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PM&R Resident E-Newsletter

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April 2017

From Your Resident Physician Council (RPC)

Fellowship Spotlight: Spinal Cord Injury

Arlene Lazaro, DO
PGY3, Mount Sinai NYC

 




Baris Mehmet Kural, MD
Spinal Cord Injury Fellow, Mount Sinai NYC




Dr. Lazaro: How and why did you decide on pursuing a fellowship in spinal cord injury?
Dr. Kural: I have been dealing with trauma and spinal cord injury (SCI) patients as a physician even before my PM&R residency. I did a surgical preliminary year and spent almost 8 months as a trauma intern. During my PM&R residency, our program didn’t have a dedicated unit for SCI patients, but I still received significant SCI exposure. SCI rehab is unique and patients need specific treatment options to manage bowel, bladder, skin, spasticity, etc. I am also personally interested in sports-related SCI. All of these experiences led me to pursue an SCI fellowship.

Dr. Lazaro: In what ways did you broaden your exposure to SCI patients during residency?
Dr. Kural: In my residency, our affiliated hospital was world-renowned for trauma, which afforded me trauma patient exposure, many of which sustained SCI and TBI. We also had to cover high school football and Maritime college, so I had good exposure to sports and sports-related injuries. In terms of electives and research, I did not complete electives or research in SCI during my residency, however, I still had a very successful match.

Dr. Lazaro: Did you find that elective times or research in SCI-related topics was a requirement for when you were applying to fellowship?
Dr. Kural: It is not a requirement, but it is good to see how SCI rehab is different compared to other areas of rehab. If your residency program does not have an SCI unit or SCI program, it is better to do an elective so that you can get specific SCI exposure and experience.

Dr. Lazaro: What advice do you offer to those considering applying for SCI fellowship?
Dr. Kural: It is a unique medical specialty. After you meet your patient for the first time, you need to remember that you will likely follow their progress for their entire life. Choosing an SCI fellowship will only add more to your PM&R residency training and will give you an opportunity to specialize on the unique care for SCI patients and SCI-related rehabilitation. It is a very demanding specialty and needs special training.

Dr. Lazaro: What was the most valuable aspect of your fellowship?
Dr. Kural: The opportunity to work with world-renowned physicians and learn the most evidence-based SCI practice. I also had more opportunities to do spasticity care with baclofen trials, pump care, and Botox injections during my fellowship. I am also interested in specific myelopathies, which is the focus of my research.

Dr. Lazaro: What is the most rewarding part of working with the SCI population?
Dr. Kural: When a patient tells you the difference between functional status before and after admission, that is the most rewarding. If a patient tells you “Doctor, I was mainly bed bound and needed 24/7 help for my daily activities, but now look at me, I am able to go out, move my wheelchair, and insert my catheter. I feel confident and more independent.” This is absolutely rewarding.

Dr. Lazaro: How do you envision your career after completing fellowship?
Dr. Kural: I would like to have a private practice, but also with academic exposure. I have a good MSK background, combining with SCI fellowship education making me more confident for the rest of my career.

The Business of Medicine: Part 1

Rachael Brashears, DO, MBA
PGY2, University of Missouri School of Medicine

As residents we spend much of our time working, studying, mastering our physical exam, building patient relationships, and learning the field of PM&R. There are many looming questions that hang over our heads as we near the end of our residency: Where will I work? Do I want a job in academics or private practice? Would I rather be employed or a business entrepreneur? At this point in our careers, we seldom think about the various payment models of reimbursement for physicians and health care systems. Furthermore, throughout our medical training there is very little emphasis on education for the business of medicine or the economic infrastructure of this complicated system. The purpose of this article is to educate residents on various payment models and how they may impact future physiatric practice.

There are many existing and emerging health care payment models. Although each model is different, they do share one unifying factor: quality. Quality outcome metrics are key in the final reimbursement rates of the payment models. The 8 basic types of health care payment models we will discuss include: Fee-for-Service, Pay-for-Coordination, Pay-for-Performance, Bundled Payment, Upside Shared Savings Programs, Downside Shared Savings Programs, Partial or Full Capitation, and finally Global Budget1. This may seem overwhelming at this point; however, through the next 2 the PM&R Resident newsletters, we will break down each of the payment models. This article will cover the following 4 health care payment models: Fee-for-Service, Pay-for-Coordination, Pay-for-Performance, and Bundled Payments.

Fee-for-Service (FFS)
This is the most traditional of all of the health care payment models, and likely the most familiar. With this model, payers or patients pay health care providers for each particular service performed1. This emphasizes more of a focus on volume-based care over value-based care, since reimbursement increases as the number of services increases. There is a continuing debate over whether this model incentivizes providers to prescribe more and more services1. With FFS, a sick patient is worth more money to a provider than a healthy patient. This model of payment has been implicated as having directly contributed to the rising medical costs in our country2. In our current health care era, where there is a focus on health care costs, this model is quickly being phased out. Incentives are lacking with this model to implement preventative care strategies, prevent hospitalizations or take any other cost-saving measures2. The providers are not at any risk of losing any money; instead, they can only increase their income by providing and billing for a greater number of services.

Pay-for-Coordination
The most common Pay-for-Coordination model is the “Patient-Centered Medical Home.” This model focuses on coordinating the care between a patient’s primary care physician and specialists. It is a team-based approach consisting of physicians, nurses, medical assistants, pharmacists, nutritionists, social workers, and care coordinators, and it also integrates mental health and specialty services for holistic patient care3. One of the focuses of this model that is overlooked by the traditional FFS model is the substantial amount of nonclinical work that goes into coordinating patient care, including patient education, communications with various health care providers, phone calls, emails, scheduling appointments, and interactions with patients outside the clinical setting. This model relies heavily on health information technology and electronic medical records to help coordinate care and facilitate communication amongst the various providers3. Improving communication can reduce the redundancy of expensive tests and procedures between the primary care provider and the various specialists. It also helps drive down the overall costs of health care with a focus on preventative care in an attempt to reduce expensive emergency room visits and hospital admissions. The transformation of primary care practices into patient-centered medical homes is supported by several Centers for Medicare & Medicaid Services (CMS) Innovation Center programs, including the Multi-Payer Advanced Primary Care Practice (MAPCP) Demonstration and the Comprehensive Primary Care (CPC) Initiative3.

Pay-for-Performance (P4P)
This model is also commonly called “Value-Based Reimbursement.” With this model, financial rewards are offered to providers who achieve, improve or exceed their expected performance on specified quality and cost measures, which essentially incentivizes providers to improve the quality and efficiency of health care. A certain set of quality measures are defined and clinicians can then earn a bonus or increase their future earnings based on their performance within the quality measures. Such quality measures include patient access to care, use of electronic medical record systems, and the patient’s experience or satisfaction with their care2. This model also penalizes health care providers by reducing reimbursement rates in the event of poor outcomes, hospital readmissions, medical errors, and for increased costs of medical care4. It is meant to improve the quality of care and is quickly gaining market share. In fact, more than half of commercial health maintenance organizations are using this model, and recent legislation has required CMS to adopt this model for Medicare4. This model encompasses many different types of measures, such as process, outcomes, patient experience, and structure. For instance, measuring blood pressure at every office visit, lowering a patient’s blood pressure over time or counseling patients to stop smoking are all measures that are recorded and can affect reimbursement over time.

Bundled Payment Model
This model is also known as “Episode-of-Care Payment.” With this model, the health care system is provided with a set sum of money to cover the entire episode of care. Commonly-bundled episodes of care examples include an inpatient hospital stay for a heart attack or an inpatient rehabilitation stay for a stroke. It covers all care related to an entire “episode” of illness. Medicare’s Diagnosis Related Group (DRG) payments to hospitals are essentially a form of Bundled Payment5, where a hospital is reimbursed a set sum of money based on the diagnosis being treated during that stay. This model is considered to be the middle ground between FFS and Global Payment models. It typically requires providers and facilities to take on a financial risk for certain designated care, while leaving the FFS payment system intact for all other services5. For example, a defined episode of care for the bundle could include a time frame of 3 days prior to a knee replacement surgery and include all care extending to 30 days past a patient’s discharge from the hospital for the procedure. Services delivered by multiple providers are “bundled” into a single payment and then the payment is divided amongst the providers (orthopedic surgeon, anesthesiologist, physiatrist) and facilities (acute hospital or surgical center, rehabilitation hospital, nursing and therapy staff) taking care of the patient during that time period5. This promotes a team-based approach to health care. This model is similar to the FFS model, in that it compensates providers for treating sick patients, but without specific incentives to provide preventative care6. This reimbursement method is commonly used in the rehab setting with bundled payments for total hip and knee replacements under Medicare's Comprehensive Care for Joint Replacement model. Furthermore, rehabilitation centers will start to see more bundled payments as they are on the horizon for hip and femur fractures and cardiac rehab.

Stay tuned for the next the PM&R Resident newsletter in June, where we will break down the remaining 4 health care payment models: Upside Shared Savings Programs, Downside Shared Savings Programs, Full or Partial Capitation, and Global Budget.

References:

  1. “Healthcare Payment Models: Types of Payment Models.” McKesson, 2017, http://www.mckesson.com/population-health-management/resources/what-payment-models-exist/. Accessed 1 Jan. 2017.
  2. Harold D. Miller (September–October 2009). "From Volume to Value: Better ways to pay for health care". Health Affairs (Project Hope). 28 (5): 1418–1428. doi:10.1377/hlthaff.28.5.1418. PMID 19738259.
  3. Breakaway Policy Strategies for FasterCures. “A Closer Look At Alternative Payment Models.” Fastercures, 2017, http://www.fastercures.org/assets/Uploads/PDF/VC-Brief-AlternativePaymentModels.pdf. Accessed 8 Jan. 2017.
  4. Hughes, Justin. “Difference Between Pay-for-Performance and Fee-for-Service Payment Models.” CureMD, 5 Nov. 2013, https://blog.curemd.com/difference-between-pay-for-performance-and-fee-for-service-payment-models/. Accessed 8 Jan. 2017.
  5. Burton, Rachel. “Payment Reform: Bundled Episodes vs. Global Payments: A debate between Francois de Brantes and Robert Berenson.” Timely Analysis of Immediate Health Policy Issues, Sep. 2012, http://www.urban.org/sites/default/files/publication/25816/412655-Payment-Reform-Bundled-Episodes-vs-Global-Payments.PDF. Accessed 1 Jan. 2017.
  6. "Bundle Medicare’s Payments to Health Care Providers." OPTIONS FOR REDUCING THE DEFICIT: 2014 TO 2023. Congressional Budget
The Osteopathic Perspective

Adam Lewno, DO
PGY4, University of Pittsburgh School of Medicine

In the late 19th century, Dr. Andrew Still became frustrated with the medical practices of his time as they could be as dangerous to the patients as the pathology that they were battling. From this frustration was born a desire to develop a preventative and integrative form of medicine that would eventually become known as osteopathic medicine. This philosophy continues today with the emergence of 33 different osteopathic medical schools with 48 different training sites and more than 74,000 osteopathic-trained physicians practicing within the United States. These physicians focus on the patient’s mind, body, and spirit knowing that they are closely interrelated, just as our body’s structure and function are intimately tied together. These tenets have been at the core of osteopathic medicine since its inception, and with the passage of time they have become values shared by all physicians as we focus on providing the best possible care to our patients. This is why, when a patient looks to us for advice, we are not “MD” or “DO,” but simply doctor.

In the realm of medicine, this integration of philosophies is arguably the strongest within physiatry. However, it is not these philosophies that osteopathic physicians are most remembered for. Instead, it is their use of manual techniques known as osteopathic manipulative medicine (OMM). OMM is often shrouded in mystery as it encompasses a vast number of manual techniques from high velocity low amplitude “snap, cracks, and pops” reminiscent of chiropractors, to muscle energy that is often favored in physical therapists’ mobilizations or the more esoteric cranial sacral therapies. Though these manual techniques exist throughout the spectrum of patient care, they are supported by a limited number of high-quality research trials with only theorized mechanisms of action. Upon graduation, only 1 in 7 osteopathic medical students admit that they will continue using OMM. Among those who continue to provide OMM, it may seem that co-residents and the hospital staff, rather than the patients, are those who benefit from these skills the most!

Taken at face value, it would seem OMM is a specialized skill set rarely used. However, OMM is not limited to a catalog of techniques. Over the extra 200 hours of hands-on OMM training that is required by all osteopathic medical schools, OMM teaches medical students how tissues move, the influence of structure with function, how the body is a complex integrated unit, and just how a simple touch of a hand can create a link between patient and physician, stronger than any words can express. OMM is more than a series of manual techniques; it is a tool to help find a diagnosis, an expression of a holistic philosophy, and a method to connect with patients when fear and uncertainty grips them. Though these skills are honed in osteopathic medical schools, they are encouraged and flourish within all of our residencies. Therefore, the next time you leave a patient’s room, take a moment to ask yourself if you used the osteopathic perspective.


Top Stories You Need to Know 


Newly-Matched Fellows—Update Your Information

Have you recently matched into a fellowship? Congratulations! The RPC Board would like to recognize you in this newsletter and website. Please fill out this brief form so we have your updated contact information.

#AAPMR2017 Registration Opens Mid-May

AAPM&R’s 2017 Annual Assembly is meeting October 12–15 in Denver, Colorado. To help you Thrive Through Transformation, we’re making big changes to our program to give you the PM&R education and experience you need:

  • You asked and we answered! New this year, resident/early-career activities will take place throughout the Annual Assembly for a complete event experience. Sessions begin on Thursday afternoon.
  • We’re expanding preconference course offerings to include 5 in-depth, educational opportunities in the areas of ultrasound, spasticity, cancer rehabilitation medicine, imaging, and leadership.
  • Sessions will be “tagged” by clinical and practice topics, embracing the diversity of the specialty, while making the experience easier to navigate.
  • Experience the new Learning Center, which offers hands-on demonstration stations and live presentations from leading experts in 4 popular areas! Three-hour hands-on learning sessions will focus on: emerging technologies, ultrasound, electrodiagnosis, and chemodenervation—all included with your registration fee.
  • More intensive skills labs and didactic sessions will balance your experience, so that you can implement learnings and new skills immediately in your practice.
  • Denver brews 200 different beers daily, so why wouldn’t we have our President’s Reception at a brewery? Attendees will taste craft brews, enjoy live entertainment and games, and try a freshly-brewed glass of custom AAPM&R beer at the Wynkoop Brewing Company.

Learn more and stay tuned for details—registration opens soon.

We’re Celebrating YOU During National Volunteer Week—
April 23–29, 2017

April is one of our favorite times of the year because we get to recognize our 500+ volunteers who dedicate their time and effort to the Academy each year. Yep, you read that right. More than 500 of your peers volunteer with us each year to help move physiatry forward. Without them, we couldn’t advocate for the specialty, create educational resources that enhance your learning, develop a fantastic Annual Assembly program that brings together thousands of your peers, and so much more. Thank you!

Career Planning Advice

One of the most valuable resources your Academy provides is information on your career. As a member, you have access to products and services created by your peers, including CV resources, podcasts, career planning advice, fellowship resources, and more. Learn more.

QPPR Confirms AAOS Guideline

The Quality, Practice, Policy, and Research (QPPR) Committee affirmed the AAOS guideline on Osteoarthritis of the Hip. The Clinical Practice Guidelines Committee (CPG) reviewed the guideline and recommended the Academy affirm and not endorse because the guideline lacked clear auditing criteria and limiting evidence for arthroscopy.

For more health policy/advocacy updates from AAPM&R, please visit the following pages:

Resources for You

What’s Coming Next
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