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The Relative Value Unit (RVU) has become a ubiquitous metric in the lives of health care providers is this age of the employed physician. While this tool is purported to be a standard, universally applicable and egalitarian measure of physician productivity, it is anything but. How did this come to pass and what are other options for determining the amorphous imprecise activity known as productivitywhich is all too often limited in scope to financial productivity, a topic that as I recall, is not covered in the Hippocratic Oath?(1) In the late 1980s, in an attempt to quantify efforts across medical specialties, a group at Harvard developed a series of vignettes ...
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This is an exciting time of year for many of us in academic practices because we are getting ever so close to the match. In fact, I have been spending a significant amount of time in medical student advising related to schedules for next year, picking electives and making plans for interviews in anticipation of Match 2018! By the time you read this, the 2017 Match Day may have passed. Even for those who are not involved in medical student training, resident education and/or the resident selection process, you likely remember the process. There were interviews, and the anxiety and uncertainty related to how good a program really was. Would you fit in? Would they ...
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In his annual State of the Union address on January 20, 2015, President Barack Obama announced the Precision Medicine Initiative (PMI). The National Institutes of Health were charged to begin planning, recruiting and initiating preliminary consultations with the goal of funding awards to begin recruiting participants in 2017. This is to serve as a major impetus behind data-driven research, encompassing the intersection of lifestyle, environmental and genetic factors to develop more effective ways to prolong health and treat disease in a patient-specific model. The italics are mine. From this executive order, the All of Us Research Model was created. So, what ...
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I dont know if there is proper protocol for these columns, so I am taking a bit of a chance and going to mention my kids. I had the opportunity (or maybe it was a fatherly requirement) to spend about 10 hours each day for two days straight in a climbing gym, plus a 90-minute drive each way both days to see my kids compete in a USA Climbing Regional meet. Just like in medicine and spine care, many things are available now that were not around when I was younger. My kids dont love when I say When I was a kid., and I also need to make sure I am not saying that to residents, medical students and junior faculty. But, when I was a kid, rock climbing, especially ...
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I grew up in New York City. Well, thats technically true, but really I grew up in Brooklyn and Staten Island, two of the five boroughs of the city of New York. As strange as it might sound to someone raised outside of the Big Apple, when we said we were going into the city, it meant we were taking an adventurous trip to the island of Manhattan, a place like none other in the world. In practicality, if you were going into the city, it meant you were going to be there all day. Unlike Bostonthe city in which I now live where you can work all day, go home to the suburbs, and then come back at night for dinneronce in the city, you stayed until it was time to go home. ...
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I drive...a lot! As a native Detroiter, I recently got a new Ford pickup. Earlier this month at its one-year anniversary, I realized I put nearly 28,000 miles on it this year. This included a trip to Montana in early summer (a rock climbing competition for my kids) as well as our annual drive to Michigan. We also did Phoenix for spring break which included stopping at Flagstaff (including outdoor bouldering) and Santa Fe. Add work and regular trips to the mountains, and it is clear, I drive...a lot! One of the benefits of so much time spent driving is I also listen to a lot of music. I hope I'm not bumming anyone out by getting lyrics from a 1974 easy listening ...
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What sort of person, indeed? I am not referring to racing drivers but to health care providers. The job always entailed a form of madness, committing to protracted, competitive training, rather long work hours, significant stress and a tendency toward group isolation. The expected rewards were to be enormous: satisfaction, achievement, selflessness and gratitude. While any reasonable measure of satisfaction cannot be expressed in a simple costbenefit analysis, current data suggest that the rewards are lagging a bit behind expectations. With medicine becoming increasingly quantifiable and businesslike, these expectations begin to seem not only unfulfilled, ...
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I believe our incoming NASS President would agree there may be some similarities between auto racing and spine care, but Ill get to the above quotes in a bit. As you may know, this is one of my favorite columns of the year to write, because I get to introduce the next president of the North American Spine Society. Even though he doesnt officially take office until October at the annual meeting, we ask the First Vice President to write a guest column for SpineLine in the July/August edition. It gives the current president a break as they continue preparations for the annual meeting, and it gives us a chance to hear from the next person in line. F. Todd Wetzel, ...
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I’ll be frank. The title of this SpineLine piece is confusing and strange. In fact, it’s meant to be confusing enough that you’ll want to read on and find out what on earth it could possibly mean. Stick with it, if you can. In the least, you’ll get a little glimpse into some of what my lovely wife has to contend with. The Dishwasher. I load the dishwasher at home. This does not mean to imply that my wife, who is an excellent stay-at-home mom, raising our three kids, is incapable of loading the dishwasher. She loads it, too. But I will unsubtly follow behind her and rearrange it. It’s completely obnoxious, which I realize and have fully admitted to both ...
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No, I’m not going anywhere, so unless there is something I don’t know, you are stuck with me and my columns for a bit longer. But my son did have his 8th grade graduation yesterday (relative to when I wrote this), and it got me thinking about graduation and moving on. I actually don’t remember if I had an 8th grade graduation. I remember high school graduation, although I bet most people in attendance wish I wasn’t allowed to give a speech. It was probably my first ever, and public speaking is something I’ve had to work on ever since! I barely remember my medical school graduation, but know I have not stopped learning. The quotes above are from people I ...
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A few moments during the night, I temporarily forgot where I was. As I turned from side to side on a vinyl padded chair, fitted with a sheet that began its service neatly tucked in at the cushion’s edges but by now was rolled into a disorganized mass by my feet, there were times that I drifted deeply enough into sleep that I could dream. These moments were ephemeral, punctuated by longer stretches of semi-consciousness made irritant by the rhythmic chirping of an angry IV infusion machine and my father’s moaning. At other times, I was fully conscious, awake and communicative with the 2 am nurse who came in to check his drain output and dressing. “Is it slowing ...
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As I likely mentioned in previous March/April columns, spring is a time of activity, rebirth and renewal. Spring started pretty poorly for me, and those who know me know why. In reality, I should not be so emotionally invested in NCAA March Madness! I am now writing this in the midst of a perfect spring day: blue sky, no wind, sunny and warm. As the days get longer, I seem to have better stamina, no longer wanting to sleep as soon as it gets dark. I also seem to find myself stretched in different areas. But this is the fun part, and really makes time fly! Volunteering for plans and projects can really fill up these longer days, and doing so for NASS is not ...
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Spine on the Hill

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House Conducts Oversight Hearing on MACRA Implementation During a Capitol Hill hearing last week, members of the House Energy and Commerce Health Subcommittee asked Deputy Administrator for Innovation and Quality & the Centers of Medicare and Medicaid Services’ (CMS) Chief Medical Officer, Patrick Conway, MD, to provide an update on his agency’s progress in implementing Medicare’s new physician payment program. Passed into law last year, the Medicare Access and Chip Reauthorization Act (MACRA) establishes a new Merit-Based Incentive Payment System (MIPS) which consolidates Medicare’s existing physician reporting programs into a single payment system. ...
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Spine on the Hill

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MU Hardship Exception Extended In February, the Centers for Medicare and Medicaid Services (CMS) announced they would extend the deadline to apply for a hardship exception for the Electronic Health Record (EHR) Incentive Program, also known as the Meaningful Use (MU) program, for eligible providers (EPs) from March 15 to July 1, 2016. In a brief statement, CMS said the extension is being given “so providers have sufficient time to submit their applications to avoid negative adjustments to their Medicare payments in 2017.” For a full statement from CMS on the meaningful use hardship exception, please click HERE . Instructions for filing out an ...
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Why? In life, we ask why everything happens. Why do earthquakes occur? Why do people commit crimes? Why do black holes exist? Why do I get a headache every time I read another article by Bono? We know “why” only a small fraction of the time. For the remainder of our imploring, we are left in darkness as there are no known explanations. As children, we fill in these gaps of knowledge with imagination. My kids are content to imagine that clouds are fluffy pieces of cotton floating in the sky that, if they jump high enough, they can reach and touch. As adults, we imagine by hypothesis and speculation, sometimes rational and other times irrational. ...
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I am writing this the day after Super Bowl 50, having delayed the column in hopes of a big Broncos win, which indeed came to pass. So it is really my fault this issue is delayed! The metaphors between sports (including team sports like football) and spine care are numerous: team work, common goals, preparation and a little luck. Physical medicine and rehabilitation specialists are trained from the onset to think as team members with multiple other professionals. As spine providers, most of us work in teams, whether we are surgeons, PM&R, anesthesia, physical therapists, internists, chiropractors, researchers or any others. Even surgeons in solo, private ...
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Spine on the Hill

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CBO Estimates Senate Medicare Appeals Reform Will Cost $1.7B Last week, the Congressional Budget Office (CBO) released estimates that a bipartisan plan to reform the Medicare appeals process would increase direct spending by $1.7 billion and increase indirect spending by $35 million over the next 10 years. The bill, S. 2368 the “Audit and Appeals Fairness, Integrity and Reforms in Medicare Act” , overhauls the backlogged Medicare appeals with reforms like sending claims back to the first level of appeals when new evidence is introduced and creating Medicare Magistrates to handle certain appeals. The bill would also allow the Department of Health and ...
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Spine on the Hill

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Medicare Nears HHS Goal Transitioning Payments Away from Fee-For-Service Last week, the Obama Administration announced that they are nearing their goal of transitioning 30 percent of all Medicare reimbursements away from the traditional fee-for-service model. It has been more than one year since Health and Human Services (HHS) Secretary Sylvia Burwell announced the Administration’s plan to shift payments to health care providers away from volume towards a system that rewards value, primarily through incentivizing alternative payment models (APMs) and coordinated care arrangements like accountable care organizations (ACOs) . By 2018, Burwell has said ...
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Spine on the Hill

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NASS Identifies Top Five Advocacy Issues for 2016 Last year, the NASS Advocacy Council collaborated with the Health Policy and Research Councils in an effort to formalize an advocacy agenda for 2016. Below are the top five advocacy issues that were developed as a result of this effort. The NASS Advocacy Council will proactively engage Congress and related regulatory agencies on these issues, directly influencing the development and outcome of specific policy proposals from the spine providers’ perspective this year. Inappropriate Medicare Claims Denials NASS will engage with policymakers to advocate for specific improvements in the ...
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As I sit down to write this, my first official presidential SpineLine article (the previous one was as First Vice President), I am not really sure how it’s going to turn out. We are going to find out together. What I am sure about are the feelings that I want to convey. If my medical/interventional and research colleagues can indulge me for a bit, I would like to commiserate with my fellow surgeons. That’s not to say that medical/interventional folks cannot empathize. It’s just that these specific situations and feelings take on a different character when you have operated on someone. In a way, once you’ve operated on another person, you are “married,” ...
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