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PM&R Resident E-Newsletter

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December 2017

From Your Physiatrist in Training Council (PHiT)


A Letter from the President

Nathaniel V. Zuziak, DO 
PGY3, Mercy Medical Center, Rockville Centre, NY

“Who is your ONE?”

With that question, Mick Ebeling opened the 2017 AAPMR Annual Assembly in Denver, Colorado. His answer? A 16-year-old named Daniel who lost his arms during a bombing at age 14 in Sudan. Receiving his own prosthetic arms from Mr. Ebeling’s 3D printing lab, Daniel ate on his own for the first time in two years. With the theme of Thriving through Transformation, Daniel's story was the most fitting way to commence this year’s conference, exemplifying the far-reaching power of physiatry to help others and improve function and quality of life.

The more than 3,300 participants were immersed in AAPMR’s vision of transformation and innovation with more opportunities for education, networking and collaboration. The experience did not disappoint. With five preconference courses, 174 sessions and 20 skills labs, the sessions were redesigned to better reflect the true diversity of our specialty, focusing on community, leadership, patient care, and technology. Attendees had the chance to discover real world applications of the latest products and resources, connect with colleagues in the community network lounge, and participate in demonstrations at the newly revamped PM&R Pavilion Learning Center.

Early career physiatrists, trainees, and medical students were also treated to additions to their respective programs. Sessions provided insight on the business of physiatry and the process of transitioning from trainee to attending. There were opportunities for networking at the Job Fair and Residents’ Reception and for friendly competition at the Annual Resident Quiz Bowl. Thank you to the teams who participated and a hearty congratulations to the University of Miami, our 2017 winners!

Perhaps some of the biggest highlights of the Annual Assembly were our plenary speakers. From the inspiring opening session by Mick Ebeling to the impassioned recounting of the aftermath following the Boston marathon bombing by Dr. David M. Crandell, the resounding messages were about evolution, resilience, progress, and most importantly, unity. Physiatry is clearly in a unique position to navigate today's rapidly changing health care environment. 

The former AAPMR Resident Physician Council underwent its own reconstruction this year. With the inclusion of those in fellowship, the aim was to better represent the needs of trainees and enhance the value of our membership within the Academy. Renamed the Physiatrist in Training (PHiT) Council, the Assembly welcomed the new officers and liaisons, of whom I am both excited and honored to lead. The PHiT Council reviewed last year's initiatives and ran the Resident Town Hall, where current challenges were addressed in round table discussions, and potential solutions proposed. We are excited to continue the work of years past and forge forward with new ventures.

Thankfully, it was not all business in the beautiful Mile High City! Early risers on Friday morning enjoyed the one-of-a-kind vistas in the annual PM&R 5K Rock and Roll. At the President’s Reception, attendees experienced one of Denver’s finest, the Wynkoop Brewing Company, who specially crafted the ReHOPilitation beer just for the event. With great drinks, food, and company, it was nothing short of an amazing time!

This year’s conference truly captured the mission behind PM&R BOLD highlighting the vital role physiatrists play in patient care from the point of evaluation and diagnosis to rehabilitation and recovery. As we push our boundaries, physiatry will continue to move toward an age of innovation and creativity, where what we aim to transform is anything but impossible. We have been called to help one, in order to help many. So we must decide, who IS our one?

P.S. To Dr. Charles Taylor and Dr. Rahul Biljani— I’m comin’ for you at next year’s 360˚ Challenge! See you all October 25-28, 2018 in Orlando, FL!


Fellowship Spotlight: Neuromuscular Medicine

Dr. Nassim Rad
Neuromuscular Medicine Fellow (2016-17)
University of Michigan, Ann Arbor, MI

 

 

 

Dr. Colin Franz
Neuromuscular Medicine Fellow (2017-18)
Shirley Ryan AbilityLab and Northwestern University, Chicago, IL

 

 

Dr. Kyriakos Dalamagkas
Intern (2016-17), Internal Medicine, Weiss Memorial Hospital, Chicago, IL
Resident (2017-2020), Physical Medicine & Rehabilitation, TIRR Memorial Hermann, Houston, TX

Dr. Dalamagkas: I’d like to begin by congratulating Drs. Rad and Franz each for accepting their first staff positions at the University of Washington and the Shirley Ryan AbilityLab (formerly the Rehabilitation Institute of Chicago) respectively. My first question for both is what motivated you to pursue a fellowship in neuromuscular medicine?

Dr. Rad: I wanted to expand my electrodiagnostic skills by being exposed to more cases of neuromuscular junction disorders, myopathies, and motor neuron diseases, which can be limited in residency. That being said, a neuromuscular fellowship is much more than additional electrodiagnostic training. I also wanted to be able to expand the care for my patients with neuromuscular disorders to include diagnosis and treatment while following them through their functional loss. I wanted to start the relationships with my patients and their family earlier in their battle with degenerative diseases.

Dr. Franz: I love physiatry in general, but I came to our specialty with a lot of research experience in the fields of axon regeneration and motor neuron diseases, and that heavily influenced my desire to build a clinical practice around neuromuscular disease. Fortunately for me, I have enjoyed my exposure to patients with ALS, nerve injuries, and other related disorders during residency, which I think made it an easy decision to pursue a sub-specialty training program in neuromuscular medicine. After I complete fellowship, I will be able to take care of patients with ALS from both a neuromuscular medicine and rehabilitation stand point.

Dr. Dalamagkas: What impact do you think you will have on patients’ lives after you finish your fellowship?

Dr. Rad: A residency in physical medicine and rehabilitation is a natural fit for a neuromuscular fellowship as we have learned the skills to assist patients with progressive disorders. My hope is that a neuromuscular fellowship will not only allow me to have a better understanding of their diagnosis but become an expert in their medical care. Ultimately, I hope that I will be able to bring the problem-solving skills I learned during fellowship that expand beyond therapeutic interventions to improve their quality of life.

Dr. Franz: Firstly, my biggest hope is that my research agenda can eventually lead to new treatment options to help regenerate axons and/or protect against motor neuron degeneration. In addition to that, I think as a neuromuscular rehabilitation specialist I can act to maximize function better than any other provider during the processes of both nerve regeneration and degeneration. This may range from the appropriate prescription of braces or exercises to the use of ultrasound-guided peripheral joint injections to facilitate the use of adaptive equipment.

Dr. Dalamagkas: What would be your advice to the students and residents that would like to become future leaders in the field of neuromuscular disorders?

Dr. Rad: Applications to neuromuscular fellowship start early as they follow the neurology timeline so residents should be prepared to apply early in the third year of residency. Given the earlier application time, residents who are considering fellowship should try to get exposure to neuromuscular disorders and electrodiagnostics early in residency to make sure this is something that they enjoy.

Dr. Franz: To piggy back on the last part of Dr. Rad’s answer, I think it’s ideal to figure out what you “enjoy” and pursue it as early as possible in your residency training. Being highly interested in what you do every day is key to both achieving and maintaining a successful clinical practice or research program.

Dr. Dalamagkas: Which aspects of your exposure to neuromuscular disorders have you found to be more fascinating and which ones have you found more challenging?

Dr. Rad: Every day in fellowship I feel like I am solving puzzles. Not only during electrodiagnostic testing but when listening to a patient’s symptoms. You never want to miss something reversible and this keeps you on your toes. The most fascinating parts include diagnosing rare conditions. However, many of the conditions are life-limiting and delivering this news to patients on a daily basis can be quite challenging.

Dr. Franz: In addition to solving diagnostic puzzles, I really feel rewarded when I find a solution to a practical problem that my patient is having that impairs their functioning. For example, to prescribe the appropriate hand orthotic to improve a patient’s grasp or an adaptive utensil to allow them to feed themselves independently. Delivering bad news is definitely the most challenging aspect.

Dr. Dalamagkas: What are your aspirations after the end of the fellowship?

Dr. Rad: I plan to combine my physical medicine and rehabilitation skills with my neuromuscular training to provide patients with a continuum of care from diagnosis to disease management in a multidisciplinary setting. Given the medical complexity, psychosocial, and rehabilitation needs, multidisciplinary care is optimal for these patients’ quality of life.

Dr. Franz: I recently signed on to start my own translational research laboratory at the Shirley Ryan AbilityLab (formerly known as RIC). I’m joining a rapidly-growing regenerative rehabilitation program under the leadership of Dr. Rick Lieber. I am adding my expertise in disease in a dish modeling of motor axon regeneration and ALS. Given the well-known limitations to relying on just animal models of disease, I believe the use of induced-pluripotent stem cells to generate human preclinical models will be enormously important for our field. I’ll spend my clinical time performing EMGs as well as seeing my own patients with motor neuron disease and nerve injury.


About the PM&R Resident and How to Get Involved

Ann Hulme, MD
PGY3, University of Pennsylvania

The PM&R Resident is the official AAPM&R online newsletter for physiatry residents written by residents. Several newsletters are published throughout the year with additional articles on the Academy’s Facebook page highlighting topics relevant to residents.

Previous topics include the business of medicine, patient spotlights, and personal perspectives. The newsletter’s fellowship series is highly rated. These articles often provide insight into the plethora of subspecialties within physiatry and contain peer advice on applying to post-residency positions and special considerations for the specific field. If you are pursuing a small or unique subspecialty of physiatry, please consider submitting an article to share your experience.

The newsletter also looks to include personal accounts of resident life, commentary on volunteer opportunities, and discussions on preparing for life after residency. While this is not a peer-reviewed journal and original research is not a highlight of the newsletter, articles can feature peer advice on research or educational topics.

The goal of this publication is to provide information on topics relevant to residents. If there is a subject you would like to see discussed, submit your ideas as well as articles. The PM&R Resident is always open to suggestions and contributions.

Basic guidelines for article submissions:

  • All physiatrist authors must be AAPM&R members
  • Articles should be approximately 500 words or less
  • Corresponding pictures are encouraged (including authors)
  • Submissions or ideas should be sent to ann.hulme@uphs.upenn.edu
  • Submissions are accepted year-round

I look forward to serving as your AAPM&R PHiT Board Secretary and Editor of the PM&R Resident. Please email me with any questions or suggestions.


The Relevancy of the Relative Value Unit

Rachael Brashears, DO, MBA
PGY3, University of Missouri School of Medicine

The business side of medicine lives in a world of acronyms. One of the most important acronyms that residents need to become familiar with as we transition from training as residents to practicing as attendings is the Relative Value Unit (RVU). Medicare uses the RVU, along with the Geographic Practice Cost Indices (GPCI) and a Conversion Factor (CF) to calculate the payment a physician will receive for a given service. Medicare describes this fee schedule as a Resource-Based Relative Value Scale (RBRVS) and utilizes it to determine the payment amount for more than 7,500 physician services that are described or billed using Current Procedural Terminology (CPT) codes1. The purpose of this article is to explain the subtypes of RVUs and how to calculate reimbursement using the RVUs, GCPI, and the CF, see figure 1.

Figure 1. Total physician reimbursement is determined by the sum of the Physician Work Relative Value Unit, Practice Expense Relative Value Unit and Malpractice Expense Relative Value Unit, each adjusted for by the Geographic Practice Cost Index, and ultimately converted to a dollar amount using the Conversion Factor. Image obtained from: https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/downloads/MedcrephysFeeSchedfctsht.pdf

The Physician’s Work RVU takes into account the technical skill, the stress related to, and the mental and physical effort it takes to perform a given service or procedure1. It also takes into account the amount of prep time, the time it takes to actually perform the service, and the time it takes the physician to wrap everything up after the service is complete. Altogether, it encompasses your professional skill, medical knowledge, and your time for various services. For instance, the Physician’s Work RVU for CPT code 63685 (inserting a spinal cord stimulator) is 5.192, while the Physician’s Work RVU for CPT code 99213 (low complexity office follow-up visit, approximately 15 minutes) is only 0.973. A service is assigned a higher Physician’s Work RVU to reflect the increased complexity and additional technical skills and effort it takes to perform over other services, thus creating a relative scale. This higher RVU will ultimately translate to increased reimbursement.

Practice Expense RVU’s cover the general overhead expenses of a practice4. This includes labor costs of non-physician clinical staff and nonclinical or administrative staff. It also covers business expenses including medical equipment, office supplies, and the rent for an office space1,5. This RVU will vary depending on the location in which the procedure or service is provided. The location can be categorized as either “facility,” including hospitals, surgical centers, or other ambulatory settings, or as “non-facility,” generally referring to a physician’s office. The practice expense RVU for an office-based service is typically higher than the practice expense RVU for the same service performed in a facility, such as a hospital. The lower RVU value for a facility-based service is based on the fact that when a physician provides a service in a facility, the costs of clinical personnel, equipment, and supplies are typically incurred by the facility, not the physician. Compare this to an office-based service in a private practice where the physician practice does incur all the practice expenses related to the delivery of that particular service, it makes sense that Medicare would reimburse a higher practice expense RVU to the physician practicing in this setting over a facility setting to help offset the associated costs. For example, using a CPT code of 64635 (radio-frequency ablation of a lumbar face), if the procedure is performed in the physician’s office, the physician’s payment would be based on a practice expense RVU of 7.66; if the same procedure is performed in a facility, the payment would be based on a practice expense RVU of 2.306. This difference in RVU value is referred to as the “Site of Service” differential4. Only the practice expense RVU can vary based on the health care setting, the Physician’s Work RVU, and the Professional Liability Insurance RVU (or Malpractice RVU) for a given code remains the same whether the service is provided in the physician office, an inpatient hospital, or any other health care setting7.

The cost of malpractice insurance premiums is accounted for by the Professional Liability Insurance (or Malpractice Expense) RVU. Malpractice information must be weighted both geographically and across specialties because malpractice costs can vary considerably by state and by medical specialty. These RVUs are based on insurance premiums that are reported by each specialty1. Congress requires CMS to review each of the categories of RVUs at least every 5 years and it must develop RVUs for new services8.

RVUs for individual CPT/HCPCS codes can be accessed from the CMS website via the Physician Fee Schedule Look-Up Tool, https://www.cms.gov/apps/physician-fee-schedule/search/search-criteria.aspx. First, select a year. Then under the type of information tab, choose Relative Value Units. Under select HCPCS criteria, choose Single HCPCS Code. Then type in the CPT/HCPCS code for the service/procedure of interest. Under the modifier tab, choose either global or all modifiers and finally click submit. This will give you values for the 3 subtypes of RVUs for a given CPT code. The following link has a list of the most common CPT codes used in a PM&R and interventional pain management clinics: http://thepainsource.com/homepage/cpt-codes-pmr-pain-management-billing-and-coding/

In addition to RVUs, another variable that Medicare uses to determine the final payment a physician will receive for a given service is the Geographic Practice Cost Indices (GPCI). Because things in New York are more expensive than things in St. Louis, the RVU is adjusted for cost factors related to various geographic locations and is updated by CMS every 3 years4,7. The value for the GPCI is relative to 1.000, where 1.000 is considered the national average. For instance, a Practice Expense GPCI of 1.300 indicates that practice expenses in that area are 30% above the national average, whereas a Practice Expense GPCI of 0.700 indicates that practices expenses in that area are 30 percent below the national average8. Each of the 3 different RVU types are multiplied by a separate GPCI factor to get an adjusted RVU for that category. These adjusted RVUs are then added together to get a total adjusted RVU for a given service in a given location, see figure 1. For Instance, the GPCI for the St. Louis Metropolitan in 2017 is 1.000 for the Physician Work RVU, 0.957 for the Practice Expense RVU, and 1.039 for the Malpractice RVU9. Comparing those values to the GPCI values for Manhattan New York: 1.052 for the Physician Work RVU, 1.174 for the Practice Expense RVU, and 1.690 for the Malpractice RVU10, one could see how these higher GPCI values would increase overall reimbursement. This would effectively give a higher reimbursement amount to a physician practicing in Manhattan than a physician practicing in St. Louis who is performing the exact same service. This is intended to counteract the cost of practicing expenses for various geographic locations.

GPCIs for various geographic locations can be accessed from the CMS website via the Physician Fee Schedule Look-Up Tool, www.cms.gov/apps/physician-fee-schedule/search/search-criteria.aspx. Select a year, under the type of information tab choose Geographic Practice Cost Index, under select MAC option choose Specific MAC or Specific Locality. Then use the drop-down menu under MAC to choose your specific location of interest. Click submit and this will give the GCPI information for each of the RVU subtypes for the specific geographic location you chose.

The last variable that contributes to the final physician payment amount is the Conversion Factor. The purpose of this variable is to convert the adjusted RVU total into a dollar amount for reimbursement. The conversion factor is a set dollar amount that is determined by Medicare and is adjusted on an annual basis5. For 2017, the Conversion Factor (CF) has been set at $35.888711 and the CF for 2018 will be $35.9996. This number is multiplied by the sum of each RVU component adjusted by the GPCI for each RVU, see figure 1.

The complex task of calculating physician reimbursement for medical services becomes easier to understand when each of the components of the equation are broken down. Assigning an RVU to Physician’s Work, Practice Expense, and Professional Liability Insurance helps create a universal standard value for each service. Then, to account for cost variances based on geographic location each RVU subtype is multiplied by a GPCI for a given location. Finally, the sum of the adjusted RVUs are converted from an arbitrary number to a dollar amount using the CF. As our health care system starts to focus more on quality of care and as we begin transitioning into a pay-for-performance payment model, look for this payment calculation to include a variable that will adjust payment based on quality indicators in the very near future.

References:

  1. Coberly, Sally. “The Basics: Relative Value Units (RVUs).” National Health Policy Forum, 12 Jan 2015, https://www.nhpf.org/library/the-basics/Basics_RVUs_01-12-15.pdf. Accessed 23 Aug 2017.
  2. “Physician Fee Schedule Search.” Centers for Medicare and Medicaid Services, 05 Oct 2017, https://www.cms.gov/apps/physician-fee-schedule/search/search-results.aspx?Y=0&T=2&HT=0&H1=63685&M=5. Accessed 9 Oct 2017.
  3. “Physician Fee Schedule Search.” Centers for Medicare and Medicaid Services, 05 Oct 2017, https://www.cms.gov/apps/physician-fee-schedule/search/search-results.aspx?Y=0&T=2&HT=0&H1=99213&M=5. Accessed 9 Oct 2017.
  4. Quan, J. “The Basics of RVUs & RBRVS.” UCSF.edu, 04 Apr 2007, http://medgroup.ucsf.edu/sites/medgroup.ucsf.edu/files/the_basics_of_rvus_and_rbrvs_0.pdf. Accessed 23 Aug 2017.
  5. U.S. Department of Health & Human Services (HHS). “MLN Fact Sheet: Medicare Physician Fee Schedule.” CMS.gov, Feb 2017, https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/downloads/MedcrephysFeeSchedfctsht.pdf. Accessed 08 Sep 2017.
  6. “Physician Fee Schedule Search.” Centers for Medicare and Medicaid Services, 05 Oct 2017, https://www.cms.gov/apps/physician-fee-schedule/search/search-results.aspx?Y=0&T=2&HT=0&H1=64635&M=5. Accessed 9 Oct 2017.
  7. Verhovshek, John. “Relative Value Units: The Basis of Medicare Payments.” AAPC: Advancing the Business of Healthcare, 01 Jan 2016, https://www.aapc.com/blog/33228-relative-value-units-the-basis-of-medicare-payments/. Accessed 08 Sep 2017.
  8. MaCurdy, Thomas, et al. “Final Report on the CY 2015 Update of the Malpractice Relative Value Units for the Medicare Physician Fee Schedule.” CMS.gov, Nov 2014, https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeeSched/Downloads/CY2015-PFS-FR-Malpractice-RVU.pdf. Accessed 23 Aug 2017.
  9. “Physician Fee Schedule Search.” Centers for Medicare and Medicaid Services, 05 Oct 2017, https://www.cms.gov/apps/physician-fee-schedule/search/search-results.aspx?Y=0&T=3&CT=2&C=61. Accessed 16 Oct 2017.
  10. “Physician Fee Schedule Search.” Centers for Medicare and Medicaid Services, 05 Oct 2017, https://www.cms.gov/apps/physician-fee-schedule/search/search-results.aspx?Y=0&T=3&CT=2&C=100. Accessed 16 Oct 2017.
  11. “2017 Final Medicare Physician Fee Schedule Analysis Exclusively for MGMA Members.” MGMA-ACMPE, 2016, http://www.mgma.com/Libraries/Assets/Government%20Affairs/2017-Final-Medicare-Physician-Fee-Schedule-Analysis-12-1-16.pdf?ext=.pdf. Accessed 16 Oct 2017.


Top Stories You Need to Know 


AAPM&R Membership After Residency: Announcing New Pathways to Valuable Opportunities

Upon graduation from PM&R residency, you have a lot on your plate. AAPM&R spoke with residents and early-career physiatrists to better understand the challenges you face and the resources you need to successfully transition into practice.

As your primary medical society, AAPM&R’s mission is to lead the advancement of physiatry’s impact throughout health care. That starts with investing in the future of our specialty—you! AAPM&R is excited to offer 2 membership pathways to graduating PM&R residents, both of which lead to a complimentary Annual Assembly, if you maintain membership from residency! The new membership pathways will launch in July 2018.

PGY4 residents: You will be the first class to follow a pathway. If you are going into a fellowship, let us know by spring 2018.

Each pathway is designed to support you during this time of transition, while encouraging continued engagement with your primary specialty. Stay tuned for more details.

Thanks for Joining Us at #AAPMR2017!

At this year’s AAPM&R Annual Assembly in Denver, we had more than 3,300 attendees take over the Colorado Convention Center. THANK YOU! Read a detailed recap here.

Plus, get excited for the 2018 Annual Assembly—the largest gathering of PM&R residents—in Orlando, FL, October 25-28. We're throwing our President’s Reception at Universal Orlando Resort™ with dinner at Universal CityWalk™ followed by exclusive access to a special section of the Universal's Islands of Adventure™ theme park. It's a night of unforgettable excitement! See a sneak peek of the fun that's waiting for you in Orlando.

#PhysiatryDay2017 Video Spotlight

Did you catch all of our Physiatry Day videos? Take a look at this one featuring PM&R Residencies in Action! Click here to view the Physiatry Day recap, and to access all the videos featured on Physiatry Day!

SAE-R Study Tools from Your Academy

The AAPM&R self-assessment examination for residents (SAE-R) takes place January 26-27, 2018 and consists of 150 multiple-choice questions. Are you prepared?

Your Academy has several online resources to help you study. Many of these resources are available on mē® at a discounted rate for residents.

  • Abridged SAE-Rs: Each abridged SAE-R provides a taste of what to expect with January’s exam by featuring questions covering 10-12 clinical areas of PM&R.
  • Self-Assessment Examinations for Practitioners (SAE-Ps): SAE-Ps are a great way to zone in on one clinical area and evaluate your knowledge. Plus, some include review articles.
  • Certification Exam Prep Qbank: This online exam study tool covers the 12 PM&R core topics of the specialty through 800+ questions and provides immediate feedback with comprehensive commentary and references.
Newly-Matched Fellows—Update Your Information

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

Resources for You

What’s Coming Next
Look for the next issue of the PM&R Resident in your email inbox in February. 

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