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July 2013

From the Governor

July—it’s a time for summer cookouts, swimming, Fourth of July festivities, and other fun activities. July 1 is also the chaotic time when our new residents traditionally begin the next stage of their medical career as neophyte first-year residents, mentored by second-year residents who were first-years the day before. I get a lot of comments from my colleagues about how “medicine isn’t what it used to be” and how “training was better in the old days.” That’s true: nothing is really as it was. However, instead of being negative, we should reflect on this milestone and the changes that have occurred in medical education over the years and those coming down the road. I would maintain that a lot of things have improved since I was a resident.

July 1, 2013 is also the implementation date for the ACGME’s “Next Accreditation System” (NAS) for Internal Medicine and six other Phase I specialties (Phase II (Transitional Year and remaining specialties) will enter NAS on July 1, 2014). New components introduced in NAS will include the Educational Milestone data from the semiannual evaluation of residents, aggregated to the level of the program. New data will also include a Faculty Survey (implemented in Winter 2012-2013), and a scholarly activity report form that replaces the detailed faculty curricula vitae (CVs) currently in use.

To summarize: NAS will focus on outcomes rather than arcane rules and regulations, and will be more of a “continuous” accreditation system rather than the “old” system which was basically a “biopsy” of the program every few years. NAS will allow high-performing programs the freedom to meet the detailed requirements with alternatives and provide such programs the opportunity to innovate (as well as potentially longer accreditation cycles).

The Educational Milestones (milestones) are observable developmental steps, organized under the six competency areas, which describe the progression on the competencies from novice (entering resident) to proficient (graduating resident) and, ultimately, to expert/master (independently practicing physician). The milestones for each specialty have been developed by a Working Group made up of members of the respective Review Committee, the American Board of Medical Specialties (ABMS) certifying board, program directors, and residents.

The benefits of the milestones are that they articulate shared understanding of tangible expectations, set aspirational goals of excellence, provide a framework and language for discussions, and allow us to track what is most important: the educational outcomes of the residency program and whether a practitioner is fit for independent practice or not.

Since the release of the Institute of Medicine’s report on resident hours and patient safety, many have called for enhanced institutional oversight of the quality and safety of care in teaching hospitals. In response, the ACGME established the Clinical Learning Environment Review (CLER) program as a key component of the NAS, with the aim to promote safety and quality of care. CLER focuses on six areas important to the safety and quality of care in teaching hospitals and the care residents will provide in a lifetime of practice after completion of education:
1) engagement of residents in patient safety;
2) engagement of residents in quality improvement (including opportunities for reducing health disparities);
3) enhancing transitions of care;
4) promoting appropriate resident supervision;
5) duty hour oversight and fatigue management;
6) enhancing professionalism in the learning environment and in reporting to the ACGME.

Another novel concept is that the RRC will no longer assign cycle lengths to programs. The ACGME will be using a “continuous accreditation model” with collection and review of annual data from each program. All programs, with the exception of applications and very newly-accredited programs, will have a scheduled self-study visit every ten years. In addition, programs may have focused or diagnostic site visits, if the annual data submission suggests a potential problem.

Yes, “things aren’t like they used to be” regarding resident training. In the residency model I trained under, first-year residents (“interns”) were the workhorses who did most of the work (and worked the most hours), and it seemed that time spent on the wards decreased as one progressed to third year. Somewhere along the line, the powers that be in residency accreditation decided that this was not a good idea. It was felt that responsibility and work hours should increase as one progresses in PGY year and acquisition of medical knowledge and skills. The NAS embraces these concepts. Working 36-hour days in internship may evoke nostalgia, but it’s hard to justify that it was a good practice in today’s world of quality and safety. We must find new, creative ways to innovate and maximize our residents’ educational experiences while they are here. It’s always better to view the glass as half full rather than half empty.

I, for one, am happy that the ACGME is gearing up efforts to evaluate residents and programs based on tangible metrics: quality/safety data, milestones, clinical outcomes, enhanced clinical supervision, patient satisfaction. This puts the ACGME more in line with what other organizations (e.g., TJC) are doing. While some of us may lament the demise of the “good old days,” sometimes we just need to move on and embrace the future. These new guidelines provide the opportunity to re-invent our curricula and train the next generation of physicians to be prepared for a more complex health care system than we could have ever imagined. Isn’t this what we all want to be?

As always I would like to hear back from ACP members about we can be doing to bring new initiatives to the chapter. I can be contacted at jneal6@iuhealth.org or (765) 747-4350.

J. Matthew Neal, MD, MBA, FACP
Governor, Indiana Chapter


Upcoming Indiana Chapter Webinars—Save the Date!

August 22, 2013 6:30-7:30 pm EST

“HIPAA Compliance for Physicians”
Michelle Altobella, JD
Vice President/General Counsel
IU Health Ball Memorial Hospital

Jane Welch
HIPAA Privacy Officer
IU Health Ball Memorial Hospital

September 10, 2013 6:30-7:30 pm EST

“Contract Negotiation for Physicians”
Julie Reed, JD
General Counsel
Indiana State Medical Association


Hold the date for the 2013 Indiana Chapter Meeting!

November 15-16, 2013
The Marten House Hotel & Lilly Conference Center
Indianapolis, IN


Items of Interest

Hospitals Considering Exit From ACO Pioneer Program

Bloomberg News (6/29, Wayne) reported that almost one-third “of 32 hospitals and health systems involved in an experiment aimed at changing the way medical providers are paid may exit the program, a potential threat to the Affordable Care Act’s ambitious cost-saving goals.” The Medicare Pioneer program was designed to save Medicare up to $940 million through 2015 while paying hospitals up to $1.9 billion in bonuses. CMS spokesman Brian Cook said nine members have notified the government that they may leave the program, while “at least four may join other accountable-care programs that carry less financial risk.” Bloomberg News notes that providers may have experienced higher costs and less “clinical control” over patients in the program.

Modern Healthcare (6/28, Evans, Subscription Publication) reported that CMS spokesman Alper Ozinal said, “We’re encouraged that these organizations want to continue in programs that promote better care at lower costs. We fully anticipated that as these programs get up and running, some organizations would shift between models.”

Analysis: ACA Exchanges Impose Big Premium Hikes On Some Healthy Workers

The Wall Street Journal (7/1, A1, Radnofsy, Subscription Publication), in a front-page analysis titled, “Health-Insurance Costs Set For A Jolt,” reports that Americans who lack employer-sponsored healthcare benefits, but are generally healthy, may face huge increases in the price of their health insurance as a result of the Affordable Care Act. According to the Journal, a 40-year-old in Virginia who does not smoke can currently get health insurance, with a deductible of $5000, for $63 a month, but the ACA exchanges offer the same worker plans no cheaper than $193 a month. The most expensive option for the same 40-year-old will be about $400 a month, according to the Journal. However, the Journal also notes that single people with incomes around the Federal poverty level of $11,490 a year qualify for a subsidy of as much as $234 a month – though that subsidy is eliminated completely for anyone making more than $33,150 annually.

Older, Sicker Americans To See Lower Premiums As A Result Of ACA

Kaiser Health News (6/28, Appleby) reported on the “flip side” of the “rate shock” debate surrounding the Affordable Care Act: “new rules that broaden benefits, prohibit discrimination against those with health issues and cap consumers’ out-of-pocket costs, which can cut far deeper than premiums.” As the article explains, “Whether individuals will be better or worse off under those rules depends on their age, health status, where they live – and perhaps most important, whether they end up needing substantial medical care in the coming year. Generally speaking, those who are younger and healthier may pay more than they would have, while older and sicker people are likely to be better off.”

House Committees Progress Toward SGR Overhaul

The Hill (6/28, Viebeck) “Healthwatch” blog reported that the House Energy and Commerce and Ways and Means Committees “are claiming momentum for their effort to repeal and replace Medicare’s flawed physician payment formula, the sustainable growth rate (SGR).” The Committees on Friday “released a more detailed version of their long-term ‘doc fix’ proposal and requested stakeholder feedback by July 9.” Energy and Commerce Committee Chairman Fred Upton (R-MI) said in statement, “We remain committed to a deliberate and transparent process as we work to help our doctors, help our seniors and ensure we have a fair system with the best quality of care.”

CQ (6/28, Ethridge, Subscription Publication) noted that this “the draft is the latest, and most complete, outline the committee has released for repealing the current payment formula.”

Modern Healthcare (6/28, Zigmond, Subscription Publication) added that “Friday’s announcement from the two committees did not offer a funding solution, but House Energy and Commerce Committee Chairman Fred Upton (R-Mich.) indicated that the committees will address the issue.”

House Bill Looks To Lessen Influence Of Medicare RUC

The Hill (7/1, Viebeck) “Healthwatch” blog reported that a bill from Representative Jim McDermott (D-WA) “would change how Medicare sets its doctor fees by lessening the influence of an advisory panel criticized as secretive and weighted toward medical specialists.” McDermott, “the top Democrat on the Ways and Means health subcommittee, introduced a measure that would create a panel of independent experts to govern the much-debated Relative Value Scale Update Committee (RUC).” A memo from McDermott’s office alleged that the RUC is “unevenly weighted by procedural specialists over primary-care doctors and relies heavily on anecdotal and self-serving survey evidence.”

Health Insurance Costs Set for a Jolt

Healthy consumers could see insurance rates double or even triple when they look for coverage under the reform law later this year, while the premiums paid by sicker people are set to become cheaper. (WALL STREET JOURNAL)


Contact Information

Indiana Chapter Governor:
J. Matthew Neal, MD, MBA, CPE, FACP, FACE
Email: jneal6@iuhealth.org
(765) 747-4350; Fax (765) 751-1451

Donna Seawards
Executive Director
Email: donnaseawards@gmail.com
Ph: 623-225-5527

Chapter Address:
4319 West Clara Lane, PMB #288
Muncie, Indiana 47304