The Sunshine Act and Open Payments

Today was a busy day for news about the Sunshine Act and Open Payments. I was asked to present pertinent information about the Sunshine Act to some of the leadership of the medical school where I work, the Indiana University School of Medicine, about this topic.  Essentially, the Physician Payment Sunshine Act (PPSA, shortened to “Sunshine Act”) came out of the Affordable Care Act, and requires that manufacturers of drugs and medical devices (which I'll call “industry”) collect, track and report all payments and financial relationships with physicians and teaching hospitals.  This system was designed to establish a transparent national disclosure system.

As a result, the Center for Medicare and Medicaid Services, or CMS, was tasked with creating a website that provided information about these relationships so that the public can make informed decisions.  That website is known as “Open Payments”.   

As of the time of this writing, for approximately the next three weeks, the “Dispute” period  is still open, whereby individual physicians can register on the website, and review their own data.  If one feels there is a discrepancy, then s/he can file a dispute that industry companies will need to review, and ultimately reconcile.

For my presentation today, I carefully made detailed slides for the leadership to share with the faculty.  I decided today to add in some screen shots of what the report looks like to an individual doctor.  To my dismay, this was the screen I found.

Intrigued with the word "portlet", I sent a request to the CMS Help Desk.  I was pleased with the response time of just a few hours.  This was the response:

[The] portal is down for maintenance at this time.  There is no ETA at this point, but we are working to get this resolved as soon as possible.  We apologize for any inconvenience and Thank you for your understanding.

For further questions please feel free to contact the open payments help desk at 1-855-326-8366.  We are open Monday - Friday from 7:30 am to 6:30 pm CST, excluding Federal holidays.

Thank you,

Open Payments

I wondered what the issue could be.  It turns out that earlier today, this piece was posted by ProPublica.  

How timely! 

I really do hope for two big fixes.  First, that examples like this one here (which generated the ProPublica story) are rare.  The registration to gain access to one’s Open Payments information is complex and cumbersome (the User Guide is unfortunately not much simpler, at 359 pages in length), which one might assume means that CMS is really trying to make sure that someone who logs in is indeed who s/he said s/he is.  Second, that the website can be opened back up very soon. Time is slowly ticking away in the Dispute period.

I am all for transparency, but if a system is going to be put in place to “provide the public with information to make informed decisions”, the information in that system needs to be a) relatively easy to access, and b) correct first and foremost.  It would make sense to me that at the least, industry use the NPI numbers (each physician is assigned a unique number for ONLY that physician and no one else) to insure that physicians with similar names are not mixed up.

-For information about the Sunshine Act and the Open Payments process, see this from the AAMC. 

 -For a step-by-step process about how to register, review, and potentially dispute one’s data, see this from Stanford, along with this FAQ.

 -For a very recent survey of industry and of physicians (85% of whom stated they would like to review their own data BEFORE its submitted to CMS; 7% actually have reviewed their data, however), see this.

By the way, the presentation went fine.  Faculty leaders had great questions.  The take home discussion from many who have already gone through the process: allot two hours for the entire process of registering, waiting for clearance, and potentially for disputing any data that one feels is incorrect.

Fellow doctors, please take the time to review the process and your own data.  After all, we are curious about the details.

GME Funding: A New Recommendation and Discussion

Today, the Institute of Medicine (IOM) presented a recommendation report on the future of GME funding to meet the health care needs of the population.  

In this report, the IOM experts suggested a 35% drop in the amount of current payments to teaching hospitals for GME.  Among other things, five principles for reform were described: accountability, meeting the needs of the public, innovation, stability in the funding, and aligning education and clinical care.  They also discussed the creation of a GME Policy Council within HHS to help develop a strategic plan for a physician workforce, and phasing out direct and indirect medical education in favor of a global operational fund.

Other constituencies quickly provided comments voicing their concern over the IOM’s specific recommendations.  The AAMC’s comments were titled “IOM’s Vision of GME Will Not Meet Real-World Patient Needs”, and stated: “ …the IOM’s proposal to radically overhaul GME and make major cuts to patient care would threaten the world’s best training programs for health professionals and jeopardize patients, particularly those who are the most medical vulnerable.”  

In addition, the American Hospital Association noted: “Today’s report on GME is the wrong prescription for training tomorrow’s physicians.  We are especially disappointed that the report proposes phasing out the current Medicare GME funding provided to hospitals and offering it to other entities that do not treat Medicare patients.”  

So what do I think?  This is a very complex issue, first of all.  I do believe that GME funding needs to change because, fundamentally, we (the health care system and the training of future physicians within that system) need to meet the future health care needs of the population.  I believe that we do need more physicians, not fewer.  While reform is likely important, it is costly to educate residents.  Just look at colleges, and how much it costs to educate undergraduate students.  The same is true for residents.

So where do we go from here?  I am not sure, but as a residency educator, I hope that today’s recommendations do not jeopardize the fine training program that I have the privilege of overseeing and other outstanding educators across the country also oversee.  I hope that educators who do the day-to-day work to train the physicians of tomorrow are listened to.  I hope that residents who are currently in the training programs can have their voices heard too.  Let’s advocate for GME to continue to train competent residents who will leave and be ready for independent practice, and for funding that can accomplish that.  After all, THAT is why we are here, to provide much needed health care to the patients.  In all of the discussions and counterarguments, that needs to be the essential core.  As Francis Peabody stated in JAMA in 1927: “The secret in caring for the patient is to care for the patient.” 

GME Funding

A recent post from the NY Times discusses the issue of the physician workforce of the future.  I believe it accurately describes some of the concerns about GME training.  Yes, GME training is indeed the bottleneck by which new physicians come into the workforce.  Yes, we need new physicians (and other health care professionals) to care for an aging population.  We especially need primary care physicians for this, but we also need general surgeons, many types of subspecialists, and we need physicians to go into underserved areas, particularly rural areas.

There are bills that, if passed, could help fund more GME slots.  Dr. Atul Grover from the AAMCdescribes them well here in this post.  Residency programs accredited by the ACGME take new graduates from medical school, and appropriately train them to go out and practice medicine independently.  I also personally disagree with a proposal from Missouri that advocates for "assistantphysicians".  Simply put, these graduates need adequate training (a minimum of 3-4 years for most residency programs, with some like neurosurgery taking as long as 7-8 years), and that is what GME provides.

Please advocate for future GME funding: it is the best way to begin to create a physician workforce that will help care for our society.

Scholarship, Emerging Technology and Medical Education

Those who know me know my interest in emerging technology in medicine and medical education continues to flourish.  I am always looking for ways that technology can help drive medical education.  Specifically, social media has the capability of disseminating information to a much greater number of learners than in the past via traditional formats.  One such example is this great video by the AAMC on using wearable technologies in medical education, featuring Dr. Warren Wiechmann.

In discussing this within my academic environment, conversations almost always come back to scholarship, specifically, publishing in peer-reviewed journals.  Articles on the use of social media in medicine are sparse, but are beginning to crop up in mainstream medical journals.  Leaders such as Dr. Terry Kind are really demonstrating the impact via a scholarly approach.

It is with excitement that I read some recent articles (this and this) by some innovators in emergency medicine that can get physicians started using online resources and thinking about peer review with respect to blogs.  Simply put, these articles are phenomenal!  It is exciting to see that journal editors are beginning to see the impact of technology and social media for their readers.  

With this blog, I am excited to announce a new opportunity for me: as social media editor for the Journal of Continuing Education in the Health Professions (@JCEHP).  I thank JCEHP's senior editor, Curt Olson, for his vision to allow me to become involved in growing the journal's reach by utilizing social media, specifically twitter.  In the coming year, we will work on creating and disseminating information via a blog for readers to provide comments on articles of interest, and will push content out to those interested via online social networks.

There are great ways of using social media for the betterment of medicine and medical education.  One such way we have been utilizing at the Indiana University School of Medicine is to tweet our Pediatrics Grand Rounds (follow on Wednesday mornings, 8 am EST, at #iupedsgrrounds), which we've been doing for several years now.  But how do we show (in a peer-reviewed journal) the impact of this activity?  Many specialties have written about tweeting national conferences (including Oncology, Surgery, Nephrology and Urology, to name a few).  

So how can we demonstrate this impact in the JCEHP journal?  By including a presence within social media, we hope to start a conversation on how social media can provide an impact within medical education.  It's a start, but we have to start somewhere.  I'm excited to be a small part of this journey, both at my institution and at JCEHP.

Blogging

This last week, our institution hosted the 2^nd annual Mobile Computing in Medical Education conference.  Our keynote speaker, Dr. Bryan Vartabedian from Baylor, spoke eloquently about the “public physician”, and what literacies the physician of the future may need in order to succeed.  Audience members asked about how emergency medicine providers such as Dr. Zubin Damania (AKA ZDoggMD) seem to be ahead of the curve on social media and blogging.  Bryan himself later blogged about it here. 

In addition, Dr. Aaron Carroll, one of my IUSM pediatric faculty colleagues, blogs often on a variety of health care topics in today’s society.  Here is one of his recent blogs. 

Reading these helped me reflect about my own blogging and how I could do better. So what is the “secret sauce of success” related to blogging in health care?  From the examples above, it seems so simple.

Tip #1: You have to have something to write about.

Tip #1.5: If you can include a reference or a link, it adds some credibility.

Tip #2: You have to keep it short and sweet.

So here’s my attempt to take my own advice.

From #1, today’s blog is about blogging. 

From #1.5, see this reference.

From #2, I need to end this blog very soon.

If you have something to say, say it; the fewer words, the better.  Thanks for reading.

Burnout and Resiliency in Medicine

I have not blogged in a while; there are many reasons for this, including many things going on in my life as well as with my work as a medical educator and administrator.  The weather here in the Midwest has also been challenging this winter (and another storm headed this way over the next 24 hours) which likely has contributed to my lack of blogging.

Nevertheless, I really enjoy what I do and find meaning in my work.  In fact, a timely discussion with residents during a teaching clinic highlighting this really hit home.  We were talking about burnout and ways to combat it.  The practice of medicine is hard: helping improve the health of our patients is a privilege which brings great responsibility.  This can, however, impact physicians’ own lives in various ways.

Social media itself (in the form of blogging) can be a great tool to ease burnout in medicine.  See this recent blog on this very topic. 

Can burnout be prevented?  What about resiliency in medicine?  Does one's resiliency lessen the potential impact of burnout?  Our institution is proud to host the FIRM (Finding Inspiration and Resilience in Medicine) conference on April 25, 2014.  This conference is being organized by medical students, which really demonstrates how our future generation is paving the way for the necessary changes to the way medicine can and will be practiced.  At that conference, one of our own faculty who wrote a recent post on this topic will be featured. 

So what steps do you take to prevent burnout?  How can you develop the resilience necessary to stay on top of your game and be the best you can be for patients and for yourself/your family?  Some have described interventions during training that impact burnout.  These curricular efforts should be applauded, and are one step towards an improved culture in medicine that helps everyone: patients and health care professionals alike. 

CPR, High Value Care, and MedPeds

What a whirlwind of a day today.  Lots of productive meetings, and some incredible learning along the way.  I have two “A-HA” learning moments from today.

The first was our Pediatrics Grand Rounds at Riley Hospital for Children.  Our PICU physicians set up a truly innovative Grand Rounds to have a discussion about the topic of “Do Everything?” regarding pediatric patients in the ICU.  It was co-hosted by a nurse researcher at our Ethics Center who has studied "Moral Distress", and a PICU nurse who provided an amazing perspective to the discussion.  It featured two role playing scenarios in how health care professionals speak with families of terminally ill children about CPR.  It was a great way to engage the audience to think about how families understand outcomes from CPR.  A critical learning point of this topic, common to many regarding patient-physician communication, is to avoid overly complex medical terminology, or jargon, when speaking with families.  In addition to talking about using language that matters, we discussed this paper from 1996, in which the authors evaluated the rate of successful CPR on television shows and compared it to the actual rate of survival in real patients.

This blog here is a recent update to that piece with a great infographic comparing the rates on specific shows.  The other great part was that this grand rounds was totally packed: not an open seat in the room!  For a CME person like myself, it is nice to see that so many participants were able to benefit from this presentation.  My tweets from today (1/15/14) convey much of the content of this educational session, for those with further interest on this topic.

Secondly, I am proud to announce that we piloted our first “High Value Care” curriculum to our MedPeds residents today.  The ABIM Foundation has been leading the charge on this, with the creation of the Choosing Wisely campaign.  Luckily, we did not have to reinvent the wheel, and were able to utilize this amazing high value care teaching resource from the ACP which was recently rolled out.  The residents were as engaged in this discussion as they have ever been.  I think this phrase captures their sentiments: “We want to be part of the solution to the costs of health care crisis and not just order tests indiscriminately”.  I couldn’t have been more proud!

For those interested in finding and using ready-made resources to teach cost-conscious care to residents or students, I can say that we were able to easily complete one of the five current modules with 8 formal multiple choice questions in less than one hour, with ample opportunity for robust in-depth discussion of some of the points.  We elaborated on clinical decision making in the context of cost conscious care.  Kudos to Dr. Daisy Smith of the ACP for creating these online modules that educators can use “off the shelf” right away in their training programs.  One does not even need to be an ACP member to gain access to these modules!

Looking back on these two topics noted above, I now see that they are a perfect example of the variety of training in MedPeds: both a Pediatric topic and an Internal Medicine topic in the same day!  Hooray for MedPeds!  I only hope that other days can be as “educationally productive and rewarding” as today was for me.