October 2011 - Vol. 30 No. 10

Quality Improvement: One Resident at a Time
Rahul K. Shah, M.D, George Washington University School of Medicine, Children’s National Medical Center, Washington, DC When we discuss quality improvement, many of us speak at a high level, discussing interventions nationally, regionally, or within health systems. However, some of the biggest gains from the quality improvement initiatives begin at the ground level. In smaller settings, quality improvement initiatives can have a tremendous impact. On Saturday, July 15, 2011, I was part of such an opportunity with the second annual Otolaryngology Emergencies Boot Camp, in Washington, DC. The course directors were Academy members Ellen S. Deutsch, MD, Sonya Malekzadeh, MD, and Kelly Michele Malloy, MD. The course was so popular among residents that the course directors had to close off the registration due to space constraints—understandably, as it is impossible to have an unlimited number of participants in a hands-on simulation course. The stations were varied but focused on the key technical, communication, and knowledge-based skills that nascent residents desperately need, such as management of epistaxis, fundamental airway skills, and simulated team training exercises. What was most fascinating was watching the learning curve become steeper right in front of our eyes. For example, I was shocked by how many PGY-2s have never intubated a patient. However, as otolaryngologists, depending on the circumstances, everyone will be looking at them to intubate a patient in extremis after all the other team members have been unsuccessful. Similarly, how many PGY-2s in early July have placed a posterior nasal pack? There is great satisfaction for the faculty in knowing that next time a resident faces one of these scenarios, he or she has already been through the cognitive and hands-on part of the skill and will be able to take better care of the patient. The basic tenet of a quality improvement initiative is to produce something that when implemented can increase or improve the quality of care for our patients. The Emergencies Boot Camp is an example of such a program. The patients who will come under the care of those 30 residents in the ensuing weeks and months will perhaps have a better outcome or receive better care because their doctor had been to the Boot Camp. If the quality case exists, then a business case follows. The steep rise in the learning curve witnessed by the faculty gives credence to this model of teaching. Further, the students do not need to spend an inordinate amount of time in such a course, rather just be exposed to some basic, hands-on fundamentals. The return on the investment of attending the Boot Camp can be looked at from varying angles. With less time spent on such education by the primary institution’s faculty, there is more time for producing revenue.  Additional cost savings will be seen as the Boot Camp-educated residents do things right the first time, rather than setting instruments up, etc., for the first time during an emergency. Such emergency-ready residents can save resources and, potentially, a patient’s life. I am confident that by spending a Saturday at this course, the residents’ skills and confidence have increased tremendously. It is great for them and the patients whom they are going to be taking care of in the coming months. However, what about the residents across the country who did not attend this boot camp? When I was a resident, this concept did not exist and there was nothing as innovative as today’s simulators.  Typically it was a senior resident teaching the basics to the junior. You can immediately see the flaw in such teaching paradigm. A case can be made to have perhaps a dozen Emergencies Boot Camp sites across the country that PGY-2 residents can attend without traveling significant distances. The impact on the training programs and the patients under their care is significant. As more novel teaching programs come about, it is imperative that we make efforts to ensure that everyone can share in this learning and that the broadest number of patients benefit by teaching fundamentals in a quasi-standardized fashion—one resident at a time. 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.
2011 G-I-N Board of Trustees
The AAO-HNS/F is delighted to announce the election of Richard M. Rosenfeld, MD, MPH, as an organizational trustee, and Richard N. Shiffman, MD, MCIS, as an individual trustee, to the Guidelines International Network (G-I-N). The Guidelines International Network (G-I-N) is an international not-for-profit association of organizations and individuals involved in clinical practice guidelines. In addition, the following organizational trustees were also elected: Frode Forland, MD, DPH (Norway), Sue Phillips, DPhil (Australia), and Duncan Service (Scotland). Dr. Rosenfeld’s passion for clinical practice guideline (CPG) development and his promotion of evidence-based medicine is epitomized by his work at the AAO-HNS/F and elsewhere. Dr. Rosenfeld has chaired the AAO-HNSF Guideline Development Task Force since its inception in 2006 and has served on multiple CPGs for the AAO-HNSF and the American Academy of Pediatrics. He is currently professor and chairman of otolaryngology at SUNY Downstate Medical Center in Brooklyn, NY, in addition to being editor-in-chief of the journal Otolaryngology–Head and Neck Surgery and an editor for the Cochrane ENT Group. Dr. Rosenfeld is chair of the 2011 G-I-N Scientific Committee and was a member of the 2010 G-I-N Scientific Committee and Conferences and Promotions Committee. Dr. Rosenfeld has written five books and more than 225 scientific publications and has been listed for more than 10 years as one of “America’s Top Doctors” by Castle Connolly Medical Ltd. Dr. Rosenfeld led the launch of G-I-N North America, the first regional community within G-I-N, in May 2011. As the founder and steering group chair of this new entity, Dr. Rosenfeld is committed to enhancing the guideline development community, strengthening G-I-N, and creating a model for future regional efforts. Dr. Rosenfeld’s five-year vision for G-I-N is simple: promote the relevance, importance, and sustainability of the organization by working to make G-I-N to guidelines what Cochrane is to systematic reviews—a symbol of quality, excellence, and best practice. He has proposed three initiatives for growing and strengthening G-I-N. First, seek to expand, refine, and encourage new regional G-I-N communities, using G-I-N North America as an example. When implemented properly, in a manner that creates synergy, not competition, regional communities are the best venue for growing the network.  The second initiative is to explore the development of G-I-N-endorsed standards by building upon the newly released standards from the Institute of Medicine for developing trustworthy clinical practice guidelines. These standards may lead to future accreditation of guideline developers, or certification of individual guidelines, as “G-I-N Accredited” or “G-I-N Certified,” to indicate a level of excellence. The third inititative is to ensure that all aspects of G-I-N are responsive and reflect member needs, including the library, working groups, conferences, website, and newsletter. Dr. Shiffman is professor of pediatrics and associate director of the Center for Medical Informatics at the Yale School of Medicine, New Haven, CT. Last year he served as Scientific Program Chair for the G-I-N Annual Meeting in Chicago. From 2008 to 2010, he served on the G-I-N Board of Trustees and G-I-N’s Committee on Finance and Risks. He is also a member of the Steering Committee for G-I-N North America. From 2009 to 2011, Dr. Shiffman served on the Institute of Medicine’s Committee on Standards for Developing Trustworthy Clinical Practice Guidelines. He has participated on guideline development panels for several national professional societies. Since 2008, he has served on the Advisory Panel for the National Guideline Clearinghouse and National Quality Measures Clearinghouse. Dr. Shiffman’s research investigates the transformation of knowledge from clinical practice guidelines into computer-based decision support systems. He leads the Guidelines into Decision Support (GLIDES) Project, an initiative sponsored by the Agency for Healthcare Research and Quality to define best practices for clinical decision support based on CPGs, and a partner to AAO-HNSF. He convened the Conference on Guideline Standardization in 2002, and his team at Yale developed GEM (the Guideline Elements Model), an international standard for representation of guideline documents; the COGS (Conference on Guideline Standardization) checklist for appraising guideline quality; GLIA (the GuideLine Implementability Appraisal), an instrument to identify obstacles to guideline implementation; and BRIDGE-Wiz, a software assistant to facilitate the development of clear, transparent, and implementable guideline statements. These tools were developed under the guidance of Dr. Shiffman and are now used by the AAO-HNSF guideline development panels. Congratulations to Drs. Rosenfeld and Shiffman.
Proposed Rule CY 2012 Medicare Physician Fee Schedule
Socioeconomic Survey Results  The results of the 2011 Socioeconomic Survey are now available online. Obtain the latest data on productivity, revenue, operations, and other practice patterns for otolaryngology—head and neck surgery at http://www.entnet.org/Practice/members/socioeconomic.cfm. Look for our detailed analysis of the survey in the December 2011 issue. The overall potential impact of the CY 2012 Medicare Physician Fee Schedule (MPFS) for otolaryngology—head and neck surgery will be a 1-percent increase. Note: This amount does not include the possible 29.5-percent reduction to the conversion factor (from $33.9764 to $23.9635) for CY 2012. In the proposed rule, CMS emphasizes its commitment to collaborate with Congress to permanently reform the Sustainable Growth Rate (SGR) methodology for MPFS updates, and we applaud CMS for this effort. The Academy will continue campaigning for a permanent repeal and replacement of the SGR formula. The Academy submitted comments to CMS on the MPFS proposed rule by the August 30, 2011, deadline. Practice Expense (PE) RVUs Policy Changes Impacts The most widespread specialty impacts of the Relative Value Unit (RVU) changes are generally related to several factors. First, CMS will be implementing the third year of the four-year transition to new PE RVUs using the new Physician Practice Information Survey (PPIS) data that were adopted in the CY 2010 PFS final rule. The second factor contributing to the  CY 2012 impacts shown in Table 64 (pages 559-560) is a secondary effect of the CY 2011 rescaling of the RVUs so that, in the aggregate, they match the work, Practice Expense (PE), and malpractice proportions in the rebased Medicare Economic Index (MEI) for CY 2011. The rebased MEI had a greater proportion attributable to malpractice and PE and, correspondingly, a lesser proportion attributable to work. This rebasing of the MEI benefitted otolaryngologist—head and neck surgeons because we provide many services with high PE values. Potentially Misvalued Services Under the MPFS CMS proposes to end the practice of conducting separate and “freestanding” Five-Year Reviews of work and PE RVUs, and to instead consolidate these formal Five-Year Reviews with the ongoing annual reviews of potentially misvalued codes. The review for malpractice RVUs will continue to occur at five-year intervals. CMS further proposes an annual process for the public to submit active codes, along with documentation supporting the need for review, and these submissions would occur during the 60-day public comment period following release of the PFS final rule. CMS acknowledges the recent publication of the proposed rule relating to the Fourth Five-Year Review of Work, and also notes that the AMA RUC is currently working to review additional codes. Further, CMS has developed two code lists of potentially misvalued codes, which it proposes to refer to the RUC for review: 91 evaluation and management (E/M) codes listed in Table 6 (pages 92 – 94 of the rule); and 70 high PFS expenditure procedural codes (those with CY 2010 allowed charges of greater than $10 million at the specialty level) listed in Table 7 (pages 95-96) that have presumably not been reviewed since CY 2006. The codes relevant to otolaryngology—head and neck surgery in the latter category are: 31231 (Nasal endoscopy, diagnostic, unilateral or bilateral [separate procedure] which we are currently RUC surveying for the September RUC meeting). 69210 (Removal impacted cerumen [separate procedure], one or both ears). 95117 (Removal impacted cerumen [separate procedure], one or both ears). For each code list, CMS requests that the RUC provide recommendations on the physician times, work RVUs, and direct PE inputs for at least half the codes by July 2012 and the remaining codes by July 2013. CMS rejects the RUC’s recommended work values for various CPT codes including: 42415 (Excision of parotid tumor or parotid gland; lateral lobe, with dissection and preservation of facial nerve). 42420 (Excision of parotid tumor or parotid gland; total, with dissection and preservation of facial nerve). 42440 (Excision of submandibular (submaxillary) gland). CMS’s rationale for this position on these codes is that it believes that the RUC improperly valued “23-hour stay” outpatient services by including inpatient visits, a full rather than a half-day of discharge management service, and/or exchanging inpatient post-operative visits in the original value with subsequent observation care visits, CPT code 99224. As a result, CMS uses a variety of rationales to reduce the work values for these codes, sometimes quite substantially, based on its belief that such values should be based on a different methodology. The Academy disagrees with CMS’s rationale on these codes and plans to address our opposition in our comment letter to CMS. Expanding the MPPR Policy CMS proposes to expand the Multiple Procedure Payment Reduction (MPPR) policy that now applies to the technical component (TC) of advanced imaging services (CT, MRI, and Ultrasound) to the professional component (PC) of such services, all of which are listed in Addendum F of the proposed rule. Under this policy, full payment would be made for the PC of the highest paid procedure, and payment would be reduced by 50 percent for the PC for each additional procedure furnished to the same patient in the same session. Incentives and Payment Adjustments for the eRx Incentive Program For the 2012 and 2013 Electronic Prescribing (eRx) incentive program, CMS proposes that the reporting period will be the entire calendar year (CY) for 2012 and 2013, respectively. To determine the 2013 eRx payment adjustments, in addition to the January 1, 2011, to December 21, 2011, reporting period, CMS proposes a reporting period from January 1, 2012, to June 30, 2012. For the 2014 eRx payment adjustments, CMS proposes a reporting period from January 1, 2012, to December 31, 2012, for individual eligible professionals and January 1, 2013, to June 30, 2013, for group practices. The eRx measure (G8553) as well as the 56 denominator codes (mainly evaluation and management services) used in 2011 will remain the same for CY 2012. EPs are required to select one method of reporting the eRx measure (either via claims, registry, or qualified Electronic Health Records (EHR)). The Academy commented on the potential challenges that our members will encounter because of the reporting periods for this program and will urge CMS to add more exemption categories. Proposed PQRS Changes For 2012, eligible physicians can qualify for a voluntary Physician Quality Reporting System (PQRS) incentive payment of 0.5 percent of their total estimated Medicare Physician Fee Schedule allowed charges for satisfactory reporting. In order to qualify for the incentive, a physician must report on at least 3 PQRS measures 50 percent of the time for claims-based reporting or 80 percent of the time for registry-based reporting January 1-December 31, 2012. New Measures CMS proposes a new measure group to address Sleep Apnea. To report on a measure group, a physician must report on all measures in the group for applicable patients. The Sleep Apnea measure group is the following: assessment of sleep symptoms severity assessment at initial diagnosis positive airway pressure therapy described assessment of adherence to positive airway pressure therapy. CMS also proposes the following new individual measure: referral for Otology Evaluation for Patients with Acute or Chronic Dizziness. Interim Feedback Reports CMS proposes to provide interim feedback reports to physicians who report individual measures and measure groups via claims for 2012 and beyond. The feedback reports will be based on claims for dates of service occurring on or after January 1 and processed by March 31 of the respective program year. The reports will be available summer of 2012 for the 2012 program year. Informal Appeals Process CMS proposes to retain the same informal review process that was put in place for 2011. CMS proposes to base the informal process on their current inquiry process whereby a physician can contact the Quality Net Help Desk (via phone or e-mail) for general PQRS and eRx incentive program information, information on PQRS feedback report availability and access, and/or information on PQRS portal password issues. 2015 PQRS Payment Adjustment CMS has announced reporting periods for the 2015 PQRS payment, and it will be based on the 2013 calendar year. Physicians will have to successfully participate and report on PQRS in 2013 to avoid the 1.5-percent payment adjustment in 2015. For 2016, physicians will receive a 2 percent payment adjustment for successfully reporting in PQRS. Physician Comparison  CMS proposes to publish the performance rates of the quality measures that group practices submit under the 2012 Group Practice Reporting Option (GPRO) and to report the performance rates of the quality measures that the group practices participating in the Physician Group Practice demonstration report collected. The Value-Based Modifier For the quality of care measures, CMS proposes to use measures in the core set of the PQRS for 2012, all measures in the GPRO set of the PQRS for 2012, and those in the EHR Incentive Program for 2012. (Find these measures in table 62 [pages 485 – 488] of the proposed rule.) To view a more detailed summary of the proposed rule, visit, http://www.entnet.org/Practice/members/2012PropMPFS.cfm. Reference Medicare Program; Payment Policies under the Physician Fee Schedule and Other Revisions to Part B for CY 2012; Proposed Rule. Accessed at http://tinyurl.com/NPRMMPFS on August 10, 2011.
CMS Restores Previous Supervision Requirements for Videostroboscopy and Nasopharyngoscopy
On July 18, 2011, the Centers for Medicare and Medicaid Services (CMS) officially notified the Academy that it had restored the previous supervision requirements (i.e., no supervision level assigned) for Videostroboscopy (31579) and Nasopharyngoscopy (92511) when performed by speech language pathologists. In a March meeting with CMS, Academy representatives made it clear that we support direct supervision. Background of SLP supervision level changes Effective January 1, 2011, CMS changed the supervision level for speech and language pathologists (SLP) who perform procedures using CPT code 31579 (Laryngoscopy, flexible or rigid fiberoptic, with stroboscopy) and code 92511 (Nasopharyngoscopy with endoscope) from the previous level of supervision (no level assigned) to personal supervision. CMS made this change in the Medicare Physician Fee Schedule Final Rule CY 2011 without publishing notice of the change in the proposed rule, which would have allowed for public comment. The Academy published the physician supervision change in The News and as a result, began receiving communications from many of our members, from all of the regions in the country, stating their concerns about how this change would negatively affect their practices and their ability to serve Medicare patients. After careful consideration of  AAO-HNS members’ concerns and best interests, the Academy arranged to meet with payment representatives from CMS. On Thursday, March 31, 2011, representatives from the AAO-HNS along with the American Speech and Hearing Association (ASHA) met with CMS officials at their headquarters in Baltimore, MD. CMS was provided with two journal articles co-authored by otolaryngologists and speech language pathologists and an Academy position statement addressing these services.1  The Academy representatives made it clear that we support direct supervision  and not general supervision,  meaning the physician is available, but not necessarily on the premises. Both organizations strongly urged CMS to change the supervision requirement from personal to direct supervision—that is, the physician must be “immediately available” but not necessarily in the room while the procedure is being performed.  Both societal representative groups were cautiously optimistic that CMS would make the requested change. CMS indicated that if a change were to be made, it would appear in the July proposed rule or the October quarterly CMS update 2011. In early July, the Academy became aware of a letter sent to U.S. Sen. Susan Collins, (R-ME), from Administrator Donald Berwick, MD2 stating that the supervision level would be removed from the two procedures. The reason stated was because the two procedures are considered to be diagnostic tests, which do not require the higher level of supervision by a physician. The letter stated the change would become effective October 1, 2011. On July 21, 2011, Academy President J. Regan Thomas, MD, received an official letter from CMS, informing the Academy of the removal of the supervision level for the CPT code 31579 (Laryngoscopy, flexible or rigid fiberoptic, with stroboscopy) and code 92511 (Nasopharyngoscopy with endoscope). The same reasons were cited for the change as indicated in Dr. Berwick’s letter. The Academy will respond to CMS reiterating our position that the decision to remove the supervision level completely is not desirable and that the supervision level of direct would be the correct level to assign to the two procedures. Direct supervision would be warranted to evaluate the medical necessity of the procedure and that a review and supervision of the results and recommendations would be desirable for quality of care issues. Be aware that when there is not a national supervision level assigned by Medicare, the regional Medicare Administrative Contractor (MAC) could develop a different supervision level for its particular region.  If a member becomes aware of a regional MAC that is applying a different supervision level, contact the Academy at  Healthpolicy@entnet.org. If you have any questions or concerns, please do not hesitate to contact the Health Policy staff at the Academy. References D’Antonio, LL, et al (1989). Reliability of flexible fiberoptic Nasopharyngoscopy for evaluation of velopharyngeal function in a clinical population. Cleft Palate J 26:217-225 http://digital.library.pitt.edu/c/cleftpalate/pdf/e20986v26n3.08.pdf. Bless, D. M., Hirano, M., & Feder, R. J. (1987). Videostroboscopic evaluation of the larynx. Ear, Nose and Throat J, 66:289-296. http://www.entnet.org/Practice/31579-and-92511-SLP-Sup.cfm.
Trauma Expertise Important in War and Peace
“As I began to travel to job interviews, fill out civilian credentialing applications, and mentally take off my uniform, I became uneasy and could not erase the thoughts of those heroes whom I served with each day in Iraq. I remembered the amazing Army medics and Navy corpsmen who would intervene under the most austere conditions and save the lives of their fellow soldiers and marines. Every time a marine or soldier came into my emergency room with an emergent cricothyroidotomy placed in the field, I marveled at how these young medics could place this small tube through a hole in the neck under fire, without suction, headlights, and all the other resources I have in the hospital. Without their daily heroics, all of the wounded I treated in my hospital would have never made it home to be with their families.”Excerpt from Invited Editorial,  Southern Medical Journal, publication pending. Joseph Brennan, MD, COL, USAF,  Chair, AAO-HNS Trauma Committee Great advances in the surgical management of head, facial, and neck trauma have been made during times of military combat. This includes the immediate care of the wounds, maintenance of airway and control of bleeding, upper aerodigestive tract endoscopy, neck exploration, and primary through tertiary reconstruction of defects.  Since the inception of otolaryngology—head and neck surgery as a formal specialty in the United States some 90 years ago, its practitioners have contributed to the body of knowledge of trauma management in a significant manner. Throughout WWII, the Korean and Vietnam conflicts, Gulf War I, and now Operation Iraqi Freedom and Operation Enduring Freedom, otolaryngologists have been in combat and near-combat medical facilities, providing advancing care of wounds to the head, face, and neck. Just as John Conley, MD, expanded his reconstructive head and neck surgery advances during WWII, so have our colleagues in more recent times. The civilian practice of otolaryngology—head and neck surgery has benefited from these experiences, where knowledge gained in caring for combat wounds has been translated to gunshot wounds, massive trauma from industrial and motor vehicle accidents, and other injuries seen in emergency rooms. Otolaryngologists were not members of the head and neck surgical teams deployed to Iraq during the first 18 months of Operation Iraqi Freedom. Oral surgeons managed facial trauma and airways and general surgeons managed neck trauma and endoscopy. Otolaryngologists had no role as part of a multispecialty head and neck trauma team composed of neurosurgery, ophthalmology, and oral surgery. However, the Air Force deployed otolaryngologists with their head and neck team in September 2004. Since that time, the surgical data collected in both Iraq and Afghanistan demonstrate that the otolaryngologist is the busiest and most productive member of this trauma team. Consequently, we have a moral and educational duty to maintain our excellence in head and neck trauma and to train our next generation of otolaryngologists to provide state-of-the-art trauma care. It is important to have an entity within the major practice and educational association of otolaryngology—head and neck surgeons that addresses the needs of its members who remain committed to trauma care of patients, and to further the education and training (or re-training) in this area of practice. With the threat of terrorism and national disasters looming as future medical emergencies, the AAO-HNS members and fellows are best served by emphasizing this traditional and very important aspect of patient care. In 2001, a group of committed  AAO-HNS members petitioned for and set up a Trauma Study Group to be convened at the Annual Meeting & OTO EXPO. These members strongly believe that our Academy should take the lead and emphasize the role of otolaryngologists in managing head, face, and neck trauma.  Beginning in September 2008, the AAO-HNS Trauma Study Group has convened at every annual AAO-HNSF meeting. Additionally, the Trauma Study Group has frequently conducted trauma research, organized and prepared miniseminars, and discussed future trauma endeavors in person, over the phone, and via email. In 2010, we successfully petitioned the Executive Committee of the Board for full committee standing of a new AAO-HNS Trauma Committee. Our proposal was accepted, and we convened our inaugural meeting of the AAO-HNS Trauma Committee September 12, 2011. All interested Academy members are invited to contact our Trauma Committee members if you would like to participate in our educational and research endeavors. The Trauma Committee is a unique group composed of both active duty military and civilian AAO-HNS liaison members who are absolutely dedicated to the care of our head and neck trauma patients.  We would welcome your participation with us: contact Rudy Anderson, staff liaison, 1-703-535-3718, randerson@entnet.org.
Primary Care Otolaryngology, Third Edition, Now Published as an E-book
The third edition of Primary Care Otolaryngology has been published on the Academy website as an e-book. This primer on fundamental topics in general otolaryngology has been extensively revised since the second edition was published in 2004.  Primary Care Otolaryngology is a concise, informative handbook on otolaryngology for medical students and allied health professionals. Reviewed and edited by AAO-HNSF education faculty, under the supervision of Karen T. Pitman, MD, chair of the General Otolaryngology Education Committee of the Foundation and Mark K. Wax, MD, this e-book offers new advice on evaluating patients. Each chapter ends with a short self-assessment exam. This edition of the popular handbook continues its goal of improving clinical judgment by teaching the basics of otolaryngology. This e-book helps readers manage uncomplicated clinical problems and recognize when to refer more serious conditions to an otolaryngology specialist. Highlights of the third edition include a new chapter on allergy, from presentation to treatment, and updates to all the chapters reflecting current clinical practice guidelines. “It will whet your appetite for further learning in the discipline that we love,” said Dr. Wax, former AAO-HNSF Education Coordinator. “The Foundation considers it a must-have for medical students, non-ENT physicians, and allied health professionals.” Originally authored by Gregory J. Staffel, MD, in 1996 as an introductory reference for medical students at the University of Texas School for the Health Sciences, it has evolved into a practical handbook for non-ENT clinicians who encounter general otolaryngology conditions. Dr. Staffel donated his book to the AAO-HNSF to be used as the basis for subsequent editions. The first edition of Primary Care Otolaryngology was published in 2001.  The e-book can be downloaded for viewing or printing at no charge from http://www.entnet.org/mktplace/primaryCare.cfm.
BOG Tackles the Tough Issues in Healthcare Spending
We live, and practice, in  interesting times. As I assume the role of Chair of the Board of Governors, following an intense learning year shadowing Michael D. Seidman, MD, I look back at the efforts and accomplishments of the BOG’s socioeconomic and grassroots initiatives. I also look ahead to the challenges for 2011-2012. Healthcare spending encompasses 16 percent of our nation’s Gross Domestic Product (GDP). Therefore, as we follow state and national political discourse, it is naïve to think that our profession—one-sixth of our nation’s expenditure—will not be affected. Even though ENT makes up a fraction of the house of medicine, our Academy’s voice has been a loud one in reminding our elected officials what is real in medical care. During this summer’s heated debt crisis discussions, only one plan included reforming or replacing the untenable and flawed sustainable growth rate (SGR) formula—at a cost of $298 billion over 10 years. This was to be offset by undefined savings in federal healthcare programs, suggesting that physicians might have ended up paying for the “doc fix” via lower reimbursement. That plan didn’t go through. The debt deal that was reached did not eliminate the SGR and instead created a new level of uncertainty for physician payments. The debt deal charges a newly created Joint Select Committee on Deficit Reduction (a.k.a., the Super Committee) with identifying $1.2 trillion in savings by November 23, 2011. If the committee fails to achieve the required savings, a trigger for automatic Medicare cuts will go into effect ­- a process that insulates beneficiaries and could result in a maximum 2 percent cut in physician payments from 2013 – 2021. With no SGR reform in sight, physicians face a whopping 29.5-percent decrease in Medicare payments on January 1, 2012. Our Academy has fought each prior SGR-based planned payment cut and will fight this one. It is imperative that each practicing otolaryngologist takes this “opportunity” to educate our patients and their families about the flawed SGR and the need for its repeal. Every insurance company bases its fee schedules on Medicare; a cut in Medicare means a cut in all. It has been a year and a half since the Patient Protection and Affordable Care Act (ACA), or Healthcare Reform (HCR), became law. ACA’s rollout is planned over several years. The initial phase involved expanding coverage to adult children and eliminating pre-existing condition exemptions. One portion of ACA to which AAO-HNS is adamantly opposed is the Independent Payment Advisory Board (IPAB), which would effectively be able to set physicians’ pay without the checks and balances currently in place for MedPAC. ACA also has only minimal mention of tort reform. We will continue to push at the national and state levels for fair reform of the current torts process. The Congressional Budget Office (CBO) cites the pressing need for Comparative Effectiveness Research (CER) in guiding payment decisions by the Centers for Medicare and Medicaid Services (CMS). Our Academy has been at the forefront in designing, implementing, and fine-tuning Guidelines Panels on a variety of otolaryngology topics. The goal of these panels is to provide the best CER to help physicians, patients, and payers. BOG members are welcome to participate in this process, either as panelists or as reviewers. How can you, as an otolaryngologist, make a difference? There are many ways. Attend the BOG Spring Meeting in Alexandria, VA, in 2012 and every year. You can discuss these and other pressing BOG issues in depth. In this venue, each voice is heard. We top it all off by “storming” Capitol Hill and meeting our legislators and their staff, as we emphasize our messages for improved healthcare for all. Please mark your calendars to attend Sunday, May 6, through Tuesday, May 8, 2012. Contribute* to our ENT PAC at www.entnet.org/entpac. Our PAC is guided by our needs as otolaryngologists and is party-blind. With the funds raised by the PAC, our legislative staffers are able to gain direct access to lawmakers and keep their fingers “on the pulse” of upcoming and ongoing legislation that affects ENTs. Download the Legislative and Political Grassroots Advocacy Handbook and Toolkit, linked at www.entnet.org/Community/public/BOG_SocietyResource.cfm. Join the ENT Advocacy Network at www.entnet.org/Practice/members/entAdvocacyNetwork.cfm. Read the Grassroots Media and Public Relations Handbook, linked at http://www.entnet.org/Community/outreach.cfm, and join the Media Experts Database by sending your information to  newsroom@entnet.org. Attend the Fall BOG meeting in conjunction with the Foundation’s Annual Meeting & OTO EXPO. The committee meetings are on the Saturday before the annual meeting starts, and the General Assembly meeting is the Monday evening of the annual meeting. Contact us. Send your ideas, questions, thoughts to bog@entnet.org. I look forward to working with you and for you in this upcoming year. *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
Reflection of our Specialty’s Dedication
This year has proved to be successful for the Academy and Foundation, with remarkable advances in strength and support, in effectiveness, and in innovation during times of a slow economic recovery and uncertainty.As you review the Annual Report within this issue, you will observe the recognized growth and development of our education, research, advocacy, and member services departments. I am proud of this growth. I am also proud to note that this growth would not have been possible without the dedication and vision of you, the member. Although we are blessed with great formal leadership capacity, I am convinced that the strength of our specialty lies in the quiet and sometimes obscure or unnoticed daily dedication you demonstrate to achieving the highest level of compassionate and effective care you render in your community. We are well represented and respected at all levels and areas of leadership from the international healthcare community to the National Academy of Science, to national and state medical associations, and to our armed services. I want to specifically thank the dedicated members of the Academy for the support and effort of each of you. As our Academy continues to grow, progress, and change, we also face opposition along the way. There is little doubt that for most engaged in change, it requires great courage to demonstrate appropriate leadership. If we are to ensure that the transitions we make are correct and effective, and that we fulfill our professional obligation to our patients, it is essential that we be courageous. Everett Rogers’ publication, Diffusion of Innovations, brought the term “early adopters” into our daily lexicon, describing those who apply progressive, influential, and respected leadership for substantive and positive change. Our specialty is acknowledging change by fulfilling essential leadership roles in improving healthcare and addressing the unavoidable challenges that we as otolaryngologists face. You, as a dedicated and committed member of the Academy, are the backbone and foundation upon which successful transition to better models of delivery of care, patient safety, improved clinical outcomes, and better public health will be balanced. There is no substitute for the honor, integrity, and personal sacrifices you make daily on behalf of your patients. I want to extend my gratitude to our dedicated leadership for their contributions and service to the Academy this past year. We are excited to embark on a new journey as we welcome the new, incoming leadership, and are excited to acknowledge the positive change and growth our Academy will assume. As we begin to plan for the 2012 Annual Meeting & OTO EXPO, September 9-12 in Washington, DC, I charge all members to engage in a significant role within your Academy. There are many programs, activities, committees, and opportunities available to make the Academy an even better place in 2012. See the November Bulletin package for a new AAO-HNS/F engagement brochure. As we begin a new organizational year,  we welcome our newly elected officers and say thank you to those who are leaving. I express my personal thanks to Dr. J. Regan Thomas for exceptional leadership, collegiality, and guidance this year.  I know you join with me in warmly welcoming Dr. Rodney P. Lusk as President and look forward to his leadership. I, along with the Academy staff, join with you in committing to act with honesty, honor, and integrity in all we do clinically, politically, socially, and personally. We pledge with you to sincerely, in the original root sense of that word, “without a false step” continue our dedication to the highest quality of healthcare in the world.
Good Stewards of Great Information
It is clear now, more than ever, that your Academy needs to be the most robust and diverse source of ENT information for physicians, patients, and the general public. It is difficult to meet the needs of these diverse users, but a website that is appropriately designed and organized can provide efficient searches for all.  We have a responsibility to be good stewards of all this content. To that end, portals will be created to provide the needed content. This is already happening through the members-only portal where content that is provided to you as a member is different from the content available to the general public. The main conduit for dissemination of all of this content has to be through our website. When lay researchers arrive at our website, they know what they are looking for but they frequently can’t find the information. Patients are looking for information regarding symptoms, diseases, and treatments. Physicians and our members need timely and accurate access to information regarding diseases and therapies on our website as well as other relevant websites and journals. Our content should be a reliable source of information that you and your patients can rely on for accuracy. Members of the Academy also need to connect with each other to do the work of the organization. My mission, as President, is to make sure that everyone who depends on the Academy for content can access the information when and where they need it. I am committed to building a website that keeps our membership and the public coming back to us for their clinical content. Our website currently enjoys a significant amount of traffic, mostly from the public. Over the last fiscal year, there were more than 2.5 million visits to our website. There are approximately 5,000 searches a month to locate an ENT physician. The good news is that lay researchers are finding our site as they search for information, and our publication readers spend considerable time, more than a quarter hour regularly within our online publications. However, the bad news is that 80 percent of the visitors go no further than the home page. We have, therefore, concluded they are not finding what they need. While we don’t have in-depth research to assess the experience of our membership, empirical evidence tells us that you are struggling to find the information as well. It is our responsibility to serve all our constituents by taking the following initiatives: Create a well-indexed site and map for improved searching. Assign appropriate tags and key words to all content. Provide a user-friendly search engine. Provide ongoing maintenance and updates for all our content. Strategically plan new clinical content. This will be an ongoing process involving all AAO-HNS/F committee’s and staff members. To paraphrase Lewis Carroll, “If you don’t know where you are going, any road will take you there!” During my tenure, we will start the journey of making our website “THE” destination for ENT or otolaryngology information for both patients and our membership. Simply put, your searches within the Academy website should be more refined than a Google search, but broader than a PubMed search. Specialists may require even more targeted searches, and we will be exploring mechanisms of providing even more targeted searches. To accomplish this, we will: Install a new search engine: Academy IT division has chosen the Google Search Appliance. Reassess all of our web content for relevancy and currency. Assign “key words” to all content to improve the search engines’ capabilities. Through collaboration of various stakeholders and Academy committees, develop new content. Our immediate goals  therefore are: By this time next year, we will deliver content that is updated and easily searchable. Explore the use of mobile apps and podcasts; both are currently under development. Develop mobile optimization of our web content that can be delivered to you whenever and wherever you need it through any device connected to the web, such as computers, tablets and or smartphones. Explore dynamic ePublishing for the Journal and Bulletin. Technology will continue to evolve, and we will have to continue to adapt. Rest assured that this is now a priority for the Academy, and our website will become a conduit for many future educational tools for our membership and the public.