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PM&R Resident E-Newsletter

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June 2017

From Your Resident Physician Council (RPC)

Exciting Information About the RPC Name Change

G. Sunny Sharma, MD
PGY3, VA Greater Los Angeles/University of California, Los Angeles
RPC President

On April 30, you should have received an email from me with information about a potential name change to the RPC. In case you didn’t, I’ll provide a quick recap. Our Academy Board of Governors met at the end of April for their annual spring meeting. Many important initiatives were discussed, including a potential change to the official name of the RPC, which was recommended by the Academy’s Membership Committee. This means that the Resident Physician Council (RPC) would change to the Physiatrist-in-Training Council (PHiT).

The change will help incorporate those who are currently in a fellowship, in addition to residents. We feel that this more accurately represents the Academy’s resident and associate fellow members, who utilize many of the same early-career resources available through the Academy.

In early June, our Board of Governors voted to officially change the name from RPC to PHiT. We’re excited about this change and look forward to welcoming our fellowship peers into this community.

P.S. The PHiT Nominating Committee is seeking Board nominations. Any interested, current AAPM&R resident and associate fellow (those in fellowship 2017-2018) members are encouraged to apply. View position descriptions and more.


Fellowship Spotlight: Sports and Interventional Spine

Dustin Anderson, MD
PGY2, University of Colorado Physical Medicine and Rehabilitation


 

Scott R. Laker, MD, FAAPMR
Medical Director, Lone Tree Health Center, University of Colorado Hospital
AAPM&R Board of Governors Quality, Practice, Policy, and Research Chair

Physiatrists have the unique option of specializing in sports medicine, pain medicine, or the combination of sports and interventional spine, the latter of which can be ACGME-accredited or non-ACGME accredited. I connected with Dr. Scott Laker, a specialist board certified in sports medicine and pain, to help navigate the fellowship landscape.

Dr. Anderson: Can you tell us a little about what inspired you to explore a career path involving sports, pain, and interventional spine?
Dr. Laker: I have always been involved in sports throughout my life, and when I was in residency, I gravitated toward those clinics. I found that I enjoyed the procedural aspect of physiatry immensely. I was lucky to work with some very talented mentors (Drs. Venu Akuthota, Bill Sullivan, and Deb Saint-Phard) during my residency at the University of Colorado. They are gifted physicians and I remember clearly wanting to practice like them when I was starting my career.

Dr. Anderson: Regarding combined sports/interventional spine programs, how much variation is there between sports coverage and procedural experience?
Dr. Laker: There is a tremendous amount of variation for the combined programs. It is similar for residencies. All residencies have certain requirements, but each residency has different strengths and areas of focus. For ACGME-accredited sports medicine fellowships, there are clear guidelines for sideline and event coverage. For ACGME-accredited pain medicine fellowships, there are no such requirements for coverage. That being said, the University of Colorado’s pain medicine fellowship does have significant sideline coverage responsibilities for several Division I sports teams. Non-ACGME programs have the most variability because they are not bound by those ACGME guidelines.

My strongest recommendation on this topic would be to ask yourself what coverage experience you need during fellowship to be able to do the job you ultimately want to do. If your career goal is to be on the sideline at the 2025 NCAA Division I football championship, then you will need significant volume high-level, hands-on experience during your fellowship to give you the opportunity to pursue that type of competitive career. Alternatively, if you want to be the director of an interventional spine clinic, then your need for sideline coverage is probably not necessary but consistent, high-volume, hands-on, supervised procedural training is essential.

This is similar when considering procedural exposure. Some programs will train you to do a wide range of procedures, from joint injections to spinal cord stimulator trials to vertebral augmentation. All of the ACGME (pain or sports) programs have similar requirements, though each will have its own areas of strengths and volumes of exposure. It is very fair to discuss the estimated numbers of procedures during your interviews.

Dr. Anderson: What do you consider the most rewarding and challenging aspects of your job?
Dr. Laker: I have a broad practice that involves spine, pain, musculoskeletal conditions, pediatric, and adult concussions. I do fluoroscopically-guided and ultrasound-guided procedures, and some EMG. I also have several administrative roles and am the medical director of a multi-specialty clinic. I love the mix of what I do and can’t imagine doing just one thing every day. This is one of the main reasons I chose physiatry in general, and my own career path. As for rewarding parts of my clinical practice, the first thing that comes to mind is knowing that if you give good education about concussions to one family and one kid, that you may be able to protect them, their siblings, and the other kids on their team. I love the idea that our ability to communicate can create some ongoing good beyond the initial visit. From a teaching standpoint, there is nothing better than being part of residents’ early careers and watching them get off to a great start, either with fellowship training or their first jobs.

Recently, I’ve been focused on how challenging it is to engage patients in long-term lifestyle change. We live and work in a quick-fix health culture. If you have appendicitis, you get an appendectomy and you get well. Some of the interventions we offer may take weeks of PT, months of home exercise, lifestyle changes, and consistent long-term work to get well and stay well.

Dr. Anderson: For those considering an ACGME versus non-ACGME fellowship, what are some factors residents should account for in their decision-making process?
Dr. Laker: Fellowship was one of the most rewarding experiences of my career and my involvement in fellowship training is a central reason I enjoy being at the University of Colorado. For the purposes of current residents, it is important to critically assess if you really need to do a fellowship. I mean it. Stop and spend some quality time thinking about why you want to pursue fellowship. It is another year of training, often in a new and far away city, and there is the opportunity cost of spending another year on a fellow’s salary. Not everyone needs a fellowship to create a wonderful career or to make a positive impact on their patients.

Secondly, it’s important to understand that fellowship training can be superb with or without ACGME accreditation. These are world-class physiatrists that run fellowships. They are devoting their time and energy to train their fellows. The fellows devote their time and energy to become better physiatrists. It’s a great gift that the faculty give the fellows and vice-versa.

If you know you want to stay in academics to publish, teach, and see patients, I would suggest that the ACGME programs are a consistently great fit. If you want to start your own private practice, manage your clinic, and be a business owner, a non-accredited fellowship working with faculty that have fulfilled those goals and can share their experience with you may be a better fit. There is a world of flexibility in physiatry. Ultimately, many of the best physiatrists have experience in academics and private practice, including inpatient and outpatient roles.

One additional thing to consider is that you’ll be spending an enormous amount of time with your fellowship faculty. Ideally, you should be working with faculty that you respect and who practice in a way that resonates with you. In the end, the role-modeling that happens during your fellowship will be much more important and long lasting than the procedural experience or journal articles you read.

Dr. Anderson: What qualities would most fellowship directors describe in their “ideal candidate?”
Dr. Laker: For the Annual Assembly, we partnered with AAPM&R to create a survey that answered that very question. It had far less to do with board scores, residency location or number of publications (though those are a part of the equation). The ideal candidate is someone that has a clear understanding of what they want to do and why they want to do it. Fellowship directors may look at hundreds of applications each year and may do dozens of interviews. They are ultimately looking to work with someone that will make the most of their talents and the hundreds of hours of training that they share with the fellow. Speaking for myself, I love training fellows that I feel will become leaders in our field. Also, I want the fellows to learn to practice in their own way and to develop their own style.

Dr. Anderson: Are there any resources you might suggest for candidates planning for fellowship training?
Dr. Laker: Along with talking with your faculty, program director, and recent alumni from your program, there are some great resources through AAPM&R to help plan for fellowship training. Our Academy has a career and fellowship advice/resources page, fellowship database (incorporated in the Job and Fellowship Board) along with a roadmap to fellowship. You can also search the ACGME website by specialty, and the NRMP puts out fellowship match data, similar to what you may have perused for residency applications. Lastly, there is a Point/Counterpoint that held a great discussion on some of the advantages and disadvantages of sports/spine combined fellowships. I posted them below.

I wish you all success in your careers, and I thank you for the impact you’ll have in your patient’s lives.

Thank you, Dr. Laker!


Pain Medicine Fellowship Q&A

Peter Lapen, DO
PGY3, Loyola University Medical Center

David Drake, MD
Pain Medicine Fellowship Program Director, Virginia Commonwealth University

Dr. Lapen: Tell us about your program.
Dr. Drake: Our fellowship is the first PM&R pain medicine fellowship to be accredited by the ACGME. We accept applicants from all backgrounds such as, (but not limited to) primary care, psychiatry, anesthesiology, and PM&R. If you look at the breadth of it, our fellows come from very diverse backgrounds of professional training.

Dr. Lapen: What is the goal of fellowship training in pain medicine?
Dr. Drake: The goal is to be able to have our fellows acquire the tools they need, and a base of knowledge they can incorporate into the practice that they want to have.

Dr. Lapen: What makes a PM&R fellowship different from an anesthesiology fellowship?
Dr. Drake: There is a bit of a difference in evaluation and management due to looking at function in addition to the history of functioning at home, falls, and more importantly, what they can do for themselves with regards to home therapy.

Dr. Lapen: What makes a potential applicant stand out?
Dr. Drake: We look at the entire applicant. Super high scores are fine, but letters usually say something that make an applicant stand out. We ask, “Do we want to work with this person?” and what applicants can bring to the table in their previous experience, is a factor as well. The program values learning from fellows as much as teaching.

Dr. Lapen: What advice do you have for potential applicants?
Dr. Drake: Be yourself, let us know who you are and your personal motivation. To convey that is the biggest thing. It doesn’t matter if you’ve never touched a needle in your life, however, if you have, are you willing to help teach your colleagues?

Dr. Lapen: What advice can you offer potential applicants about “away rotations?”
Dr. Drake: If there is a question about location, or if location is important, rotate at a fellowship to aid your decision. However, rotating or not, will not be counted for or against you.

Thank you, Dr. Drake!


The Business of Medicine: Part 2

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

The business of medicine is an important topic that has had little emphasis throughout our residency training. However, the economic climate and business aspect of medicine largely impacts our medical practices. In the last issue of the PM&R Resident, we started exploring the various health care reimbursement models and briefly covered: Fee-for-Service, Pay-for-Coordination, Pay-for-Performance, and Bundled Payment models. This article will cover the remaining 4 reimbursement models: Upside Shared Savings Programs, Downside Shared Savings Programs (commonly referred to as a two-sided risk model), Full or Partial Capitation, and Global Budget.

Upside Shared Savings Programs
Upside Shared Savings programs are also known as “Shared Savings Contracts” and the “One-Sided Model.” This model gives providers monetary incentives to provide efficient, low-cost care with specific patient populations without subjecting them to the risk of losses. For example, Medicare allows some use of this upside only model. “To participate in the Shared Savings Program, eligible providers and suppliers must form a Medicare ACO, and the ACO must apply to CMS… Under the program regulations, Medicare continues to pay individual ACO providers and suppliers for covered items and services as it currently does under the Medicare fee-for-service payment systems. CMS also develops a benchmark for each ACO against which ACO performance is measured to assess whether the ACO-generated savings or losses for the Medicare program during a performance year.1 “In an upside-only arrangement, the ACO will be allowed to keep a portion of net savings they generated during the performance year, but they don’t need to pay for a share of net losses if that is what they end up with. Providers may voluntarily participate in an ACO where they accept health care responsibility for at least 5,000 Medicare FFS patients and participate for at least 3 years7. To capitalize on the shared savings, participating ACOs must meet 33 quality measures related to patient and caregiver experience, care coordination, patient safety, preventive health, and at-risk populations8. It is attractive to provider organizations, as it poses no performance risk to providers even if they experience higher costs than expected under the benchmark set. However, all MSSP participants must move to a Downside (two-sided) model after 3 years of participating in the Upside Shared Savings Program3.

Downside (Two-Sided) Shared Savings Programs
This model is similar to the Upside Shared Savings Program in that the providers will receive a share of any of the savings realized, but with this model they will also share in the risks. The provider will be responsible to pay a share of any of the excess costs of health care delivery that exceed the set goal amount. It is similar to the upside Shared Savings Programs, in that all the same quality measures apply, but with the Downside Shared Savings they must also have per beneficiary expenditures below the established benchmark to show a cost savings1. If they fail to achieve costs savings, then they are financially penalized. Since the providers are taking on extra risk by participating in this payment model, the upside opportunity potential (the percentage of shared savings) is generally larger than in an Upside Shared Savings Program3. The providers receive proportionately larger bonuses in exchange for this risk.

With both the Upside and Downside (two-sided) shared savings programs, providers are compared against an agreed upon set of performance measures that generally include some combination of clinical process measures, outcome measures, and patient experiences. This measurement is essential to ensure that appropriate care is being delivered, and that cost savings are not the result of limiting necessary care. Shared savings programs also typically have built in buffers and distribution caps8. A buffer helps to account for statistical error and only gives providers a bonus if savings are over a certain threshold (i.e., >2% savings above the projected rate)8. Likewise, a buffer helps to protect the health care provider such that they will only be charged a penalty if the costs are greater than a certain threshold (i.e., >2% cost above the projected rate)8. A distribution cap is also generally applied and refers to a maximum allowed bonus regardless of the provider’s under budget amount for the performance year8. The purpose of the distribution cap is to help prevent the underuse of services to achieve savings, and ultimately may increase bonuses or reimbursement.

Full or Partial Capitation
The Full Capitation model is designed to be the opposite of the FFS payment model. It pays the health care provider a single assigned per member per month (PMPM) amount, and bestows all the risk of the costs of each patient’s medical care for the month upon the health care provider9. The health care provider gets a certain sum of money to cover all the costs of care for the patient for that entire month. This PMPM number is based on various patient demographics including age, race, sex, lifestyle, medical history, prior health care utilization, and insurance benefit design9. The payment is based on a certain expected usage of the health care system regardless of an individualized patient’s needs. This model is similar to Bundled Payment Models, in that providers are incentivized to help patients avoid high-cost procedures or tests. Since the amount paid per month is set, if the patient uses less medical services, the provider receives the excess of the amount that was actually used and the set PMPM amount, thereby increasing their compensation. However, if the patient utilizes a medical service that exceeds the set PMPM amount, the difference comes out of the net profits realized by the health care provider9. One can see how this would lead providers to focus on preventative health care as there would be a greater financial reward for the prevention of illness rather than treating the ill. The health care providers assume the responsibility of their patients’ unknown future health care costs, and with greater responsibility risk comes higher potential reward. This model works best with large group providers rather than small practices, as the population’s risks are diluted amongst a greater number of care providers9.

The Partial Capitation model works in a similar fashion. The main difference between Full and Partial Capitation is that Partial Capitation includes a single payment or a defined set of services, while the other services required for that patient’s care are still paid on a FFS basis. In the Patient Protection and Affordable Care Act (ACA), section 3022 created a new Medicare payment program to support Accountable Care Organizations3. Section 10307 of the ACA allows Health and Human Services (HHS) and CMS to use payment models such as partial capitation to support ACOs3.

Global Budget
Global Budget is also known as “Global Payments,” “Risk-Adjusted Capitation,” “Global Capitation,” and “Bundled Global Payments.” This type of model includes a fixed total dollar amount that is paid to a single health care organization over a set period of time (usually paid monthly per patient over a year) for all care delivered7. The amount is meant to encompass a wide range of health care needs including physician and hospital services, diagnostic tests, prescription drugs, and often other services, such as hospice and home health care7. It is applicable in the private sector via Health Maintenance Organizations and is utilized in the public sector by Medicare Advantage plans and Medicaid Managed Care plans3. This gives the providers complete control over how the medical dollars are spent, but puts the provider at a considerable financial risk. This model’s payment covers all patient care including primary care, hospitalizations, specialist care, and all ancillary services. This type of shared payment holds multiple providers in multiple settings jointly accountable for the total cost of care. It is believed that Global Budgets limit the level of health care costs and the rate of costs increase. Many health economists are supporting this model as an important strategy to help slow the growth of health care expenditures10. Incentives for patient access and quality improvement are also an important part of today’s Global Payment plans. This model differs from the Bundled Payments model in that Global Payments are made on behalf of an entire group of patients and cover all care for all conditions that are covered by the health plan10. See Figure 1 for a visual representation for the difference between the current FFS model and the future Global Payment model.

Figure 1.
Massachusetts Special Commission on the Health Care Payment System, “Recommendations of the Special Commission on the Health Care Payment System,” PowerPoint, http://valueovervolume.org/documents/massachusetts_health_care_payment_system.ppt (Boston: SPHCP, July 16, 2009).

The health care industry today is transitioning out of a volume-based care system and is moving toward a value-based reimbursement system. This means the traditional Fee-For-Service models are getting phased out as more Pay-for-Performance models are gaining the market share. The goal for the transition is to encourage health care providers to deliver the most appropriate care for the most appropriate cost. Figure 2 is a visual representation of the transitioning of reimbursement models over the next several years.

Figure 2.
Mckesson. “Value-Based Reimbursement vs. Volume-Based Care.” Population Health Management. McKesson Corporation, http://www.mckesson.com/population-health-management/population-health/know-the-challenges/. Accessed 8 Jan. 2017.

Health care reimbursement is a complex process that is influenced by multiple factors and is often viewed as an overwhelming concept at this point in our training as residents. Hopefully this article provided you with a basic understanding of the various payment models available for health care reimbursement. The current trend in our health care system is focusing more on quality of care and placing more responsibility on the health care provider for cost of care and patient outcomes. You may now appreciate why we are in the process of transitioning out of a Fee-for-Service model and into a Pay-for-Performance payment model. As the health care market is constantly evolving in an attempt to control rising costs and ensure appropriate care, the impact on health care provider reimbursement must also evolve in response to these market changes. The specific role of physiatry and the value of rehabilitation in acute hospitals, post-acute facilities, and community-based care must also continue to evolve to remain relevant in the medical care, health, and well-being of our patients.

References:

  1. https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/sharedsavingsprogram/Downloads/ACO_Providers_Factsheet_ICN907406.pdf
  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. http://www.fastercures.org/assets/Uploads/PDF/VC-Brief-AlternativePaymentModels.pdf
  4. https://www.slideshare.net/CureMDHealthcare/difference-between-pay-forperformance-and-feeforservice-payment-models
  5. http://www.urban.org/sites/default/files/publication/25816/412655-Payment-Reform-Bundled-Episodes-vs-Global-Payments.PDF
  6. "Bundle Medicare’s Payments to Health Care Providers." Options for Reducing the Deficit: 2014 TO 2023. Congressional Budget
  7. "ACO General Questions." Centers for Medicare & Medicaid Services, Frequently Asked Questions. n.p. 04 Nov 2013.
  8. "Medicare Shared Savings Program Quality Measure Benchmarks for the 2014 and 2015 Reporting Years." Centers for Medicare & Medicaid Services. n.p., n.d.
  9. Cox, T. (2011), Exposing the true risks of capitation financed healthcare. Journal of Healthcare Risk Management, 30: 34–41. doi:10.1002/jhrm.2006
  10. http://www.ncsl.org/portals/1/documents/health/GLOBAL_PAYMENTS-2010.pdf
  11. http://www.mckesson.com/population-health-management/population-health/know-the-challenges/


Top Stories You Need to Know 


Revamped Resident Program at #AAPMR2017

The Annual Assembly is the world's largest gathering of PM&R residents, providing educational and networking events tailored specifically for you. NEW this year, resident/early-career activities will take place throughout the Annual Assembly for a complete event experience. Sessions begin on Thursday afternoon. Register by August 30 for member discounts and early registration rates.

P.S. Guess what's back for round two—the Resident Quiz Bowl! We’re bringing the fun to the PM&R Pavilion floor where PM&R residents from across the country can compete for fun and test their physiatry knowledge. Sign up your team here.

Help Us Dig a Little Deeper—Complete Our Brief Resident Census

The specialty of PM&R is quite broad. As you progress in your career, there are multiple practice paths you can take post-residency. AAPM&R would like to better understand the future plans of current PM&R residents to gain a sense of what the future might hold for the specialty.

Please click here to take our quick census, which should take no more than 7 minutes. In advance, thank you so much for your time and valuable insights!

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.

Prepare for ABPMR’s Part I Exam by Utilizing AAPM&R Resources

AAPM&R has the resources to help you prepare for the American Board of Physical Medicine and Rehabilitation’s (ABPMR) Part I Examination on August 14, 2017. Get a head start on studying with these must-have resources, including:

Find all of the above and other great study resources on me.aapmr.org.

Physiatry News

Competitive Funding Opportunity for Residents/Fellows

The Accreditation Council for Graduate Medical Education (ACGME) and Council of Review Committee Residents (CRCR) have announced their new “Back to Bedside” initiative, which was designed to empower residents and fellows to develop transformative projects that combat burnout by fostering meaning in their learning environments; engaging on a deeper level with what is at the heart of medicine: their patients. Proposals are due August 5—learn more.

Resources for You

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

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