More from March 2013 - Vol. 32 No. 03
Thanks to the generous support of Academy members who donated to our humanitarian efforts projects, 15 residents and fellows-in-training received grants of $1,000 each toward medical missions from January through July 2013.
For more than a decade, our AAO-HNS Foundation’s Humanitarian Efforts Committee has selected senior residents and fellows-in-training for travel grants to accompany mission teams. While the grants of $1,000 each cannot cover the travel costs, they are an inspiration to the grantees, who return profoundly changed by their experiences. Feedback from returning residents has demonstrated how invaluable these encounters are for both their personal and professional development. Overwhelmingly, the awardees commit themselves to continuing to volunteer for missions throughout their lives.
The awardees will be recognized during the AAO-HNSF 2013 Annual Meeting and OTO EXPOSM, Vancouver Convention Centre in Vancouver, BC, during the Humanitarian Forum. Please join us in congratulating these dedicated residents and fellows-in-training.
Sarah N. Bowe, MD, Ohio State University Medical Center, Project EAR, Inc., Dominican Republic, Los Alcarrizos, April 13-21, 2013.
Do-Yeon Cho, MD, Stanford University, Myungsung Christian Foundation, Ethiopia, Addis Ababa, May 20-31, 2013.
David J. Crockett, MD, University of Utah, division of otolaryngology, Operation Restore Hope, Philippines, Cebu, February 15-24, 2013.
Ethan B. Handler, MD, Kaiser Permanente Oakland, Faces of Tomorrow, Ecuador, Quito, June 8-17, 2013.
Andrew C. Heaford, MD, University of Iowa Hospitals and Clinics; department of otolaryngology: head and neck surgery, Miles of Smiles in Guatemala; Iowa MOST mission, Guatemala, Huehuetenango, February 14-24, 2013.
Evan R. McBeath, MD, University Hospitals Case Medical Center, Case Western Reserve University, Concern for Children, El Salvador, San Salvador, January 9-19, 2013.
Bryan R. McRae, MD, Indiana University School of Medicine, department of otolaryngology-head & neck surgery, IU-Kenya Program, Kenya, Eldoret, January 19-February 3, 2013.
Sachin S. Pawar, MD, Oregon Health & Science University, FACES Foundation, Peru, Lambayeque, January 25-February 3, 2013.
Angela S. Peng, MD, University of Minnesota, department of otolaryngology-head & neck surgery, Mayflower Medical Outreach, Nicaragua, Managua, February 16-24, 2013.
Maria de Lourdes Quintanilla-Dieck, MD, Oregon Health & Science University, FACES Foundation, Peru, Lambayeque, January 25-February 3, 2013.
Joseph W. Rohrer, MD, San Antonio Uniformed Services Health Education Consortium, Face the Future Mission Rwanda, Rwanda, Kigali, February 1-10, 2013.
Dhave Setabutr, MD, Penn State Hershey Medical Center, Faces of Tomorrow, Ecuador, Quito, June 7-16, 2013.
Laura L. Shively, MD, Dartmouth-Hitchcock Medical Center, Mayflower Medical Outreach, Nicaragua, Jinotega, Managua, February 17-25, 2013.
Yi-Hsuan E. Wu, MD, Tufts Medical Center, Medical Missions for Children, Rwanda, Gitwe, March 7-17, 2013.
Estelle S. Yoo, MD, Alfred I. DuPont Hospital for Children, department of surgery/division of otolaryngology, World Hearing Foundation, Honduras, Tegucigalpa, March 23-39, 2013.
Visit the Humanitarian Efforts Member Engagement Portal to help facilitate matching critical needs with medical specialty expertise: www.entnet.org/humanitarianportal.
To learn more about Humanitarian Resident Travel Grants visit http://www.entnet.org/HumanitarianTravel. May 31, 2013, is the deadline for grant applications for mission trips during July 1 through December 31, 2013.
Join KJ Lee, MD, for the 2013 China TourKJ Lee, MD, invites you to experience China, June 5-16, after the IFOS World Congress, Seoul, South Korea, and ending at the World Chinese ENT Academy Congress, Hong Kong.
Exchange ideas with Chinese otolaryngology leaders and enjoy Chinese cultural heritage, with such famous sights as:
The Great Wall, Beijing’s Summer Palace, Tiananmen Square, and Forbidden City
Peking Opera and Peking duck banquet
Xi’an’s terra cotta warriors and the World Heritage Site, Fujian Tulou
To reserve, call 1-203-772-0060, 1-800-243-1806 or email firstname.lastname@example.org. Questions? Contact Dr. Lee, Academy past president, by calling 1-203-777-4005 or emailing email@example.com. Jean-Paul Azzi, MD
New York Eye and Ear Infirmary
On Saturday, November 3, 2012, 29 other volunteers and I from Healing the Children Northeast flew from New York City to Guayaquil, Ecuador, on our way to Babahoyo. This would be a new site for us, and with this, we expected to face new challenges. As we discussed our concerns in the airport and on the flight to Ecuador, it was clear that despite this, our goal remained the same: to help these children and their families. Upon arrival we were greeted by our hosts Drs. Roxana Roman and Rafael Hernandez, as well as the local police force who escorted us to Babahoyo and our hotel.
The team included administrators, technicians, nurses, pediatricians, anesthesiologists, and surgeons. Manoj T. Abraham, MD, a facial plastic surgeon, led the surgical team, which included myself, Augustine L. Moscatello, MD, and Craig H. Zalvan, MD—all members of the American Academy of Otolaryngology—Head and Neck Surgery. John G. Bortz, MD, an oculoplastic surgeon, also joined us.
Drs. Moscatello and Azzi entertain a preoperative cleft lip patient. Drs. Moscatello and Azzi entertain a preoperative cleft lip patient.On Sunday, we evaluated 207 patients of which 91 were scheduled to have surgery during the next five days. Ages ranged from a few weeks old to adulthood, with most requiring either revision or repair of cleft lips and palates. Many of these children and their families traveled several hours across very difficult terrain. Some traveled by foot or on donkeys for days to reach our clinic, Fundacion Ceolinda Troya, where a tent with fans and cold water was erected the evening before.
Healing the Children, with its goal of organizing humanitarian medical missions to perform surgeries on needy children around the globe, has made a lasting impact on the vulnerable and impoverished throughout the world. I feel fortunate to have contributed again this year. I’m humbled by the impact I made even as just one part of a larger effort. It really puts things in perspective. I know I speak for the entire team when I say we will continue to do everything we can to heal the children worldwide. AcademyU®, the Foundation’s otolaryngology education source, offers five types of learning formats that include knowledge resources, subscriptions, live events, eBooks, and online education. Each one contains elements that make up the breadth of the education opportunities available through the Foundation. In this second article in the series, we explore the variety of activities that make up the online education component of AcademyU®; these include online courses and lectures and COOL cases.
AcademyU® Online Education (www.entnet.org/onlinecourse) is organized by the eight subspecialties within otolaryngology-head and neck surgery to make it easy for any otolaryngology specialist to find the courses that best fit his or her education needs. In addition, the online platform makes it easy for learners to take advantage of these education opportunities on their own schedules and at their own pace.
Online Courses and Lectures
Online Courses are learning activities developed by the Foundation education committees. These peer-reviewed courses provide in-depth study of otolaryngology head and neck surgery topics determined by an expert-driven analysis of learner education needs. These high-quality courses offer 45 to 60 minutes of detailed instruction on a particular topic. Each contains rich media elements such as detailed images and short video clips.
The online courses are:
Preventing Operating Room Fires
Optimal Safety in Otolaryngic Allergy Practice
Chin Augmentation: Sliding Osteotomy and Alloplastic Implants
Alternative Medicine: Perioperative Management Issues of Herbal Supplements and Vitamins
Basic Head and Neck Pathology
Evaluation of an Adult Patient with a Benign Neck Mass
Evaluation of an Adult Patient with a Malignant Neck Mass
Loco-regional Recurrence in Head and Neck Squamous Cell Carcinoma
Introducing the AAO-HNS Expert Witness Guidelines
English-to-Spanish Ear Examination Phrases
Gender Equity in the Workplace
Understanding Stereotactic Radiation for Skull Base Tumors
The Ten Minute Exam of the Dizzy Patient
Office Otoscopy I: Normal Examination, Spectrum of Otitis Media, and Characteristic Appearances of Abnormal Pathologies
Office Otoscopy II: Case Studies
Office Otoscopy III: Clinical Case Studies Featuring Long-term Serial Examination and Anatomic Cross Section
Risks of Steroids for Sudden Sensorineural Hearing Loss
Cleft Lip and Palate Overview
Introduction to Velopharyngeal Dysfunction
Management of Sinonasal Cerebrospinal Fluid Leaks
Online Lectures are based on the Annual Meeting & OTO EXPOSM instruction courses of the same name. They are selected from the top abstracts submitted to the Annual Meeting; faculty are invited to record a condensed version of their presentation for publication to the AcademyU® website. Each lecture provides highlights of key sessions in short 20- to 40-minute segments using the speakers’ slides and audio recordings. There are online lectures available, including more than 100 from the 2012 Annual Meeting & OTO EXPO.
The 2013 Online Lectures are:
Worldwide Otolaryngology Humanitarian Missions
Developing a Quality Control Program for Surgeons
Rhinoplasty: Arming Novices for Success
Facial Aesthetic Enhancements: Chemodenervation and Tissue Augmentation
Current Management of Oropharyngeal Cancer
The Management of Glottic Cancer in 2012
Endoscopic and Robotic Thyroid Surgery
Minimally Invasive Salivary Endoscopy
Chronic Cough: Hacking Up a Treatment Algorithm
Endoscopic Microsurgical Techniques for Laryngeal Disease
Laryngopharyngeal Reflux (second edition)
Tympanoplasty/Ossicular Reconstruction—Some Novel Ideas?
Balance Problems in the Elderly
Tinnitus: New Frontiers in Radiology and Brain Imaging
Meniere’s or Migraine: Similarities, Differences, Treatments
Surgical Management of Eustachian Tube Disorders
Pediatric Obstructive Sleep Apnea What to do after T and A?
Chronic Rhinosinusitis in Children (second edition)
Stertor, Stridor, and Babies that Squeak: A Practical Approach
Up-to-Date Management of Recalcitrant Sinonasal Polyposis
Five New Landmarks to Make You a Better Sinus Surgeon
Target audiences for both the online courses and online lectures are practicing otolaryngology-head and neck physicians, surgeons, and residents. Most online courses and lectures offer continuing medical education credit.
Clinical Otolaryngology OnLine (COOL)
Clinical Otolaryngology OnLine, (COOLSM) cases are free, peer-reviewed, interactive case studies that lead the learner from patient presentation through diagnosis, treatment, and referral. COOL is an excellent instructive program for non-otolaryngologist physicians and other health professionals who regularly encounter otolaryngology-related problems.
The 34 COOL Cases are:
Adult with Otitis Media due to MRSA
Ear Canal Obstruction
Dizziness in the Elderly
Otoscopy Cholesteatoma Part I
Otoscopy Cholesteatoma Part II
Sensorineural Hearing Loss
Mouth, Neck, and Throat
An Approach to the Pediatric Patient with a Neck Mass
HPV and Head and Neck Cancer
Indications for Tonsillectomy
Management of the Thyroid Nodule
Non-Melanoma Cutaneous Malignancies
Oral Cavity Lesions
Pediatric Aerodigestive Tract Foreign Bodies
Pediatric Neck Abscess Due to MRSA
Upper Airway Obstruction—Obstructing Laryngeal Cancer
Nose and Sinus
Facial Soft Tissue Trauma
General Exam of the Nose
Management of Acute Rhinosinusitis
Orbital Complications of Rhinosinusitis in Children
Target audiences for COOL include physician assistants and nurse practitioners, non-otolaryngologist health professionals, and medical students. COOL has been reviewed and approved for AAPA Category 1 Credit by the Physician Assistant Review Panel. Rahul K. Shah, MD
George Washington University School of Medicine
Children’s National Medical Center, Washington, DC
I was a resident almost a decade ago, working with David W. Roberson, MD, at Children’s Hospital Boston when we both asked the question, “Where are we with errors in otolaryngology?” At that time, the study of patient safety and quality improvement was in a resurgence, which was in its relative infancy. To properly conduct studies, we were trained in the research methodology: ensuring a proper sample size and looking for statistical significance when comparing two groups. In an attempt to design a proper study of errors in otolaryngology, this methodology proved to be a stumbling block. There had been seminal work on a classification of errors in family medicine. That manuscript and methodology resonated with us as it elegantly provided a framework to assess, measure, quantify, and perhaps ameliorate errors in that specialty. Like good researchers, we emulated their methodology and it worked. In 2004, we published a classification of errors in otolaryngology along with the implications of those errors. When looking at zones of risk in our specialty, we would often revisit the data from that set to understand vulnerabilities in our realms of practice. We would then design a deeper dive study or approach to tackle a specific zone of risk. We have done that a few dozen times and hope we have made the practice of otolaryngology safer and more standardized.
In the past months, we have been struggling with the concept that our Academy Members’ understanding, appreciation, and sophistication vis-à-vis patient safety and quality improvement have grown tremendously as a result of specific Academy initiatives, mandates from the government and payers, and personal interest from our dedicated Academy Members. To this end, we felt it compulsory to check the pulse of our members with regard to understanding errors in otolarygnology almost a decade after our initial survey study. We needed to ensure that we would be comparing apples to apples so we could make meaningful comparisons between the data from 2004 and the current data. Hence, we used a similar question set in an updated survey tool with some additional questions focusing on the nature of our practices and perceived zones of risk, attribution for the errors, culpability, and improvement processes implemented. After much consideration, we decided we should embrace technology (and keep costs low) and use an online survey tool to conduct the survey. The survey closed at the end of November after being open for fewer than 20 days.
We have not sat down to properly classify and sort through the responses; we’ve only spent a few moments to ensure the integrity of the responses and confidential data capture of the online survey tool. We will, of course, properly classify the responses, write up the results in a peer-reviewed manuscript, and publish it for Academy members to continue to reference. However, we were shocked by the number of responses we received. In fewer than 20 days, more than 677 Academy Members took time from their busy practices in the winter season to respond to a survey that was essentially self-reporting of errors in our specialty.
The response rate is staggering and clearly shows the passion of Academy Members and sheer interest we each have in improving the quality of care we deliver. Members clearly understand that, collectively, we have the power to improve our own practices. The high response rate resonates with us because it implies that we are aware of the concept that we may proceed through our entire career and never experience an error such as mis-administration of concentrated epinephrine because it is so rare, however, if we collectively look at our practices, it is a problem that needs to be considered. The sheer volume of responses also validates the PSQI Committee’s commitment to a secure, online patient safety event reporting portal, which will be available soon on the Academy website.
As this issue of Bulletin goes to press, we will be properly classifying and understanding the huge volume of responses we received from Academy members. We should all take a moment to pause and appreciate how collectively our specialty continues to move the needle toward improving the care and safety of patients with otolaryngology diseases because we are so passionate as a specialty and as Academy Members about ensuring that we deliver quality care.
We encourage members to write us with any topic of interest and we will try to research and discuss the issue. Members’ names are published only after they have been contacted directly by Academy staff and have given consent to the use of their names. Please email the Academy at firstname.lastname@example.org to engage us in a patient safety and quality discussion that is pertinent to your practice. You’ve probably heard about CMS’ Physician Compare Website. You may even know that the development of this public website is a statutory mandate from the Affordable Care Act. Unfortunately, what many physicians and members are not aware of is the information that’s available about them, and their practices, on this website.
The first thing members should know is that this program is updated and modified on an annual basis through federal rulemaking. This means that CMS will announce proposed revisions or additions to the Physician Compare Website in the notice of proposed rulemaking (NPRM) of the Medicare Physician Fee Schedule (MPFS) each calendar year. They then accept feedback on their proposals from the public during a 60-day comment period and finalize their policies in the final MPFS for that year, typically published on or around November 1 each year. The Website can be accessed at: http://www.medicare.gov/find-a-doctor/(X(1)S(0grwmc55y5poo245uxj5ifv5))/provider-search.aspx?AspxAutoDetectCookieSupport=1.
The Physician Compare Website was launched in December 2010 and originally included data on those eligible professionals (EPs) who successfully reported on the Physician Quality Reporting System (PQRS) measures in CY 2009.
Today, the Website includes the following information on providers:
The provider’s primary, and any applicable secondary, specialty(ies);
The provider’s practice locations;
The providers group practice or hospital affiliations, where applicable;
The provider’s education information, language skills, and gender;
The names EPs who have successfully reported on quality programs, specifically e-prescribing and PQRS for CY 2011.
What to Expect in 2013
By January 2013, CMS is required to outline a plan for posting information on provider’s quality performance, as well as patient experience data, on the Physician Compare Website. CMS is presently undertaking a full Website redesign project aimed at improving the usage and function of the site. In addition, CMS has finalized the following information for release in CY 2013:
2012 data on PQRS Group Practice Reporting Option (GPRO) measures for practices that meet the minimum sample size of 20 patients;
Whether providers accept Medicare patients;
Board certification information; and
Improved information on language skills and hospital affiliations.
As part of the Website redesign project, CMS allowed the Academy to view and comment on the proposed redesign. In the letter, the Academy addressed several issues included in the proposed redesign. Visit the Academy’s “What’s New” page at: http://www.entnet.org/Practice/CMS-News.cfm to access the full letter. Areas addressed by the Academy included:
Data accuracy is paramount in the physician compare site and CMS proposes including claims based verification for physician information rather than just relying on PECOS;
Concern regarding the small sample size used for posting information such as participation in PQRS GPRO;
The posting of GPRO performance rates and the need for a review period to ensure the data posted is accurate; and
The inclusion of CG-CAHPS survey data, as well as the S-CAHPS data, into the Physician Compare website.
What to Expect in 2014 and Beyond
For 2014, CMS anticipates posting information on provider performance rates on measures reported by physician groups or Accountable Care Organizations (ACOs) via the GRPO web interface system. These groups will have 30 days to review their information for accuracy before it becomes publicly available. CMS also hopes to post patient experience survey data gathers using the CG-CAHPS survey method for groups of 100 or more providers. Finally, CMS will post information on providers who obtain PQRS maintenance of certification incentives during CY 2014.
Other information CMS is considering for inclusion on the website in the future are performance on quality measures developed by specialty societies, continued efforts to align the PQRS and value based payment modifier (VBP) program measures, the release of provider performance in these programs, as well as individual EP performance measure data.
Currently, the website pulls physician information from the PECOS enrollment system. CMS plans to verify the accuracy of PECOS information via a claims based verification, which the Academy supports. Until these changes are implemented, the Academy encourages members to check their PECOS enrollment information, as well as what information is currently available about them on the Physician Compare website, and to contact CMS if they find the information is incorrect.
The Academy’s health policy team will continue tracking the development of this important public website and will alert members to any key changes to the program in the future. Should you have any questions or concerns about the website, or your publicly available information, please contact us at email@example.com. As an Academy member, you’ve probably seen frequent requests distributed in “The News” asking for volunteers for upcoming AMA Relative Value Scale Update Committee (RUC) surveys of physician services. Many of you may have asked yourself, “what the RUC is and why are these surveys important?” During the last several years, the Academy has provided members with background on the RUC in an effort to educate and engage members in the annual RUC process. This year, we’d like to address the common questions that arise during the RUC survey process in hopes of outlining why member participation in these surveys is so critical.
What is the RUC and Who Participates?
The AMA RUC was developed in response to the transition to a physician payment system based on a Resource-Based Relative Value Scale (RBRVS). The RUC is a multispecialty committee that provides clinical expertise and input on the resources required to provide physician services. The RUC submits recommendations annually to the Centers for Medicare and Medicaid Services (CMS), which uses them to develop relative values for physician services provided to Medicare beneficiaries. The RUC, in conjunction with the Current Procedural Terminology (CPT®) Editorial Panel, has created a process where specialty societies can develop relative value recommendations for new and revised codes, and the RUC carefully reviews survey data presented by specialty societies to develop recommendations for consideration by CMS. CMS then issues final payment policies and values in the final Medicare Physician Fee Schedule rule, which is typically released around the first of November each year.
The RUC is intended to represent the entire medical profession and includes the following medical specialties: anesthesiology, cardiology, dermatology, emergency medicine, family medicine, general surgery, geriatrics, internal medicine, neurology, neurosurgery, obstetrics/gynecology, ophthalmology, orthopedic surgery, otolaryngology, pathology, pediatrics, plastic surgery, primary care (rotating seat), pulmonary medicine (rotating seat), psychiatry, radiology, rheumatology (rotating seat), thoracic surgery, urology, and vascular surgery (rotating seat). Four seats rotate on a two-year basis, with two reserved for an internal medicine subspecialty: one for a primary care representative, and one for any other specialty. The RUC chair, the co-chair of the RUC Health Care Professionals Advisory Committee Review Board, and representatives of the AMA, American Osteopathic Association, the chair of the Practice Expense Review Committee and CPT Editorial Panel hold the remaining six seats. The AMA Board of Trustees selects the RUC chair and the AMA representative to the RUC. The individual RUC members are nominated by the specialty societies and are approved by the AMA.
Who Represents the Academy at the RUC?
The Academy actively participates in the RUC process and surveys codes for nearly every RUC meeting. Meetings take place every winter, spring, and fall. The Academy’s current RUC representatives are RUC panel member Charles F. Koopmann Jr., MD, MSHA, and panel member alternate, Jane T. Dillon, MD, as well as our RUC advisors Wayne M. Koch, MD, and advisor alternate John T. Lanza, MD. It is important to recognize that the RUC panel member representatives for each specialty are not advocates for their specialties, rather, they participate in an individual capacity and represent their own views and independent judgment while serving on the panel. In contrast, AAO-HNS’ RUC advisors are responsible for working with the Physician Payment Policy Workgroup (3P) and Academy staff to develop relative value recommendations and practice expense direct inputs for otolaryngology services that are presented to the RUC on behalf of the Academy.
Why are RUC Surveys Conducted?
Surveys are used by the AMA RUC to allow medical specialty societies to have an active role in ensuring that relative values assigned to medical procedures and services are accurately and fairly presented to CMS. These surveys are critical because the values derived by member survey responses are used by our RUC advisors to make valuation recommendations to the AMA RUC. The goal of the surveys is to obtain time and complexity estimates required when performing a specific medical procedure. This information is then used to estimate a recommended physician work value.
How Does the Survey Generate a Recommended Value?
The surveys will ask physician members to compare the time, complexity, and work required to perform the procedure being surveyed as compared to another existing medical procedure. A list of possible comparator, or reference, procedures is provided to survey respondents as part of the survey.
What are the Key Components of the RUC Survey?
First, it is critical that members carefully review the code descriptor and vignette. This is critical because code descriptors may have been modified and survey respondents will be asked if the descriptor and vignette match their typical (i.e., more than 50 percent of the time) patient. If the descriptor and vignette do not match the respondent’s typical patient, the respondent will be asked to write a brief rationale for how their typical patient differs from the survey descriptor or vignette.
Next, surveyees will be asked to review and provide their basic contact information. They will then be asked to identify a reference procedure from the list of potential reference codes. Respondents should select the code from the list that is most similar in physician time and work to the new/revised CPT code descriptor and typical patient. The reference service does not have to be clinically similar to the procedure being surveyed, but must be similar in work required to perform the procedure. It is also important that respondents consider the global period of the service being reviewed. For CPT codes with 000, 010, or 090 day globals, physician services or visits provided within 24 hours prior are included and should be considered by respondents in their recommended value for the service. Likewise, for 010 and 090 globals, the post care following the procedure should be included in the estimate of physician work for a given procedure.
Another key component to the RUC survey is estimating physician time. Respondents should base their recommendations of the time it takes them to perform the procedure under review on their own personal experience. It is important to note that time estimates provided should be based on the typical patient and not the most straightforward or most complex case the physician respondent has encountered.
There are three components to time estimates. First, the pre-service time, which begins the day prior to the procedure and lasts until the time of the operative procedure. Pre-service time is divided into three activities: evaluation; positioning; and scrub, dress, and wait time. Second, the intra-service time, which includes all “skin to skin” work that is a necessary part of the procedure. And last, the post-service time, which includes the physician services provided on the day of the procedure after the procedure has been performed.One common source of confusion is the component of moderate sedation. Moderate sedation is a service provided by the operating physician or under the direct supervision of the physician performing the procedure. If anesthesia is provided separately by an anesthesiologist who is not performing the primary procedure, this work should not be included in the valuation of the procedure for the purposes of the RUC survey.
Finally, survey respondents will be asked to evaluate physician work and assign a recommended relative value unit for the work required to perform the procedure. Physician work includes the time it takes the physician to perform the procedure. Physician work should also include the mental effort and judgment necessary, as well as the technical skill required to perform the procedure. Note, time and work valuation should not include any work or service provided by clinical staff that are employed by the physician’s practice and cannot bill separately. It is important to keep in mind that the survey methodology aims to set the work RVU for the procedure under review “relative” to the comparable reference procedure selected at the outset of the survey, and respondents may want to print out the reference service list to refresh them on the value of the comparator code selected.
What About the Practice Expense Portion of My Payment?
As part of its role in the RUC process, the Academy RUC team is asked to provide the AMA RUC and CMS with information regarding the direct practice expense inputs for all procedures that undergo RUC review. This includes recommendations on clinical staff time needed during the procedure, as well as equipment and supplies required for the procedure. These recommendations are reviewed by the Practice Expense Advisory Committee (PEAC) of the RUC and approved or modified prior to being submitted to CMS for acceptance in the final CY MPFS.
What About the Malpractice Portion of My Payment?
The AMA RUC sends recommendations to CMS on practice liability crosswalks for each procedure reviewed by the AMA RUC. This occurs in May of each year and, similar to the practice expense and physician work recommendations submitted by the AMA RUC, are approved or modified by CMS in the MPFS for that calendar year. All values finalized in the final rule then take effect the following January.
Still Have Questions?
For more background on the RUC survey process, members can access the following PowerPoint presentation on the Academy website: http://www.entnet.org/Practice/upload/2012-ruc-survey-presentation.pdf. Members can also email any questions to Jenna Minton at Jminton@entnet.org. We hope this information will assist members in better understanding the composition of the RUC surveys as well as the importance of your participation in future surveys and the valuation of otolaryngology-head and neck surgery procedures. In recent months, the Federal Trade Commission (FTC) has become more involved in the states’ rulemaking process by increasing its antitrust examination of state professional board actions, particularly board decisions and regulations, state legislation relating to scope of practice. These antitrust examinations by the FTC reportedly are to promote and protect competition by prohibiting agreements that unreasonably restrict trade. However, concerns about this increased involvement exist, and the American Medical Association (AMA) with the Scope of Practice Partnership (SOPP), which the AAO-HNS is a member of, are closely monitoring and addressing the FTC’s inappropriate involvement as it arises.
The new trend by the FTC threatens patient safety and the structure of determining what is appropriate within a professional’s scope of practice. Scope of practice guidelines are typically determined by the legislature and state professional boards. These methods help to ensure that unqualified practitioners are not rendering services they are not trained to perform. There is concern that the FTC’s involvement will discourage state boards and state legislatures from engaging in defining appropriate scope of practice guidelines for fear of potential antitrust lawsuits.
The FTC recently has taken action in the form of letters and enforcement actions directed at state boards and state legislators. The FTC has issued several letters urging state boards to reject, or more thoroughly analyze, regulations that could potentially affect competition. One of the first examples of the FTC becoming more involved with state boards was a letter in 2010 that was sent to the Alabama State Board of Medical Examiners (ASBME). The FTC encouraged the board to reject a regulation that would prohibit non-physician professionals from providing advanced interventional pain management services, noting it would adversely affect competition. This letter was sent to the ASBME without any studies or evidence indicating this to be true. Although the FTC did not directly threaten to bring an antitrust action, the letter itself provided enough of a threat. The effect of the letter on the ASBME resulted in the board immediately ceasing activity on the proposed regulation. Since the letter to the ASBME in 2010, the FTC has reached out to legislators and state boards in Florida, Kentucky, Louisiana, Missouri, Tennessee, and Texas, where it commented on bills to regulate providers of interventional pain management procedures and proposed regulations to expand the scope of practice of nurses.
Some of the FTC’s activity in the states has morphed into enforcement actions. In North Carolina, the State Board of Dental Examiners was attempting to approve a regulation that would prohibit non-dentists from providing teeth-whitening services, which the board had determined constituted the practice of dentistry. The FTC issued an order directing the board to stop regulating teeth-whitening, alleging that the board was harming competition by blocking non-dentists from providing the services. The case is currently awaiting consideration in the U.S. Court of Appeals.
The AMA and the SOPP have made progress toward working with the FTC to address the over-involvement of the FTC with state boards and state legislatures. The FTC letters that are now distributed no longer attempt to make clinical judgments. Instead, disclaimers have been added outlining that FTC staff members are not subject-matter experts on clinical or patient safety issues and are not offering advice on such issues. Furthermore, the FTC has now acknowledged that “certain professional licensure requirements are necessary to protect patients.” The FTC has also agreed to work with the states by reaching out to state medical associations before drafting letters.
The AAO-HNS, the AMA, and others in the physician community are concerned that these actions by the FTC will prevent state legislatures, regulators, and medical boards from performing their duties and enacting legislation, proposing regulation, or other actions to protect patient safety for fear of reprisal and antitrust liability. The AAO-HNS will continue to work with the AMA and the SOPP as this issue progresses and advocate where necessary. For more information, email AAO-HNS State Legislative Affairs at firstname.lastname@example.org. In addition, to receive timely updates on state, federal, or grassroots initiatives, AAO-HNS members are encouraged to join the ENT Advocacy Network—a free member benefit. To join, email email@example.com.