PM&R Resident E-Newsletter

The Resident Physician Council (RPC) Board kicked off 2016 with an exciting meeting at the AAPM&R headquarters in Rosemont, IL, January 9-10! Resident leadership held productive discussions on the current and future needs of residents, changes in the health care environment and how they impact our specialty, and the role of the Academy in preparing residents for their future careers.

Much feedback was provided to the Academy on the development of resources for residents. This included innovative ideas to improve the resident program at the Annual Assembly and important factors to consider when advancing technology resources. Opportunities to gain more leadership experience, particularly in advocacy and how to influence an ever-changing health care system, were also discussed. Furthermore, residents focused on ways to advocate for and publicize the specialty of PM&R. In particular, residents demonstrated enthusiastic support for innovative educational opportunities at the Annual Assembly.

Resident leadership also held conversations on how to improve awareness of the PM&R specialty within their institutions. Plans are in place to expand the current Ambassador Program, ideally having representation from every residency program. It was agreed upon by the RPC Board that the Ambassador Program also has significant potential to help publicize and improve awareness of the specialty of PM&R, possibly through increased involvement with medical schools.

The RPC Board will continue to work hard over the next year on various projects to advocate for the needs of residents nationally. Members will attend other meetings and conference calls to continue to inspire change for the better. The RPC Board is the voice of residents nationally – the future of the specialty that will be impacted the most by any changes in our specialty and in health care. Keep an eye out for news on some exciting initiatives during the next year, started by the RPC Board based off resident needs!

Greetings from the PM&R Resident! This month marks the beginning of our fellowship series where residents offer a closer look at various topics, give peer advice, and highlight the diverse subspecialties physiatry has to offer. We would like to encourage any continued submissions related to the fellowship series or other personal accounts of resident life, volunteer opportunities, health care policy, international health care, and transitioning from residency into the job market.

Again, if you are considering a submission, here are some basic guidelines:

1. All authors must be AAPM&R members.
2. Goal word count is approximately 500 words or less.
3. Corresponding pictures are encouraged (including authors).
4. Submissions or ideas should be sent to 1gutierrezdavid@gmail.com and are accepted and reviewed year-round.
   
   

The Montefiore Medical Center/Albert Einstein College of Medicine offers one of the largest ACGME-accredited physical medicine & rehabilitation pain medicine programs in the country. The program currently accepts 4 fellows per year. Dr. Sayed E. Wahezi is the fellowship program director. Kyle Silva, MD, is one of the 2016-2017 fellows. View part 2 below for Dr. Silva's advice. 

Tell us a little bit about the program.
Dr. Wahezi: Our program is a multi-disciplinary, ACGME-accredited pain medicine fellowship that focuses on the diagnosis, treatment, and management of chronic pain primarily through outpatient-based clinics and procedure suites. Our fellowship operates out of the new Montefiore Hutchinson Campus located in the Bronx suburban area close to Westchester County.

What makes the Montefiore pain medicine fellowship stand out?
Dr. Wahezi: Our program is dedicated to providing sound-minded, ethical, and good pain care. Though our focus is interventional at its core, we do highlight the psychologic and neurologic aspects of pain medicine to identify appropriate candidates for treatments that align with their conditions.

What does your program look for in a potential fellow?
Dr. Wahezi: Team players. We look for individuals who are passionate about treating and managing pain, and those who can appreciate a truly multidisciplinary approach. Although board scores are held in high regard, personal traits and attributes are held just as high.

Where can I find more information about the Montefiore pain medicine fellowship?
Dr. Wahezi: Most of the information regarding our fellowship can be found here.

When did you decide to focus on pain medicine in your residency, and what made you decide this was your subspecialty?
Dr. Silva: Toward the end of my PGY2 year, I was fortunate enough to gain exposure to a variety of different subspecialties within PM&R. I was drawn to pain medicine because I liked the idea of developing a specialized skill set, including interpreting imaging studies, performing diagnostic & therapeutic ultrasonography, and fluoroscopic interventions. Furthermore, I enjoyed the medical complexity associated with treating chronic pain and felt that I could have a profound impact on my patients’ lives by helping to relieve their suffering.

From the applicant standpoint, can you provide a timeframe on certain milestones during residency and applying for fellowship? For instance, when should residents try to do audition rotations if their program allows them? When should they be asking for letters of recommendation?
Dr. Silva: First and foremost, be a good resident! Once you develop a strong foundation in PM&R you can start to investigate your other interests. Try to get involved in specialty groups and national organizations. Toward the end of your PGY2 year, start researching where you would like to spend your elective time and reach out to those programs. Apply for leadership positions at the local and national level. Attending conferences is another great opportunity to showcase any of your research and network. In the Fall of your third year, I would recommend reaching out to your letters of recommendation (LoR) authors. In terms of elective rotations, I feel it is best to rotate in the late Winter/early Spring so that programs can easily remember how awesome you are!

Describe your experience with the ERAS process. When did you ultimately apply for fellowship?
Dr. Silva: I began filling out my ERAS in February during my PGY3 year. The application itself will take 1-2 weeks to fill out and review. Give yourself enough time to obtain LoRs as previously mentioned. ERAS opens in December, so the earlier you can submit, the better.

Any other advice you can give to a pain medicine fellowship applicant?
Dr. Silva: Remember to take time to celebrate your accomplishments with friends and family! The road to fellowship can be long and arduous at times. Make sure to celebrate your wins, both big and small, along the way.

Major changes in the health care landscape are happening at a rapid pace with the passing of several new policies and regulations. Residents in training need to be cognizant of these upcoming changes, which will inevitably affect our future practice.

First, let’s familiarize ourselves with some of the jargon:

SGR Formula: Sustainable Growth Rate Formula

This was a method used by the Centers for Medicare & Medicaid Services (CMS) to compute payments for physician services and to control how much money CMS spent on medical care. Since SGR was implemented in the 1990s, there has been a game of catch up and patchwork to fix the SGR to align with ongoing reality. The exponential increase in the complexity of care required that the SGR be updated frequently. The updates, however, lagged advances in care and there was a persistent threat to cutting reimbursements for medical services. The proposal to cut physician payment was an effort to address the unsustainable medical spending thought to be a driver of health care costs. The SGR formula mandated a cut of 21.2% in payments and it has taken about 17 acts by Congress to stall this process. Finally, on April 16, 2015, the SGR took its last breath when President Obama signed the MACRA into law, which repealed the SGR.

MACRA: Medicare Access and CHIP Reauthorization Act of 2015

Along with the repeal of the SGR, the enactment of MACRA earlier this year is intended to help safeguard Medicare payments for physician services. The goal is to promote quality of care over quantity and to stabilize the reimbursement system. Starting in July 2015 through the end of fiscal year 2019, MACRA purports to increase Medicare payments for physician services, however, there is a catch.

MACRA introduces major shifts in current models of health care delivery—a move away from fee-for-service payment models towards fee-for-performance—with stringent reporting requirements. Under the new system, the Merit-Based Incentive Payment Systems (MIPS), reimbursements follow a carrot and stick approach. MIPS replaces the prior Medicare fee for service requirements (the Electronic Health Record (EHR), Physician Quality Reporting System (PQRS) and Value Based Modifiers). From July 2015 to 2019, all practitioners will be graded on a 0-100 scale with monetary rewards of 0.5% per year based on points allocated to the ff categories: clinical practice improvement activities (15 points), meaningful use of EHR (25 points), PQRS (30-points) and health resources (30 points). Funding for this payment is expected to come in part from an estimated $15 billion in savings from post-acute care. Starting in 2020 through 2025, low ranking performers will be penalized (reductions in payments) and the revenues will be used to reward high-ranking individuals satisfying the target performance requirements.

The Secretary of the Department of Health and Human Services will set the performance thresholds based on all recorded MIPS scores. The fewer the number of people who score on the high performing end, the higher the incentives to be awarded for the those in the top quartile (based on an allotted bonus funding pool of $500 million per year). Between 2020 and 2025, there will be no payment increases. By 2026, the practitioners in accountable care organizations and alternative payment model systems will receive up to 0.75% annual updates in reimbursements. For post-acute care providers, reimbursements will be capped at 1% in fiscal year 2018 for home health, hospice, inpatient rehab, long-term care hospitals, and skilled nursing facilities. CMS will also start posting quality and utilization data on physician compare websites.

APMs: Alternative Payment Models

With the passage of MACRA, physicians face an uncertain future of penalties as outlined above. Alternative Payment Models (APMs) are a way to counter this punitive paradigm by offering a way for physicians (dubbed eligible professionals [EPs]) to qualify for incentives and benefits under MACRA through bonus payments starting in 2019. APMs are based on the same quality measures established by MIPS (many of which are tailored for primary care instead of specialties, like physiatry), accountable care organizations, and patient centered-medical homes. Lump sum incentive payments will go to the groups to which the EPs belong to as a way of encouraging collaboration and teamwork. Groups could be hospitals, physician or non-physician owned practices. Unfortunately, APMs are associated with a certain amount of financial risk such as start-up expenses, equipment and overhead costs, data analysis expenses, etc. CMS is yet to set the criteria for judging whether a proposed APM qualifies under MACRA; however, MACRA specifies that participating in CMS-authorized, patient-centered medical homes will allow physicians to qualify for APM bonuses without the financial risks.

Due to the fact that there are currently very few APMs, MACRA strongly encourages physicians to develop new payment models. Some options for physiatrists could potentially be through spine care, pediatric rehab, TBI, stroke care models, etc. Besides monetary incentives, another benefit for physicians participating in model development is that this qualifies them for the clinical practice improvement activity portion of MIPS (15 points). In addition, physicians may have other MIPS requirements waived. Participating APMs will receive a 5% percent lump-sum incentive payment effective from 2019 to 2024 (once they meet the threshold score set by the Department of Health and Human Services) to help offset any financial/monetary losses incurred in APM set up. By the end of 2016, it is anticipated that 30% of Medicare payments will be tied to APMs. This will increase to 50% of Medicare payments by the end of fiscal year 2018.

As future physiatrists, we must not only actively advocate for our specialty, but also remain engaged in health care policy practice management initiatives in the rapidly-changing milieu of health systems in the United St¬¬ates.

For more information, please visit the Academy’s quality and practice content, advocacy content, and also check out this video prepared by the Academy to educate membership on the upcoming changes.

You can also learn more about possible alternative payment and practice models for PM&R in your February issue of The Physiatrist.

Take Home Points:

• MACRA kicked out SGR. RIP SGR (1997 to 2015).
• MACRA was signed into law April 16, 2015 and introduces MIPS and APMs.
• MIPS will provide a scorecard to monitor all physicians’ performance, with associated penalties and rewards for low vs. high performers, respectively.
• True effective date of MIPS is 2017 with a focus on high quality and high value patient care. Although the monetary rewards and penalties do not start until 2019, they will be based on information reported starting in 2017.
• APMs provide a way for physicians to earn bonuses as part of a collaborative team approach to care.
• Trainees need to start learning how to engage in clinical practice improvement activities.