Published: October 24, 2013

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.

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.

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.

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.”