Published: October 24, 2013

Diversity Committee Report: Healthcare Disparities in Head and Neck Cancer

Randal A. Otto, MD Professor and Chairman Thomas Walthall Folbre, MD Endowed Chair in Otolaryngology University of Texas, San Antonio for the AAO-HNS Committee Although treatment for head and neck cancer has seen tremendous technological advances in surgery, radiation therapy, and chemotherapy, unfortunately we have not achieved an appreciable change in survival for several decades. This promises to change as we shift from simply recognizing tumors by their histologic characteristics to a better understanding of their pathogenesis at the molecular level. This alone, however, will not suffice. To illustrate, while we know that cancer incidence and death rates differ among racial and ethnic groups and the data demonstrate higher death rates in blacks than in whites, there is no consensus as to the etiology of these differences.1-5 Indeed, laryngeal cancer mortality in African-American men is more than double that in white men and ranks second only to prostate cancer mortality in magnitude of disparity.1,2 Similar data regarding the Hispanic population is scarce but also may represent areas of healthcare disparities and gaps in our understanding.6-8 Although some reports note differences in access to care, stage at diagnosis, insurance status, and attitudes of health providers playing an important role in these disparities, the degree to which significant biological factors account for the disparities remains largely undefined and mandates elucidation.8,9 This is substantiated by the National Cancer Institute Black/White Cancer Survival Study launched in the 1980s. This demonstrated poorer survival for black versus white patients with colon, breast, uterine, bladder tumors, and head and neck cancers after adjustment for both clinical and socioeconomic characteristics.10-12 These findings support the concept that some cancers may be biologically more aggressive in blacks than whites. Understanding of the nuances that may combine the social, economic, and biologic factors rendering healthcare disparities is beginning to emerge.8,13-16 In 2009 Settle, et al., the University of Maryland Marlene and Stewart Greenebaum Cancer Center in Baltimore and Harvard Medical School’s Dana-Farber Cancer Institute in Boston reported a higher incidence (nine-fold) of human papillomavirus (HPV)-related head and neck cancers in caucasians versus blacks.15 This represented a somewhat unexpected explanation for the poor survival of blacks with head and neck cancer. After testing tumor samples from 201 patients for the presence of HPV-16, which has been definitively linked to oropharyngeal and cervical cancers, these authors discovered more whites were found to have the HPV-positive tumors and more whites than blacks were still alive five years after their diagnoses. Specifically, 80 percent of whites with HPV-positive tumors in the study were alive five years after diagnosis compared with fewer than 40 percent of both whites and blacks with HPV-negative tumors. There were too few blacks with HPV-positive tumors to determine their survival rate. Subsequently Weinberger, et al., reported none of their black patients were likely to have HPV-active disease compared to 21 percent of their white patients, and patients with HPV-active cancers had an improved overall five-year survival of 59.7 percent versus HPV-negative and HPV-inactive patients of 16.9 percent (P=.003)14 In an editorial in Cancer Prevention Research, hematologist-oncologist Otis Brawley, the chief medical officer of the American Cancer Society, stated that sexual habits in young teens may explain why blacks and whites have such different rates of HPV-positive tumors.17 According to a study by the Centers for Disease Control and Prevention, adolescent blacks are much more likely than whites to have genital sex before they have oral sex. Acquiring a genital HPV infection may provoke an immune response that protects a person from a subsequent oropharyngeal HPV infection because the immune response acts like a vaccination.17-18 Brawley points out that when it comes to cancer research, it’s important to look more than skin-deep and that we should always be thinking about sociocultural factors that can explain black-white differences, instead of just ending the discussion at race. It is the duty and obligation of our specialty and society to understand these differences if we wish to improve the outcomes. To paraphrase Einstein, to continue to do the same thing and expect different results is unsound. References 1. Ries LAG, Melbert D, Krapcho M, et al., editors. SEER Cancer Statistics Review, 1975–2005, National Cancer Institute. Bethesda, MD: National Cancer Institute; 2008. [Accessed: October 15, 2008]. http://seer.cancer.gov/csr/1975_2005/ 2. American Cancer Society. Cancer Facts and Figures for African Americans 2007–2008. Atlanta, GA: American Cancer Society; 2007. 1-27 3. Ward E, Jemal A, Cokkinides V, et al. Cancer disparities by race/ethnicity and socioeconomic status. CA Cancer J Clin. 2004;54(2):78–93. [PubMed] 4. Bach PB, Schrag D, Brawley OW, Galaznik A, Yakren S, Begg CB. Survival of blacks and whites after a cancer diagnosis. JAMA. 2002;287(16):2106–2113. [PubMed] 5. Molina, M. A., Cheung, M. C., Perez, E. A., Byrne, M. M., Franceschi, D., Moffat, F. L., Livingstone, A. S., Goodwin, W. J., Gutierrez, J. C. and Koniaris, L. G. (2008), African-American and poor patients have a dramatically worse prognosis for head and neck cancer. Cancer, 113: 2797–280 6. doi: 10.1002/cncr.238896. Franco EL, Dib LL, Pinto DS, Lombardo V, Contesini H. Race and gender influences on the survival of patients with mouth cancer. J Clin Epidemiol. 1993;46(1):37–46. [PubMed] 7. Harris GJ, Clark GM, Von Hoff DD. Hispanic patients with head and neck cancer do not have a worse prognosis than Anglo-American patients. Cancer. 1992;69(4):1003–1007. [PubMed] 8. Chen LM, Li G, Reitzel LR, Pytynia KB, Zafereo ME, Wei Q, Sturgis EM. Matched-pair analysis of race or ethnicity in outcomes of head and neck cancer patients receiving similar multidisciplinary care. Cancer Prev Res (Phila). 2009 Sep;2(9):782-91. Epub 2009 Sep 8 9. Gourin CG, Podolsky RH.  Racial disparities in patients with head and neck squamous cell carcinoma. Laryngoscope. 2006 Nov;116(11):2098 10. Hunter CP, Redmond CK, Chen VW et al. Breast cancer: factors associated with stage at diagnosis in black and white women.  Black/ white Cancer Survival Study group. J Natl Cancer Inst 1993;85:1129-37 11. Eley JW, Hill HA, Chen VW. Racial differences in survival from breast cancer. Results in survival from breast cancer. Results of the National Cancer Institute Blake / White Cancer Survival Study. JAMA 1994;947-54 12. Howard J, Hankey BF, Greenberg RS, et al, A collaborative study of differences in the survival rates of black patients and white patients with cancer. Cancer. 1992;69:2349-2360 13. Ragin CC, Langevin SM, Marzouk M, Grandis J, Taioli E. Determinants of head and neck cancer survival by race. Head Neck. 2010;1-9 14. Weinberger PM, Merkley MA, Khichi SS, Lee JR, Psyrri A, Jackson LL, Dynan WS. Human papillomavirus-active head and neck cancer and ethnic health disparities. Laryngoscope. 2010 Aug; 120(8):1531-7 15. Settle K, Posner MR et al  Racial Survival Disparity in Head and Neck Cancer Results from Low Prevalence of Human Papilloma Infection in Black Oropharyngeal Cancer Patients; Cancer Prev Res 2009;2(9) OF1-6 16. Chernock RD, Zhang Q, El-Mofty SK et al; Human Papillomavirus-Related Squamous Cell Carcinoma of the Oropharynx  A comparative Study in Whites and African Americans.  Arch Oto HNS 2011:137(2):163-169 17. Brawley, O; Cancer prevention research 2009, 2(9) Sept 2009 OF1-3 18. Brawley OW. Population categorization and cancer statistics. Cancer Metastasis Rev 2003; 22:11-9

Randal A. Otto, MD
Professor and Chairman

Thomas Walthall Folbre, MD Endowed Chair in Otolaryngology
University of Texas, San Antonio for the AAO-HNS Committee

Although treatment for head and neck cancer has seen tremendous technological advances in surgery, radiation therapy, and chemotherapy, unfortunately we have not achieved an appreciable change in survival for several decades. This promises to change as we shift from simply recognizing tumors by their histologic characteristics to a better understanding of their pathogenesis at the molecular level. This alone, however, will not suffice. To illustrate, while we know that cancer incidence and death rates differ among racial and ethnic groups and the data demonstrate higher death rates in blacks than in whites, there is no consensus as to the etiology of these differences.1-5

Indeed, laryngeal cancer mortality in African-American men is more than double that in white men and ranks second only to prostate cancer mortality in magnitude of disparity.1,2 Similar data regarding the Hispanic population is scarce but also may represent areas of healthcare disparities and gaps in our understanding.6-8 Although some reports note differences in access to care, stage at diagnosis, insurance status, and attitudes of health providers playing an important role in these disparities, the degree to which significant biological factors account for the disparities remains largely undefined and mandates elucidation.8,9

This is substantiated by the National Cancer Institute Black/White Cancer Survival Study launched in the 1980s. This demonstrated poorer survival for black versus white patients with colon, breast, uterine, bladder tumors, and head and neck cancers after adjustment for both clinical and socioeconomic characteristics.10-12 These findings support the concept that some cancers may be biologically more aggressive in blacks than whites. Understanding of the nuances that may combine the social, economic, and biologic factors rendering healthcare disparities is beginning to emerge.8,13-16

In 2009 Settle, et al., the University of Maryland Marlene and Stewart Greenebaum Cancer Center in Baltimore and Harvard Medical School’s Dana-Farber Cancer Institute in Boston reported a higher incidence (nine-fold) of human papillomavirus (HPV)-related head and neck cancers in caucasians versus blacks.15 This represented a somewhat unexpected explanation for the poor survival of blacks with head and neck cancer.

After testing tumor samples from 201 patients for the presence of HPV-16, which has been definitively linked to oropharyngeal and cervical cancers, these authors discovered more whites were found to have the HPV-positive tumors and more whites than blacks were still alive five years after their diagnoses. Specifically, 80 percent of whites with HPV-positive tumors in the study were alive five years after diagnosis compared with fewer than 40 percent of both whites and blacks with HPV-negative tumors. There were too few blacks with HPV-positive tumors to determine their survival rate.

Subsequently Weinberger, et al., reported none of their black patients were likely to have HPV-active disease compared to 21 percent of their white patients, and patients with HPV-active cancers had an improved overall five-year survival of 59.7 percent versus HPV-negative and HPV-inactive patients of 16.9 percent (P=.003)14

In an editorial in Cancer Prevention Research, hematologist-oncologist Otis Brawley, the chief medical officer of the American Cancer Society, stated that sexual habits in young teens may explain why blacks and whites have such different rates of HPV-positive tumors.17 According to a study by the Centers for Disease Control and Prevention, adolescent blacks are much more likely than whites to have genital sex before they have oral sex. Acquiring a genital HPV infection may provoke an immune response that protects a person from a subsequent oropharyngeal HPV infection because the immune response acts like a vaccination.17-18 Brawley points out that when it comes to cancer research, it’s important to look more than skin-deep and that we should always be thinking about sociocultural factors that can explain black-white differences, instead of just ending the discussion at race.

It is the duty and obligation of our specialty and society to understand these differences if we wish to improve the outcomes. To paraphrase Einstein, to continue to do the same thing and expect different results is unsound.

References

1. Ries LAG, Melbert D, Krapcho M, et al., editors. SEER Cancer Statistics Review, 1975–2005, National Cancer Institute. Bethesda, MD: National Cancer Institute; 2008. [Accessed: October 15, 2008]. http://seer.cancer.gov/csr/1975_2005/
2. American Cancer Society. Cancer Facts and Figures for African Americans 2007–2008. Atlanta, GA: American Cancer Society; 2007. 1-27
3. Ward E, Jemal A, Cokkinides V, et al. Cancer disparities by race/ethnicity and socioeconomic status. CA Cancer J Clin. 2004;54(2):78–93. [PubMed]
4. Bach PB, Schrag D, Brawley OW, Galaznik A, Yakren S, Begg CB. Survival of blacks and whites after a cancer diagnosis. JAMA. 2002;287(16):2106–2113. [PubMed]
5. Molina, M. A., Cheung, M. C., Perez, E. A., Byrne, M. M., Franceschi, D., Moffat, F. L., Livingstone, A. S., Goodwin, W. J., Gutierrez, J. C. and Koniaris, L. G. (2008), African-American and poor patients have a dramatically worse prognosis for head and neck cancer. Cancer, 113: 2797–280
6. doi: 10.1002/cncr.238896. Franco EL, Dib LL, Pinto DS, Lombardo V, Contesini H. Race and gender influences on the survival of patients with mouth cancer. J Clin Epidemiol. 1993;46(1):37–46. [PubMed]
7. Harris GJ, Clark GM, Von Hoff DD. Hispanic patients with head and neck cancer do not have a worse prognosis than Anglo-American patients. Cancer. 1992;69(4):1003–1007. [PubMed]
8. Chen LM, Li G, Reitzel LR, Pytynia KB, Zafereo ME, Wei Q, Sturgis EM. Matched-pair analysis of race or ethnicity in outcomes of head and neck cancer patients receiving similar multidisciplinary care. Cancer Prev Res (Phila). 2009 Sep;2(9):782-91. Epub 2009 Sep 8
9. Gourin CG, Podolsky RH.  Racial disparities in patients with head and neck squamous cell carcinoma. Laryngoscope. 2006 Nov;116(11):2098
10. Hunter CP, Redmond CK, Chen VW et al. Breast cancer: factors associated with stage at diagnosis in black and white women.  Black/ white Cancer Survival Study group. J Natl Cancer Inst 1993;85:1129-37
11. Eley JW, Hill HA, Chen VW. Racial differences in survival from breast cancer. Results in survival from breast cancer. Results of the National Cancer Institute Blake / White Cancer Survival Study. JAMA 1994;947-54
12. Howard J, Hankey BF, Greenberg RS, et al, A collaborative study of differences in the survival rates of black patients and white patients with cancer. Cancer. 1992;69:2349-2360
13. Ragin CC, Langevin SM, Marzouk M, Grandis J, Taioli E. Determinants of head and neck cancer survival by race. Head Neck. 2010;1-9
14. Weinberger PM, Merkley MA, Khichi SS, Lee JR, Psyrri A, Jackson LL, Dynan WS. Human papillomavirus-active head and neck cancer and ethnic health disparities. Laryngoscope. 2010 Aug; 120(8):1531-7
15. Settle K, Posner MR et al  Racial Survival Disparity in Head and Neck Cancer Results from Low Prevalence of Human Papilloma Infection in Black Oropharyngeal Cancer Patients; Cancer Prev Res 2009;2(9) OF1-6
16. Chernock RD, Zhang Q, El-Mofty SK et al; Human Papillomavirus-Related Squamous Cell Carcinoma of the Oropharynx  A comparative Study in Whites and African Americans.  Arch Oto HNS 2011:137(2):163-169
17. Brawley, O; Cancer prevention research 2009, 2(9) Sept 2009 OF1-3
18. Brawley OW. Population categorization and cancer statistics. Cancer Metastasis Rev 2003; 22:11-9

More from June 2011 - Vol. 30 No. 06
Linda N. Lee, MD, was part of a 26-member team that traveled to Antigua, Guatemala, with Medical Missions for Children.
MMFC Cleft Mission in Antigua, Guatemala
Linda N. Lee, MD Resident Humanitarian Travel Grantee I am an otolaryngology resident with the Harvard program. In January, I had the amazing opportunity to travel to Antigua, Guatemala, with Medical Missions for Children. The 26-member team led by Noah S. Siegel, MD, included members from surgery, dental, anesthesia, and OR and PACU nursing from all over the country. We treated Guatemalan children with cleft lip, cleft palate, and microtia, and performed 75 surgical procedures and 63 dental treatments at the San Pedro Hospital, Antigua. During our preoperative clinic, we met hundreds of families, some of whom had traveled for hours to bring their child to see us. I was struck by the overwhelming feeling of hope as well as the immediate trust they put in us to take good care of their children. Each day, I took part in multiple surgeries—from cleft lip and palate repair to stages I, II, and III of microtia repair. I learned operative techniques and peri-operative patient care, but I was most touched by seeing the patients and families in the recovery room. Seeing parents holding their bandaged babies with smiles on their faces solidified the importance of the trip for me. A relatively short procedure can change these children’s lives forever, and I am grateful that my surgical training gives me the chance to be a part of this process. For me, the trip was possible because of an AAO-HNS Foundation humanitarian travel grant funded by Alcon Foundation. I am grateful to the Academy for supporting me and other residents and allowing us to have exposure to these valuable experiences early in our careers. Without a doubt, it was one of the most meaningful experiences of my life, and I hope I have the privilege of continuing these mission trips throughout the rest of my career. To learn more about this non-profit and its work around the globe, visit www.mmfc.org, or contact Executive Director Liz Desmarais at 1-978-387-2749.
CDC Dives into Swimmer’s Ear Prevention
Preventing AOE DO keep your ears as dry as possible. • Use a bathing cap, ear plugs, or custom-fitted swim molds when swimming to keep water out of ears. DO dry your ears thoroughly after swimming or showering. • Use a towel to dry your ears. • Tilt your head to hold each ear facing down to allow water to escape the ear canal. • Pull your earlobe in different directions while the ear is faced down to help water drain out. • If there is still water left in ears, consider using a hair dryer to move air within the ear canal. • Be sure the hair dryer is on the lowest heat and speed setting. • Hold the hair dryer several inches from the ear. DON’T put objects in the ear canal (including cotton-tip swabs, pencils or fingers). DON’T try to remove ear wax. Ear wax helps protect your ear canal from infection. • If you think the ear canal is blocked by ear wax, consult your healthcare provider rather than trying to remove it yourself. CONSULT your healthcare provider about using commercial, alcohol-based ear drops or a 1:1 mixture of rubbing alcohol and white vinegar after swimming.  • Drops should not be used by people with ear tubes, damaged ear drums, outer ear infection, or ear drainage (pus or liquid coming from the ear). CONSULT your healthcare provider if your ears are itchy, flaky, swollen, or painful, or if you have drainage from them. For more info … About Recreational Water Illness and Injury Prevention Week, visit: http://www.cdc.gov/healthywater/swimming/rwi/ rwi-prevention-week/index.html From CDC about recreational water illnesses, visit: http://www.cdc.gov/healthywater/swimming/rwi/ For your patients about swimmer’s ear, visit: • http://www.cdc.gov/healthywater/swimming/ rwi/illnesses/swimmers-ear.html or • www.entnet.org/HealthInformation/swimmersEar.cfm Emily Piercefield, MD, DVM; Sarah Collier, MPH; Michele Hlavsa, RN, MPH; Ken Kazahaya, MD, MBA; Evelyn Kluka, MD;  and Michael Beach, PhD Editor’s Note: Recently the CDC contacted the Academy office to request our participation in an observance week with a focus on preventing swimmer’s ear. The following piece is offered for members to share with your primary care referral list as an educational outreach tool on how to avoid this common infection and with that cut down on the need for treatment of a preventable disease and the use of antibiotics.  Temperatures are warming up outside, and swimming season has started in many parts of the country. Along with increased recreational water activity comes swimmer’s ear or acute otitis externa (AOE). This year’s Recreational Water Illness and Injury Prevention Week (RWIIPW), May 23–29, focused on this condition’s prevention. AOE is a common problem for recreational water users of all ages, potentially resulting in ear pain, medical expenses, lost days of work, and missed social activities. During RWIIPW 2011, the Centers for Disease Control and Prevention’s (CDC) Healthy Swimming Program and its partners provided the public with information and recommendations on how to prevent swimmer’s ear. Now is a prime time to talk with your patients about some simple ways to prevent AOE. Studies have demonstrated that AOE is more likely to occur among swimmers, and that high ambient temperature and humidity are predisposing factors. The longer swimmers are in the water and the more frequently they submerge their heads while swimming, the more at risk they are for AOE. Exposing the skin of the external ear canal to water, particularly for prolonged periods, can lead to skin maceration, making the external ear canal more vulnerable to minor trauma and infection. Minor trauma could be caused by anything inserted in the macerated ear canal such as cotton-tip swabs, hearing aids, other foreign objects, or even one’s own finger when scratching itchy ears. Water exposure also can wash away protective cerumen, which normally serves as a water-repellent coating for the skin of the external ear canal and provides some antimicrobial protection. Some research indicates that frequent showering or bathing increases risk for AOE, although other investigations did not find an association. Soaps, shampoos, and chlorine from pool water might irritate the skin of the external ear canal and also contribute to the loss of protective cerumen. Patients with underlying skin conditions (e.g., eczema or seborrheic dermatitis) or with comorbid conditions (e.g., diabetes or immunosuppression) are at particular risk for getting AOE. In rare cases, infection can progress to necrotizing “malignant” otitis externa, particularly among immunocompromised patients. A recent CDC analysis estimated that 2.4 million U.S. healthcare visits result in a diagnosis of AOE annually (8.1 visits/1,000 population), affecting at least one in 123 persons each year. In 2007, one in 324 emergency department visits and one in 481 ambulatory care clinic visits resulted in a diagnosis of AOE. Rates of ambulatory care visits for AOE from  2003 to 2007 were highest among children aged 5 to 9 years (18.6/1,000) and 10 to 14 years (15.8/1,000).  However, 53 percent of ambulatory care AOE visits are by adults 20 years or older (5.3/1,000). Incidence peaks during the summer months and is highest (9.1/1,000) in the South (as defined by the U.S. Census Bureau). Nonhospitalized visits for AOE cost an estimated $498 million in direct healthcare costs and at least 598,000 hours of ambulatory care clinicians’ time annually. Although AOE is generally a mild illness, it is a frequently diagnosed condition responsible for a substantial burden in terms of healthcare dollars and clinicians’ time. AOE is a potentially preventable disease, and the burden can be reduced. The literature is lacking in scientific studies on preventive measures, so we rely instead on reducing established predisposing factors. Strategies for preventing AOE involve preventing or limiting the ear canal’s exposure to water and maintaining a healthy barrier (cerumen and skin) against infection in the external ear canal. See “Preventing AOE” on this page for prevention messages to share with patients in addition to using bathing caps or ear plugs to minimize the amount of water that enters the ear canal. Clinicians might recommend the use of alcohol-based ear solutions after water exposure for persons with recurring episodes of AOE as long as the tympanic membrane is intact and no ear tubes or acute infection are present.
pharmacist
Medicare E-Prescribing Incentive Program
To promote the adoption of e-prescribing systems, the Medicare Improvements for Patients and Providers Act of 2008 (MIPPA) authorized a five-year program of incentive payments for eligible professionals who electronically prescribe for the Medicare patients they treat. This program began on January 1, 2009, and will end in 2014. Eligibility Criteria  To be eligible to participate in the 2011 eRx Incentive Program, office visits should represent at least 10 percent of your total Medicare Part B Physician Fee Schedule charges. You can only report the eRx measure for office visits that are separately listed on your Medicare claims and separately payable by Medicare. In order to be eligible to receive an eRx incentive payment, you must generate and report one or more electronic prescriptions associated with a minimum of 25 unique patient visits per year. Each visit must be accompanied by the electronic prescribing G-code (G8553 – At least one prescription created during the encounter was generated and transmitted electronically using a qualified ERX System) attesting that during the patient visit at least one prescription was electronically prescribed. The Centers for Medicare and Medicaid Services (CMS) requires that you use a “qualified” electronic prescribing system (stand-alone or an electronic health record system (EHR) with eRx functionality), which has all of the following capabilities: • Generating a complete active medication list incorporating electronic data received from applicable pharmacies and pharmacy benefit managers, if available • Selecting medications, printing prescriptions, electronically transmitting prescriptions, and conducting all alerts • Providing information related to lower cost, therapeutically appropriate alternatives (if any). The availability of an eRx system to receive tiered formulary information, if available, would meet this requirement for 2011 • Providing information on formulary or tiered formulary medications, patient eligibility, and authorization requirements received electronically from the patient’s drug plan, if available. While free software and hardware e-prescribing programs are available, generally, the cost of stand-alone e-prescribing systems, including software and training, ranges from $500 to $2,500. Mechanisms for Reporting the eRx Measure There is no pre-registration required to participate in the eRx program. To participate in the 2011 eRx Incentive program, you may choose to report on your adoption and use of a qualified eRx system by submitting information on one eRx measure, G code, G8553 to: 1. CMS on their Medicare part B claims, 2. A qualified registry, (for a list of qualified registries, visit http://www.cms.gov/ERxIncentive/08_Alternative%20Reporting%20Mechanism.asp#TopOfPage) or, 3. CMS via a qualified electronic health record (EHR) product Though you may begin reporting the eRx measure at any time from January 1, 2011, to December 31, 2011, to avoid accruing penalty payment adjustments in 2012, you must start reporting the eRx measure by June 30, 2011. Incentives and Penalties If you successfully e-prescribe medications and report the eRx measure in 2011, you will earn incentives equal to 1 percent of your total Medicare payments for that year. (You will obtain payment bonuses after the conclusion of the calendar year in which you e-prescribed for your Medicare patients, not as an immediate payment.) Table 1 shows the incentives and penalties in the eRx program. Table 1. Incentive and penalty percentages Calendar Year of E-Prescribing Incentive Amount (%) Penalty Amount (%) 2011 1.0 – 2012 1.0 -1.0 2013 0.5 -1.5 2014 – -2.0 To avoid the 2012 eRx penalty payment adjustment, you must report on a minimum of 10 unique visits using claims-based reporting from January 1, 2011, through June 30, 2011. Please note that electronically generated refills do not count and faxes do not qualify as electronic prescriptions. Office visits provided as part of a global surgical package will not count toward the calculation of penalties for not adopting e-prescribing. To avoid the 2013 eRx penalty, you will need to report the 25 electronic prescriptions through a single method using claims-based reporting, registry-based submission, or EHR-based submission. Note that future rule-making from CMS may further define application of the 2013 eRx Payment Adjustment. The eRx penalty will not apply to you if you do not: • Have at least 100 cases containing an encounter code in the measure denominator • Meet the 10 percent denominator threshold June Update: More Exemption Categories Based on the House of Medicine’s urging, CMS issued a proposed ruling on June 1 that makes significant changes to the e-prescribing penalty program by adding more exemption categories so that physicians are not unfairly penalized for failing to meet the requirements under the 2012 e-prescribing penalty program. Physicians are still required to e-prescribe using a qualifying e-prescribing system and report the G8553 code on at least 10 Medicare Part B claims from January 1, 2011, through June 30, 2011, to avoid the 2012 e-prescribing penalty. In order to avoid the 2012 e-prescribing penalty, physicians will have the opportunity to attest through an online web portal that they should be eligible for one of the following exemptions: • Physician’s practice is located in a rural area without high-speed internet access • Physician’s practice is located in an area without sufficient available pharmacies for electronic prescribing • Physician is registered to participate in the Medicare of Medicaid EHR Incentive Program and has adopted certified EHR technology • Physician is unable to electronically prescribe due to local, state, or federal law or regulation (e.g., prescribes controlled substances) • Physician infrequently prescribes (e.g. prescribe fewer than 10 prescriptions between January 1, 2011, and June 20, 2011) • There are insufficient opportunities to report the e-prescribing measure due to program limitations Physicians will have to apply for an exemption from the 2012 e-prescribing penalty via the web portal tool by October 1, 2011. Participation  You will not be able to obtain incentives from both the Medicare eRx and the Medicare EHR incentive programs simultaneously. However, you may participate in the Physician Quality Reporting System and the eRx program at the same time. Also, you may participate in the Medicaid EHR incentive program and still qualify for incentives under the eRx program. If you have more questions on the eRx program, contact Healthpolicy@entnet.org or visit http://www.entnet.org/eRx.
Update from the 3P Workgroup
Michael Setzen, MD, coordinator for Practice Affairs and Richard W. Waguespack, MD, coordinator for Socioeconomic Affairs, co-chairs of 3P; with Jenna Kappel, director, Health Policy; Tricia Bardon, assistant director, Health Policy; and Udo Kaja, program manager, Payer Advocacy The Physician Payment Policy Workgroup (3P), chaired by Richard W. Waguespack, MD, and Michael Setzen, MD, is the senior advisory body to Academy leadership and staff on issues related to socioeconomic advocacy, regulatory activity, coding or reimbursement, and practice services or management. 3P and the Health Policy staff continue to ensure that members’ interests are appropriately represented.  Below, we have highlighted some advocacy efforts. For the latest health policy updates, visit the What’s New page (http://www.entnet.org/Practice/CMS-News.cfm) on our website. Major Win  On January 18, Drs. Setzen and Waguespack; J. Randall Jordan, MD, chair of the Plastic & Reconstructive Committee; Health Policy staff; representatives from sub-specialty societies Pete S. Batra, MD (ARS); John S. Rhee, MD; Steve Duffy (AAFPRS); Deborah S. Bash, MD, and Melanie Dolak (ASPS) had a conference call with Richard Justman, MD, the United Healthcare (UHC) national medical director, and other UHC officials. During this call, UHC agreed to revise its guideline on Rhinoplasty, Septoplasty and Repair of Vestibular Stenosis. Substantial progress was made with this revision. At the end of March, UHC incorporated almost all of our requests into the policy. Specifically, the insurer made the following changes based on our feedback. 1. All references to “anterior (primarily cartilaginous)” were removed from the requirements for coverage relating to septoplasty. 2. The description for posterior septal deviation was removed. 3. The definition for cartilaginous septal deviation was removed. 4. Indicated that isolated septal spurs generally do not cause a physiological impairment. 5. Reviews for nasal septal deviation will no longer reference anterior or posterior. The next revision for the policy is February 2012. UHC will only consider revising the policy before February 2012 if it determines that its medical directors are consistently misinterpreting sections of the policy and/or if it is causing undue burden to patients and physicians. The Academy and the other specialty groups involved in this effort are generally satisfied with this revised policy and thank UHC for allowing an open dialogue to discuss our issues. We anticipate that the number of non-certifications will decrease due to these revisions. However, if you are still experiencing non-certifications, please contact your local UHC medical director and copy healthpolicy@entnet.org on the request and outcome. Health Policy staff plan to continue monitoring these denials and will follow up with UHC if necessary. Also, we are drafting an appeal template letter to assist you with septoplasty denials and will post a final copy of the letter to the website and in a future issue of the Bulletin. We sincerely thank all the listed specialty and sub-specialty societies involved in this endeavor as well as the Association of Otolaryngology Administrators. For more information, please visit our website, http://www.entnet.org/Practice/CMS-News.cfm#ADV. Medical Policy Review Requests from Private Payers It has been a busy year so far with requests from private payers to review their medical policy drafts. We received requests to review the following policies: WellPoint • Functional Endoscopic Sinus Surgery and Balloon Sinuplasty for Treatment of Chronic Sinusitis. The Rhinology and Paranasal Sinus Committee reviewed both policies. • Cochlear implants. This policy was reviewed by the Implantable Hearing Devices Subcommittee (IHD). United Healthcare • Surgical Treatment of Obstructive Sleep Apnea. This policy was reviewed by the Sleep Disorders Committee. • Cochlear implants. This policy was reviewed by the IHD. • Transtympanic Micropressure. This policy was reviewed by the Equilibrium Committee. The process for reviewing medical policy drafts requires time, attention to detail, and collaboration among committee members. The members review these policy drafts to ensure they are based on evidence-based guidelines and current medical practice. They also provide scientific literature references to support the positions rendered in their reviews. The average time it takes to review these policies is four weeks. We cannot emphasize enough the importance of these medical policy review requests. National payers such as UHC and WellPoint cover more than 100 million people in the United States.  In addition, WellPoint medical policies are the reference policies for the Blue Cross and Blue Shield Association. Generally, WellPoint hosts quarterly Medical Policy & Technology Assessment Committee (MPTAC) meetings where it reviews our submitted feedback as well as input from other sources such as academic medical centers, other specialty medical societies, etc. UHC holds monthly Medical Technology Assessment Committee meetings in which input from specialty societies and other groups are discussed. Typically, after these meetings, each insurer will send us a finalized medical policy. We thank the members of the Equilibrium Committee, Implantable Hearing Devices Subcommittee, Rhinology and Paranasal Sinus Committee, and the Sleep Disorders Committee for all of their hard work and time invested in reviewing and commenting on these medical policies. Contact Healthpolicy@entnet.org if you have questions.
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Pursuit of a New Code for the Endoscopic Treatment of Zenker’s Diverticulum
By Richard W. Waguespack, MD, and Tricia Bardon During the 2010 Annual Meeting & OTO EXPO, the CPT/RUC Committee voted to request a new CPT code to capture the work done in endoscopic Zenker’s diverticulum surgery.  The Physician Policy Payment Work Group (3P) agreed to this position because there is no specific code to report the procedure when it is performed endoscopically. Also, 3P was concerned about the potential erroneous billing of the procedure with CPT code 43130 – Diverticulectomy of hypopharynx or esophagus, with or without myotomy; cervical approach, which was created to report the procedure when performed openly. Currently, the appropriate code to report the procedure when performed endoscopically is 43499 – Unlisted procedure, esophagus. (For more coding guidance on this procedure, visit http://www.entnet.org/Practice/CPT4ENT-Zenkers.cfm.) 3P also feared that if some members were incorrectly reporting the procedure they may be exposed to denials and/or audits from payers. 3P determined that although some segments of the specialty (typically academically based subspecialists) were appropriately reimbursed for Zenker’s diverticulum when they reported the unlisted code (43499), much of the general membership experienced significant reimbursement challenges for the procedure. Members of 3P, the CPT & Relative Value Committee, and other interested parties deliberated on whether the Academy should request a new code for the endoscopic treatment of Zenker’s diverticulum in time to be published in the 2012 CPT book.  (In order to be included, a new code must be accepted by March of the year prior to publication of the CPT coding book.) As a result of these discussions, 3P decided to disseminate a survey in January 2011 through The News, the Academy’s electronic newsletter. After analyzing the results of the survey, 3P determined it was in members’ best interests not to request a new code for the endoscopic procedure at that time. Subsequently, 3P made the decision to re-survey members to reach a larger audience to determine if the Academy should pursue a new code for the procedure. As such, we will repeat the January 2011 survey before the end of the year. Please take this survey when it is available and ensure your Academy fully captures your coding needs for endoscopic Zenker’s diverticulum. If the generated data from the survey leads us to request a new code for endoscopic Zenker’s diverticulum, this code would be available for billing in the 2013 CPT coding manual. For more information, contact Tricia Bardon at TBardon@entnet.org.
Be Prepared for an RAC Audit
Risk tip provided by Academy Advantage Premier Partner: The Doctors Company Any medical practice submitting claims to a government program such as Medicare may contend with a Recovery Audit Contractor (RAC). RAC audits are not one-time or intermittent reviews. They are a systematic and concurrent operating processes for ensuring compliance with Medicare’s clinical payment criteria, documentation, and billing requirements. The Medicare RAC program was signed into law by the Medicare Prescription Drug Improvement and Modernization Act of 2003 and made permanent by the Tax Relief and Health Care Act of 2006. Its purpose is to identify improper Medicare payments—both overpayments and underpayments—nationwide. In three years of RAC audits, almost $1 billion in overpayments have been identified by the auditors. RAC refinements enacted in February have put limits on the number of medical records that they can request, based on physician group size, and the number of entities based on practice size is limited to tax ID number for groups. The RACs use proprietary software programs to identify potential payment errors in such areas as duplicate payments, fiscal intermediaries’ mistakes, medical necessity, and coding. RACs also conduct medical record reviews. Implementing appropriate compliance plans now will reduce anxiety and uncertainty if you are subjected to an audit. Assign a member of your staff the job of implementing a compliance plan, or consider hiring a contractor specifically for this task. The person who is responsible for implementing the plan should regularly: • Review denied claims categories during the RAC demonstration program. • Keep abreast of notifications on the CMS website. • Review the annual Office of Inspector General (OIG) Work Plan document to assist providers in determining potential areas of RAC audits. • Monitor RAC progress at your regional RAC. Each of the four regional RACs maintains a website posting information on new audit focus areas and the status of a provider’s audits. • Perform an audit of your own billing practices—a snapshot audit may illustrate areas that need work. If you are audited: • Before you send records to the auditor, be sure to review them in a “self-review.” Are there common themes? Are you coding with the correct documentation? • Make copies of everything you send to the RAC auditor, and keep all of your documentation. Here is information the person implementing the compliance plan should know: • Staying on top of the RAC audits is important, as there are multiple policies and procedures governing RAC audits. The RAC can request a maximum of 10 medical records from a provider in a 45-day period. The time period that may be reviewed has changed from four years to three years. • Responses are time sensitive, and significant penalties may result if not handled properly. RAC contractors are paid on a contingency basis, which means they are only paid when they find either overpayments made by CMS or potential fraud by a provider. The Doctors Company provides its members with MediGuard core coverage, which protects against regulatory risks including Medicaid and Medicare RAC allegations. MediGuard PLUS is an enhanced coverage available to members and includes higher limits and expanded features. For more information, visit www.thedoctors.com/mediguardplus. For further information on the refinements to CMS policy, please visit www.cms.gov/rac.
Does “Sorry” Pay?
Rahul K. Shah, MD George Washington University School of Medicine, Children’s National Medical Center, Washington, DC In 2001, the University of Michigan Health System implemented a novel concept that many of us at the time considered taboo – apologizing to patients for a medical error. Many of us have recently heard of this program, and it has indeed reached national acclaim. The policy’s core concept is a full disclosure of medical error, with an offer of compensation. This program was unique from other disclosure programs in that an offer of compensation was made in addition to full disclosure and apology. The system is similar to many medical centers in that prior to 2001 it had a traditional risk liability model in an essentially closed medical staff model. In a closed system, the settlements are made in the institution’s name rather than the individual physician’s, which of course prevents reporting to the National Practitioner Data Bank. The traditional liability model for healthcare is criticized for the undue delay in receiving a settlement and because a minority of claims receive compensation. So, in addition to looking at the obvious metric of whether the settlement amounts and rates of litigation increased, the authors also studied the time to claims pay out and the proportion of claims that resulted in compensation. There are a handful of disclosure programs in place across the country, which are beyond the scope of this column. However, there are several attributes of the University of Michigan Health System’s program that are unique and perhaps transferable to other institutions. The manuscript referenced at the end of this article is certainly worth perusing to understand the impact of this policy. It perhaps may be best to take a view from 30,000 feet to attest to the merits of the full disclosure with a compensation policy. If you consider the patient/family perspective, when an error occurs, you are notified, apologized to, and amends are offered. This can be juxtaposed to the current model where the blame game begins and the patient/family many times are left uninformed and in limbo, often for many years. From an institutional perspective, it is the right thing to do from an ethical imperative. As such, this study tangentially implies that it is also in the fiduciary interest of the institution and the physician. The institution will have a lower compensation payout and significantly reduced administrative costs for handling medical errors. The physician benefits by keeping an honest relationship with the patient/family and may avoid direct reporting to the National Practitioner Data Bank. It is worth noting that during the time period of the full disclosure with compensation, there was more rapid claims resolution, lower total liability costs, reduction in administrative costs, and reduction in the claims rate. We were very fortunate at the 2010 Annual Meeting & OTO EXPO to have a miniseminar on Disclosure and Apology. This year we will be holding the miniseminar again, with a slightly different panel of experts. It will be well-worth your time to understand the national trends in disclosure and apology. This study from the University of Michigan’s system will certainly be discussed as well as the implications of its findings on the broader risk liability landscape within healthcare. Many of us have wanted to apologize and disclose a medical error. With data such as this, our case becomes compelling and assuages our concern about increasing our exposure through personal and/or institutional risk when fully disclosing errors. Reference 1. Kachalia A, Kaufman SR, Boothman R, Anderson S, Welch K, Saint S, Rogers MA. Liability claims and costs before and after implementation of a medical error disclosure program. Ann Intern Med. 2010 Aug 17;153(4):213-21. 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 qualityimprovement@entnet.org to engage us in a patient safety and quality discussion that is pertinent to your practice.
Where Does Your State Rank?
Mock Results for 2010 % Participation in State Delaware – 25.93% Number of NEW ENT PAC Members in State New York – 13 Dollars Raised New York – $31,260 Average Contribution in State Missouri – $578 New: ENT PAC Leadership Club Levels This year, the ENT PAC Board of Advisors is launching the new PAC “Leadership Club,” giving levels to encourage new and increased contributions. If you are interested in learning more about the club levels and their associated benefits, visit the ENT PAC webpage at www.entnet.org/entpac or contact staff at entpac@entnet.org. In today’s political and legislative environment, the AAO-HNS must work to strengthen every aspect of our advocacy efforts. ENT PAC, the political action committee of the AAO-HNS, provides U.S. Academy members with the opportunity to pool their voluntary contributions in support of Members of Congress who will champion issues important to otolaryngology—head and neck surgery.* Despite ENT PAC’s recent fundraising success during the last election cycle, we are increasing our efforts to expand the PAC’s membership base and financial clout for 2011 and beyond. At the Board of Governors (BOG) Spring Meeting in March, the ENT PAC Board of Advisors launched a new state-based PAC fundraising and membership recruitment program. The campaign, designed to spur friendly competition among AAO-HNS members, measures ENT PAC calendar year activity in each state based on four metrics: percent participation, number of new members, dollars raised, and average contribution. The winning state in each category will receive the ENT PAC “Academy Award” and recognition in various AAO-HNS publications. To learn more about the 2011 ENT PAC State Fundraising and Membership Challenge, or to view current program standings, visit the PAC website at www.entnet.org/entpac. * Contributions to ENT PAC are not deductible as charitable contributions for federal income tax purposes. Contributions are voluntary, and all members of the American Academy of Otolaryngology – Head and Neck Surgery have the right to refuse to contribute without reprisal. Federal law prohibits ENT PAC from accepting contributions from foreign nationals. By law, if your contributions are made using a personal check or credit card, ENT PAC may use your contribution only to support candidates in federal elections. All corporate contributions to ENT PAC will be used for educational and administrative fees of AAO-HNS, and other activities permissible under federal law. Federal law requires ENT PAC to use its best efforts to collect and report the name, mailing address, occupation, and the name of the employer of individuals whose contributions exceed $200 in a calendar year. ENT PAC is a program of the AAO-HNS, which is exempt from the federal income tax under section 501 (c)(6) of the Internal Revenue Code.
Dr. Steve Levine (center) participated in the Mock Congressional role-playing with former Rep. Steve Buyer (right).
Surgeons Unite on Capitol Hill
Sponsoring Organizations of JSAC 2011 Included: American Academy of Facial Plastic & Reconstructive Surgery, American Academy of Ophthalmology, American Academy of Orthopaedic Surgeons, American Academy of Otolaryngology–Head and Neck Surgery, American Association of Neurological Surgeons, American College of Obstetricians & Gynecologists, American College of Osteopathic Surgeons, American College of Surgeons, American Osteopathic Academy of Orthopedics, American Osteopathic Colleges of Ophthalmology and Otolaryngology–Head and Neck Surgery, American Society for Metabolic and Bariatric Surgery, American Society of Anesthesiologists, American Society of Breast Surgeons, Congress of Neurological Surgeons, Society for Vascular Surgeons, Society of Gynecological Oncologists, The American Society of Cataract & Refractive Surgery, and The Society of Thoracic SurgeonsBold denotes JSAC 2011 planning committee members. The Fourth Annual Joint Surgical Advocacy Conference (JSAC) was held Sunday, March 27, through Tuesday, March 29, at the J.W. Marriott Hotel, in Washington, DC. JSAC activities kicked off Sunday with an exclusive AAO-HNS members-only legislative briefing followed by a networking reception, to officially open the conference and welcome attendees. More than 240 surgeons from 17 surgical societies and the AAO-HNS attended the three-day conference. The AAO-HNS was well-represented by 69 otolaryngologists, making ENT physicians the second largest group for the fourth year in a row. The conference programming began Monday, March 28, with a CME course on Accountable Care Organizations (ACOs). Concurrently, an “Advocacy 101” session was held for residents, young surgeons, and first-time attendees. During that session, Judy Schneider, with the Congressional Research Service of the Library of Congress, discussed the basics of how Congress operates, and surgical society staff provided tips for meetings with Members of Congress. Advocacy programming continued through the day with a legislative briefing on key issues by surgical society staff, followed by a networking lunch. A new addition to the conference was a Capitol Hill role-playing exercise during the Advanced Advocacy training. The session featured former Rep. Steve Buyer of Indiana, and was moderated by media expert, Patricia Clark. An AAO-HNS member participated in each of the four mock Congressional meetings during the role-playing exercises. The Advanced Advocacy training session also included a new “Advocacy Beyond the Beltway” component presented by Jane C.K. Fitch, MD, the American Society of Anesthesiologists (ASA) Governmental Affairs Committee chair. Dr. Fitch provided attendees with advice and information about how to build relationships with elected officials in their respective states. Attendees also heard from several of the “New Physicians in Congress,” including Reps. Dan Benishek, MD, of Michigan, Larry Bucshon, MD, of Indiana, and Andy Harris, MD, of Maryland. Monday evening concluded with the Surgical Society Political Action Committee Fundraiser. Onsite contributors to ENT PAC, the Academy’s political action committee, were invited to attend a fundraising reception held in the Rotunda Room of the Ronald Reagan Building & International Trade Center. Attendees networked with their surgical peers while enjoying live entertainment from a jazz quartet. ENT PAC donors of $1,000 or more were also invited to a VIP reception in the presidential suite of the J.W. Marriott Hotel with special guest Rep. Pete Sessions of Texas, chairman of the National Republican Congressional Committee. Thanks to the generosity of our members, ENT PAC surpassed its fundraising goal and raised more than $22,000 in donations during JSAC. The conference culminated with a full day of meetings with Members of Congress and/or their staff. Sixty-two ENT physicians traveled to Capitol Hill and joined their surgical colleagues to meet with more than 90 Congressional offices representing 30 states and the District of Columbia. Physicians spoke to legislators and staff regarding several issues of importance to the surgical community including, Medicare physician payment reform, repeal of the Independent Payment Advisory Board, medical liability reform, and healthcare truth-in-advertising legislation. A debriefing room on Capitol Hill gave attendees the opportunity to provide feedback to surgical society staff on their meetings before they left Washington, DC. The Academy’s Government Affairs team appreciates the AAO-HNS members who took time out of their demanding schedules to attend JSAC 2011. This year, JSAC attendees will be noted during the 2011 Annual Meeting & OTO EXPO with badge ribbons to recognize their leadership on behalf of the specialty. For more information on JSAC, please visit www.entnet.org/jsac.
The Sinus and Allergy Health Partnership: 1998-2010
Surgeon Scientist Career Development Award In 2006, the SAHP awarded a $99,997 Surgeon Scientist Career Development Award to Noam A. Cohen, MD, PhD, for his project entitled Altered Sinonasal Ciliary Dynamics in Chronic Rhinosinusitis. Chronic rhinosinusitis is a common debilitating disease, principally affecting sinonasal epithelial function with a resultant diminution of mucociliary transport. At the time, little was known about how this disease process affects the sinonasal epithelial ciliated cells. The experiments proposed by Dr. Cohen systematically investigated CRS associated alterations in sinonasal physiology and attempted to determine molecular mechanisms responsible for these alterations. These data have advanced the current understanding of sinonasal pathophysiology, but also highlight discrete pathways to be targeted by novel therapeutic strategies in the management of chronic rhinosinusitis. The project aimed to determine: 1. ciliary response to pharmacologic stimulation in mucosa from patients with and without CRS; 2. the reversibility of the blunted ciliary response associated with CRS; and 3. whether exogenously applied cytokines/chemokines associated with chronic rhinosinusitis can alter ciliary function. This study yielded six publications in Otolaryngology Head Neck Surgery, Am. J. Rhinol. and Biotechniquesand eight presentations at the American Rhinologic Society meetings. In 1997 a Sinusitis Initiative was launched by the American Academy of Allergy, Asthma and Immunology (AAAAI), with task force members averring that the “unique capability of the allergist to diagnose and manage sinusitis will contribute to the well-being of the public and will enhance our practice position,” and that allergists should become the “primary physician to evaluate children and adults with recurrent and/or chronic sinusitis.” A distinguished lecture series was promulgated, with the initial topic being “emerging importance of sinusitis and allergy in asthma,” and the following year “advances in pediatric rhinitis and sinusitis: a course for the primary care physician.” The Conjoined Board of Allergy and Immunology added nasal endoscopy and the management of sinusitis to training program requirements. Though organized otolaryngology accepted that allergists had a role in the management of some nasal issues, the role of  “primary physician” for rhinosinusitis was not acceptable. In the following year, the boards of the American Academy of Otolaryngology—Head and Neck Surgery (AAO-HNS), American Academy of Otolaryngic Allergy (AAOA), and American Rhinologic Society (ARS) organized an outreach to patients and primary care physicians called the Sinus and Allergy Health Partnership (SAHP), comprising three volunteers and $10,000 from each academy. The CEOs of the AAO-HNS and AAOA served gratis as administrators for the first year, thereafter with Jami Lucas of the AAOA serving solo. These founders prioritized (1) promulgation of the benefits of otolaryngologist care of nasal/sinus issues to patients and primary care providers, and (2) support for clinical and research guidelines on rhinosinusitis.  They periodically reported to the Academy Boards and circulated a newsletter for the first few years, later deferring to the newsletters of the three constituents. The SAHP was incorporated as a non-profit entity in early 2000, and fundraising started in earnest; by 2002 the SAHP had raised $1.4 million from pharmaceutical sources similar to those underwriting the AAAAI initiative. As funds accumulated, programs launched. “ENT Outreach” involved a media relations firm that distributed “copy ready” articles penned by the SAHP and its constituents, which reached hundreds of second and third tier newspapers, radio, and TV programs across the nation within the first year of a three-year effort. A “Professor of the Day” series, with two slide sets (rhinosinusitis and allergic rhinitis), targeted family practice training programs, and hospital staff meetings. The SAHP staff lined up lecture slots, recruiting local otolaryngologists, particularly from the AAO-HNS Board of Governors, and reimbursing $500 per lecture; 193 lectures were given in two years. Similarly, a distinguished lecture series was assembled for presentation at the meetings of state medical associations and medical specialty societies. A “Founding Supporter” donation of $100,000 was made to the National Health Museum to assure organized otolaryngology a voice in how the section on the head and neck would be presented. The SAHP also selectively supported appeals to third-party payer restrictions to endoscopic sinus surgery, in particular to multi-state Blue Cross/Blue Shield denials of post-surgical sinus debridement. On another tack, the SAHP sponsored multi-specialty meetings of experts on rhinosinusitis, with the consequence of the publication of three major supplements to Otolaryngology—Head and Neck Surgery from 2000 to 2004 under the direction of the editor and SAHP member, Michael S. Benninger, MD. The supplements are among the journal’s most circulated articles and have netted $565,000 from reprint sales. Other publications resulting from SAHP activities are listed below. By 2003 the AAAAI had folded the Sinusitis Initiative, and the next year the AAO-HNS and AAAAI agreed to joint publication of guidelines for future directions in clinical research on rhinosinusitis. The AAOA and AAAAI resumed consultation on procedure codes and relative work values related to skin testing and immunotherapy, for which a joint position at Relative Update Committee of the American Medical Association was extremely helpful. The SAHP re-directed toward the research side of its original charter, shifting emphasis from socioeconomic and “turf” issues. A “TAP Study” was underwritten, and established endoscopically obtained middle meatal culture as acceptable to the Food and Drug Administration in lieu of the more painful transantral puncture route. The SAHP also joined the CORE grant system administered by the AAO-HNS and awarded substantial grants to a multi-year project on chronic rhinosinusitis. Two years ago, the SAHP considered whether its now solely research and publication sponsorship functions could be delegated to the founding constituents. The answer was yes, and last year $250,000 was transferred to each of the AAO-HNS, AAOA and ARS, with a final distribution this year. In addition to such “return” on the initial $10,000, the AAO-HNS journal revenue from supplements, the support for CORE, and a sizeable PR effort directed by our specialty to primary care providers and patients were dividends. Have a good day. The SAHP is signing off. J. David Osguthorpe, MD, * James A. Hadley, MD, and John A. Fornadley, MD,* for members 1998-2011 Jack B. Anon, MD Michael S. Benninger, MD* Edwyn L. Boyd, MD Stephen J. Chadwick, MD Karen H. Calhoun, MD James C. Denneny III, MD* Ivor A. Emanuel, MD Richard E. Hayden, MD Joseph B. Jacobs, MD David W. Kennedy, MD Donald C. Lanza, MD, MS Howard L. Levine, MD* Bradley F. Marple, MD Timothy L. Smith, MD, MPH James A. Stankiewicz, MD (* = Chair) References  1. Osguthorpe JD. Surgical outcomes in rhinosinusitis: what we know. Otolaryngol Head Neck Surg 1999;120:451-453 2. Sinus and Allergy Health Partnership. Antimicrobial treatment guidelines for acute bacterial rhinosinusitis. Otolaryngol Head Neck Surg 2000;123:S1-31 3. Benninger M, Appelbaum P, Denneny J, Osguthorpe J, Stankiewicz J. Maxillary sinus puncture and culture in the diagnosis of acute rhinosinusitis: The case for pursuing alternative culture methods. Otolaryngol Head Neck Surg 2002;127:7-12 4. Benninger M, Ferguson B, Hadley J, Hamilos D, Jacobs M, Kennedy D, Lanza D, Marple B, Osguthorpe J, Stankiewicz J, Anon J, Denneny J, Emanuel I, Levine H. Adult chronic rhinosinusitis: Definitions, diagnosis, epidemiology, and pathophysiology. Otolaryngol Head Neck Surg 2003;129:S1-32 5. Benninger M, Hadley J, Osguthorpe J. Diagnosing acute bacterial rhinosinusitis. Arch Intern Med 2004;164:568-570 6. Sinus and Allergy Health Partnership. Antimicrobial treatment guidelines for acute bacterial rhinosinusitis. Otolaryngol Head Neck Surg 2004;130:S1-45 7. Benninger M, Payne S, Ferguson B, Hadley J, Ahmad N. Endoscopically directed middle meatal cultures versus maxillary sinus taps in acute bacterial maxillary rhinosinusitis: a meta-analysis. Otolaryngol Head Neck Surg 2006;134:3-9 8. Gudis D, Cohen N. Cilia dysfunction. Otolaryngol Clin N Am 2010;43:461-472
AAO-HNSF Donors “Pay It Forward” for the Next Generation
How You Can Pay It Forward Join the Millennium Society Make a $1,000 or greater donation to the AAO-HNSF’s annual fund and be recognized as one of our prestigious Millennium Society donors. www.entnet.org/donate Enroll Your Group in Partners for Progress Make a corporate donation from your academic or private group and partner with us in support of our shared mission.  www.entnet.org/partners Hal Foster, MD, Endowment Campaign Pledge a cash or planned endowment gift that will secure the AAO-HNSF’s mission in the future by providing vital, sustained funding to help address future challenges faced by the specialty. www.entnet.org/endowment The Changing Face of Otolaryngology Endowment Campaign Give a gift to support programs that foster a culture of inclusion and that will attract the best and the brightest to our specialty. www.entnet.org/change orwww.entnet.org/donate Jay S. Youngerman, MD Chair, Board of Governors Development Task Force While preparing this article, I spent time reflecting about the many AAO-HNSF donors I have met over the years while involved with AAO-HNSF Development. As I looked at the list of our Millennium Society members, generous donors who support our mission, I considered who they were — many of them leaders in the specialty – and what they have accomplished. Each of the donors, though, has given for a unique reason. Some gave for very private reasons – in honor or in memory of a loved one. Some gave for more public reasons – out of gratitude for the gifts of a mentor. Many donors give out of an understanding that the AAO-HNSF has been an integral and valuable key to their lives as otolaryngologist—head and neck surgeons. But, in most cases, the stories of these donors lead to a shared sentiment of “paying it forward” for the future of the specialty. Through this article, I want to share a few of the reasons donors choose to pay it forward in meaningful ways that have significant influence on our ability to fulfill the AAO-HNSF mission. AAO-HNS members today are a diverse representation of cultures and backgrounds – each having unique contributions to make toward the specialty’s advancement. Through the AAO-HNSF, donors can support a culture that embraces diversity. They appreciate that the AAO-HNSF and members/donors can collectively offer an environment that welcomes increased opportunity for under-represented populations – both those wishing to pursue a career in this specialty and those who are treated by practitioners. Donors want to support the next generation of leaders who will help address the concerns facing tomorrow’s practitioners, just as their mentors and leaders supported their needs by leading this fine organization. And members see the unique opportunity to do this by supporting the AAO-HNS Resident Leadership Grants Program so that residents can participate in the world’s largest educational gathering of our specialty and in exceptional leadership development. Some received CORE grants years ago that enabled them to become engaged in NIH-funded research. This makes it simple to consider the start they had in research, and to choose to pay it forward to another young investigator. Donors may choose to give because they want to ensure that the same journal that helped them disseminate their knowledge and encourage the best patient care will continue to be one of the premier journals in the world. Some choose to give because they are grateful for the incredible professional experience they have been afforded by presenting in the annual meeting and recognize how that has led to their stature as a leader in the specialty. Others give because they realize the incredible need for securing representation, fair payment, and reimbursement for their practice in today’s environment, and they realize this requires resources for ultimate success. And then there’s the reason we became doctors in the first place – to help those most in need to receive healthcare. Our international and humanitarian efforts inspire donations because it is easy to see the tremendous impact on global health that can be achieved with a donation. Have you benefited from your experiences with the AAO-HNS/F? Why not consider paying it forward so others may benefit too? Thank you for your consideration.
Don’t Forget These Dates!
June 1 Register now for the 2011 AAO-HNSF Annual Meeting & OTO EXPO. Save up to 50 percent June 1 Monthly mini PR campaign: Summer ENT at www.entnet.org/Community/outreach.cfm June 26 Notifications for Otolaryngology Historical Society abstracts sent June 27 Early registration deadline for the AAO-HNSF Annual Meeting & OTO EXPO
William Harry Barnes, MD, was the first African-American to be certified by an American specialty board when he became a diplomate of the American Board of Otolaryngology in 1927.
William Harry Barnes: Pioneer for the Specialty
Duane J. Taylor, MD Chair, Diversity Committee My deep and committed involvement in the Academy for the past 20+ years has been due in large part to my initial and long-standing involvement as a member of the Board of Governors representing the W. Harry Barnes Society and Otolaryngology Section of the National Medical Association (NMA). The NMA represents the organization of African-American physicians in our specialty. The name William Harry Barnes has most recently been linked with an Academy-sponsored Endowed Leadership Grant to honor his legacy. However, I am sure the majority of our Academy members may ask, “Who was Dr. William Harry Barnes?” Dr. Barnes became the first African-American to be certified by an American specialty board in 1927. That was the year he became a diplomate of the American Board of Otolaryngology. Dr. Barnes was born to a life of humble beginnings in Philadephia in 1887. His desire to become a doctor started at a very young age. In 1908, he graduated from Central High School of Philadelphia with a bachelor of arts degree. After taking a competitive entry exam, he received a four-year scholarship to the University of Pennsylvania Medical School, becoming the first African-American to be awarded this scholarship. In 1912, he received his MD degree and then completed his internship at Douglass and Mercy Hospitals in Philadelphia. He respected the value of hard work and believed education to be an ongoing process. These tenets were a consistent source of his drive and determination for his many accomplishments during his relatively short life. Dr. Barnes had his first appointment as an assistant otolaryngologist at Frederick Douglass Hospital in 1913 in Philadelphia. In 1918, he served as an acting assistant surgeon in the U.S. Public Health Service. Three years later, he took further postgraduate studies in otolaryngology and head and neck surgery at the University of Pennsylvania. He subsequently was appointed chief otolaryngologist of Frederick Douglass Hospital and clinical assistant otolaryngologist at Jefferson Medical School, in Philadelphia in 1916. In 1922, Dr. Barnes announced he would devote his practice exclusively to ear, nose, and throat disorders. Two years later, he was appointed consultant otolaryngologist at Mercy Hospital and desired further training in otolaryngology. Unable to receive this training in the United States, he went to the University of Paris and the University of Bordeaux to undertake more advanced studies during 1924. He found himself studying under Dr. Pierre Sebileau, professeur de la Faculté de médecine de Paris; L. Baldenweck, MD, in Paris; and Dr. Emil-Jean Moure, professor of otology, University of Bourdeaux. After his return to the United States, he took more courses with Dr. Unger in 1926. Dr. Barnes was drawn to the work that Dr. Chevalier Jackson was doing in Philadelphia with bronchoesophagology and studied under him to master this technique. In the early 1930s, he organized and headed the department of bronchoscopy at Mercy Hospital and received an appointment as a lecturer and consultant at Howard University Medical School in Washington, DC, in bronchoscopy. He taught many physicians his techniques and published numerous papers on a variety of topics in the specialty. Dr. Barnes served as the 37th president of the NMA in 1936, the largest organization of African-American physicians in the world. He was the founder of the Society for the Promotion of Negro Specialists in Medicine and served as President of the Philadelphia Academy of Medicine and Allied Sciences. He was a member of the Philadelphia County Medical Society, the Pennsylvania State Medical Society, American Laryngological Association, and the AMA. He also was known as an inventor and innovator. He invented the hypophyscope for visualizing the pituitary through a transeptal approach. He developed an early medical record system and devised instruments for removal of lingual tonsils. He also developed an operative technique for drainage of peritonsillar abscesses and myringotomy. Dr. Barnes was a humanitarian and donated much of his time and talent to those who could not afford care. He was active in his church, serving as the president of the board of trustees of Zoar Methodist Church, and was appointed as one of the original members of the Philadelphia Housing Authority, which he served on until his death. He was married to Mattie Thomas and had five sons, two of whom were physicians. He died January 15,1945, of pneumonia. He was 58. References 1. Cobb, M. Medical History. Journal of the National Medical Association (JNMA).1955 Jan: 64-66. 2. Smith Jr., A.P. The Society for the Promotion of Negro Specialists in Medicine. JNMA. 1954 Jul.
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With the SRF in Mind: This Meeting Is for You
Collin B. Grabarek The AAO-HNS recognizes resident otolaryngologists are the specialty’s future. Continually seeking to improve patient care, the Academy provides the next generation of otolaryngologists with resources they can use to advance and refine their field. During the 2011 Annual Meeting & OTO EXPO in September in San Francisco, the Foundation and its Section for Residents and Fellows-in-Training (SRF) invite residents to participate in a number of events designed specifically for them. The annual Leadership Development Training Session on Saturday afternoon, September 10, will provide residents with a crash course in AAO-HNSF 101. Here, residents can learn about the organization’s structure, operation, and goals. Attendees will discover opportunities to get involved in the Academy as volunteers and network with leaders in the field. Attending the Leadership Development Training Session is the perfect way for residents to gain a better understanding of the AAO-HNS and all it offers. Moreover, residents are encouraged to attend the SRF-sponsored miniseminar, “Practice Considerations and Contracts for New Employment.” At 10:30 a.m., on Tuesday, September 13, this program will explore common career concerns of both emerging otolaryngologists and those entering new practice opportunities. From interviewing basics to contract negotiation tips, residents will glean knowledge they can use to progress in the world of professional medicine and protect themselves while doing so. The Academy also invites residents to participate in the SRF General Assembly at 2:30 pm, on Monday, September 12. By having a voting member on the Academy’s Board of Governors (BOG) and by interacting with the Academy’s Board of Directors, the SRF ensures that residents’ opinions reach the ears of those who can make things happen in the Academy. At the General Assembly, residents not only receive updates from the Section’s leadership and take part in breakout sessions, but they also get to cast their votes for the SRF Governing Council. The Academy encourages all residents to help elect next year’s SRF Governing Council members, who bring residents’ concerns to the attention of the Board of Governors and the American Board of Otolaryngology (ABOto). Please let your voice be heard. Residents also may take part in the always popular Academic Bowl at 10:30 am, on Sunday, September 11. Audience members can watch—and join in—as teams from four of the nation’s outstanding residency programs compete in a test of clinical knowledge. Loyola University, Tulane University, the University of Mississippi, and the University of Texas Southwestern will be competing. Participants are encouraged to play along, using an anonymous wireless response system. The Academic Bowl is a fun and exciting way to interact with fellow Academy members, and to brush up on important information in preparation for the ABOto’s upcoming Maintenance of Certification (MOC) process. Through the Academic Bowl, you can even earn CME. Far from exhaustive, this brief article does not do the Annual Meeting justice, and it covers only a handful of the many events that residents may find intriguing, enlightening, and useful. Please check future issues of the Bulletin for more about the Annual Meeting, and visit the meeting website at www.entnet.org/annual_meeting. We look forward to seeing you in San Francisco. Please note that all event times are subject to change.  For the most up-to-date schedule, visit www.entnet.org/annual_meeting.
2011 Model Committees Announced
J. Regan Thomas, MD, AAO-HNS/F president, announced his selection for the 2011 Model Committees. The committees and chairs are listed below. Model Committees and Chairs Diversity Committee: Duane J. Taylor, MD, Chair Outcomes, Research, and Evidence-Based Medicine: Scott E. Brietzke, MD, Chair Head and Neck Surgery and Oncology Committee: Daniel G. Deschler, MD, Chair Patient Safety and Quality Improvement (PSQI): David W. Roberson, MD, Co-Chair; Rahul K. Shah, MD, Co-Chair Women In Otolaryngology Committee: Sonya Malekzadeh, MD, Chair; Shannon P. Pryor, MD, Chair-Elect Characteristics of a Model Committee  Model committees contribute in ways that lead to the success of the AAO-HNS/F mission: empowering otolaryngologist—head and neck surgeons to deliver the best patient care. Model committees have a passion for the AAO-HNS/F’s vision and for accomplishing the activities outlined in the AAO-HNS/F strategic plan. Model committees are successful because they share specific characteristics, including, but not limited to: • strong committee chair leadership; • engaged and active committee members who have a desire to volunteer time and resources; • committed support from the Board and staff liaisons; and • a well-articulated charge and supporting work plan that is revised at least annually. These committees generate a body of knowledge giving the AAO-HNSF the ability to provide resources that empower members’ delivery of quality care.
Proposed 2011-2012 Combined Budget
John W. House, MD Secretary-Treasurer Each spring, AAO-HNS/F staff leadership works with members of the Finance and Investment Subcommittee (FISC) to develop a proposed combined AAO-HNS/F budget for the next fiscal year. The process begins by taking into account the direction provided from the Boards of Directors (Boards) of the Academy and the Foundation during the December strategic planning meeting. Once the proposed combined budget has been thoroughly vetted by the FISC, the budget is reviewed by the Executive Committees and presented to the Boards for approval. Per the AAO-HNS/F bylaws, a summary of the proposed budget must be published in an appropriate Academy publication and that a copy shall be made available to any member requesting it in writing reasonably in advance of its adoption. The proposed combined budget presented here has been discussed in detail with the full Boards and will be officially approved as of June 30. The proposed 2011-2012 combined budget conditionally approved by the Boards takes into account the trends that are shaping the future of the industry. These include increasing continuing education needs; increasing sub-specialization; increasing needs for research, quality, and evidence-based medicine (EBM); increasing pressure for cost-effectiveness; increasing government involvement; increasing use of technology and connectedness; and evolving workforce supply and demand. In addition to prioritizing the direction of the Boards, the budget was developed based on current year operations, with adjustments for anticipated changes in program revenues and expenses. It is presented on a modified cash basis and reflects break-even operations. The majority of revenue is earned from two areas: membership dues and Annual Meeting registrations and fees. The proposed 2011-2012 combined budget reflects a 2.5 percent increase in membership dues. The other major areas of budgeted revenue are product and program sales, royalties, and corporate and individual support, which continue to be very strong. Expenses are separated into two areas: direct operating costs related to each business unit; and allocated costs, related to staffing and benefits as well as the operating costs that are incurred for the good of the whole organization. The complete budget is available to any Academy member who requests it in writing. Send requests to  Brenda S. Hargett, CPA, CAE, chief operating officer, care of Bulletin@entnet.org. AAO-HNSF Combined Budgets Approved Budget 2010-11 Proposed Budget 2011-12 Revenue Dues & Membership $6,200,000 $6,350,000 Royalties 1,338,531 2,352,000 Corporate & Individual Support 1,554,700 1,030,000 Meetings 6,392,215 6,626,000 Products & Program Sales 2,225,340 1,542,500 Investments 618,000 664,000 Funds Released from Restrictions 222,900 483,500 Miscellaneous 117,000 78,000 Total Revenue $18,668,686 $19,126,000 Expenses Direct Operating Costs Office Expense $705,258 $423,400 Occupancy 196,500 182,500 Travel & Entertainment 706,745 818,100 Meetings 2,604,199 2,595,900 Printing and Production 1,295,870 541,200 Communication & Software 398,384 320,100 Consultants & Professional Fees 2,872,646 3,743,000 Total Direct Operating $8,779,602 $8,624,200 Allocated Costs Salaries & Benefits $7,089,698 $7,765,200 Occupancy 1,728,799 1,626,800 Support 1,070,587 1,109,800 Total Allocated $9,889,084 $10,501,800 Total Expenses $18,668,686 $19,126,000
AMA PRA Enduring Material Minimum Performance Level Takes Effect July 1
The AMA has made changes in how physicians receive CME credit for enduring materials in its 2010 version of the Physician Recognition Award (PRA) credit system. As of July 1, 2011, a minimum performance level must be demonstrated for enduring materials in order to successfully complete the activity for AMA PRA Category 1 Credit™. “The purpose of this new requirement is to ensure that learners are actively engaging in the content of the activity and showing improved proficiency in patient care as a result of their participation in the activity,” said Mark K. Wax, MD, coordinator for education. To be certified for AMA PRA Category 1 Credit™ an enduring material activity must: • Meet all AMA certification requirements; • Provide clear successful completion instructions to the learner; • Provide an assessment of the learner that measures achievement of educational objectives with an established minimum performance level; • Communicate to participants the minimum performance level; and • Provide access to bibliographic sources to allow for further study. In order to comply with this new requirement, the AAO-HNSF has established a minimum passing score of 70 percent for all of its enduring materials including Home Study Course, Patient of the Month, AcademyU®, and Online Lectures. This minimum passing score requirement will be in effect for all activities released after July 1, 2011. Preparations are under way to align AAO-HNSF’s enduring materials with this new AMA requirement that learners achieve a passing score upon completion of an enduring CME activity in order to receive AMA PRA Category 1 Credit™ for the activity. For each activity, the physician learner will have the opportunity to retest if he or she does not achieve the 70 percent score on the first attempt. Home Study Course participants will be able to retest one time. All other activities will allow for up to two retests. Participants will be given their score after each test and will be provided instructions on how to retest if necessary. The Academy is working to build this new scoring and retesting process into the technology supporting its various continuing education activities. “We are committed to ensuring this new requirement becomes a seamless part of our enduring materials and to maintaining the same high quality of content our members and participants have come to expect,” said Mary Pat Cornett, CAE, CMP, senior director of education. More information regarding this change in enduring materials will be available soon on the Academy website. If you have any questions, please send an email to ce@entnet.org.
Smiles were among the many things shared over energizing conversations — here with Dr. Sujana Chandrasekhar.
The AAO-HNS and Women: Membership Enters a New Era
Section Leadership and Standing Committees • Governing Council (Sonya Malekzadeh, MD) consists of all of the committee leaders, is charged with developing the charter, and coordinates efforts among the committees. • Leadership Development/Mentorship (Mona M. Abaza, MD) is already devising a plan for building relationships between Academy members seeking or offering assistance in navigating the various waters of our profession among other projects. • Awards (Valerie A. Flanary, MD) is tasked to identify and nominate women deserving of recognition for otherwise unrecognized contributions to the greater good of their community. • Program (Lauren S. Zaretsky, MD) will coordinate annual meeting programming of particular interest to women but with broad appeal for all members as well as plan the annual WIO luncheon. • Research/Survey (Linda S. Brodsky, MD) is already working in concert with the Mentorship group on surveying the membership to create a mentoring program that best meets its needs. • Communications (Susan R. Cordes, MD) is charged with informing the AAO-HNS membership of the WIO’s activities and initiatives. • Development and Endowments (Pell Ann Wardrop, MD) is charged with ensuring that the proceeds from the exemplary fundraising efforts that gave rise to the WIO Endowment are well managed in collaboration with the Section’s Governing Council. A. Kristina E. Hart, MD, with contributions from Susan R. Cordes, MD, and Sonya Malekzadeh, MD, for the Women in Otolaryngology Section The AAO-HNS membership and its Board of Directors (BOD) achieved a new milestone in early December 2010 when it approved the Women in Otolaryngology (WIO) Committee’s formal request to become the Academy’s second Section. (The Section for Residents and Fellows was the first.) The foundation for this meteoric progression to enhanced representation for the fastest-growing segment of the AAO-HNS membership was laid well before 2001 when the WIO was formalized as a committee. For many previous decades, a handful of women met informally at the Annual Meeting & OTO EXPO to support each other as they navigated personal and professional challenges unique to women otolaryngologists. Eventually, the findings of a study group organized in 2000 gave way to the fully empowered WIO committee that was formed in half the typical committee gestation time. While women represent only 14 percent of the AAO-HNS membership, we constitute 29 percent of the 25- to 35-year-old age demographic, 31 percent of residents in otolaryngology—head and neck surgery, and 50 percent of medical school graduates today. The groundswell of enthusiasm for greater collaboration, involvement, and voice in AAO-HNS matters was reflected first in a WIO Committee generated survey. (See “What Do Women in Otolaryngology Think?” in the December 2010 Bulletinfor details.) It was personified in September by the crowd of more than 250 people attending the WIO Committee luncheon held during the Annual Meeting in Boston. Although previous WIO luncheons had been well-attended by both men and women, the luncheon had been in hiatus in recent years. Lively conversations have always been a hallmark of these luncheons. However, this one was unique in that it featured the first presentation of the survey results and then gave attendees a productive voice regarding topics including work/life balance, leadership, identification and elimination of barriers, pay equity, and mentorship. This momentum was further fueled by three of the committee’s members who put their heads and their wallets together. They pledged seed money for an endowment to support the goals of the WIO Section. In less than four days, an unprecedented $400,000 endowment was established from contributions made. In some cases, people who had not previously contributed to the AAO-HNSF donated. With Sonya Malekzadeh, MD, at the helm and the AAO-HNS Executive Committee’s blessing, the WIO Committee submitted a proposal to become a Section when it became clear that a committee structure would no longer allow for the full participation and engagement of women in addressing matters of importance. Section status will provide the Women in Otolaryngology greater autonomy as a constituent group and facilitate AAO-HNS member recruitment and retention. Simultaneously, this will allow the AAO-HNS at large to carry out a vital part of its strategic plan to enhance member engagement, foster leadership development, and harness the energy of this membership segment. A committee, as defined within the parameters of the AAO-HNS organization, is purely a governance structure whose purpose is to carry out tasks requested by the AAO-HNS Board. It is not designed to represent a constituent group. The proposal to convert the WIO Committee to a Section was approved by the BOD at the December meeting, and the work of developing a charter outlining bylaws and Section structure is now completed. Although 82 percent of the 2,000 survey respondents preferred a separate function held during annual meeting hours, women clearly wish to be more integral to the Academy’s team. As part of a Section, women will be better able to raise issues, backed by well-thought-out solutions that present challenges not only to them but also to the membership as a whole. Six working groups established as a direct result of objectives identified by survey responses and the luncheon collaborations will be re-designated as Section committees and will provide a portion of the framework for the WIO Section. (See “Section Leadership” on this page.) The objective of increasing women’s representation within the AAO-HNS leadership will be achieved through the development of women as leaders both within the WIO Section and through their mandated presence at, and participation in, meetings of the BOD and Board of Governors. The WIO Committee’s collaboration with other committees will continue beyond its re-designation as a Section. Perhaps the WIO Committee’s most notable team effort to date has been in its work with the Ethics Committee with which it developed a gender equity policy. This policy once again vaulted the AAO-HNS into the forefront by virtue of its being among the first of its kind among surgical subspecialty societies. We anticipate many other collaborative efforts that will not only keep the AAO-HNS at the forefront of representative organizations but that will support its men and women as the entire OTO-HNS workforce moves further into the 21st century with its attendant challenges. We’ve all come a long way as an organization and, while we’re excited by our re-organization as a Section, we acknowledge there’s still much work to be done. We invite you to keep the momentum going by joining us as we roll up our sleeves, put on our thinking caps, and continue to take on matters that may perhaps seem unique to women in otolaryngology but which truly affect us all as members of the AAO-HNS.
Michael D. Seidman, MD, Chair, Board of Governors
BOG Spring Meeting: What You Missed
Over the March 26 weekend, a large and dedicated group of BOG members and related organizations descended on Alexandria, VA, and Washington, DC, to take part in the Board of Governors (BOG) Annual Spring Meeting and the Joint Surgical Advocacy Conference (JSAC). The event started with an “ice breaker,” in which we considered each of our individual strengths in the four domains of leadership critical for success: execution, influence, relationship building, and strategic thinking. The BOG Socioeconomics and Grassroots Committee, under the guidance of Denis C. Lafreniere, MD, and Steven B. Levine, MD, led us through a packed agenda beginning with an overview of maintenance of certification by Robert H. Miller, MD, MBA. John R. Houck, Jr., MD, led a discussion of “Bundling Practices, “followed by Brian J. Broker, MD, who presented “Fragmentation of the Otolaryngologist.” The discussion was engaging and lively. Susan R. Cordes, MD, BOG member-at-large, led a panel discussion on how state societies can best share the message of their specific state and Academy activities. This went a long way to answer the question: “What has the Academy done for me lately?” It amazes me that the wonderful work done by the Academy, including the grassroots efforts of our members and your BOG, are not well-known by our membership, despite multimodal strategies to  disseminate that information via the Bulletin, emails, tweets, and more. Please don’t hit the “delete” button so quickly on the emails. I am pleased to report that for “card-carrying” members of the AAO-HNS, your $820 dues has a calculable return on investment of about $12,000 to $15,000 secured by coding changes, unbundling, and other efforts made by your leadership and staff at the AAO-HNS. Also, we need to consider supporting the non-partisan ENT PAC*, the Academy’s political action committee. Ninety-plus percent of trial lawyers contribute to their respective PACs, but only 11 percent of us contributed to ENT PAC last year. While many of our PAC donors give $365 or more, any contribution will help us expand the strength of ENT PAC. The more members we have, the greater our leverage on Capitol Hill. The Development/Fundraising Task Force led by Jay S. Youngerman, MD, presented the ongoing outstanding philanthropic initiative; the Hal Foster, MD, Endowment Society has nearly $5 million pledged and is well on the way to its $30 million goal.  If you have not yet considered the concept of a legacy (or any other form) gift to the Foundation, please join the Millennium Society and support important activities of the AAO-HNSF. During the Legislative Representatives meeting spearheaded by Paul Imber, DO, and Stacey L. Ishman, MD, we heard about ways to get more involved in state and federal legislative activities. A true highlight was hearing Rep. Tom Price, MD, R-GA, speak to us about opportunities for success in healthcare reform. He advised each of us to “befriend” one or two of our representatives by sending emails, making calls, and supporting them locally. The more they see your face and hear your name, the more likely they are to use you as a valuable resource for promoting our agenda of great healthcare for all. Sujana S. Chandrasekhar, MD, BOG chair-elect, led a discussion about incorporating mid-level providers (MLPs) into your practice. To be ready for the increasing number of patients who will have access to our care, we need to train these providers to work in our offices as “physician extenders.” The following day opened with the Keynote Address from Gail Warden, past CEO of Henry Ford Health System, who has chaired numerous committees at the Institute of Medicine. He is the chairman emeritus of the National Quality Forum, the National Committee for Quality Assurance, a past chair of the American Hospital Association, and currently serves as an advisor on the RAND Health Board. He also has advised the past two U.S. presidents, as well as President Barack Obama on healthcare reform. The President also asked him to serve on the Independent Payment Advisory Board (IPAB), but he declined. It was indeed an honor to learn from him about ways to positively affect healthcare reform for our patients and the future of our practices. We segued to JSAC, and once again otolaryngologists were the second largest represented group of surgeons in attendance. Congratulations to those of you who helped spread our message. This was a wonderful opportunity to talk about our concerns regarding the IPAB and the Sustainable Growth Rate, medical liability reform, healthcare truth-in-advertising legislation, and quality improvement initiatives. We will meet again at the Annual Meeting in San Francisco, and we have an outstanding miniseminar, “Hot Topics in Otolaryngology:  2011,” planned by Peter Abramson, MD, BOG secretary, on Tuesday, September 13. I am here to serve. Please contact me with any questions or comments mseidma1@hfhs.org. * Contributions to ENT PAC are not deductible as charitable contributions for federal income tax purposes. Contributions are voluntary, and all members of the American Academy of Otolaryngology-Head and Neck Surgery have the right to refuse to contribute without reprisal. Federal law prohibits ENT PAC from accepting contributions from foreign nationals. By law, if your contributions are made using a personal check or credit card, ENT PAC may use your contribution only to support candidates in federal elections. All corporate contributions to ENT PAC will be used for educational and administrative fees of ENT PAC, and other activities permissible under federal law. Federal law requires ENT PAC to use its best efforts to collect and report the name, mailing address, occupation, and the name of the employer of individuals whose contributions exceed $200 in a calendar year.
David R. Nielsen, MD, AAO-HNS/F EVP/CEO
The Art of Communication
Electronic or virtual methods of sharing information continue to increasingly dominate the way humans communicate with one another. In the last few years, text messaging has overtaken all other media as the most frequently used method of communication. In fact, more text messages are sent every day than are emails, voice, voice mail, mail, fax, television, and radio broadcasts combined. This is a worldwide phenomenon and, ironically, more prevalent in developing nations than in the United States. Impoverished communities without television, radio, or computer access to the Internet frequently have cell phones, and they are used far more for texting than for voice calls. Although the characteristics of immediacy, ease, affordability, and viral universality of texting are obvious, many experts in communication are wary of the unintended and often unexpected consequences of increasing “virtual” conversations. Consider the following real-life incident as reported in T+D magazine, the flagship magazine of The American Society for Training and Development: “A CEO who thought he saw too few parked cars [in the company parking lot] early and late in the day blasted an angry email to 400 managers. He complained that the employees weren’t working enough hours. An employee forwarded the CEO’s email outside the company, and it was posted on Yahoo.com. Stock market analysts and investors found out and were concerned that negative events at the company were behind such an angry message from the CEO. The New York Times picked up the story. The company’s stock price fell 22 percent in just three days.” There are many such examples of viral spread of messages: YouTube videos of natural disasters, tweets of immediate events, personal blogs, or amateur productions. Some, like the spread of a talented musicians’ work, or the text message fundraising effort for the victims of the earthquake in Haiti or the tsunami in Japan, are immensely positive. Others, like financial scams, computer viruses, or “online bullying,” are exploitative, horribly unfair, and destructive. Incredibly powerful forces have been unleashed in the last few months through the use of uncontrolled personal electronic communications, causing political upheaval in nations with restrictive regimes and leading to war and destruction, as well as liberation and freedom. Closer to home, we struggle as individuals each day in managing the demand on our time and our lives created by this deluge of messages. Even with spam filters, blocked messages, junk email folders, and software solutions, it is not uncommon for an average teenager to receive hundreds of texts, emails, and tweets per day. A typical U.S. teen checks messages on an average of once every 6.5 minutes throughout the day. And though the older, less connected generation may not be as frequently affected, the gap is closing. The rate at which texting and Internet usage is increasing is greatest among the over-50 crowd. So, how do we, as your faithful Academy staff, find the “sweet spot” of communicating with you enough to maximize your satisfaction with our service, keeping you up to date on the rush of relevant information, and, at the same time, cluttering your junk email box and cluttering up your already busy lives with excess information? In addition to the information we wish to  “push out,” there is rarely a day when a well-meaning member does not want us to “poll the membership” regarding an issue of importance or to share our membership email list (which we do not). Or publish an online survey. Or a click-through message in The News. More importantly, how do we use mobile communications and related devices to add value to your lives, simplify immediate access to the information you desire, and deliver it exactly when and where you want it? The advances in mobile communications make it possible for us to provide real-time, point-of-care, on demand, interactive, learner-centered, mobile access to medical education, decision support services, and documentation of quality performance in practice. As the Academy integrates its comprehensive otolaryngology content, including the journal Otolaryngology–Head and Neck Surgery, AcademyU, the Home Study Course, the Otolaryngology Online Study Guide, COCLIA, as well as other offerings, you will be seeing the development of mobile applications and the ability to “push” or “pull” content you desire. These offerings will be tailored to your needs and targeted to specific purposes you designate. As we move forward more rapidly in using digital technology effectively, let’s remember the critical importance of face-to-face communication. The rich blessing of personal contact, voice, touch, and the non-verbal communication that comes from “real” conversation will never be replaced by electronic means.
J. Regan Thomas, MD, AAO-HNS/F President
From the President: Building Long-Term Financial Stability and a Strong Specialty
I am pleased to report that the Academy is in a sound financial position. In this issue, AAO-HNS/F Treasurer John W. House, MD, presents the proposed FY 2011-2012 combined budgets, which has been reviewed in detail by the Finance and Investment Subcommittee (FISC) and the Boards of Directors. You will note that the budget is balanced and has been prepared on a modified cash basis, taking into account, for the first time, all debt service payments. Dr. House reports too that operations for FY 2010-2011 are expected to provide a contribution to reserves as the result of a great annual meeting experience in Boston and the savings generated in other areas. This budget has been closely linked by our leadership to our strategic priorities and reflects our commitment to prepare for present and future trends. These include demands for: • offering performance-based, behavior-modifying continuing education; • researching and offering evidence-based treatment options; • providing high-quality patient care that is universal; • affecting influence on the increasing government involvement in care delivery; • integrating technology in care and communication; and • anticipating shifting workforce issues. I am grateful to Dr. House, the FISC, and the boards for the leadership they have shown in developing such a responsible budget. The manner in which this is done puts our U.S. Congress to shame. This is a budget that can lead us into the future and sustain the legacy that is otolaryngology. As you review “Candidates for Leadership” on page 31 of this issue, keep in mind the kind of leadership we need to meet these future needs. Guideline Leadership Another positive acknowledgment for the activities of the Foundation came this spring when the Institute of Medicine (IOM) released its long-awaited report, “Clinical Practice Guidelines We Can Trust,” and a companion report, “Finding What Works in Healthcare – Standards for Systematic Reviews.” Of note, the IOM report referenced the participation and comments of Richard M. Rosenfeld, MD, MPH, Foundation journal editor, and referenced the Foundation’s “Clinical Practice Guideline Development Manual,” June 2009, in multiple places throughout the report. The Academy is not only in close alignment with published best practices, but was cited for its processes as reference for IOM recommendations. Part of the report’s work has been to update us all on the evolution of clinical guidelines. In the 20 years since the IOM’s first report on the subject, the definition of a guideline has changed from the original “systematically developed statements to assist practitioner and patient decisions about appropriate healthcare for specific clinical circumstances” to “clinical practice guidelines are statements that include recommendations intended to optimize patient care that are informed by a systematic review of evidence and an assessment of the benefits and harms of alternative care options.” The Foundation’s influence has been palpable. Membership Renewal Successes Membership retention activities for our Academy have been successful for 2011. This year’s dues billing cycle began with a total membership of 11,635, including 10,219 dues paying active members and 1,416 life and honorary members. As of this writing, we fully expect to reach our stretch goal of 98 percent retention rate for the 2011 membership cycle. In order to continue to refine the dues renewal process, a greater emphasis was placed on encouraging members to renew online. About 37 percent of renewals were completed online, an 11 percent increase over online payments for 2010. With increased focus on online renewals, we were able to reach more members with email reminders. This enabled us to delay the mailing of a physical second dues invoice until late February. As shown in the month-by-month renewal data, we maintained strong renewals while decreasing the size of our second dues mailing from 2,812 in 2010 to 2,517 in 2011. It Calls to Me In the spring I met with Foundation staff to arrange a site visit to begin hands-on preparations for the upcoming AAO-HNSF Annual Meeting & OTO EXPO, September 11-14 in San Francisco. Our time there was well spent. Although the weather was typical of spring anywhere, a little rain and a little sun, the city of San Francisco itself was thrilling in its proverbial display of a dramatic setting combined with cosmopolitan polish. To bring some of that zest to you first-hand, as you begin to register for the meeting, our site team put together a few video presentations that you will see throughout the summer in emails and on the special annual meeting website that opened last month. We hope some of the city’s flavor comes through to you as you watch these clips. I am looking forward to seeing all of you in San Francisco for this terrific annual meeting.
twitterscreen
Technology Offers Physicians Opportunity, Peril
M. Steele Brown, special to the Bulletin In the ever-changing world of medicine, technology can be used as a tool to break down the wall between doctor and patient. Websites, electronic medical records, blogs, and email — all of these technologies can serve as tools to bring doctors and patients closer together. Although technology can increase a communicator’s reach, it is also important to point out that the technology cannot do the actual communicating itself. David Reiter, MD, DMD, MBA, professor of otolaryngology—head & neck surgery and facial plastic & reconstructive surgery at Jefferson Medical College in Philadelphia, said he has spent considerable time researching the relationship between doctor-patient communication and patient outcomes. He said his research shows strong indications that patients do better when their doctors communicate more effectively with them. The problem is, doctors aren’t always the best at discourse. “Physicians, for whatever reason, haven’t always been good at listening to what the patient is saying,” he said. “Instead, we expect the patient to focus on what we are saying, which can lead to missing out on certain information. Many patients feel intimidated in the traditional face-to-face doctor-patient encounter and forget to mention everything they planned to discuss when they came into the office.” Dr. Reiter, who is also the associate chief medical officer of Jefferson University Hospitals, as well as the medical editor of Facial Plastic Times, said that while this news is not groundbreaking, it does present an opportunity. Using technology, physicians can supply patients with a more thoughtful forum in which to discuss their condition and ask questions. “Patients cannot remember everything — even if they write all of their questions down, if they feel intimidated by the physician, they might not think to ask the right questions until they are driving home in their car. Then, it is too late,” he said. “But now, with technologies like email and texting, patients have more time to organize their thoughts and asks questions more completely. Instead of forgetting about the unanswered questions, patients can send the doctor a well-thought-out message that better conveys their issues.” Dr. Reiter said that in his experience, many doctors are resistant to taking full advantage of electronic communication tools because they see this “e-relationship” with patients as one that allows the patient to question the physician’s expertise. That, he said, is a mistake. “Physicians have to accept that this is not an adversarial relationship, but one that enhances openness,” Dr. Reiter said. “There is a finality to the encounter in the office that does not exist when you bring electronic communication tools into the mix. Back to School Dr. Reiter said that education and practice, as well as feedback on performance, are the keys to helping physicians become truly effective communicators. And unless you become a better communicator, you have no business worrying about electronic media as a path to your clients’ hearts. Technology is the tool, not the answer. “You cannot communicate effectively simply because you’ve thrown your message out on more channels without any regard to what you’re saying or who you’re saying it to,” he said. “A lot of studies show that physicians are not well-trained in communication, but what’s worse is that most of them believe that they are a lot better communicators than their patients think they are. Again, we are not listening to our patients.” The Doctor Is Always In One of the great benefits of technology is that it can give patients 24-hours-a-day access to their physician. Of course, that is also one of technology’s real downsides, Dr. Reiter said. But it doesn’t have to be. “Physicians used to schedule time to answer phone calls and respond to patient questions,” he said. “Most doctors still adhere to that, but what makes technology great is that it is easier to respond because you are not limited to the normal contact hours. With email, you can respond to your messages during dinnertime without interrupting your patients at home. So now, doctors have more flexibility and are able to use their in-office hours more productively because they are not making calls for two hours a day, nor are they sitting by the phone waiting for a callback.” Social media platforms such as Facebook, Twitter, and blogs also allow physicians an opportunity to reach new patients and protect their reputation. Christopher Y. Chang, MD, a private practitioner at Fauquier ENT Consultants in Warrenton, VA, said he primarily uses YouTube and his blog — http://fauquierent.wordpress.com/ — because he can control the message. “The whole point, in the end, is to promote the practice,” he said. “People are reading the information I want them to read and they are subscribing because they are interested in the topics. There is a lot of garbage out there. If I can give people more accurate, up-to-date information, it is good for potential patients and it is good for the practice.” Dr. Chang said he uses Twitter and Facebook mainly to drive traffic to YouTube and the Fauquier ENT Blog, which increases his chances of showing up higher on the list during a Google search. “When people do a search on an otolaryngology topic, I want to be No. 1 on the top of those search results,” he said. “I have the blog linking back to my practice’s website, as well as any YouTube content and my Twitter page. “With all of these linked together, when someone subscribes to my blog, the chances are greater they’ll click through to one of these pages. This traffic gets you a higher ranking from Google.” Dr. Reiter said there are many physicians who feel there is insufficient time to build on-line relationships and promote their practices this way, deciding to stay away from social media altogether. “It is very important that a physician should embrace every avenue available to him or her to get in touch with the patient population,” he said. “Isolation from the community has been a problem for physicians for years. Social media is one way for doctors to become a more integral part of the community, and physicians who use it are more likely to have good relationship with that community.” Ryan D. Madanick, MD, director of the UNC Gastroenterology & Hepatology Fellowship Program at the University of North Carolina School of Medicine in Chapel Hill, is using the Internet to get his message out. In a recent entry on his “Gut Check” blog (http://ryan madanickmd.wordpress.com/2011/03/06/131/), Dr. Madanick wrote about his experience in an ER when he was getting his broken nose reset by a group of otolaryngology residents. “I’m a doctor, so I want to throw out the caveat that it is possible that my emergency room experience was anything but typical,” he said. “But it was great because the group of residents seeing me gave me the choice of whether to get my nose set right there or come back and have it done later under sedation. They included me in the process, educating me about the options rather than telling me what to do and when to do it. Over all, I was really impressed, so I talked about it in my blog as an example of what to do when treating patients.” Dr. Madanick said that his blog allows him to get in the habit of writing more, as well as get in touch with students and patients. “As an academic, I need to write more,” he said. “On the altruistic side, I want to get out into the public domain and get my opinions about patient-based topics out there – things they should ask or explaining how and why we, as physicians, do things. The other is to give to doctors a patient-centered approach in context of being a GI.” Of course, while these types of websites allow for greater accessibility, they also allow for potentially inappropriate exchanges with patients, Dr. Reiter said. “A blog can give insight into the doctor, as well as the other way around,” he said. “But if you’re going to do it, you have to be honest and open too, without taking on an assumed persona. “I liken it to online dating sites where people lie about who they are. People need to keep a balanced perspective regarding what they read online, because it is just as easy to be seduced by a cerebrally adept doctor as it is by an online dater.” Dr. Reiter said that physicians also need to remember that whatever information they put out into the electronic domain will remain there forever. “Everyone needs to remember once committed to e-media, it is permanently archived for the world to find,” he said. “People write things in anger and haste, forgetting that everything you say in a blog or in an email is there for the scrutiny of the world forever. Dr. Reiter said physicians also need to be careful in responding to those that are not yet bona-fide patients. “If you are putting medical advice out on a blog, for example, there is the potential you are establishing a doctor–patient relationship without ever talking to these folks,” he said. “You need to think just as carefully about what you are saying to people online as you do when you say it in person. Once you commit it to the electronic forum, it is there for people to read for the rest of your career. So again, you had better make sure you are communicating your ideas and thoughts clearly, because the computer is not going to do it for you.”