved with your Academy? Apply to become a committee member! The 2014 applications will open November 1. You can join an education committee to become more involved in the Academy’s education activities, a BOG committee to become more involved in the grassroots arm of the Academy, or one of the Academy or Foundation committees that fits your area of expertise. Learn more at www.entnet.org/community/committees.cfm.

From the OHS: Avicenna’s Treatise on Otology in Ancient Persia

Hossein Mahboubi, MD, Yaser Ghavami, MD, and Hamid R. Djalilian, MD, for the Otolargyngology Historical Society Avicenna (AD 980-1037), born in ancient Persia, is one of the best-known physicians of all time whose legacy has lasted for centuries. As the king’s physician and governor of two major states, who had access to the Samanid royal library, Avicenna wrote 450 books and added many original contributions to the diagnosis and treatment of diseases in addition to what was known in Persian and Greek medicine. He is best recognized for his book, The Canon of Medicine, which was one of the primary medical textbooks throughout Europe and the Persian Empire for more than five centuries. The Canon of Medicine, described as the medical bible by Sir William Osler, consists of five volumes discussing general principles of physiology and hygiene, simple drugs and their effects, diseases, and medication recipes. Otologic diseases have a dedicated chapter in the Canon consisting of separate treatises for ear anatomy, earache, tinnitus, ear purulence and ulcers, ear obstruction, water in the ear, bleeding from the ear, insects in the ear, and trauma. Despite restricting Islamic rules on autopsy, Avicenna’s description of the ear anatomy resembles the modern classifications. His theories on hearing damage and types of hearing loss were quite fascinating for his time. He classified hearing loss into three types and distinguished between conductive and sensorineural hearing loss. He described earaches that were caused by inflammation, foreign objects, ear trauma, and cold and warm temperatures. Although he thought of tinnitus as a ringing sound generated by the movement of air inside the ears of patients with powerful or weak senses, his recognition of trauma, inflammation, and drugs as causes of tinnitus was remarkable. He described a variety of topical therapies for tinnitus. Avicenna’s theories on abscess formation were based on humors similar to his predecessors. He treated abscesses by drainage using a knife. To alleviate abscess-associated pain, his prescription consisted of salt, chamomile, or poppy ointment. In his second book, where he described the ear diseases, he usually recommended topical medications as treatment. Avicenna’s review on otology provided new information and greater insight into the anatomy and physiology of the ear. His in-depth descriptions of the pathology, signs, and symptoms of various ear diseases and how to effectively treat them illuminated the path to modern otology. Reference Avicenna’s treatise on otology in Medieval Persia. Hamidi S, Sajjadi H, Boroujerdi A, Golshahi B, Djalilian HR. Otol Neurotol. 2008. Dec;29(8):1198-203. Next Month in the Bulletin: Every month the Bulletin delivers news relevant to your membership and the specialty. November will feature: Bell’s Palsy Clinical Guideline Executive Summary The New Committee Rosters And editorials by Richard W. Waguespack, MD; David R. Nielsen, MD, and Joseph E. Hart, MD On the go, access the Bulletin at www.entnet.org/bulletin to read each issue online.

From the OHS: History of Pediatric Airway Reconstruction

Ron B. Mitchell, MD Chief of Pediatric Otolaryngology University of Texas Southwestern and Children’s Medical Center, Dallas for the Otolaryngology Historical Society Laryngotracheal stenosis has plagued its victims and frustrated otolaryngologists for more than a century.1 Before 1935, laryngeal infections, including diphtheria and syphilis, were the main causes of laryngotracheal stenosis. Between 1935 and 1970, trauma (mostly by motor vehicle accidents) became the leading cause of laryngotracheal stenosis. Post-1970, prolonged endotracheal intubation in neonates became and remains the primary cause of laryngotracheal stenosis in children. Chevalier Jackson, MD,2 considered by many as the father of bronchoesophagology, performed laryngoscopy in the pre-1935 era. This was an open procedure performed under local anesthesia with a solution of cocaine, salt, and carbolic acid. He referred to these patients as canulard, a French word meaning “a patient who cannot abandon his cannula.” Dr. Jackson reported successful decannulation in more than 80 percent of patients, all of whom were adults. The procedure was time-consuming and tedious, but considered a worthwhile alternative to a permanent tracheotomy. In 1938, Edward A. Looper, MD,3 reported the use of the hyoid bone as a graft for correction of laryngotracheal stenosis. In the 1950s, Aurel Rethi, MD,4 began dividing both the anterior and posterior lamina of the cricoid cartilage to enable expansion of the subglottic lumen. Advancements using tissue grafts and techniques to expand the subglottic space foretold their widespread use in future laryngotracheal surgery in children. However, these procedures involved a long postoperative course and high recurrence rates. Around the 1960s, tracheotomy was increasingly performed in neonates for laryngotracheal stenosis caused by prolonged intubation. Mortality rates as high as 24 percent were reported. This set the stage for pioneering work directed at avoiding this unacceptable mortality rate in children. Blair W. Fearon, MD, and Robin T. Cotton, MD,5 started working on methods of enlarging the cricoid lumen using laryngotracheal reconstruction with costal cartilage. John N.G. Evans, MD, FRCS, reported success with a laryngotracheoplasty involving division of the thyroid and cricoid cartilages followed by castellation of the proximal trachea. Drs. Cotton and Evans, in a collaborative manuscript in 1981, reported a 90 percent decannulation rate and concluded that the procedures were largely interchangeable. In 1993, Philippe Monnier, MD,6 introduced the use of cricotracheal resection (CTR) for severe laryngotracheal stenosis in children and reported decannulation in the vast majority of these patients. These advances have resulted in decreased morbidity, tolerability, shorter recovery time, and fewer stages of reconstruction, as well as a success rate that surpasses 99 percent. With the addition of transplantation, there may be a time in the near future when children with laryngotracheal stenosis will live a life independent of a tracheotomy tube. References Santos D, Mitchell RB. The History of Pediatric Airway Reconstruction. Laryngoscope. 2010 Apr;120(4):815-820. Jackson C, Jackson CL. Diseases and Management of the Larynx. 2nd ed. New York, NY:MacMillan Company; 1942:202-207. Looper, EA. Use of the hyoid bone as a graft in laryngeal stenosis. Arch Otolaryngol. 1938;28:105-111. Rethi, A. An operation for cicatricial stenosis of the larynx. J Laryngol Otol. 1956;70: 283-293. Cotton RT, Evans JN. Laryngotracheal Reconstruction in Children–Five Year Follow Up. Ann Otol Rhinol Laryngol. 1981;90:516-520. Monnier P, Savary M, Chapuis G. Partial cricoid resection with primary tracheal anastomosis in infants and children. Laryngoscope. 1993;103:1273-1283.

Board of Governors Update

Regionalization of the Board of Governors This is the start of another exciting year in the Board of Governors (BOG). This year implementation and activation of the Regional Plan will be high on the priority list. This plan divides the country into 10 regions following roughly the same lines of division as the Department of Health and Human Services (DHHS). There will be a regional representative from each of the regions charged with keeping the BOG up to date on socioeconomic and grassroots issues affecting each area of the country. The plan is that this will be done primarily through regional reports at the fall and spring BOG meetings, Academy staff coordinated conference calls, and direct communication with the BOG Executive Committee. This plan puts a point of communication closer to the area of action. This is a two-way street. Our goal is not only to receive important updates from the regions but also to use this as an effective tool to stream critical information from the BOG to member societies and practicing physicians. Thus far we have had regional reporting at the last two annual fall meetings. As valuable information is shared, trends emerge and action plans are developed and communicated back to those groups and individuals in the regions that can help us achieve our goals on your behalf. The idea of regionalization of the BOG has been at least two years in development and has come a long way. This large task cannot be accomplished effectively without the direct help of every member society and otolaryngologist in these regions. The regional reps will be reaching out to you within the next several months. Please help us get closer to the concerns that affect you on the ground level. Polls As we implement the regional plan, the BOG from time to time will be polling the membership on topics of importance. Our first go at this was a poll on the member opinion on subcertification in advanced pediatric otolaryngology. More than 30 member societies responded, a 42 percent response rate. More than 1,000 individuals responded representing almost 4,500 members. The BOG received exceedingly positive feedback for engaging the membership in this fashion. We found an impassioned voice from our responders and time and time again commentary indicated an appreciation for asking their opinion. We will continue this method of feedback and will rely on the member societies to help us implement this powerful technique of information gathering. In the coming year we will be helping the societies to discover the most effective method of implementation for maximal input. Your participation is a necessity and empowers the membership. Your thoughts and concerns do matter and they guide and empower the BOG to develop thoughtful, effective, timely, and prescient action plans that benefit our entire community. Residents, Fellows, and Young Practicing Physicians Young physician, resident, and fellow involvement has been and will remain a priority for the BOG. The BOG Executive Committee and Academy staff have made it a priority to harness the energy of our youngest otolaryngologists and those in training. We had more than 30 residents and fellows at the BOG Spring Meeting, many of whom were recipients of generous member, member society, and academy grants for participation. Also, the residency program directors and chairs were gracious in allowing the residents the time and support they needed to participate. We had quite a few young physicians join us as well. This group is one of the most active and passionate that we have. They want to be involved and have a positive influence in the future of our specialty. It is our responsibility to help them make sure this happens.

Committing to Self-government

Each October signals the tenure of a new round of Academy leadership. Not only do we inaugurate and honor a new Academy president, but a significant number of board members of both the Academy and the Foundation, as well as committee members and chairs, turn over each year. As I reflect on the “changing of the guard,” I experience two strong emotional responses. First, I am continually amazed and honored to be allowed to work so closely with such effective, selfless, and dedicated leadership. Working so closely with these remarkable men and women inspires me with confidence for the future. It is reassuring to know that we have an endless supply of talent and inspirational leadership. Second, my gratitude for the voluntary service represented by these leaders (emblematic of the culture of service that pervades our entire membership) is hard to put into words. So it is with great thanks and some sadness that we say “thank you” to James L. Netterville, MD, for his very personable, gracious, and effective leadership during the last year, and welcome with enthusiasm and anticipation the energy and guidance of our new president, Richard W. Waguespack, MD. As you all know, for nearly two decades we have alternated the selection of many of our officers, board, and committees members between community-based and academic otolaryngologists. In that manner, directly elected board directors, Nominating Committee members, as well as the president always bring the perspective of our entire membership, not just a popular or more vocal segment, to the table. This is a timely reminder, since this October issue of the Bulletin devotes focus to our membership and several committees. The structure of our Boards of Directors, the BOG, and our relationship with state, regional, or other specialty societies is designed to strike the optimal balance between the common ground that unites all of us as otolaryngologists and the desired autonomy of smaller societies who effectively provide community, subspecialty, or other interest or focus. The manner in which humans organize themselves to achieve things together that they could not achieve alone makes for interesting study. Whether forming a new neighborhood tree house club or a new nation, humans have sought safety, camaraderie, solace, community, or collective action with likeminded people since before recorded history. While the consequences of the boundaries we formally place around our relationships, and the number of “groups” we feel a kinship with has a serious impact on many aspects of our lives, some of what we learn over time makes us ask, “What were they thinking?” (Or, perhaps more to the point, “What were we thinking?!”) In his book, How the States Got Their Shapes, Mark Stein comments on the tremendous insight to be gained from researching this question. “Far more knowledge results from exploring why a set of conditions exists than from simply accepting those conditions and committing them to memory. Asking why a state has the borders it does unlocks a history of human struggles–far more history…” than the question implies. In studying why our geographic boundaries are the way they are, we learn about politics, war, grants, gifts, generosity, forgiveness, complaisance, incompetence, resignation, and regret. We discover the challenge of overcoming the inertia of culture, the bonds of familiarity, and the fear of the uncertain. These ideas are affecting how we move forward as otolaryngologists in both our internal and external environments. Internally, we have for years benefited from addressing the challenge of asking why we are organized the way we are, why we do things the way we do, and are our traditions, assumptions, and expectations still valid and relevant. We are drafting an entirely new version of our Member Handbook, complete with standard operating procedures, documentation of processes, and accurate and updated application of bylaws, policies, and positions that benefit our members, and by extension, our patients. Externally, we are being forced by economics, politics, and our professional desire to be the best to challenge foundational assumptions of how we organize healthcare, delivery and payment models, and methods for ensuring the highest quality of care can be delivered with the most effective utilization of resources. As we return to our practices after another successful Annual Meeting & OTO EXPOSM, let us meet the challenge to bring out the best in each other, professionally, personally, and organizationally. Let us use our leadership to focus on what unites us. Let’s be sure that when it comes to the American Academy of Otolaryngology–Head and Neck Surgery that the whole is much greater than the sum of its parts.

A New Beginning in a Familiar Place

This is a new beginning for me, but I am not a stranger here. I received my medical degree from Louisiana State University School of Medicine in New Orleans and completed my residency at the University of Texas Medical Branch, Galveston, in 1980. After being a community-based practitioner for 33 years, I now have moved from that setting to become a clinical professor at the University of Alabama at Birmingham. I also serve as otolaryngology section chief at the Birmingham VA Medical Center. Within our Academy, I have served in many different roles including board member, coordinator for socioeconomic affairs, and BOG chair. I am also a reviewer for Otolaryngology-Head & Neck Surgery. Throughout the years, I have chaired 3P (Physician Payment Policy Work Group) and our CPT/RVU Committee. On the education side, I have been a member of the Program Advisory Committee, the Instruction Course Advisory Committee, and, until recently, the Education Steering Committee, while chairing Core Otolaryngology Practice Management Education Committee. It is my honor now to serve you this next year as president of the Academy. Within the specialty, I have been a senior examiner for the American Board of Otolaryngology (2008-2012) and on the Editorial Board of the Laryngoscope. I was honored to be named to the AMA CPT Editorial Panel (2004-2008), the body that creates and maintains CPT codes. So, I come to this position with a variety of perspectives, especially in health policy and education, and am certain there are a number of opportunities for us to make a difference together. In my June 2012 official statement as a candidate for AAO-HNS/F president-elect, I stated that our greatest strengths are our strategic planning process and the caliber of Academy leadership. Virtually every significant Academy activity is viewed from the perspective of adherence to this long-range planning that addresses the best interests of our members, and by extension, our patients. This strategic planning is as integral to our operations, as is the identification and mentoring of the next generation of leaders. Our vulnerabilities include the risk of fragmentation, loss of specialty unity, and our relatively small size within the house of medicine. To thrive, we must engage the diversity within the specialty as we identify potential leaders and engage our subspecialty societies to further our advocacy, research and quality, and education activities. So this year I would like to help you, our members, continue to provide quality patient care both by leveraging our strengths and mitigating our weaknesses. Education Our tradition shows that we have been in the forefront of specialty education, but with your help we are adopting new methods of delivering relevant materials to members. For example, the award-winning Academy QTM is helping many prepare for certification on their own schedule. Also note that AAO-HNSF collaboration with the American Board of Otolaryngology on the Fundamentals of Clinical Otolaryngology, (special educational offerings during this year’s Annual Meeting) allowed participants to directly earn maintenance of certification credits. Coordinating education, advocacy, and research within the Academy and with our societies should help avoid duplication and boost productivity, while maintaining the highest standards. We can work to strengthen these activities. Policy and Research Combine for Quality Care The relentless trend of decreased reimbursement coupled with increasing expense and administrative burden continues. Regardless of the fate of the Affordable Care Act, this squeeze is inexorable and will likely result in changes uncoupling reimbursement from the traditional fee-for-service model. I am committed to advancing quality-driven patient care, and enhancing the specialty of otolaryngology-head and neck surgery. This requires evidence-based, health services research, which Academy leadership must help coordinate, foster, and disseminate. Our cross specialty guideline development gives us visibility with primary care physicians, physician assistants, and nurse practitioners as well as consumer groups and ultimately the public. Working with primary care professionals allows us both to strengthen our working relationship and potentially open avenues for investigation for integrated services. The same is true of our RUC and CPT efforts. Through the Ad HOC Payment Model Work Group, we are actively participating and innovating within new models for payment delivery reform. These models are designed to meet the three aims of the National Quality Strategy in the delivery of healthcare services: better care, affordable care, and healthy people and communities. For more detail, visit http://www.entnet.org/practice/paymentreform.cfm. My overarching goal this year is to provide members with as many tools as possible to deal with these challenges and, wherever possible, mitigate unreasonable burdens on our practices and patients.