Podcasts about rvus

Healthcare is drowning in inefficiency - 80% of data is noise, and clinicians waste precious time on tasks that don't improve patient outcomes. But AI is flipping the script. Imagine diagnosing lung cancer in seconds instead of digging through hours of records, or boosting revenue (RVUs) while actually enhancing care quality. Uncover the real barriers to AI adoption and how new platforms are cutting through vendor lock-in to make AI tools accessible in weeks, not months. From radiology to care coordination, AI isn't just the future - it's the lifeline healthcare needs today.

Listen to Part 2 of this 4-part Women in Cancer Surgery podcast series on finance hosted through SurgOnc Today®. In this episode, Women in Cancer Surgery Committee Members, Drs. Maggie DiNome and Andrea Barrio, are joined by Karen Price, Senior Revenue Manager - Department of Surgery, at Duke University. They will focus on an in-depth discussion of coding strategies and tips to improve billing, understand the use of relevant modifiers, and the use of time-based billing.

Strap in for a wild ride through the Medicare mess threatening radiation oncology in 2026. From a bizarre AMA survey that thinks we're just radiology's quirky cousin, to ASTRO's head-scratching distractions, we break down the...break down?Recorded at midnight in the Vermont Mountain Basements™, this episode unpacks the Byzantine world of CPT codes, RVUs, and a 40% practice expense gut punch that could turn off the lights. OOTB is produced by Photon Media.Contact: jason@becktamd.com

SummaryIn this interview, Dr. Susan Trocciola, a cardiothoracic surgeon, discussed her experiences with locum tenens work and expert witness consulting. Dr. Trocciola shared her journey from traditional employment to locums after facing challenges in finding the right job fit and dealing with personal health issues. She emphasized how locums work has allowed her to achieve better work-life balance, earning twice as much while working half as much compared to her previous full-time job. Dr. Trocciola detailed her approach to determining value in locums work, recommending rates starting at $2,500 per day, and discussed the importance of establishing boundaries with locums companies. She also shared insights about her expert witness work, explaining how it has made her a better doctor through improved documentation practices. The discussion highlighted the benefits of locums work in providing flexibility, better patient care options, and opportunities for professional growth.ChaptersIntroduction and Background of Dr. Susan TrocciolaDr. Trocciola introduced herself as a cardiothoracic surgeon trained at prestigious programs including Cornell, NYU, and Texas Heart. She shared her journey through traditional employment challenges, personal health issues, and eventual transition to locums work.Benefits of Locums WorkDr. Trocciola discussed how locums work has transformed her approach to medicine, allowing her to focus on patient care rather than RVUs. She shared an example of prioritizing patient care over personal convenience in a recent case. Determining Value in Locums WorkDr. Trocciola explained her approach to establishing value in locums work, recommending working with multiple companies to understand market rates and emphasizing the importance of negotiating fair compensation. Navigating Locums AssignmentsDr. Trocciola shared insights about identifying good locums companies, establishing boundaries, and recognizing when to leave assignments that aren't a good fit.Expert Witness WorkDr. Trocciola discussed her journey into expert witness work, how it has improved her practice, and the importance of honesty and thorough documentation in both expert witness cases and clinical practice.Future Plans and Work-Life BalanceDr. Trocciola expressed her desire to reduce clinical work and increase expert witness work, emphasizing the importance of maintaining work-life balance and having time for personal activities.Action ItemsDr. Trocciola recommends starting locums assignments with shorter commitments to allow for better evaluation and negotiation opportunitiesDr. Trocciola advises establishing a minimum daily rate of at least $2,500 for locums workDr. Trocciola suggests working with multiple locums companies to understand market rates and negotiate better contractsDr. Trocciola emphasizes the importance of thorough documentation in both clinical practice and expert witness work

February 28, 2025 Scott, Mark, and Dr. Ray Painter break down the challenges of securing fair compensation for extra work performed in urology procedures when using modifier 22, unlisted codes, or Category III codes. They discuss effective strategies for communicating with payers and contract administrators, ensuring proper documentation, and negotiating fair work RVU adjustments.Free Kidney Stone Coding CalculatorDownload NowPRS Billing and Other Services - Book a Call with Mark Painter or Marianne DescioseClick Here to Get More Information and Request a Quote Join the Urology Pharma and Tech Pioneer GroupEmpowering urology practices to adopt new technology faster by providing clear reimbursement strategies—ensuring the practice gets paid and patients benefit sooner.https://www.prsnetwork.com/joinuptp Click Here to Start Your Free Trial of AUACodingToday.com   The Thriving Urology Practice Facebook group.The Thriving Urology Practice Facebook Group link to join:https://www.facebook.com/groups/ThrivingPractice/ 

Send us a textThere's a lot to consider when it comes to RVUs (Relative Value Units). In this episode, Captain Integrity Bob Wade breaks down wRVUs & more with Matt BonDurant, Co-Founder & SVP at ProCARE. Hear what a Comp RVU is, the nuts & bolts of RVUs, why RVUs are so complicated, how to approach benchmark data, and Bob's story from Philmont Scout Ranch. Learn more at CaptainIntegrity.com

 February 14, 2025 Scott, Mark, and Ray discuss questions that came into the PRS Network Community.Our doctor's occasionally use the ESWL (Extracorporeal Shock Wave Lithotripsy) for bladder stones. Insurance requires a laterality modifier. I am not sure if we can bill for it or not. If we can bill for it, what is the correct way to do it?Can you please clarify the relaxation of the in person requirement for supervision in 2025? As I read it and as I understand that you have explained it, this is a new rule stating essentially that if I am a physician supervising a nurse practitioner, the in person supervision is waived and I only need to be available via telecommunication. Am I interpreting this correctly? My coders are pushing back saying that this only applies to telehealth visits not in person visits for my supervisoion of a nurse practitioner.Coding Challenging Stone Cases: Is there a CPT code I'm missing here? What financial incentive is there to use the suction/vacuum technology and perform FANS/DISS for larger stones? Just the 22-modifer? Seems like from a billing/time perspective, it's not worth tackling larger stones with either FANS or DISS. Does the 22-modifier really make that much difference? Can you provide an example of generally what additional time (ie double/triple, etc) actually generates for additional RVUs? Free Kidney Stone Coding CalculatorDownload NowPRS Billing and Other Services - Book a Call with Mark Painter or Marianne DescioseClick Here to Get More Information and Request a Quote Join the Urology Pharma and Tech Pioneer GroupEmpowering urology practices to adopt new technology faster by providing clear reimbursement strategies—ensuring the practice gets paid and patients benefit sooner.https://www.prsnetwork.com/joinuptp Click Here to Start Your Free Trial of AUACodingToday.com   The Thriving Urology Practice Facebook group.The Thriving Urology Practice Facebook Group link to join:https://www.facebook.com/groups/ThrivingPractice/ 

Understanding RVUs and the Future of Pediatric PaymentsIn this episode, sponsored by Hippo Health and Freed.ai, the hosts engage in a detailed conversation with Chip Hart, an expert in managing pediatric practices. They discuss the concept of Relative Value Units (RVUs), their origins, and their impact on pediatricians and primary care physicians. Chip explains how RVUs affect billing and physician compensation, the disparities they introduce, and their contribution to physician burnout. The discussion also explores alternative payment models, such as value-based care, and the complexities of implementing them in pediatric settings. The episode concludes with insights into the future of pediatric compensation and the importance of recognizing and properly valuing primary care in pediatrics.00:00 Introduction and Sponsor Message00:46 Welcoming Chip Hart02:03 Understanding RVUs05:33 Impact of RVUs on Pediatricians08:47 Challenges with Value-Based Care18:21 Disparities in Healthcare23:57 Physician Burnout and Systemic Issues32:29 AI Solutions and Future Outlook33:23 Fee-for-Service Model Concerns34:30 Misunderstandings and Overbilling in Medical Practices35:12 Specialist Overuse and Financial Implications37:24 RVU Impact on Pediatric Practices40:12 Medicaid and Medicare Payment Structures44:14 Challenges with RVU-Based Compensation55:12 Value-Based Contracts and Pediatric Care01:02:21 Direct Primary Care and Financial Models01:09:04 Final Thoughts and Call to ActionSupport the show

In this episode, Drs. Patrick Georgoff, Teddy Puzio, and Jason Brill are joined by special guest Dr. Pat Murphy, who helps us delve into the evolving field of acute care surgery (ACS), exploring its history, challenges, and the nuances of defining full-time employment in this demanding specialty. The discussion highlights the origins of ACS as a response to unmet emergency surgical needs and its three foundational pillars: trauma surgery, emergency general surgery, and surgical critical care, with additional roles like surgical rescue evolving over time. Dr. Murphy share insights into the workload, including night shifts, call schedules, and the toll on surgeons' health, emphasizing the importance of fair compensation, equitable shift distribution, and transparency in job expectations. The episode underscores the value ACS surgeons bring to hospitals, likening them to essential infrastructure like firefighters, with their impact often unrecognized in traditional productivity metrics like RVUs.    Dr. Murphy would like to thank the many collaborators who made this volume of work possible including the many acute care surgeons who have taken the time to participate in the research and their dedication to patient care and surgeon wellbeing Learning Objectives: 1)        Define and understand the evolution of acute care surgery as a surgical subspecialty, including its historical development, key components (trauma, surgical critical care, emergency general surgery, surgical rescue), and its unique role within the surgical landscape. 2)        Analyze the concept of "full-time equivalent" (FTE) for acute care surgeons, considering factors such as call schedules, shift length, service demands, and the impact of varying case volumes and intensities on workload. 3)        Discuss the challenges of defining and measuring the value of acute care surgeons, considering factors beyond traditional productivity metrics (e.g., RVUs) such as the impact of surgical rescue, patient safety, and the value of 24/7 availability in preventing adverse outcomes. 4)        Explore the importance of recognizing the unique demands and contributions of acute care surgeons, including the impact of high-stress environments, irregular schedules, and the importance of work-life balance and clinician well-being on long-term sustainability within the specialty. This episode of Big T Trauma was sponsored by Teleflex, a global provider of medical devices. Learn more at teleflex.com and at the Teleflex Trauma and Emergency Medicine LinkedIn page. ***SPECIALTY TEAM APPLICATION LINK: https://docs.google.com/forms/d/e/1FAIpQLSdX2a_zsiyaz-NwxKuUUa5cUFolWhOw3945ZRFoRcJR1wjZ4w/viewform?usp=sharing Please visit https://behindtheknife.org to access other high-yield surgical education podcasts, videos and more.  If you liked this episode, check out our recent episodes here: https://app.behindtheknife.org/listen BIG T Trauma Series: https://app.behindtheknife.org/podcast-series/big-t-trauma

In this episode, Dr. Kristan Staudenmayer discusses the critical intersection of healthcare economics and trauma surgery. She emphasizes the need for surgeons to understand financial aspects to advocate effectively for their patients. The conversation explores the role of the Healthcare Economics Committee, the challenges posed by Relative value units (RVUs) in measuring surgical work, and the importance of building tools for advocacy in healthcare economics.TakeawaysSurgeons often lack training in healthcare economics.Understanding finance empowers better patient care.RVUs do not accurately reflect the work of acute care surgeons.Financial literacy is essential for effective advocacy.Value in healthcare is a complex and multifaceted concept.Billing practices need improvement among surgeons.The workload of trauma surgeons is often invisible to others.Advocacy tools are being developed for better communication with leadership.Research is needed to address workforce issues in acute care surgery.

“Labor is supposed to happen naturally. It's not this big medical intervention that occasionally happens naturally. It's this natural process that occasionally needs medical intervention.”Paige Boran is a certified nurse-midwife from Fort Collins, Colorado. She and her colleague, Jess, practice independently at A Woman's Place. They have rights to deliver babies at the hospital but are not employed through the hospital system so they are not subject to physician oversight. Their patients benefit from a low-intervention environment within a hospital setting but without the restriction of hospital policies.Lily Wyn, our Content Creator and Social Media Admin, joins us today as well! Lily shares why she chose Paige to support her through her current VBAC pregnancy. Lily is a beautiful example of how to diligently interview providers, keep an open mind, process past fears with the provider you choose, and what developing a relationship looks like to create an empowering birthing experience. Paige shows us just how valuable midwifery care can be, especially when going for a VBAC. If you're looking for a truly VBAC-supportive provider, this is a great episode on how to do it! The VBAC Link's VBAC Supportive Provider ListA Woman's PlaceHow to VBAC: The Ultimate Prep Course for ParentsFull Transcript under Episode Details Paige: Yeah, so I'm a certified nurse-midwife. I work in northern Colorado in Fort Collins at A Woman's Place. We're a small midwifery-owned practice. Right now, there are just two CNMs. That's the whole practice. It's just me and my colleague, Jess, who owns it which is really cool because we get to push the boundaries because we are not really locked into the hospital system. We are able to catch babies there but we are not actually employed through the bigger hospital systems which is nice because we don't have that physician oversight and stuff like that. I think we are able to do a lot more and honor that midwifery care model which is really cool. Sometimes people feel locked into policies and their overseeing physician and things like that but when it's just two midwives, we get to do what we want and what feels best for the patient. I really like that. That was a big thing when I first got into the certified nurse midwifery world. I was like, where do I want to work? I had offers from bigger hospital systems and it just didn't feel like the right fit so working at a small, privately-owned practice felt like the right answer for me so I was able to practice in a way I felt was right for people. I didn't want to be locked in by a policy and overseeing physicians. I just wanted to grow with other midwives. Meagan: Yes. I love that so much. I don't know. Maybe I should say I know it feels to me– I don't know it as an actual fact, but that feels like a unique situation and a unique setup to me. We don't really have that that I know of here in Utah. We either have out-of-hospital CPMs or we have in-hospital CNMs who are just hospital. I know that one hospital system is trying to do the attached birth center, but it is still very different. They are still the hospital umbrella midwives I guess I could say. So is that unique or is that just something that feels like it?Paige: I think it's unique because where I came from in Florida, if you were a CNM, you 100% practiced in the hospital which we do but it was that you were owned by a larger group of physicians essentially. Florida was working towards independent practice when I was there. Colorado is an independent-practiced state for nurse practitioners which is really cool because we don't have to have that oversight. I don't know if Florida ever got there but I know it varies state to state on if you have to be overseen by a physician or not. Honestly, that's why a lot of people when they are ready to become a midwife, if they don't have independent practice rights as a CNM even if they are a nurse, they will go for a CPM which is a certified professional midwife because they actually have more autonomy to do what they want outside of the hospital because they are not bound by all of the laws and stipulations which is interesting. Meagan: Exactly. I think that's a big thing– the CPM/CNM thing when people are looking for midwives. Do you have any suggestions about CPM versus CNM? If a VBAC mom is looking at a CPM, is that a safe and reasonable option?Paige: Absolutely. Yes. I think CPMs and CNMs are both reasonable, safe options. They both have training in that. They both can honor your holistic journey. I would say the biggest thing is who you feel most connected to because I think trusting your team, you will have people who have the worst birthing outcome and horrible stories but they are like, “I look back and I feel so good about it because I trusted my team.” I think that is what's important. If a CPM seems like your person and that's who you are going to trust, then that's who you should go for whereas a CNM, if that seems like that's your person and who you trust, I think that would be a good route too. I think a lot of people think, “Oh, they do home births. They must catch babies in a barn and there is no regulation. Even sometimes when I say, “midwife,” people are like, “What? Do you dress like a nun and catch babies in a barn?”Meagan: Yes, this is real though. These are real thoughts. If you are listening, and not to make fun of you if you think this, this is a real thing. This is a myth surrounding midwifery care, especially out-of-hospital midwives where a lot of people think a lot of different things. Paige: Absolutely. Meagan: I think I had a chicken chaser or something where a dad was like, “Do you chase chickens?” I was like, “What?” He said, “Well, that's what the midwives do so that's what the doulas do.” I'm like, “What? No, we don't chase chickens.” Paige: That is such old-school thinking but realistically, midwives started in the home and that was their history. It's cool that they've been able to step into the hospital and bring some of that back into the hospital because I think that is needed. Meagan: It is needed, yeah. Paige: We are starting to see that physicians are starting to be a little bit more holistic and see things in the whole picture, but I'm glad that the midwives did step into the hospital because I think that needed to be there but I'm so glad that people are still doing it at home because I think that is such a good option for people. Meagan: Yeah, so talking abou the midwives in the hospital, a lot of people are talking about how they are overseen by OBs. Is this common? Does this happen where you are at? You kind of said you are separated but do the hospital midwives in your area or in most areas, are they always overseen by OBs? Paige: Not necessarily. It would vary state to state and hospital to hospital. We actually just got privileges and admitting privileges a couple of years ago. Actually, my boss, Jess, who owns the practice where I work, had worked in Denver where they were allowed to admit their patients and everything. They didn't have to have any physician oversight but when she was there, she had to have physician oversight. She was like, “It's an hour drive north, why would that make a difference?” It was the same hospital system so she fought when she bought the practice and the physician who owned it prior left, she was alone and she had to have that physician oversight so she fought for independent practice privileges and she got it. Some of the midwives at first weren't so happy about it because they had liked being overseen by the doctor and someone signing off on all of their things. Some of the midwives were like, “Finally. We should be able to practice independently.” It's going to vary at each place. But I think that's a good thing to ask, “If something is going wrong, will a physician just come unannounced into my room in the hospital?” That's not the case with ours. We have to invite them in and if we are inviting them in, we've probably had a conversation multiple times with the patient where it's like, we need to have this. Meagan: Yeah. For the patients who do have the oversight of the OBs, do you have any suggestions? I feel like sometimes, at least here in Utah with my own doula clients when we have that situation, it can get a little confusing and hard when we've got an OB over here saying one thing but then we've got a midwife saying another. For instance with a VBAC candidate, “Oh, you really have a lower chance of having a VBAC. I'll support it. I'll sign off, but you have a really low chance,” but then the midwife is like, “Don't worry about that. You actually have a great chance. It is totally possible.” It gets confusing. Paige: Yeah, and it's like, who do you trust in that scenario? I think that's where evidence comes in because I think midwives and physicians both practice evidence-based but some people may have newer evidence than others. I've worked with OBs who probably roll over in their grave when I say certain things because it wasn't the old way but it is the new way. If somebody can come in with their own evidence and they're like, “I've looked into this and I think I'm a good candidate for x, y, and z,” I think physicians respond well to that because they are like, “Okay, they've done their research. Maybe I need to do some research.” Meagan: Yeah. Paige: When they have that thought, they know that this is an educated person and I can't just say whatever I want and they're going to take my word as the Holy Bible. Meagan: Yeah. No, really. Exactly. It always comes down to education and the more information we can have in our toolbelt or in our toolbox or whatever it may be, it's powerful so I love that you point that out. I think it's also important to note that if you do have two providers saying different things, that it's okay to ask for that evidence. “Hey, you had mentioned this. Can you tell me where you got that from or why you are saying that?” Then you can discuss that with your other provider. Paige: Yeah, and following intuition too. I think you can have all of the evidence in the world. What is your gut telling you too? Who do you trust more and what feels right in your body in the moment? I think we are all experts of our own bodies and there's a lot that goes into a VBAC and stuff like that. It's more than just the evidence. People have to feel mentally and physically ready for it too. I wish more people focused sometimes on the mental and spiritual aspect of it because I think a lot of people get ready physically but maybe mentally they weren't prepared for the emotional switch there. Meagan: Totally. Thinking about that, Paige, I mean Lily, tell us a little bit about why you went the midwifery route. I know you really wanted to find the right provider. Lily: Yeah. So I think for me, I have always been drawn to midwifery care. I was a little bit of a birth nerd prior to even working for The VBAC Link or even having my own kiddos. Prior to my son, we had a miscarriage and an ectopic pregnancy so I experienced OB care with my ectopic. I was bounced around a lot in a practice and had OBs who were great and equally some OBs where it was such a rushed visit that I had an OB miss an infection in my incisions because my pain was dismissed and just some really tough stuff. When it came to getting our rainbow rainbow baby, I was like, I really don't want to be in a hospital at all. I want midwives. That's the route that we went. The very brief story of my son is that he flipped breech 44 hours into labor and that's when we legally had to transfer to the hospital and I had my Cesarean. So in planning my VBAC, I planned to go back to the birth center and was a little devastated when it was out of our financial means this time. I was so panicked. I remember texting you, Meagan, and being like, “What do I do? I can't be at the birth center anymore and I don't want to be in a hospital.” We interviewed another birth center that's about an hour away that is in network with our insurance and talk about trusting your gut, it just didn't feel right. It didn't feel warm and fuzzy. Those are the feelings I got with our first birth center. I loved them so much and I still do. Then I met with Paige and her practice partner, Jess, and I came in loaded to the teeth. I was prepared to fight with someone because that's what I had in my brain and that's what I expected. I sat down with them. They met me after hours after clinic. I sat down with my three pages of questions and by the way, if you are listening and you have questions, we have a great blog on it and some social media posts of the questions that I specifically used. We talked for over an hour and every question I asked, they just had the ultimate answer to. I felt so at peace after talking with both of them and I remember telling my husband going into it, “I'm really worried that I'm going to like these people because I don't want to deliver at a hospital and then I'm going to have to choose a far away birth center that is out-of-hospital or providers that I like but it's a hospital.” It just feels like everything has been serendipitous for us. Our hospital opened a low-intervention portion of their birth floor so I'll still get to have the birth tub and all of the things, but truly have just been blow away by Paige and have just buddied up. She's dealt with all of my anxiety in pregnancy and VBAC and all of my questions. It just feels like such holistic care compared to my experience with OBs in the past. Meagan: That is so amazing and I was actually going to ask how has your care been during this pregnancy? It sounds like it's just been absolutely incredible and exactly what you needed. I remember you texting me and feeling that, oh crap. I don't know what to do. What do I do? You know? I just think it's so great that you have found Paige. Did you say that Jess is your partner? Paige: Yes. Meagan: Jess, yeah. I'm so glad that you found them because it really does sound like you are exactly where you need to be. Lily: Yeah. It made a huge difference for me and I just tell Paige all the time I truly didn't know that care in a hospital setting could look the way that it does. I feel like I'm getting– I experienced birth center care. I had an out-of-hospital experience until we transferred and I can say with confidence that my care has been the same if not better with Paige and just having the conversations and the good stuff and feeling really safe and confident. One thing that they pointed out that I thought was great when I went in and asked all of my questions is that Jess looked at me and she was like, “Okay, it sounds like you have a lot of anxiety around hospital transfer.” And I did. With my son, that was my worst fear and it came true. I had a lot of anxious, what if I have to transfer? She was like, “The thing is there is no transferring. We can induce you if you need to be induced and we can come with you into the OR with your Cesarean if that ever happened to be another thing.” For me, that brought a lot of peace to know that no matter what, the provider that I know and feel comfortable with is going to be with me. I again, didn't expect to feel that way, but it's been a really great reassurance for me personally. Meagan: Yeah. It's the same with a doula. Knowing that there's someone in your corner that you know who you've established care with who can follow you to your birth with you in your journey is just so comforting. So Paige, I wanted to talk about midwifery care and also just lowering the chance of Cesarean. Sometimes people do choose midwifery care specifically because they are like, “I think I have a lower chance of a Cesarean if I go the midwifery route.” Can we talk to that a little bit?Paige: Yes, that's true. A lot of people know that there are benefits to midwives but I think when people think of midwives, it's just like, “Oh, it's just a better experience. I trust my team more.” That's definitely there. There have been studies and people felt more at peace and empowered through their birthing journeys with midwives than they did with OBs. It's been studied but there is also a decrease in C-section risk. Your C-section risk drops 30-40% when you have a midwife which I think is a pretty significant drop. Meagan: Yeah. Paige: Yeah, especially when we look at the United States at our birthing outcomes and birthing mortality and C-section rates, it is way too high for as developed of a country as we are. I think that's really where midwifery care is stepping in and starting to help lower those rates to get it down to where it should be. The World Health Organization has been nominating and promoting midwifery care because it really is the answer to how we get these C-section rates lowered and these bad outcomes lowered. Midwives also have lower chance of an operative vaginal birth. That would be with forceps or a vacuum or an episiotomy so lower chances of those things as well. Lower chance of preterm birth which is interesting and probably because one, we do take lower-risk people. I think that's true but also because we are looking at it holistically. We are looking at everything. We are not just looking at you as a sick person. A lot of people look at pregnancy as an illness and pregnancy is not an illness. It's just a natural part of life and we've got to look at the whole picture of life if we're just going to look at the one thing too. I think that helps to reduce preterm birth risk. We also have lower interventions just overall. We're more in tune with people's bodies and we want to honor what their bodies are meant to do. Labor is supposed to happen naturally. It's not this big medical intervention that occasionally happens naturally. It's this natural process that occasionally needs medical intervention. The midwifery model is so important. I think when you go to the traditional medical model, you look at the present illness so they see pregnancy as an illness. What can go wrong? Don't get me wrong. There are a sleu of things that can go wrong in pregnancy and you do have to watch for them. But I think with midwifery care, you know when to use your hands but you also know when to sit on them. Meagan: Yes. Oh my gosh. I love that so much. I feel like we need– we used to get quotes from our podcast episodes and turn them into t-shirts and I feel like that is a t-shirt podcast quote-worthy. Oh my gosh. It's a worthy quote. That is amazing and it's so true though. Paige: It is. Meagan: It's not to rag on OBs. You guys, OBs are amazing. They are wonderful. They do an amazing job. We love the. But there is something different with midwifery care. You mentioned preterm birth. I remember when I was going through my interview process to have my VBAC after two C-section baby and I finally established care mid-pregnancy because I switched. That was one of the things in the very beginning that my midwife was like, “Let's talk about things. Let's talk about nutrition. Let's talk about supplements. Let's talk about where you are at.” It was just honing in on that which I was surprised by because I figured she'd be like, “Let's talk about your history. Let's talk about this,” but it was like, “No. Let's talk about what we can do to make sure you have the healthiest pregnancy,” but also started commentingo n mental stuff. It helped me get healthy in my mind. I just would never have had that experience with OB where they wanted to learn what I was scared about and what I was feeling and all of those things. Not only was I learning how to nourish myself physically, but mentally and it was just a really big deal. I do feel like it played a big impact in my labor. Paige: Yeah. A lot of people discredit how much nutrition and debunking fears and stuff like that can go because I think a lot of that– I mean, we look at nutrition-wise and we could avoid almost all of preeclampsia with nutrition alone which is incredible. I'm like, “I really think you should read Real Food for Pregnancy and people are like, “Oh, but it's such a big book,” and I'm like, “But it's so important to know this information about what we should be putting in our bodies.” 100 grams of protein– you've already got it. Meagan: I want to see how many pages for it. It's got, okay. We've got 300 pages but it has recipes and all of these amazing things in the end so it's not even a full book. Paige: Yes. People are like, “Oh man, I don't know if I want to read the whole thing,” but I'm like, “It's so important.” I think when people do read it, they come back and are like, “Did you know that I could decrease my risk of this if I ate more Vitamin A?” I'm like, “Yes. That's why I wanted you to read this book.” It is a wealth of information and I have such healthier pregnancy outcomes when people follow that high protein diet and looking at micronutrients with their Vitamin A, their choline, and all sorts of things. Meagan: Yeah. All of the things that we talk about a lot here on the podcast because we are partnered with Needed and we love them so much because we talk about the choline and the Vitamin A and the Vitamin B's and the Vitamin D's. Lily Nichols, not this Lily on the podcast today, she also wrote Real Food for Gestational Diabetes and that's another really powerful book as well. But yeah. It's just hard because OBs don't tend to have the time. I think some OBs would actually love the time to sit down and dig deep into this but they don't have the time either. I do think that's a big difference between OBs and midwives. What does your standard prenatal look like? When a mom comes in, a patient comes in, what do you guys do through a visit? Paige: Yeah. We follow the standard what everywhere in America does like once a month roughly in the first trimester and second trimester then when you hit 28 weeks, every 2 weeks, and then when you hit 36 weeks, every week. If you go to 41, we'll see you twice in that week. We follow those stipulations but our appointments are a little bit longer. When you are in a big practice, a lot of time it's driven by RVU use so the more patients somebody can see, the more they are going to get paid and the bigger their bonus is at the end of year. A lot of people feel like they are running through the cattle herd and they've been in and out in 15 minutes if that. At my practice, it's a little bit different because we are not RVU based. We're not getting any bonus. We're not trying to see as many patients as we can. Will we ever be the richest at what we do? No, but that's okay with me and Jess. We are small on purpose and we love to take the time. At Lily's appointments, we always book her for at least 30 minutes because we know that me and her like to talk. We've done an hour for some people because we know there is always going to be that long conversation. Don't get me wrong though, that fourth mom whose had three vaginal births and going for her fourth, she may be like, “Paige, there's really nothing to talk about today and that's okay.” Sometimes they are 15 minutes. Sometimes they are 30. Sometimes they are an hour. Our first appointment is always an hour because there is just so much to dive into with how we can be preparing ourselves, what does your history look like especially if they are brand new to our practice and we've never met them before, starting to build that relationship early on. It just depends on how far along they are, who the person is, and those things. But I do like that I can spend as much time as I need. Sometimes I tell my people, “Bring a book because I tend to get behind because I tend to talk to people longer than I book for,” but that's okay. We know that we can do that because we are a smaller practice. I think when people are thinking about what kind of care they want, they should probably consider how are these people paid? Is it by how many they can see in a day? Because you're probably going to get a different level of care than a practice that isn't drive by those RVUs. Yeah, that's a really good point. I feel like my shortest visit with my midwife was 20 minutes. Paige: Yeah. Lily: Yeah. Meagan: Which to me is pretty dang long because when I was going with my other two daughters, I think it was probably 6-7 minutes if that with my provider. I mean, it was get in. My nurse would check my fundal height and all of that and then oh, the doctor will be in here. Then came in, quick out. Yeah. It is really, really different. Lily: I know for me too, I love that we don't just talk about nutrition and things like that but even in my last appointment, I was talking with Paige about the things that can be triggering coming back into labor and going back into a hospital so my ectopic pregnancy was at the hospital that I'll be delivering at and I had to go into the emergency room and the way that you go to labor and delivery after hours is through the ER so Paige and I were talking. She was like, “I can just meet you outside. We will badge you in and we will avoid the emergency room if that feels triggering.” It's just those things that you don't get with an OB necessarily to talk through tiny little triggers. They are probably generally less accommodating to those little things of, “Well that's just the standard. You're going to have to get over that and just go through the ED and come on up.” I think that's been huge. I also have a dear friend who is going to school to be an OB. I told Paige at my last appointment that she may possibly be at my birth. She's my crunchy friend so she'll be a great OB but I have such a desire to be like, “Come see a VBAC. Come see it so that you have it in your brain and you know that they can be safe and look at what can be done,” so I think that is so huge too as we continue to train and uplift our next generation of providers. What does that look like to show them? I think her internship or something is going to be a midwife and OB partnership practice which is really cool but I'm like, “Yes. Come. Come to my birth. Please. I want you to see all the things.” That's really cool too and that Paige is open to, “My friend might be there.” Meagan: Yeah. Paige: Bring whoever. Meagan: I love that. I love that you were pointing out too this next generation of providers. Let's see that birth and VBAC is actually very normal and very possible because there's a lot of people who have maybe seen trauma or an unfortunate situation which could have happened because we blasted them with interventions or could have happened out of a fluke thing. You don't know all of the time. But I do think if we can keep trying to get these providers, these new provider to see a different light, we will also see that Cesarean rate drop a little bit. We really, I always tell people that we have a problem. They're like, “It's really not that big of a deal.” I'm like, “No, it's a very big deal. It's a very, very big deal. We have a problem in this medical world.” I do believe that it needs to change and midwifery care is definitely going to impact that. I hope that what you were saying in the beginning how policies don't trump a lot of the midwives. I wanted to ask you. This isn't something we talked about, but is it possible to ask your midwife, “Hey, what policies do you lie under?” Is that appropriate? Paige: Yes. Actually, that was one of my favorite things when Lily came in to meet and greet us. She came and she was like, “What are the policies for a VBAC?” We dove into that. We've been diving into that and what are we going to be okay with and what are we not going to be okay with? That's the beauty is that I'm not employed by the larger hospital system that I work under so I feel like a policy is not a law. I feel like there is informed consent and I think informed consent is so important but at the same time, there is informed declination and you should be able to decline anything. That's true. We can never force anybody into surgery. We can never force anybody into anything. I think a lot of people aren't having those conversations where it's actually informed so then people are like, “Oh, they are just refusing everything.” I hate the word refuse because no, they are not refusing it. They are declining it because they are informed. They know the risk. They have all the information at their fingertips and they know that this is the best decision for them and their baby and we have to honor that. That's why I'm really glad that I'm able to practice in that way, but I do know I've met and I've worked with people who feel like they are boxed in and have to follow those policies. We've started to talk about what our policies are with TOLACs and VBACs and things like that. One of them is that they are supposed to have two IVs. I've already gone against that before and I've had a beautiful, unmedicated VBAC. She walked in. I said, “We've talked about it. She was also laboring outside when we talked about it. It's not an issue when you come in. You know what? When we get up there, I'm just going to tell them that you know why they recommend two IVs and you are declining.” She walks in and she's clearly going to have this baby within the hour. I told the nurse, “We're not doing the IVs. We've talked about it. We're going to decline them.” That was the end of the discussion. We didn't have to talk about it again which was nice. She shouldn't have had to advocate in that moment for herself. We've already had those conversations. Meagan: Yes. Paige: Another one is continuous monitoring and the whole idea is if you start to rupture, that's how we are going to catch it. The baby is going to tank and that's how we are going to save the baby's life. Don't get me wrong. I think continuous monitoring can be really valuable for a lot of things but it's actually not evidence-based. We have not improved neonatal outcomes with continuous fetal monitoring. We've talked about that with Lily and she's going to opt for intermittent oscillation and I think that's very appropriate because she plans to go unmedicated. Let's be honest, if you are unmedicated and your uterus starts to rupture, moms will tell me that something is not right. This is beyond labor. Her saying that and being aware of that, we would notice it a lot sooner than we would the baby tanking kind of thing. Meagan: Yeah. I do know that with uterine rupture, we can have decelerations but like you were saying, there's usually so many other signs before baby is actually even struggling and I know a couple of uterine rupture stories where providers didn't believe the mom that something was going on because that one thing wasn't happening. The baby wasn't struggling. Paige: Yes. Meagan: It's like, you guys! When it comes to continuous fetal monitoring in the hospital, people have to fight to have that intermittent. It's yeah. Anyway. These policies are not law. I love that you said that too. There's another t-shirt quote. Paige: I think people should start asking if they are planning a VBAC, start asking what is the policy and start thinking, is that what they want? I do have some moms who are like, “No, I want the two IVs because it's hard for me to get a stick,” and they need that backup in case. That makes them feel more at peace but other people are like, “It makes me feel like a patient. I don't like it.” People don't like needles and that's okay. They have that right to say no. I tell people that in a true emergency, we will get an IV in you if something really, really bad were to be happening. That's part of training if somebody walks in off the street. We're not going to be like, “Oh, when was the last time you ate? Sorry, you can't have the surgery.” We know something bad is happening right now. We will get the IVs. We will do all of the things. Getting the IVs really won't save as much time as people think it will. Meagan: Yeah, and there are other things. Say we are having our baby and we are having higher blood loss than we would like or we have some concern of some hemorrhaging, there are other things that we can do. We can put Pitocin in a leg. We can do Cytotec rectally. There are things that we can do. We can get that baby to our breast and start stimulating and try to help that way. There are things that we can do while we are waiting for an IV, right? Paige: Yes. I tell people that all the time. Most of the postpartum hemorrhage meds that we use can be given without an IV. There is only one that truly has to be given through an IV and that's TXA but the rest can all be given other routes. A lot of times, those work better than IV Pitocin. Sometimes the ion Pitocin works better. Sometimes the ion Methergine works better. It's not this, oh we have to have a little just in case kind of thing because if there was a just in case moment, yes. We can be working on the IV and doing other things. I have to be kind of secretive about it. I have tinctures and stuff with shepherd's purse and yarrow. Those things actually have great evidence. They are really helpful for postpartum blood loss. I have a lot of moms who are more interested in doing something more holistic and natural before they try medication. Cypress essential oil, you can rub that in. I'll have doulas use my cypress roller and give them a massage while I'm trying to manage the hemorrhage and that cypress oil can help a lot too. Sometimes going back to our instinctual, old medicine that we have been using well before medicine was used for birth. Meagan: Yeah. This is a random question for both of you. Lil, I really wonder if you have seen it or heard about this too because you are so heavily in our DMs. This is going to be weird. People are going to be like, what? But I did this. We did this because we weren't sure. We cut the umbilical cord and put it in our mouth. It's really weird. Paige is like, what? You put it down in the gum area like in between your teeth and your cheek. It sits there. Okay, you guys. I've seen it just a couple of times, myself included. Yes, I put my umbilical cord in my mouth. Yes, it's weird. Paige: That's okay. Meagan: It felt like a little gummy. It was fine. I wasn't chewing on it. It was just sitting there. But anyway, it's weird but with my other client too we did it and all of her hemorrhaging symptoms just went away. Paige: That's cool. Meagan: I know this is really random but we just cut a little piece of our umbilical cord and put it in their mouth. Paige: That's so interesting. So a piece of the umbilical cord or the entire thing once it's clamped and cut and still attached? Meagan: They clamped and cut it, cut a piece, and put it in my mouth. Paige: I would be so willing to try that. I mean, what is there in that nun? Meagan: I don't know. I don't know, but it did diminish the hemorrhaging symptoms. Paige: Cool. Meagan: So very interesting, right? Okay, so are midwives restricted when it comes to VBAC on what they can accept? Lily, you are a VBAC. I was a VBAC after two C-sections. You can obviously take Lily. Could you accept me?Paige: Yes. Luckily in midwifery care, at least in Colorado, there is a lot of gray for certified nurse midwives. It's not always black and white. VBACs are okay but there is no direct, “Oh, if you have this many C-sections, we can't do it.” I think that's because ACOG also strangely doesn't have an opinion on that. They actually agree. There is limited evidence beyond one C-section. My practice has done several VBACs after two Cesareans. I don't think we've ever done one for a third or greater than two probably because I think those people a lot of times don't even consider VBAC and they just already have been seeing their doctor for their repeat C-section with each pregnancy. But I'd love to see more people going for a VBAC after multiple Cesareans because I think VBACs after two Cesareans have a whole different level of feeling empowered after that. I thin that's really cool and even special scars and stuff, there is really limited evidence on all of these things and I'd like to see more people pushing the limits a little bit. Especially since I am in a hospital, I do have an OB hospitalist on call 24/7 at the disposal of my fingertips if I need them. We are close to an OR so I think if for somebody the fear is there and they are like, “I just don't know if it's more risky because of this,” I think it's worth it to try because the more people who go for it and are successful, the better evidence we're going to get from it. Meagan: Yeah. That is exactly what I am thinking. There's not a lot of evidence after two Cesareans because it's just not happening. It hasn't really been studied and a lot of that is because people aren't even given the option. Paige: Yeah. I'll have people where it is their third or fourth C-section and they were never even given that option. They were told, “Oh, I was told I have CPD.” I'm like, “The chances of you actually having CPD are low.” Then you look at their records and it was fetal distress or something like that. Yeah. CPD is so rare. I've heard it so many times. “Baby is never going to come out of that pelvis ever.” That breaks my heart every time I hear it because there are times when I'm like, I don't know and then an 8-pound baby comes out. We can't go off of those things because the body does what it's supposed to in those moments. Don't get me wrong. Things do go wrong and C-sections do happen sometimes but yeah. To hear everybody has CPD just because they've had three C-sections, I'm like, I don't know. That would be quite a few people. Way more than we know are true. Meagan: Yeah. We're all walking around with tiny pelvises. That's just what everyone thinks anyway.Lily, being in our DMs, hearing the podcast, understanding and seeing so many of these people and what they say, do you have any advice for them when they are looking for their provider or just any advice in general? Do you have any advice from a VBAC-prepping mom? Lily: Yeah, I think for me, it is to go into it open-handed. I think we hear so many horror stories about providers often and I think that's why I went into looking for a provider with both fists up ready to fight and what has surprised me the most is just I think I said earlier that I didn't know hospital care could look like this. I remember we even posted something and I had posted on The VBAC Link that a hospital birth can be equally as beautiful as an out-of-hospital birth and there were people arguing and people saying, “No, absolutely that's not possible. That's not a thing.” Gosh, how discouraging if we go into things thinking that we can't have beautiful outcomes in different settings. Certainly, there are areas around our country that need improvement. There's not a low-intervention floor at every hospital and there are not midwives who are doing what Paige is doing everywhere but I think the more that we seek out that care and look for that care and advocate for that care, the more we will see it. As much as it sucks that we have to be our advocates, it's also a really cool opportunity that we pave the way for VBAC moms and the moms who have never had a C-section that we are paving the way for care that doesn't end up in a Cesarean. I would just say to be open-handed and yes. You can be prepared to fight and you can be prepared with your statistics. Be prepared to ask the why behind questions, but ultimately, I think that care can be so much more than we expected if we go into it thinking, Gosh, well what can I get out of this and how can I make these things happen? Like Paige said, we've had lots of conversations around, Well, this is the policy, but the policy is not the law. I'm here to support you in that. At our last appointment, she was like, “Hey, make sure you bring your doula to your appointment where we are going to talk about your birth plan because I want to make sure that she is there, that we all hear each other, that we are on the same page.” I think that's helpful too. And then having a doula. My doula was my doula with my C-section. She was with us. She was whoever was on call at the birth center actually and again, I think it was so serendipitous because she is a VBAC mom. I think I needed her then and I'm so stoked to have her now that she is just a really special human who I know is also always in my corner and constantly texting her like, “Oh my gosh, look at the new birth rooms. Oh my gosh, I had this great conversation. Oh my gosh, I'm so excited.” I think having your doula there to be your partner in advocacy is really helpful too. Meagan: Yes. Okay, that's a good question too when it comes to doulas and midwives. Sometimes I think people think that if I'm hiring a midwife, I don't need a doula and then we of course know that a lot of people just mistake doulas and midwives together. But Paige, how do you feel about doula care and working with doula care? Is it necessary? How do you work together as doula and midwife?Paige: Yes. I love doulas. I wish everybody had access to a doula truly because doulas, just like midwives, have been studied and they have better birth outcomes, more empowered births, and all of the things. Doulas are so important and doulas and midwives work really closely. I think a doula is there with that constant presence, that constant helping with anything and a really good advocate which I think is important especially if you don't have a good relationship with your provider maybe or you don't know who you're going to get. Maybe you see 7 different providers and you get who you're going to get when you're in labor. So to have that doula there to constantly be advocating for you is such an important piece. Yeah, I really wish everybody could have access to a doula because it just makes a world of difference. I can't think of any bad outcomes I've ever had when a doula was present. It's just a different level of care. Usually, people who have sought out a doula have also taken the time to seek out and do all of the things that are going to make a healthier pregnancy and a better birthing outcome. It's why I think everybody deserves doula care. It's because it does lead to better outcomes. Midwives are always known to work closely with doulas and really support them. It's a team effort. Meagan: Yeah. Yeah. We love our relationships with our midwives here. It's really great to just know how we work and know how we need to support the client and it is sometimes hard when we go to a hospital and we don't know who we are getting. And sometimes that OB or that midwife we have worked with before and sometimes it's a whole new face so it does bring us comfort to know that the client and the family know us and we know them and we can all work together. I love that. Okay, do either of you guys have anything else that you would like to say to our beautiful VBAC community before we go? Paige: I don't think so. Yeah, thank you so much for having me. This was wonderful and I just hope that everybody who is thinking about a VBAC really does their research and looks for the best provider and really finds that perfect fit because there are so many good providers out there– OBs, midwives, professional midwives, all the things. Meagan: I agree. It's okay to interview multiple people. It's also okay that if mid-pregnancy, the end of pregnancy, during, and even in labor that if something is not feeling right, you can request a different provider. You can go out and start interviewing again and find that provider that is right for you. Paige: Yes. Meagan: Well, thank you Paige and Lily for joining us today, and thank you so much for doing so much in your community. I really love your setup and hope that we can see that type of setup happening in the US because it just feels perfect in a lot of ways. Yeah. Yes. I'm loving it. Okay, ladies. Well, thank you so much. Paige: Thank you. Lily: Yeah, thanks, Meagan. Meagan: Bye. Lily: Bye!ClosingWould you like to be a guest on the podcast? Tell us about your experience at thevbaclink.com/share. For more information on all things VBAC including online and in-person VBAC classes, The VBAC Link blog, and Meagan's bio, head over to thevbaclink.com. Congratulations on starting your journey of learning and discovery with The VBAC Link.Support this podcast at — https://redcircle.com/the-vbac-link/donationsAdvertising Inquiries: https://redcircle.com/brands

Women's health has a history of being underfunded in the United States, leading many women to receive suboptimal care. In this episode of the BackTable OBGYN podcast, hosts Dr. Mark Hoffman and Dr. Amy Park engage in a detailed discussion with Dr. Louise P. King, a minimally invasive gynecologic surgeon, and Christopher Robertson, a law professor at Boston University, regarding the inequitable reimbursement structures that persist within the field of OBGYN. --- SYNPOSIS The guests emphasize the systemic discrepancies between gynecologic and other surgical disciplines. The conversation delves into the origins of these disparities, the complexities of revising current codes and creating new codes, and potential legislative and legal remedies to address gender-based inequities. The guests also stress the importance of patient care outcomes and the role of proper reimbursement in enhancing healthcare delivery. --- TIMESTAMPS 00:00 - Introduction 06:28 - Background on RVUs and Disparities in OBGYN 12:39 - Gender Disparities in Medical Billing 18:00 - Efforts to Address Inequities 31:22 - RUC Structure and Surgical Specialties 32:42 - Billing and Reimbursement Inequities 35:15 - Diagnosis Related Groups 36:42 - Turnover Times and Gender Disparities 40:21 - Advocacy and Legislative Solutions 48:23 - Legal Approaches for Change 52:44 - Conclusion --- RESOURCES Watson KL, King LP. Double Discrimination, the Pay Gap in Gynecologic Surgery, and Its Association With Quality of Care. Obstet Gynecol. 2021 Apr 1;137(4):657-661. doi: 10.1097/AOG.0000000000004309. PMID: 33706362. Robertson, Christopher T. and Kupke, Annabel and King, Louise P., Structural Sex Discrimination: Why Gynecology Patients Suffer Avoidable Injuries and What the Law Can Do About It (May 9, 2024). Emory Law Journal, Forthcoming, Boston Univ. School of Law Research Paper Forthcoming, Available at SSRN: https://ssrn.com/abstract=4800783 or http://dx.doi.org/10.2139/ssrn.4800783

In this episode, we dive into the most pressing questions from our audience about medical compensation trends, including regional comparisons between anesthesiologists and CRNAs, the impact of inflation on RVUs, and the benefits of including annual salary increases. Join us as we provide concise answers and insights into how various medical specialties are navigating these challenges. Jon invites individuals to contact Contract Diagnostics through phone, chat, or email for personalized assistance, visit www.ContractDiagnostics.com

For a full transcript of this episode, click here. “Anyone who isn't confused really doesn't understand the situation.” That's a quote by Edward R. Murrow and very apropos. I started thinking about this conversation that I had had with Brian Klepper, PhD, because so much going on right now—so many discussions and dissections taking place about primary care financial struggles, about what is value in healthcare. And the RUC (Relative Value Scale Update Committee) is, at a minimum, an underlying factor; but yet it doesn't come up. Almost ever. Merrill Goozner called the RUC the AMA's (American Medical Association's) “dark secret,” and I can see why. Just one procedural note before I roll tape with Brian Klepper. We're gonna go a little rogue today because you kind of got to understand what the RUC is before I can get into the two points I really want to make about it. So, here's my outrageous plan, which will shake up our standard Relentless Health Value format. Today, I'm gonna make the points I want to make after the interview, not before, like usual. I will, however, just mention the two points so you can keep them in mind as I talk with Brian. Here's the first point, and it's about the doomed financials of primary care. Why is it that primary care has a lot of times no business model unless part of the business model includes driving profitable downstream utilization? And when I say utilization, do I mean services with bigger RVUs (relative value units)? Why, yes, I think I do. We'll dig into this later. Here's my second point, and it's my view on the nature of any postulations that the “value of healthcare services” is equivalent to the prices that we pay for said services. Again, more on that later, but here is my original conversation with Brian Klepper. Brian Klepper is a longtime healthcare analyst and former CEO of the National Business Coalition on Health. Also mentioned in this episode are Merrill Goozner and Elizabeth Mitchell. People who have written about primary care: Scott Conard, MD; Paul Buehrens, MD, FAAFP; Larry McNeely; Primary Care Collaborative; Nisha Mehta, MD; Dan Mendelson; Tony Lin, MD; Juliet Breeze, MD; Raymond Tsai, MD; Linda Brady; Guy Culpepper, MD; David Muhlestein, PhD, JD   You can learn more in this article and on the AMA Web site.   Brian Klepper, PhD, is principal of Worksite Health Advisors and a nationally prominent healthcare analyst and commentator. He speaks, writes, and advises extensively on the management of clinical and financial risk, on high-performance healthcare, and on realizing the potential of primary care. His current focus is on high-performing healthcare organizations that consistently deliver better health outcomes at lower cost than usual approaches in high-value niches and how, integrated with advanced primary care, they can be configured into turnkey comprehensive high-value health plans that can disrupt the status quo.   02:29 What is the RUC? 06:26 Why is primary care not the “easy” specialty? 09:42 What are three low-value things per RUC? 10:33 EP436 with Elizabeth Mitchell. 10:38 What is a root cause of why primary care doesn't get paid more? 12:50 Why doesn't value equal money?   You can learn more in this article and on the AMA Web site.   @bklepper1 discusses #TPA and #primaryhealthcare and #mentalhealth on our #healthcarepodcast. #healthcare #podcast #digitalhealth #healthcareleadership #healthcaretransformation #healthcareinnovation   Recent past interviews: Click a guest's name for their latest RHV episode! Elizabeth Mitchell, David Scheinker (Encore! EP363), Dan Mendelson, Dr Benjamin Schwartz, Justin Leader, Dr Scott Conard (Encore! EP391), Jerry Durham (Encore! EP297), Kate Wolin, Dr Kenny Cole, Barbara Wachsman  

I am delighted to reconnect with Dr. Casey Means today. Dr. Means is the Co-founder of Levels, a health technology company dedicated to reversing the global metabolic health crisis. She is also the co-author of the book Good Energy, along with her brother Callie Means.  In our discussion today, we dive into mitochondria and metabolism, looking at the impact of cognitive dissonance and the reductionistic philosophies of medical specialization. We explore the effects of siloing, the challenges posed by our broken medical system, the Flexner Report, the role of RVUs, the effects of insulin resistance on metabolic health and mitochondrial dysfunction, and the symptoms commonly seen in women. Dr. Means also offers her insights on advocacy, continuous glucose monitors, and the labs she finds impactful, and she shares the incredible story of her mother's health journey.  Good Energy is an outstanding book that will benefit every listener and clinician, and I will often recommend it. IN THIS EPISODE YOU WILL LEARN: How energy gets created in the body The link between insulin resistance and acne How insulin resistance impacts fertility How underpowered parts of the brain and neurological system can show up as depression or anxiety, potentially leading to dementia The problem of our siloed, reactive, and specialist-obsessed culture The importance of getting your biomarkers tested and learning simple strategies to improve your metabolism, based on the results  What are the conditions encompassed by the metabolic spectrum disease?  The labs that Dr. Means finds most impactful Dr. Means shares her thoughts on continuous glucose monitors. The benefits of looking at your basic eating patterns in a non-judgmental and curious way before implementing any changes Dr. Means shares the powerful story of her mother's health journey.   Bio: Dr. Casey Means Casey Means, MD, is a Stanford-trained physician and co-founder of Levels, a health technology company with the mission of reversing the world's metabolic health crisis. Her book on metabolic health, Good Energy, comes out in May 2024 with Penguin Random House. She received her BA with honors and MD from Stanford, was President of her Stanford class, and has served on Stanford faculty. She trained in Head & Neck Surgery before leaving traditional medicine to devote her life to tackling the root cause of why Americans are sick. She has been featured in The New York Times, The New Yorker, The Wall Street Journal, Forbes, Women's Health, and more.  Connect with Cynthia Thurlow Follow on Twitter Instagram LinkedIn Check out Cynthia's website Submit your questions to support@cynthiathurlow.com Connect with Casey Means On her website Good Energy  Newsletter signup On Instagram, Twitter, TikTok, YouTube, and LinkedIn Good Energy, by Casey and Calley Means, is available from Amazon and most anyplace good books are sold.

In this episode, Dr. Mark Royer, private practice otolaryngologist and medical director of ENTLocums.com, joins BackTable to discuss salary negotiation for physicians. Dr. Royer begins by using his personal career journey to highlight the importance of negotiation skills. Then, he describes how to develop these skills. Throughout the episode, Dr. Royer emphasizes the importance of knowing one's value as a surgical subspecialist and tailoring your strategy to best suit your employer's perspective and your needs. Relevant topics covered include selecting a practice, starting salaries, RVUs, locums, and non-compete agreements. Dr. Royer concludes by encouraging otolaryngologists to reflect on what they truly want out of their careers as they approach the negotiation table. --- SHOW NOTES 00:00 - Introduction 01:22 - Salary Negotiation 05:24 - Dr. Royer's Journey from Residency to Entrepreneurship 10:16 - Negotiating Your Salary: Essential Tips and Strategies 26:27 - Different Approaches to Negotiation: Hospital vs. Private Practice 28:40 - Exploring the World of Locum Tenens 31:59 - Mid-Career Physician Negotiations and Raises 41:26 - Mastering Negotiation Tactics and Strategies: Tips from “Never Split the Difference” 47:38 - Navigating Non-Compete Clauses & Final Thoughts --- RESOURCES ENT Surgery Solutions, LLC: https://www.entlocums.com/ BackTable ENT Episode 57, “Locums Opportunities in ENT with Dr. Allison Royer:” https://www.backtable.com/shows/ent/podcasts/57/locums-opportunities-in-ent BackTable ENT Episode 107, “How Do I Negotiate My Physician Contract? Part I with Michael Johnson Jr., Esq:” https://www.backtable.com/shows/ent/podcasts/107/how-do-i-negotiate-my-physician-contract-part-i BackTable ENT Episode 108, “How Do I Negotiate My Physician Contract? Part II with Michael Johnson Jr., Esq:” https://www.backtable.com/shows/ent/podcasts/108/how-do-i-negotiate-my-physician-contract-part-ii “Never Split the Difference” by Chris Voss: https://www.amazon.com/Never-Split-Difference-Negotiating-Depended/dp/0062407805

On today's show…  • How do I choose the right tax preparer?  • Why didn't my automatic payment come out for my mortgage?  • Should we move closer to our parents?  • Should I count on hitting my RVUs?  • Should I buy into my surgery center?  • I am 10-years from retirement, should I cancel my life and DI insurance?  • How do we combine finances in my second marriage? Listen in to hear the answers then ask your own question by emailing us at podcast@physician family.com   ARE YOU GETTING ALL THE TAX BREAKS YOU REALLY DESERVE? To find out, get your copy of The Overtaxed Doctor's Retirement Investing Checklist at https://physicianfamily.com/go GOT A QUESTION? Write to us at podcast@physicianfamily.com. NOTICE Physician Family Financial Advisors Inc., a registered investment advisor, has reasonable belief that the information and content as a whole does not include any false or materially misleading statements or omissions of facts regarding services, investments, or client experience. Information presented is for educational purposes only and does not intend to make an offer or solicitation for the sale or purchase of any specific securities, investments, or investment strategies.  Investments involve risk and unless otherwise stated, are not guaranteed. Information expressed does not take into account the specific situation or objectives of individuals and is not intended as recommendations appropriate for all individuals. Listeners are encouraged to seek advice from a qualified tax, legal, or investment adviser to determine whether any information presented may be suitable for their specific situation.  Past performance is not indicative of future performance.

This is a transcript of a podcast episode featuring Dr. Nabilah Noor, a urogynecologist, discussing the lessons she learned in developing her practice after completing her fellowship. The key topics covered include understanding compensation models and revenue generation, effective time management strategies, maximizing efficiency in the operating room, building a strong professional network, and achieving work-life balance. Dr. Noor shares her insights on leveraging her team, delegating tasks, pre-planning for clinic and surgery days, communicating clearly with staff, and prioritizing self-care to avoid burnout. The conversation highlights the importance of adapting to the specific needs and resources of one's practice environment while maintaining focus on providing quality patient care. Chapters 00:01:28Introduction and Background The host, Dr. Amy Vertings, introduces the guest, Dr. Nabilah Noor, a urogynecologist employed in a large hospital network. Dr. Noor shares her educational and training background, including medical school at Duke University, residency at Mount Sinai, and fellowship at Beth Israel Deaconess Medical Center. She explains her decision to join her current practice, driven by the desire to maintain a busy surgical volume and operate regularly. 00:06:32Lesson 1: Understanding Compensation Models and Revenue Generation Dr. Noor discusses the importance of understanding the compensation model in her practice, which is based on relative value units (RVUs) and revenue generation. She learned to identify the revenue-generating activities, such as surgical cases, and prioritize seeing patients who could potentially convert to surgery. Dr. Noor worked closely with her team, including physician assistants and schedulers, to streamline the patient flow and ensure efficient use of resources. 00:21:00Lesson 2: Effective Time Management Dr. Noor shares her strategies for effective time management, including pre-planning clinic notes, utilizing downtime between surgeries, and dedicating specific times for administrative tasks. She emphasizes the importance of not taking work home and maintaining a work-life balance. Dr. Noor also highlights the value of leveraging her team's skills and delegating tasks to the appropriate personnel. 00:29:27Lesson 3: Maximizing Efficiency in the Operating Room Dr. Noor discusses her approach to maximizing efficiency in the operating room, which involves pre-planning surgeries, visualizing potential challenges, and ensuring the availability of necessary instruments and equipment. She emphasizes the importance of clear communication with the surgical team and requesting specific staff members who work well with her to streamline the process. Dr. Noor also highlights the value of remaining calm and in control during challenging situations. 00:35:10Lesson 4: Building a Strong Professional Network and Collaboration Dr. Noor emphasizes the importance of building a strong professional network and collaborating with colleagues from various specialties. She discusses the value of clear communication, setting boundaries, and accommodating each other's schedules when working on combined cases. Dr. Noor also acknowledges the support of her family, including her husband and parents, in helping her balance her professional and personal responsibilities. 00:41:45Closing Remarks Dr. Noor concludes by encouraging surgeons not to give up on their careers due to burnout or workplace challenges. She emphasizes the importance of adapting to different practice models and environments while maintaining confidence in one's abilities. Dr. Noor expresses her willingness to share her experiences and insights with others in the field. Action Items 00:07:24Understand the compensation model and identify revenue-generating activities to prioritize in your practice. 00:23:31Implement effective time management strategies, such as pre-planning clinic notes, utilizing downtime, and delegating tasks to appropriate team members. 00:31:04Pre-plan surgeries, visualize potential challenges, and ensure the availability of necessary instruments and equipment to maximize efficiency in the operating room. 00:35:22Build a strong professional network and collaborate with colleagues from various specialties, communicating clearly and accommodating each other's schedules. 00:36:45Seek support from family and loved ones to achieve a healthy work-life balance and avoid burnout. 00:41:17Adapt to different practice models and environments while maintaining confidence in your abilities as a surgeon. 00:41:00Share your experiences and insights with others in the field to help them navigate the challenges of developing a successful surgical practice.

Last month, the MedSLP Collective hosted a free four-day workshop to help medical SLPs accomplish more by doing less! This week, we're going to share Day 2 of the workshop on the Swallow Your Pride podcast! Let's face it, productivity can be a bit of a maze, with each facility and setting having its own unique calculations and expectations. But fear not, my friends, in today's episode we're breaking it all down.  Tune in so you can hear Kristin Dolan, a seasoned speech pathologist with over two decades of experience under her belt, share her experiences and expertise. With a deep understanding of productivity from both the clinical and managerial perspectives, Kristin offers her wisdom on the inner workings of productivity in our field. Kristin and Theresa define the differences between productivity & efficiency, share 10 tips to improve your efficiency, and illustrate how you can map out your workdays with the help of a free productivity calculator.  From deciphering productivity formulas to exploring strategies for efficiency and effectiveness, we're on a mission to demystify the process and empower you to thrive in your role. Interested in listening to the entire workshop? You can catch the entire workshop HERE: medslpcollective.com/effectiveslp Timestamps: Understanding Productivity (00:00:00) Accessing Workshop Recordings (00:00:59) Highlighting Productivity Tips (00:02:15) Leadership and Teamwork Method (00:03:26) Discussion on Productivity (00:06:20) Understanding Productivity and Efficiency (00:09:32) Empowering Therapists (00:13:51) Value-Based Systems (00:19:51) Understanding Productivity Calculation (00:22:46) Efficiency in Patient Treatment (00:23:30) Adapting to Patient Needs (00:25:37) Challenging Productivity Expectations (00:29:21) Differentiating Managers and Leaders (00:31:43) Understanding RVUs in Productivity (00:34:22) Maximizing Efficiency with RVUs (00:38:35) Tools for Efficient Documentation (00:41:12) Balancing Efficiency and Quality in Documentation (00:43:35) The importance of taking time to review repetitive tasks (00:45:35) Improving department effectiveness (00:46:04) Utilizing downtime forms for concise documentation (00:47:27) Reducing decision fatigue and time management (00:49:39) Delegating tasks and setting priorities (00:50:02) Analyzing time usage and efficiency (00:54:48) Understanding productivity calculations and advocating for change (00:55:20) Managing non-billable but required activities (00:57:31) Efficiency tools and resources (01:00:07) MetaSLP Collective membership and support (01:03:14) The post 322 – Understanding & Calculating Productivity vs. Efficiency appeared first on Swallow Your Pride Podcast.

Have you thought about the evolving role of surgeons in today's complex healthcare environment? The latest BOSS podcast features the inspiring Dr. Frank Opelka, a true leader in the field of surgery. We left residency thinking that we were the leaders of the team. Our jobs told us that our value is in wRVUs. With the rise of AI, the reality is that information will be a leading influence on the team, and without proper understanding and supervision, we could be led with misinformation. From predictive medicine to the value of surgeons in a changing system, Dr. Opelka's expertise sheds light on a whole new dimension of patient care. “Medicine is not getting less complicated over time. It's getting more complicated, because our understanding of the science keeps growing. But our patient complexity is also growing. ” -Dr. Frank Opelka Key Takeaways Gain insights into the evolving landscape of surgery and stay ahead of the curve in healthcare advancements. Discover the importance of transparency in healthcare and how it can positively impact patient outcomes and satisfaction. Learn strategies to help patients attain their goals in care, leading to improved overall well-being and recovery. Explore the benefits of surgeon coaching for professional development and enhancing surgical skills. Uncover the potential of AI in shaping the future of surgery and its impact on patient care and surgical outcomes. About Dr. Frank Opelka Frank Opelka, MD FACS is a recognized expert in healthcare quality and health policy. He is currently the primary consultant having founded Episodes of Care Solutions, LLC. Dr. Opelka is the immediate past medical director for quality and health policy for the American College of Surgeons. He has served the College in various quality and policy roles for over 30 years. His expertise stretches from payment policy to systems design, quality measurement, and includes healthcare informatics. His roles have included an advisory capacity and surgical representative to various health policy and quality committees throughout the Washington DC landscape. He has testified and advised both houses of the US Congress as well as served in an advisory role to four presidential administrations and a long list of federal agencies. Dr. Opelka's early work involved standing up the Relative Value Update Committee, known as the RUC. In his recent work, he has moved away from defining surgeons by RVUs and promotes the value of a surgeon for the many contributions surgeons bring that are outside the boundaries of RVUs. Dr. Opelka served on the Medicare Episode Grouper development project that created open standards for defining surgical episodes of care. He currently serves as the chair of the board of the PACES Center which is the non-profit organization that continues to promote physician-defined episode definitions for use in price transparency. Dr. Opelka is involved in several consultant projects to better align surgical quality to meet the patients needs in finding care, to aid surgeons in driving improvement, and to assisting payers in understanding aligned incentives to reward care. In addition, Dr. Opelka's work in informatics highlights the importance of expertise in a generative AI world of knowledge management. He insists we are on the cusp of a knowledge explosion in healthcare and the importance of specialists to find the "signal" amidst all the "noise" has increasing relevance. It is less about EHRs and registries and more about trusted knowledge. He supports policy efforts to secure knowledge bases that are filtered by experts before seeking generative AI analytics. Finally, Dr. Opelka is an author and public speaker with countless contributions in texts, peer-reviewed journals, editorial staff and policy manuscripts. Key Moments 00:00:02 - Introduction and Guest Introduction 00:03:07 - The Complexity of the System 00:07:10 - Overcoming Barriers in Healthcare 00:12:45 - Trustworthy Knowledge Sources 00:16:38 - Current Data Pools and Future Considerations 00:17:07 - Enhancing Data Integrity 00:18:49 - Health Information Exchange 00:20:29 - Patient Goal Attainment 00:23:38 - Transition to Patient-Centric Care 00:30:38 - Predictive Medicine and Knowledge Management 00:34:11 - The Future of Medical Education and Residencies 00:35:26 - The Role of AI in Healthcare 00:37:33 - Developing Surgeons as Leaders 00:39:12 - The Role of a Surgeon Coach 00:43:24 - Dr. Opelka's Projects and Future Endeavors

“Wherever you're working, whatever setting you're working in, whatever profession you are, if you're working with humans, you should be trauma-informed.” Rachel Archambault, MA, CCC-SLP dropped ALL the mics within the first three minutes of our discussion in today's episode of the Swallow Your Pride Podcast! Trauma-informed care, empathy, and just the human touch are all crucial in our profession, but there's an obvious tension between meeting productivity standards and providing this level of care. It's palpable. Does our current productivity model harm the quality of care we can provide? What does trauma-informed care look like, and what can we actually do to make it work without stressing over time-based codes and RVUs? Tune in to this week's discussion and see what Rachel has to say about it and join her call to action! Get the show notes: https://syppodcast.com/311 Timestamps: Introduction (00:00:02) Discovering Trauma-Informed Care (00:01:33) Challenges in Implementing Trauma-Informed Care (00:04:23) Advocating for Change (00:06:01) Impact of Trauma-Informed Care (00:09:14) Six Pillars of Trauma-Informed Care (00:13:35) Looking at the conversation through a trauma-informed lens (00:14:15) Trust and transparency in provider relationships (00:15:23) Fostering trust and transparency with clients (00:16:58) Peer support, collaboration, and mutuality (00:17:26) Empowerment, voice, and choice in therapy (00:20:21) Consideration of cultural, historical, and gender issues (00:23:09) Personal experiences with trauma-informed care (00:24:50) Trauma-informed care (00:28:03) Cultural and religious considerations (00:29:33) Resources for trauma-informed care (00:31:38) Training and implementation (00:34:14) Connect with Rachel (00:35:38) The post 311 – Compassion Over Metrics: Prioritizing Trauma-Informed Care as Medical SLPs appeared first on Swallow Your Pride Podcast.

Welcome back to Common Sense Medicine! This is a great interview with a physician who is working in the intersection of the care navigation space. Patient-centered care can mean a lot of things to a lot of people. For me, it means that patients are heard in their care journeys and feel as though they have agency in a system which is often confusing and not at all “human-centered.” My guest today is trying to change that through providing a better solution care navigation in cancer care. Dr. Hillary Lin is a Stanford-trained, board-certified internal medicine physician and the Co-founder and CEO of Curio, a HealthTech startup addressing health equity and outcomes via Al-enabled navigation. Dr. Lin has contributed to neuroscience and oncology with her peer-reviewed research work. She is a frequent speaker and advisor for programs, including Headstream Innovation and Cornell BioVenture eLab. In her personal life, she enjoys immersive experiences and has completed over 200 escape rooms worldwide.Video Version[00:59] Hillary's background in medicine, and Curio's start * She entered medicine because she was passionate about the “human experience,” she knows how complicated life can be and how important health is * It's about all of the aspects around health that you also have to manage when you are sick and not just the disease itself* There's too much focus on the facts of medicine and the facts of biology and it sucked out the “soul” of medicine for her * We're asked as physicians to remember more facts and be computers rather than a person to help guide the journey (AI can help here)* Drove her to specialize in oncology because she wanted to be deep in the process of answering existential questions, but when she got there she found out it's mostly running in and out of bedrooms and clinic rooms. She was trained in internal medicine at Stanford and then went to Columbia for a brief time in an Oncology fellow role* You don't get time to sit down with the patient that much* She found that she wasn't answering the existential questions she wanted to, so she went to digital health innovation and sampled the smorgasbord of what she could be doing, and finally she landed on cancer care navigation[06:16] What is so compelling about care navigation for patients? * Took her a long time, she was seeking for years to land in a field to innovate in* In the beginning, as a relatively new founder, like many founders, she went straight to where the problem was—when founders do this, they try and create a tech-enabled clinical platform for whatever they want to solve quickly. She thinks this is the first-order solution, rather than the final state* They found that with more serious healthcare concerns, a lot of it comes down to navigation problems / concerns. Health literacy, access, and equity are prevalent in the U.S. where we have a convoluted system. It's very hard for them to get optimal treatment and care[08:44] All about Curio—what is it & how does it help their end customers? * Problem they're solving: Help patients get the resources they need in order to optimize their health * The tooling behind that (which is growing) is vast, and it's growing in real time Shree's note: the tooling now may be different then when we recorded this podcast in November 2023* One example of a tool is a natural language parsing tool to provide the opportunity to explain a problem and can connect to a in-person navigator to find those services, or use the AI to find them a personalized service which can help them find the solution for their specific issue * The next level of that is to guide them through the steps to get the resources that they need. Instead of having a case manager or a social worker on the line, they can use the AI to navigate the next level * The key thing to understand is a B2B company which works with health delivery platforms, non-profits, patient support services, and similar entities. 80-90% of the time, there is a human in the loop, such as a social worker or another personnel* Rather than focusing on just a patient assistance program in a specific zip code, you can use Curio to add additional parameters (i.e., age, family members, etc.) to add greater “precision level resourcing” for cancer patients* There's also a level of communicative support which uses generative AI to help individualize to the patient's health literacy level in an SMS or email communication[14:35] What are patients most using Curio for? * Financial assistance is by far the largest problem which patients face with a cancer diagnosis, and financial toxicity is the main focus of Biden's Cancer X initiative* It takes up to 80% of people's bandwidth and mindshare. Cancer care is so incredibly expensive that people max out their deductible pretty quickly. There's also legal type of concerns especially with their employers (i.e., leaves of absences)* In an earlier rendition, Curio was a mental healthcare company. They found that for cancer care, mental health is a secondary concern, after people are able to pay for their medications and their base needs. There are a lot more resources to tackle mental health than other issues though[18:12] Curio's business model * They sell to intermediaries, navigation and utilization discovery services. The ecosystem has become very bloated with point solutions for digital health that benefits administrators get burned out* Shree's take: Curio is really trying to differentiate their navigation solution based on its personalization through partnerships. For example, if you have a MSK issue, Curio will basically tell you which piece of education you need to read for your particular issue* They use both human / automated version of finding those resources, but they prefer a partnership because then it is more intricately tied to the experience of navigating care* They use a tiered utilization pricing model for Curio's care navigation solutions. They align well for utilization based pricing model because sometimes there's very low utilization of those benefits [27:16] What do oncologists think about this tool? * Trust is key to get buy-in from various providers. They are trying to establish strong relations with patient advocacy groups—this is not to just have their logo on their website, but to have relationships with them * Hospitals don't reimburse for care navigation services, so it's pretty awesome to see that patients are getting these services outside the hospital. Doctors don't get paid (RVUs) based on them helping the patient navigate the system; social workers are strapped for their time. If patients find Curio or another tool, it can be a real game changer for them* They are also working on the pharma side where they are focused on getting patients more adherent onto their treatment, and focusing on patient engagement. Pharma companies want to know why patients aren't continuing on their treatment (i.e., copay, adverse events, etc.) so it's actually pretty helpful for them to understand where in the patient journey they are losing the consumer[32:49] Does Curio help with finding second opinions? * They work with advocacy groups to help find second opinions for their patients. In fact, in Hillary's opinion, a lot of doctors do value second opinions and look to get them from academic institutions (i.e., you have one oncologist at an academic institution and one in a community setting) * They are working on getting a database for clinical trials so patients can use that to find trials which are very helpful to them. Patients are very skeptical of trials, so according to her, getting patients there is 90% of the issue* A lot of the convincing happens at the education level and the risks and benefits of the trial[40:16] What is different about Curio? * Shree's note: I read an market map of the Generative AI in healthcare space, where they talked about how the care navigation space is becoming crowded—so I asked Hillary about her opinions in the care navigation nicheNavigation companies, such as Navvi Health, Collective Health, Auxa, and Talktomira, focus on helping employees and patients navigate their healthcare benefits and options. However, these companies face challenges like overcoming vendor fatigue and budget constraints in the current economic climate. Interestingly, these companies have the largest amount of funding in this category and the lowest amount of median funding per company, which implies the category is more saturated and less capital intensive then other patient-facing categories. We're excited to see how generative AI can streamline user experiences, interpret health information, and guide patients more holistically, potentially reducing readmissions and encouraging proactive care.* Curio is good at patient engagement, which a lot of digital health companies have not been successful at (according to Hillary)* Each product / feature release has to be laser-focused on that particular use case—they are trying to solve problems with technology rather than with humans * A lot of care navigation companies are human first, with technology enablement, where she thinks it has to be reversed—tech first, with human enablement at points, so that it can scale* Now with generative AI, this scalable solution is now possible[45:48] What is the future of Curio? * They are trying to provide a broader layer of tech for the vision of healthcare—a human person is more than their disease, so they have to have a broad way to access that care * Rather than becoming verticalized, they want to go more horizontal—focus on nutrition, wellness, or other places[47:04] Why go into Digital Health? * It took her years to get her legs underneath her as an entrepreneur. She believes we're living in a world where healthcare is stuck in an outdated mode of manual labor* Looking very closely at other industries, all other industries are moving towards this idea of personalization, but why can't we focus that on scaling up healthcare for a lot more people? This is a public episode. If you would like to discuss this with other subscribers or get access to bonus episodes, visit www.shreenadkarni.com

In this episode of The Nurse Practitioner Podcast, Julia Rogers, DNP, APRN, CNS, FNP-BC, FAANP discusses having a voice in the payment system based on RVUs for CPT® codes. Physician Fee Schedule: https://www.cms.gov/medicare/medicare-fee-service-payment/physicianfeesched/pfs-relative-value-files/rvu23b _________________________________________________________________ Podcast Sponsored By: Dakins Wound Cleanser When it comes to treating persistent, hard-to-heal, or complex wounds, you need a solution you can trust. Dakin's Wound Cleanser is an FDA approved device for wound cleansing and management. It's powerful, cost effective, and easy to order. Studies have shown this formulation to be effective in killing 99.99999% of MRSA, VRE and biofilm-forming bacteria within 30 seconds! (Barsoumian et. al) Visit http://shop.getdakins.com/affiliates/default.aspx?Affiliate=4&Target=Home to request a sample today!

Healthcare transparency is essential for patients to make informed decisions, yet price disparities in the industry remain a major issue. In this podcast episode, we explore how financial incentives and contracts between hospitals and insurance companies can misalign the incentives of brokers, employers, doctors, and patients. We discuss the importance of understanding the influence of these incentives and the need for accountability in developing an equitable healthcare system. Through transparent communication and a focus on an equitable system, we can help ensure that patients receive the care they need and deserve.Episode Outline:(00:00:02) Healthcare Transparency(00:04:42) Price Disparity in Healthcare(00:09:37) Health Insurance Incentives(00:14:21) Doctor Compensation Metrics(00:19:05) Incentive MisalignmentQuotes:(00:03:21) The thing that boggles my mind about healthcare is that in most of healthcare, neither the consumer, which in healthcare is the patient, nor the provider of the goods or services, which in most cases is the doctor, neither one of those parties know what the price is going to be until long after the services are already rendered.(00:09:10) You might only be paying a copay or you might only be paying your $200 and $5500 out of pocket that's falling off of your coinsurance. And they have no idea until they get the EOB what the build charges were and what the allowed charge was. So I think they're so disconnected from how much health care actually costs.(00:12:23) But I'm going to put it really bluntly and I think I got this from Dave Chase, this little metaphor here. But imagine for a minute if fire departments only got paid when there was a fire, they would want as many fires to occur as possible. And the bigger the fire, the more money they get.(00:17:22) And not only that, I think to deny that you're influenced by the financial incentives is to deny you're human. I mean, we've operated on financial incentives long before currency even existed.(00:21:08) I challenge you, if you are not already, if you're a consultant, even if you're a patient, if you're an employer, figure out what you can do. What one thing can you do differently to turn that incentive around?Social Post:Are you tired of feeling like you have a healthcare hangover? We've all been there. That's why we created the Healthcare Hangover podcast. We dive into the headaches we've been encountering in the healthcare system that are leaving us feeling a little hungover. In our latest episode, we talk about the importance of healthcare transparency. We heard a story about a patient who was charged $475 for an X-ray at a hospital, when they could have gotten the same X-ray at a chiropractor's office for less than $75. We also spoke with a hernia surgeon who was able to do the same procedure for $7,200 instead of the $20,000 quoted by a local general hospital. Tune in to the Healthcare Hangover podcast to learn more about the importance of healthcare transparency and how it can save you money.Are you curious about how doctors are paid? Tune in to the latest episode of The Healthcare Hangover podcast to find out! From patient volume to RVUs, David Contorno and Emma Fox break down the complex system of doctor pay and how it influences health care decisions. Plus, they discuss how traditional brokers are put in an unfair position and how financial incentives can be used to deliver better outcomes. Don't miss out on this eye-opening episode! #TheHealthcareHangover #DoctorPay #HealthcareAre you tired of the broken healthcare system? Tune in to the latest episode of The Healthcare Hangover to learn how the system was designed to benefit certain people and how you can help turn the incentives around! From the perverse incentives of commission-based compensation to the Cigna CEO's 20 million dollar salary, David Contorno and Emma Fox will take you through the details of the current system and how you can help build an alternative. Don't miss out! #TheHealthcareHangover #BrokenHealthcareSystem #IncentivesBlog Post:The healthcare system is broken, and it's time to start fixing it. In this episode of Healthcare Hangover, hosts David Contorno and Emma Fox explore the lack of price transparency in healthcare, and how providers are taking advantage of patients by charging them more than necessary. Insurance companies make money by renewing plans every year, regardless of how much they pay out, and people often think that more expensive care results in better outcomes, which is not true. Unfortunately, people often cannot afford their out-of-pocket costs, leading to debt or even lawsuits. Insurance companies do not provide any positive benefits to doctors, employers, or patients, and people have been led to believe that they need health insurance to get quality health care, which is false. The hosts also discuss how fire departments operate on a fixed budget, while health care systems make more money the sicker people are. Health insurance companies have a massive workforce that they pay very little to, and they have bonus programs for brokers that are available on their websites. Hospitals are not changing their practices due to lack of consumer demand, and MRF (Machine Readable File) is not human readable, requiring a middleman to translate the data. Additionally, hospitals often put programming on their website to prevent spiders from finding the data. David Contorno and Emma Fox also discuss how cash prices are almost always the lowest prices on hospital spreadsheets, and the disparity between prices for the same procedure from different carriers is outrageous. Commercial carriers pay the highest reimbursement rate to hospitals, and patients are disconnected from the cost of healthcare due to copays and coinsurance. To illustrate this, David Contorno visited a chiropractor for an X-ray of his shoulder and was asked if he was okay with the price before the X-ray was taken. The X-ray cost $75 at the chiropractor's office, but the same X-ray would have cost $475 at Atrium, the hospital system next door. Michael Reinhorn, a hernia surgeon in the Boston area, charges $7,200 for hernia surgery, while a local general hospital charges $20,000. The hosts also compare the healthcare system to the veterinary system, noting that veterinarians often give customers options and prices up front before giving any treatment. Doctors, on the other hand, are typically paid based on two metrics: patient volume and RVU (Revenue Value Unit). Patient volume is the number of patients seen in a day, with some doctors having minimum patient volume requirements of up to 30 patients per day. RVU is a measurement of how much revenue a doctor is helping generate for the health system, often in areas outside of their office. Doctors are incentivized to prescribe opioids to deal with pain, and to send patients to the most expensive care, regardless of whether it is the appropriate treatment. The most likely outcome of back surgery in the US is a second back surgery. Additionally, traditional brokers are paid more when they retain their book of business and cross-sell additional products that benefit the carrier they represent. Healthcare and health insurance employees often think they are doing good, even though the results they keep delivering are bad. The company bills their clients and has a performance bonus for achieving the client's goals of paying less for healthcare. Ultimately, the hosts conclude that people should focus on changing one thing at a time to build an alternative system that is more affordable. The Cigna CEO made 20 million dollars last year, and the sicker people are, the more money they make. It's time to start demanding more transparency and accountability from health insurance companies, and for patients to take control of their own healthcare. We have the power to create a system of trust between providers and patients, and to make healthcare more affordable and accessible.Episode Links:Connect with Emma FoxWebsiteEmma's WebsiteConnect with David ContornoLinkedInWebsiteOther MaterialsThese materials help you promote your podcast. Quotes can be used for audio & video grams or quote cards. Blog and social posts will help your website and social media presence.

In this episode, co-hosts Drs. Ally Baheti and Mike Barraza interview Dr. Ted Wen of Texas Radiology Associates and Dhruv Chopra of Collaborative Imaging about perspectives and helpful technology when managing an independent radiology practice. --- CHECK OUT OUR SPONSOR RADPAD® Radiation Protection https://www.radpad.com/ --- SHOW NOTES Dr. Wen shares reasons why he and his colleagues chose to keep their practice independent. The fast-growing group spent eight years doing due diligence about private equity (PE) to decide if that was the right model for them. Dr. Wen met with PE firms around the country to explore the process of transitioning into PE practice ownership and its implications for current colleagues and future physician hires. Selling to PE would disproportionately benefit senior partners, who were ready to be bought out, over junior partners who would not qualify for the same deal. Additionally PE management could have the power to raise minimum RVU requirements and enforce highly restrictive noncompetes. Texas Radiology Associates ultimately decided that in order to compete in the radiology marketplace as an independent practice, they needed to make significant investments in technology to better serve their patients. They started to connect with Collaborative Imaging to pursue this mission. Dhruv notes that PE has the potential to bring in financial support, strategic relationships, and pathways to growth, but he also warns the audience that not all PE contracts are transparent nor designed to benefit physicians. Workflow, staffing, and collaboration with referring doctors can be extremely difficult when firms value cost savings and RVUs over patient care. All of these stressors have negatively impacted the radiology burnout rate. Dhruv describes the start of Collaborative Imaging, in 2018, as an attempt to integrate a revenue cycle management (RCM) system with radiology workflow at Texas Radiology Associates. This provided a cost-efficient solution that frees up funds to invest in other areas of the practice. Collaborative Imaging is currently working on an AI-driven system to notify patients of actionable findings that come up in their imaging. They are also exploring technology that will adapt the style of radiology reports to different referrers' preferences. Both guests discuss the common inefficiencies that independent radiology practices face, including RCM, clarification over patients' payment plans, and office wait times. Collaborative Imaging is working with practices around the country to build solutions. Radiology groups can contribute a percentage of their revenue into Collaborative Imaging and receive dividends, or they can license the RCM solution. --- RESOURCES Ep. 277- Private Equity and the Radiology Job Environment with Dr. Ben White: https://www.backtable.com/shows/vi/podcasts/277/private-equity-the-radiology-job-environment Texas Radiology Associates: https://texasradiology.com/ Collaborative Imaging: https://collaborativeimaging.com/

Medication non-adherence leads to preventable hospitalizations and costs US healthcare $500 billion each year. Bruce Berger explains how motivational interviewing can help, with Jim Cagliostro.    Episode Introduction  Bruce explains that motivational interviewing is still the most effective intervention for substance abuse, why adherence hasn't improved in 40 years, and why discharge counseling should be provided the day before patients leave hospital. He also shares how MI interventions reduced the patient dropout rate from 13% to 1.2%, saving $93 million for one biotech company in four months, and urges healthcare leaders to stop objectifying patients.      Show Topics   Motivational interviewing (MI) began in the 1970s Why MI is not about motivating patients  All of us are sense-makers Genuinely connecting with what's emotionally important to patients Restricting patient time is at the heart of burnout Healthcare needs to stop objectifying workers and patients     03:54 Motivational interviewing (MI) began in the 1970s Bruce explained how MI was originally developed to treat people with substance abuse problems.  ‘'Well, motivational interviewing was first developed by a clinical psychologist named William Miller, and it was developed back in the '70s to actually treat people with substance abuse problems. And here's the irony, Jim, to this day, it is still the most effective intervention for substance abuse, and yet, we hardly hear about it in healthcare. We've got an opioid crisis, we've got substance use and rarely do you hear people talking about using motivational interviewing to intervene. And I've done a number of webinars on this. And here's one of the reasons why, we are huge in healthcare on evidence-based medicine, but not evidence-based communication. And in fact, this year, for the first time, the American Council on Pharmaceutical Education is including motivational interviewing as part of their accreditation standards. I'd like to think I'm part of the reason why, because I wrote a five-page single-space letter saying, how can you talk about evidence-based pharmacy and medicine, but not evidence-based communication?''   05:17 Why MI is not about motivating patients  Bruce said people might know how to communicate, but often lack the skills to be effective. ‘'And we graduate people who think everybody knows how to communicate, but that doesn't mean they know how to do it effectively. And so, what MI is, motivational interviewing is a set of skills and a way of being with patients. It's kind of a misnomer, it's not about motivating patients, it's an interview, in a sense, to explore the patient's motivation. "Okay, now you've found out you've got diabetes and the doctor has told you, "You got to take this medicine, watch what you eat, get some exercise." What do you think about all this? In other words, how important is it to you to get your blood sugar down? Tell me in your own words, what does having diabetes mean to you?" The idea behind motivational interviewing, because it's patient-centered, and you asked how is it different than what we do? We have this literally crazy idea in healthcare that we're driving the bus and the patient's a passenger, the reality is the patient has always driven the bus, what we're trying to do is influence the route. Does that make sense?''   09:33 All of us are sense-makers  Bruce said changing your approach to patients helps to overcome non-adherence.  ‘'….all of us are sense-makers. Even as we're talking right now, we're deciding whether we make sense of each other based upon what we bring to the conversation. So we're trying to train people to listen for, how is this patient making sense? And in their sense-making, what information is either missing or misinformation? Let me give you a really simple example. Patient with high blood pressure says, "I don't know why I need this medicine. I feel fine.'' Now most healthcare professionals will look at the patient and say, "Listen, you can't tell when your blood pressure's up. You can't feel when it's up." And they might as well just say, "Stupid," at the end of that sentence. We would say, "Because you're feeling okay, you're really wondering, why do you need this medicine?" What's the patient going to say now? Exactly. And what will they have learned? That I've listened to them without judgment. Now I'm going to say, "That's a reasonable thing to ask. Would you mind if I shared some thoughts? And I'd like to hear what you think." You notice the sharing?'' We're negotiating here. And so, now I would tell the patient that, "Unfortunately, high blood pressure is one of those conditions that doesn't have any symptoms, and the first symptom is stroke or heart attack. This medicine can greatly reduce your risk of having a stroke or heart attack even when you feel okay." I'm now not going to say, "Therefore, you need to take it," I'm now going to say, "Where does that leave you in terms of thinking about taking the medicine to reduce your risk?" So I've listened to what the patient has said, I've heard in their sense-making that their sense is that if you feel okay, everything's okay. My job is to help them understand how you can feel okay and be at risk.''   18:34 Genuinely connecting with what's emotionally important to patients  Bruce said it's important to understand what's meaningful to patients. ‘'….we had an asthma patient that wasn't using her daily inhaler. She said, "I just hate being reminded that I got this thing." And I said, "Let me ask you something. What could you do?" I said, "If your asthma was under control, what would that allow you to do that you find difficult now?" She teared up and she said, "I could play tennis again." Now we found out what's important to her. It doesn't matter what's important to me, she's only going to be motivated by what's important to her. And so, we then start talking about steps that she could take to play tennis again by using the medication, and she became adherent, but you had to explore what was meaningful to her….. And I'm not talking about being false, I'm talking about genuinely connecting with what's emotionally important to the patient, and you've got to do that in order to really have influence in a positive way. And so saying to that patient, "You love your grandkids. You miss not being able to spend time with them. You want a future where you can spend time with them." And you see what I'm doing? I'm helping build pictures.''   22:53 Restricting patient time is at the heart of burnout Bruce explained why healthcare has a systems problem which affects patient care and adherence.   ‘'One industry is moving in a totally opposite direction (to other industries), healthcare. There are so many toxic systems out there that are putting profits ahead of people, people meaning their workers and the patients. We are watching burnout at a level we've never seen before because healthcare systems are basing staffing on things like number of prescriptions dispensed, number of immunizations given, RVUs, "Oh, you should only be spending 11.2 minutes with the patient and no more, even if the patient needs more time in order to have an effective outcome." Somebody asked me the other day, "Well, what am I supposed to do if I only have, at most, 30 seconds with a patient?" Well, no amount of motivational interviewing training can solve that problem, that's a systems' problem. There's a couple of videos on YouTube with me showing what happened with an asthma patient. The patient's daughter had been in the emergency room three times that year because the mother wouldn't allow the daughter to use the chronic inhaler because she looked it up and saw it was a corticosteroid, she misunderstood what that steroid was. She didn't want her daughter using a steroid. Everybody chastised her at the emergency room. I showed her understanding and in fact, said to her, "You're really worried about your daughter using a drug that you think can harm her." And for the first time somebody understood her. After we were done, the whole conversation took six minutes, the kid had not been in the emergency room for at least three years after that……And what's really horrible is we have people that are graduating from nursing school, pharmacy, school and medicine, they have a code of ethics, they have standards of practice that put patients first, and yet they go to work for organizations that set up a moral conflict for them because if your primary goal is to put patients first and the staffing makes it impossible, this is the heart of burnout and chronic stress.''   31:50 Healthcare needs to stop objectifying workers and patients Bruce said if healthcare workers are objectified, they objectify patients, and care suffers.  ‘'…if there's one message that I would give leaders in healthcare, it was you have got to stop objectifying your workers and patients. In other words, when you treat people as objects or like they're replaceable, anybody could do the job, the job's interchangeable, and you don't even give them an opportunity to have input into what's happening, you're objectifying them. And objectification begets objectification. Oftentimes, when we objectify healthcare workers, they objectify patients. It's no longer a human being, it's the diabetic in 214, that's not a person. And I'm saying, objectification is a major source of organizational problems in the delivery of care. The people in charge have got to start allowing for input on how to fix these problems and the people that are working in them and take them seriously. Right now, they're not.''   Connect with Lisa Miller on LinkedIn Connect with Jim Cagliostro on LinkedIn Connect with Bruce Berger on LinkedIn   Check out VIE Healthcare and SpendMend    You'll also hear:    Bruce's inspiration behind motivational interviewing: ‘'We've got data that shows that for the past 40 years, the rate of non-adherence to medication regimens hasn't changed at all, it's almost 50% in year two of a chronic illness. And I wanted to understand better what's going on.'' Why MI is a meeting of experts: ‘'You as a patient are an expert on what you know and understand about the illness. I need to be listening for where the gaps are.'' How MI interventions reduced the patient dropout rate from 13% to 1.2% and saved Biogen $93 million, in four months.  Discharge counseling should be carried out the day before patients leave hospital: ‘'They're a captive audience, they'd want to talk to somebody. When they're ready to get out of the hospital, they don't want to listen to us going through their med list.'' Essential healthcare leadership advice: ‘'Human beings are hardwired relational. If leaders get that, they will treat the people they lead much differently. They'll know they couldn't have gotten to that place without so many people helping them.''     What To Do Next:   Subscribe to The Economics of Healthcare and receive a special report on 15 Effective Cost Savings Strategies.   There are three ways to work with VIE Healthcare:   Benchmark a vendor contract – either an existing contract or a new agreement. We can support your team with their cost savings initiatives to add resources and expertise. We set a bold cost savings goal and work together to achieve it.  VIE can perform a cost savings opportunity assessment. We dig deep into all of your spend and uncover unique areas of cost savings.  If you are interested in learning more, the quickest way to get your questions answered is to speak with Lisa Miller at lmiller@spendmend.com or directly at 732-319-5700.  

Listen to ASCO's Journal of Clinical Oncology essay, “But Where is My Doctor? The Increasing and Relentless Fragmentation of Oncology Care,” by David Mintzer, Chief of Hematology and Medical Oncology at the Abramson Cancer Center of Pennsylvania Hospital. The essay is followed by an interview with Mintzer and host Dr. Lidia Schapira. Mintzer stresses the need for oncologists to make an effort to maintain relationships with patients as cancer care becomes more fragmented. TRANSCRIPT  Narrator: But Where is My Doctor? The Increasing and Relentless Fragmentation of Oncology Care, by David M. Mintzer, MD (10.1200/JCO.23.00805) For the past 7 years, I have cared for Michael, a man with pseudomyxoma peritonei. He has undergone two aggressive surgical resections with hyperthermic intraperitoneal chemotherapy and endured multiple chemotherapy regimens, all of which resulted in questionable benefit. Recently, his health has declined due to progression of his cancer, and he has had frequent admissions for infectious complications, obstructive symptoms, and several fistulae. I had always been his attending on previous admissions unless I was away, but when I last saw him, he asked me why I had not been his doctor this time. Even before he asked, I felt guilty for not being there for him.  For most of my career, I would see my own inpatients on a daily basis, rounding before, and sometimes after office hours. Currently, owing to system changes that likely have evolved with most practices and hospitals, only one of us sees inpatients on the teaching service, with the rest being off service. This happened long ago for our obstetrical, primary care, and other subspecialty colleagues, but for as long as possible, I held onto the belief that in oncology, we and our patient relationships were different. While most of the kerfuffle over the past few years in medicine relates to the electronic medical record and its effect on our lives and on physician-patient interactions, I think the fragmentation of care—while less frequently acknowledged—has been as relentless and impactful though more insidious. While most published articles on fragmentation define it as patients receiving care at more than one hospital, my focus is on the fragmentation of care within our own practices and institutions. Our patients are at their sickest and most frightened, thus most in need of us, when they are hospitalized. But now, instead of providing care with a consistent presence, patients are regularly passed back and forth from the outpatient to inpatient teams, then sometimes to the palliative care team, and then perhaps to a hospice team or, for those with the best outcome, transitioned to a survivorship team. While all these practitioners are kind and competent, they are not a constant.  When I am covering our inpatient service, I do not know the detailed medical history of the majority of patients who have been cared for by my colleagues. Can I seriously be expected to know their complex oncologic and other medical issues, let alone their psychosocial needs, in any appropriate depth when I walk in on a Monday to start the week covering 16 new patients?  I can be empathetic and do my best to communicate with their outpatient physician, but both emotionally and medically, it is never the same as being cared for by someone one has known and trusted throughout one's disease trajectory. Our relationship with the house staff is also fragmenting. We used to spend a month at a time as teaching attending, giving us a chance to get to know our students, interns, and residents. This has now been reduced to a week, and with our house staff rotating on an every 2 week schedule, we may work with a resident or intern for just a couple of days before one of us rotates off service. Furthermore, they spend much of teaching rounds staring into their smart phones and computer screens feverishly trying to complete their electronic workload.  As practices have become larger and medical teams more complex, care has become less personal and often less efficient. If the patient calls with an issue or sends a message, it is notclear to them, and often to us, who will be assuming responsibility for their concern. Should it be directed to my administrative assistant, our triage nurse, the nurse navigator, the palliative care nurse, my nurse practitioner, an off-site call center nurse, or myself? The inbox proliferates; the toss-up for ownership of the message begins; six people now read what used to be handled by one or two.  While I was an initial enthusiast for the early integration of palliative care alongside primary cancer care, I now also fear that it has further removed us from some of our most important interactions and deepest responsibilities. The inpatient oncologist used to be the one to provide symptomatic and supportive care and run the family meetings. Our house staff now routinely consults palliative care for even the simplest pain management issues, and we increasingly outsource goals of care and other serious discussions to our palliative care teams, who do not have a longstanding relationship with the patient or their family nor a complete understanding of their disease trajectory and past and future treatment options. Nor do I if it is not my patient and I am just the covering attending of the week. Too often it seems that palliative care has replaced us in some of the roles that used to be integral to our practice as oncologists, and we seem to have eagerly stepped back from some of these responsibilities. Our interactions with our colleagues have also fragmented. Mostly gone are the days when we would sit down in the hospital cafeteria with other physicians from other specialties for coffee or for lunch after grand rounds. And the days when we would review films with our radiologists or slides with our pathologists are mostly long gone. Our tumor boards provide some interaction, but since the pandemic, these tend to be virtual and less intimate. I mourn the loss of our sense of a hospital community. There have been some definite benefits to the fragmentation of care, which is why it has evolved and why we have accepted the bargain. As we increasingly subspecialize, we can get better and more focused on what we do which helps us cope with the explosion of data and new information across every area in our discipline. Some of us can devote more quality time to research, and it has also made our professional lives easier in some ways. How nice not to have to trek to the hospital to see very sick inpatients every day, but rather just a few weeks a year. How much easier to have someone else take charge of difficult end-of-life discussions. There is no point in bemoaning the loss of the old ways of more personalized care, as there is no going back. The current generations of physicians will not feel this loss of inpatient/outpatient continuity having grown up in an already changed environment, just as they will never have known a world before the electronic medical record. Patients have also accepted our absence from their bedside with less resistance than I would have expected, perhaps knowing from the rest of their care experience how depersonalized it has become—not that they have had much say in the matter. The changes in the delivery of health care will likely accelerate as we enter the medical metaverse and how we will navigate artificial intelligence while maintaining our emotional intelligence remains to be seen. The continued emphasis on increased efficiency and throughput of physician efforts—structuring medicine as a fragmented assembly line—runs counter to what is so meaningful to the physician-patient relationship—a function of time spent developing personal connections. As we continue our efforts to keep up to date with the rapid expansion of medical knowledge in our field, we also need to make equivalent efforts to maintain our personal and emotional connections with patients. As we have less frequent direct contact due to so much fragmentation of care, we need to make the time we do have with them more impactful. And sometimes that means going over to the hospital to see Michael after a long office day, although you are not on service. It is the right, human thing to do, and still gratifying—for all of us. Dr. Lidia Schapira: Hello and welcome to JCO's Cancer Stories: The Art of Oncology, which features essays and personal reflections from authors exploring their experience in the field of oncology. I'm your host, Dr. Lydia Schapira, Associate Editor for Art of Oncology and a Professor of Medicine at Stanford University. Today we are joined by Dr. David Mintzer, Chief of Hematology and Medical Oncology at the Abramson Cancer Center of Pennsylvania Hospital. In this episode, we will be discussing his Art of Oncology article, “‘But Where's My Doctor?': The Increasing and Relentless Fragmentation of Oncology Care.”  At the time of this recording, our guest has no disclosures.   David, welcome to our podcast, and thank you for joining us. Dr. David Mintzer: Thank you for the invitation, Lidia. Dr. Lidia Schapira: It's a pleasure to have you. I'd like to start these conversations by asking our authors if they have any books they want to recommend to listeners or if they're currently enjoying anything we should all know about.  Dr. David Mintzer: Well, I just finished David Sedaris's most recent book, which is a series of essays. I get a big kick out of him. I think I often mesh with his sense of humor and a little bit of cynicism, a lot of truth, but heartfelt and always amusing. Dr. Lidia Schapira: I love his work. Thank you. That's a great recommendation, especially for the summer.  So let's dive into your essay and your perspective, which is really such an important topic for us. You talk about the fragmentation of care and how it's impacted our practice, our relationships, and even our joy in the work that we do. Can you talk a little bit about your feelings about this? Dr. David Mintzer: Certainly. So I've been practicing medical oncology for a long time, about 40 years, so I've seen a lot of change. Favorably, most of that change is certainly in the good sense. We have so much more to offer our patients in terms of therapies that are more numerous, more effective, and less toxic. But there's been a price, I guess, to pay with those changes. We've all become more subspecialized, and the care has increasingly fragmented. And I was stimulated to write this essay because I've been disturbed to some degree by some of the changes. I think they are inevitable. I didn't want to write a piece just about how far I had to walk to school every day, uphill both ways, and complain. But I got a sense that others might have shared these observations and feelings, and I just kind of wanted to get them down.  Dr. Lidia Schapira: One of the things that you said that really resonated with me is when you talk about patients being at their most vulnerable and at their sickest and most frightened when they're hospitalized, and that's when they need us. And what you say here, what I'm interpreting that you're saying, is that by not showing up at bedside, in a way, we're abandoning them. And that is something that feels terrible to us as well, those of us who really value that presence and that relationship. Can you talk a little bit about how you're dealing with that and how you see your colleagues dealing with that? Dr. David Mintzer: Well, it's a bit of a Catch-22. Yes. I think a lot of this is driven by guilt, by not being there for patients that we cared for sometimes for many years and know well. And although this happened in university hospitals a long time ago, in our hospital it was relatively recent, that it was recommended in part for house staff accreditation regulations to have only one attending on service at a time, which is understandable so as not to confuse the house staff.  But in doing so, we're not there for our patients every day. And so you're kind of torn between running over to the hospital after a long day when you're exhausted and seeing your patients and fulfilling what feels like some responsibility, and also feeling that this is no longer my role, this is no longer the way medicine is practiced. It's not efficient. I don't get paid if I go over, someone else is collecting the RVUs. And in addition to that, the concern that the patients may not be getting not just the optimal emotional care, but even the medical issues. Certainly, the doctors covering are good and do their best, but they don't know these patients. They don't know their whole history, they don't know their complications in the past. That's the trade-off we make.  Dr. Lidia Schapira: Let's talk a little bit about those relationships that we invest in so heavily in oncology. Oncology is different than many other fields and we've always valued the time we spend with patients and forming those relationships. Can you talk a little bit about how you see those relationships threatened when you as the oncologist and the person who's given them guidance for the entire trajectory of their illness can't be present just when they're at their sickest and most vulnerable?  Dr. David Mintzer: So care of cancer patients certainly takes a village and we have tremendous support with so many different practitioners, including our nurse practitioners, our palliative care nurse practitioners, palliative care attendings, nurse navigators. But as we introduce all of these people, we actually have less direct contact time with patients. We're less likely to be the ones to call them on the phone or even answer their email. And one of the great things about practicing oncology is not just the science and what we can do for patients medically, but these bonds and relationships we form. It's been chipped away at rather insidiously, but I think rather steadily over 20 years.   Medicine thinks it's so scientific and advanced and technological. But I always kind of reflect that we're probably 20 years behind every other industry, whether it's banking or going to the supermarket or the clothing store or the hardware store. You used to go to your neighborhood pharmacist and you knew him and he would give you advice or your hardware store guy would give you some advice about how to fix something. So those industries lost their personal relationships a long time ago. We're really far behind them, but we're catching up. So now everything is done more remotely, more on the phone, and as I said, there's less direct contact time, which I think we all miss. But we're different. We're different from going to your local banker or grocer or bookstore dealer.   This is medicine. These are important medical events for patients. They're very emotionally fraught, they're complicated. And so what may be adaptable to other industries, even though it seems to be being forced upon us, is not as adaptable in medicine. Now, maybe there is some respite for this. I saw recent data that telehealth is going down. We thought telehealth was going to be here to stay with COVID and everyone was going to love it. And yet it's interesting, although it may be partly regulatory and partly because of the end of the epidemic, but I get a sense that both physicians and patients are a little bit less interested in it. I think that shows that we might be a little bit different from other industries, but we'll see how that plays out. Dr. Lidia Schapira: Absolutely. I couldn't agree with you more, but you talk about relationships also with trainees, for instance, that part of this fragmentation and these new schedules that we have also limit the contact you have with the house staff when you are assigned to be the doc on service. Perhaps you don't know all these patients very well, but you also bring up the fact that you don't get to know your trainees very well either because they're coming and going with different schedules. So what I took away was sort of a sense of loss, a bit of a lament that a lot of things are being lost in this super fragmentation. Can you address that a little bit, perhaps for our listeners?   Dr. David Mintzer: Yes, I think that's exactly right. So the fragmentation that I describe is not just in patient care, although that's probably the most important to all of us, but the fragmentation with kind of the extended family that was our hospital community. We've gone now to a nuclear family. So if we're a specialist in one particular area, we still have kind of a nuclear family. But my sense is we've lost that extended family, meeting people in the cafeteria after ground rounds, dealing with other subspecialists. And if you're only in the hospital a few weeks a year, you just have less contact, passing people in the hallway, meeting them at conferences, reviewing films, as I said, with radiologists, reviewing slides with pathologists. We're all too busy, we're all sitting in front of our computers at lunch, we're all doing conferences on the phone, driving home from work, but we have less time with each other. And that holds also true for students and residents who now rotate very quickly. Dr. Lidia Schapira: Let's talk a little bit about one of the other points that you make in this very thoughtful essay, and that is that you say that you were an early enthusiast of the integration of PalCare, but now you find that certainly, the younger generation seems to be outsourcing symptom management and communication very early to PalCare. And as a result, perhaps from the patient's perspective, care becomes even more fragmented. And that's sort of a bit of a loss all around. We're not able to do some of the things that we enjoy too, in terms of family meetings and communication, but also everybody's becoming more deskilled. Talk a little bit about that. Dr. David Mintzer: Yes, I was an early enthusiast for palliative care, and I still am an enthusiast, don't get me wrong. You can't criticize palliative care. It's like criticizing mom and apple pie. But the idea was, and still is, of course, that you would work in conjunction with a palliative care specialist, that they would be called in, say, on the very difficult cases, cases that needed particular expertise, or to spend more time. And certainly, that happens, and I have tremendous respect for my palliative care colleagues. But what's happened, as you note, is that we've kind of outsourced it. It's much easier to have someone else have that difficult conversation, particularly if you're just covering a patient that belongs to someone else, you're just seeing them for a few days during the week, you don't feel comfortable in doing so. And so I'm concerned that we've abdicated our responsibility in many of these important discussions and left it to the palliative care team who, by the way, are overwhelmed because there aren't enough of them now that they are getting all these consults for almost everything.   We should, as oncologists, still be able to run the meetings, to refer patients to hospice, to discuss goals of care. But as we all become more specialized, as we become busier, we have less time and we've built this metaphorical moat between our offices and the hospital, I find that we're just doing it less and less, and I feel some guilt about that and also some loss. Dr. Lidia Schapira: David, you say in your essay, we have accepted the bargain. What I hear from you today and what I read and inferred in reading the essay when it came to us, is that there are feelings of guilt, there's less joy, there's feelings that somehow this bargain isn't so good for us after all, even though at some level it makes our work a little bit more simple and our hours perhaps a little bit more predictable. So can we think together a little bit about what lies ahead and how we get over this deep ditch that we seem to be in?  Dr. David Mintzer: Well, as you say, there's both benefit and loss involved with this and it does make our lives easier. If you're seeing relatively healthy outpatients month after month in the office, you get to feel oncology is not so bad and you can kind of put that two-week hospital rotation when everybody's in the ICU and having multiple unfixable problems and poor palliation behind you. So you can almost kind of go into denial. And it does make your quality of life easier to be able to just go to the office and go home most weeks of the year.  How are we going to deal with this going forward? I mean, we do have to make the effort. I don't think it's going to go back. I don't think writing this article is going to change the way medicine is structured. This is a more efficient way and in some ways, it may be safer and more high reliability, which are kind of the watchwords. So I'm worried. I don't know where it's going. I think it is going to be a little less personal. But my point is we have to be aware of it and in doing so make the time we have with patients more impactful, be a little bit more aware of our need to support them. Maybe if you're not at the hospital every day, go over once or twice a week, or certainly when there's a big change in event.  Dr. Lidia Schapira: Do you think we could use technology to sort of stay in touch and pay a social visit via FaceTime? Or remain connected to our patients, even if it is in a social function, but somehow, for their sake and for ours, remain connected when they're in hospice when they're hospitalized. But we're not the attending of the month.  Dr. David Mintzer: Certainly, the way we communicate has changed. I remember being a young attending and I was working at a small community hospital, and one of the surgical attendings would just call their patient on the weekend on the phone, but wouldn't bother to come in. And I thought, my gosh, that's terrible. What kind of impersonal, awful medical care is that? But indeed, now, calling or more likely, texting, communicating, emailing with patients may work.  What's coming with virtual or augmented reality or whether EPIC can eventually just plant a chip in our brain and we can all be online all the time, I don't know. But yes, any type of communication helps. I've often said that there's nothing like an unsolicited phone call to a patient to encourage them. Just, “Hey, you didn't call me, but I'm calling you. I was thinking about you. How are you doing?” So, yes, staying in touch by whatever means, I think can be greatly beneficial and mean a lot to the patient, even if it's a brief text or phone call. Dr. Lidia Schapira: Yeah, even encouraging your trainees if you have residents or fellows working with you to go with you to that unsolicited visit or participate in that, I think that sort of would model the kind of behavior that we would want if our loved one is the patient, right?  Dr. David Mintzer: For sure.  Dr. Lidia Schapira: And that's always a good question because what we hear from patients is how much they value and love their oncologists when there is a strong connection. So let's perhaps finish the conversation by going back to Michael, your patient. How did you and Michael resolve this? Dr. David Mintzer: Honestly, we haven't resolved it. So when he's in the hospital, he's now cared for by whoever's on service at the time. Fortunately, he hasn't been in the hospital lately, but I will make an effort to go over and stay in touch with him. Dr. Lidia Schapira: I'm sure Michael would appreciate your presence.   Are there any other thoughts that you would like to convey to our listeners or readers? We have dealt with some of these futuristic issues in Art of Oncology before, including one essay I remember was published years ago where there was sort of this very impersonal imagining of what it would be like for an oncology patient to basically be seen by a series of robots along the chain without this human connection. And it was really terrifying to read. So thank you for reminding us about what is lost for us as well as what is lost for patients, something that we all need to go back and revisit, I think, as we think about the future. Any final thoughts, David, for listeners? Dr. David Mintzer: So as a physician who's getting close to the end of their career, I don't want to come off as just protesting against change. We need change. You know, change is crucial, but I think it's not really been clear to a lot of people how much this has been eroded over time -  that our direct contact and the fragmentation has impacted us and our patients and other caregivers. And this separation between inpatient and outpatient, I think, is becoming steeper. Our palliative care nurses used to go over to the hospital and see the inpatients as well as the outpatients, or our physical therapists, or our nutritionists. Now everyone is divided. I still think it's a great job. I love caring for patients. I love the teams that I work with. And as medicine gets better, though, we just have to be on guard to stay in touch with our patients and our feelings.  Dr. Lidia Schapira: I really appreciate your perspective. Thank you so much for sharing it with us.   And until next time, thank you for listening to JCO's Cancer Stories: The Art of Oncology. Don't forget to give us a rating or review and be sure to subscribe so you never miss an episode. You can find all of the ASCO Shows at asco.org/podcasts.  The purpose of this podcast is to educate and to inform. This is not a substitute for professional medical care and is not intended for use in the diagnosis or treatment of individual conditions.  Guests on this podcast express their own opinions, experience, and conclusions. Guest statements on the podcast do not express the opinions of ASCO. The mention of any product, service, organization, activity, or therapy should not be construed as an ASCO endorsement.   Show Notes:  Like, share and subscribe so you never miss an episode and leave a rating or review. Guest Bio:  Dr. David Mintzer is a Chief of Hematology and Medical Oncology at the Abramson Cancer Center of Pennsylvania Hospital.  Additional Reading:  Ars Brevis, by Dr. George Sotos

In this episode, host Dr. Aparna Baheti interviews Dr. Bill Julien about the evolution of the outpatient based lab (OBL), its role in expanding patient access to IR care, and its relationship with other IR practice models around the country. --- CHECK OUT OUR SPONSORS Boston Scientific Ranger DCB https://www.bostonscientific.com/en-US/medical-specialties/vascular-surgery/drug-eluting-therapies/ranger.html?utm_source=oth_site&utm_medium=native&utm_campaign=pi-at-us-de_portfolio-hci&utm_content=n-backtable-n-backtable_site_ranger_1_2023&cid=n10012340 BD Advance Clinical Training & Education Program https://page.bd.com/Advance-Training-Program_Homepage.html Philips SymphonySuite https://www.philips.com/symphonysuite --- SHOW NOTES Dr. Julien is one of the initial OBL founders in the United States. In 2001, he started his current practice, South Florida Vascular Associates in an effort to practice independent IR. At this time, he struggled to get hospital privileges due to exclusive diagnostic radiology contracts, so he placed a C-arm in his office out of necessity. Eventually, he built a formal angio suite. As a result, patients enjoyed the efficiency and comfort of office based procedures, and he enjoyed physician autonomy and freedom from hospital politics. Dr. Julien notes that overtime, CMS has recognized the value of an office-based intervention and saw that IRs could practice high-quality care at a lower price point with higher patient satisfaction, leading to improved Medicare reimbursements. Since the conception of his OBL, Dr. Julien has seen practice structures change, especially with the influence of venture capital firms and the pressure to generate RVUs. Additionally, though some voices have pushed for more IR involvement in the clinical sphere, there has not been much progress made in advocating for IR hospital privileges. This is a significant barrier to independent IR practices, since some states require that an IR has hospital privileges before opening an OBL. Dr. Julien says that this dilemma is unique to IR, since other specialties, such as vascular surgery and cardiology, are not affected by exclusive contracts to the same extent. He believes that IR societies and leading voices should actively challenge the legal basis of these contracts and support interventionalists who want to stay independent. We highlight recent SIR and ACR position statements on this topic. Finally, Dr. Julien offers advice to IRs who are seeking to enter the OBL setting. He encourages them to perform and learn from as many procedures as possible, find ways to develop and maintain clinical skills, identify mentors, and ensure that their restrictive covenants are not too stringent. --- RESOURCES South Florida Vascular Associates: https://www.southfloridavascular.com/ Outpatient Endovascular and Interventional Society (OEIS): https://oeisweb.com/ SIR Position Statement on Exclusive Contracts: https://www.sirweb.org/globalassets/aasociety-of-interventional-radiology-home-page/practice-resources/standards_pdfs/exclusive_contracts_policy_final_approved_9-21-15.pdf ACR Position Statement on Exclusive Contracts: https://www.acr.org/-/media/ACR/Files/About-ACR/2022-2023-Digest-of-Council-Actions.pdf Line Monkey MD- “The IR Startup:” https://linemonkeymd.com/the-ir-startup/ Line Monkey MD- “Pseudoexclusive Radiology Contracts:” https://linemonkeymd.com/pseudoexclusive-radiology-contracts-our-downfall/#comment-2087

Discussion topic: Getting paid through the Medicare system Introduction to CPT codes and HICPICS codes Medicare's payment process for healthcare providers Future guests and topics related to Medicare reimbursement Mention of the Aging Here newsletter and interview opportunities Differentiating between CPT codes and ICD-10 codes History and purpose of CPT codes Explanation of RVUs (Relative Value Units) and how doctors are paid Simplified process of submitting CPT codes to Medicare for payment Potential fraud issues in fee-for-service Medicare Importance of documentation and medical necessity for CPT codes Challenges with lack of comprehensive guidelines for new codes Providers struggle with the interpretation and utilization of CPT codes. Some codes are rarely utilized, while others require expertise to maximize billing. Coding rules can be complex, with restrictions on code combinations and frequency of billing. Providers face the risk of financial penalties or legal consequences for incorrect coding. Medicare is a significant payer and requires compliance with its rules. Physicians, nurse practitioners, and physician assistants primarily use CPT codes. Modifiers can be used to bill for additional services or special circumstances. Hospice CPT codes exist separately from Part B coding. CPT codes have RVUs (Relative Value Units) that determine payment. RVUs are divided into work RVUs, which assess the labor involved in a procedure. Work RVUs consider time, technical skill, physical effort, mental effort, judgment, and stress. Work RVUs are subject to negotiation and lobbying each year. The conversion factor translates RVUs into payment amounts. The conversion factor is subject to annual adjustments and can significantly impact reimbursement.

In this episode, host Dr. Aparna Baheti interviews Dr. Bill Julien about the evolution of the outpatient based lab (OBL), its role in expanding patient access to IR care, and its relationship with other IR practice models around the country. --- CHECK OUT OUR SPONSORS Boston Scientific Ranger DCB https://www.bostonscientific.com/en-US/medical-specialties/vascular-surgery/drug-eluting-therapies/ranger.html?utm_source=oth_site&utm_medium=native&utm_campaign=pi-at-us-de_portfolio-hci&utm_content=n-backtable-n-backtable_site_ranger_1_2023&cid=n10012340 Philips SymphonySuite https://www.philips.com/symphonysuite --- SHOW NOTES Dr. Julien is one of the initial OBL founders in the United States. In 2001, he started his current practice, South Florida Vascular Associates in an effort to practice independent IR. At this time, he struggled to get hospital privileges due to exclusive diagnostic radiology contracts, so he placed a C-arm in his office out of necessity. Eventually, he built a formal angio suite. As a result, patients enjoyed the efficiency and comfort of office based procedures, and he enjoyed physician autonomy and freedom from hospital politics. Dr. Julien notes that overtime, CMS has recognized the value of an office-based intervention and saw that IRs could practice high-quality care at a lower price point with higher patient satisfaction, leading to improved Medicare reimbursements. Since the conception of his OBL, Dr. Julien has seen practice structures change, especially with the influence of venture capital firms and the pressure to generate RVUs. Additionally, though some voices have pushed for more IR involvement in the clinical sphere, there has not been much progress made in advocating for IR hospital privileges. This is a significant barrier to independent IR practices, since some states require that an IR has hospital privileges before opening an OBL. Dr. Julien says that this dilemma is unique to IR, since other specialties, such as vascular surgery and cardiology, are not affected by exclusive contracts to the same extent. He believes that IR societies and leading voices should actively challenge the legal basis of these contracts and support interventionalists who want to stay independent. We highlight recent SIR and ACR position statements on this topic. Finally, Dr. Julien offers advice to IRs who are seeking to enter the OBL setting. He encourages them to perform and learn from as many procedures as possible, find ways to develop and maintain clinical skills, identify mentors, and ensure that their restrictive covenants are not too stringent. --- RESOURCES South Florida Vascular Associates: https://www.southfloridavascular.com/ Outpatient Endovascular and Interventional Society (OEIS): https://oeisweb.com/ SIR Position Statement on Exclusive Contracts: https://www.sirweb.org/globalassets/aasociety-of-interventional-radiology-home-page/practice-resources/standards_pdfs/exclusive_contracts_policy_final_approved_9-21-15.pdf ACR Position Statement on Exclusive Contracts: https://www.acr.org/-/media/ACR/Files/About-ACR/2022-2023-Digest-of-Council-Actions.pdf Line Monkey MD- “The IR Startup:” https://linemonkeymd.com/the-ir-startup/ Line Monkey MD- “Pseudoexclusive Radiology Contracts:” https://linemonkeymd.com/pseudoexclusive-radiology-contracts-our-downfall/#comment-2087

From non-competes and relocation to compensation thresholds and parental leave, negotiating your contract can be complicated.  Join Alex, Avery, Biddy, Erin, Jon and Sam as they share their stories, insights and strategies regarding the ins and outs of navigating your contract.  OUR CO-HOSTS Alex Jenny Ky, MD, FACS, FASCRS New York, NY Dr. Ky has been in practice for 22 years and is one of the busiest surgeons in her hospital.  She is a former president of the New York Colon and Rectal Society and currently serves as president-elect of the Chinese American Medical Society.  Married for 29 years, she is the proud mom of 3 children and in her spare time she enjoys playing golf and squash. Avery Walker, MD, FACS, FASCRS El Paso, TX Avery Walker is dually board-certified in General Surgery and Colorectal Surgery. He earned his medical degree at the University of Illinois in Chicago, his General Surgery residency at Madigan Army Medical Center in Tacoma, Washington, and his Fellowship in Colon and Rectal Surgery at The Ochsner Clinic in New Orleans. A former active-duty officer in the United States Army, Dr. Walker served 13 years as a general and colorectal surgeon with his most recent duty station in El Paso, TX at William Beaumont Army Medical Center. While there he was the Chief of Colon and Rectal surgery as well as the Assistant Program Director for the general surgery residency program. He currently practices colon and rectal surgery at The Hospitals of Providence in El Paso, TX. Dr. Avery Walker is married and has two daughters aged 13 and 9.   Biddy Das, MD, FACS Houston, TX (Twitter @BiddyDas) Dr. Bidhan “Biddy” Das has board certifications for both colon and rectal surgery, and general surgery. His passion for medical education and medical process improvement has resulted in book chapters and publications, and national and regional presentations on those subjects. Highlighting his medical expertise on fecal incontinence, he has been featured on patient education videos and national and international television and radio as a featured expert on these colorectal conditions. Dr Das also has a particular interest in surgeons redefining their careers -- he serves as both a software consultant and private equity consultant in Boston, New York City, and Houston.   Erin King-Mullins, MD, FACS, FASCRS Atlanta, GA (Twitter @eking719) Dr. Erin King-Mullins is a double board-certified general and colorectal surgeon. She graduated summa cum laude from Xavier University of Louisiana. After obtaining her medical degree at Emory University in Atlanta, she completed her internship and residency in general surgery at the Orlando Regional Medical Center in Florida. Her fellowship training in colorectal surgery at Georgia Colon & Rectal Surgical Associates concluded with her joining the practice and serving as Faculty/Research Director for the fellowship program until her transition into private practice with Colorectal Wellness Center. She has a husband with whom she shares an amazing, blended family of 4 daughters. The kids keep them pretty busy, but their favorite times are spent on warm sunny beaches.   Jonathan Abelson, MD, MS Arlington, MA (Twitter @jabelsonmd) Dr. Abelson was born and raised in Scarsdale, New York in the suburbs of New York City.  He has 2 older brothers and both of his parents are dentists.  Dr. Abelson went to college at University Pennsylvania, took 2 years off between college and medical school to work in healthcare consulting.  He then went to medical school at University of Virginia, returned to New York for general surgery residency at Weill Cornell on the upper east side of Manhattan.  Dr. Abelson then did colorectal fellowship at Washington University in St. Louis and am now at Lahey clinic in Burlington, Massachusetts for my first job after training.  He is 2 years into practice and has a wife and two sons. His wife works in wellness consulting and they have a dog named Foster who we adopted in St. Louis.   Sam Eisenstein, MD La Jolla, CA  (Twitter @DrE_UCSD) Sam Eisenstein is an Assistant Professor of Colon and rectal surgery and director of Inflammatory Bowel Disease surgery at UC San Diego Health.  He has worked there for the past 8 years after graduating both residency and fellowship at The Mount Sinai Medical Center in New York.  Sam is best known as the founder and organizer of the IBD-NSQIP collaborative, a large multi institutional data collaborative examining outcomes after IBD surgery, but he also is involved in several clinical trials for perianal Crohn's and has extensive experience with stem cell injections for anal fistulae. He is also on the scientific advisory board for the Crohn's and Colitis Foundation for his work on the next big IBD data collaborative, IBD-SIRQC (Surgical Innovation, Research and Quality Collaborative).  Sam has a Wife and 3 kids (6,8, and 3) and spends most of his free time running around after them these days, but also enjoys traveling and getting out into nature with his family.

On this episode of BackTable Urology, Dr. Jose Silva and Dr. Jay Simhan, director of reconstructive urology at Fox Chase Cancer Center, discuss how urologists can demonstrate their value to hospital systems. --- SHOW NOTES First, Dr. Simhan explains the changing nature of urology practice. He opts for the term “health systems urologist” over “private practice urologist” because many urologists are managed by smaller medical groups that are owned by larger hospital groups. He notes that this multi-tiered system of management can cause tension around decision making and increase senior leadership turnover when hospital finances change. Then, Dr. Simhan explains the four ways that doctors can generate value, which is clinical productivity, departmental service, academics or research, and teaching. Clinical productivity is often measured by the RVU system, which assigns a certain number of value units to a procedure. Hospital systems may encourage urologists to choose surgical procedures over office-based procedures to increase RVUs. Although RVUs are arbitrarily set by the Centers for Medicare & Medicaid Services (CMS), each hospital or medical group can increase the number of RVUs per procedure to their own discretion. Dr. Simhan believes that urologists should band together to negotiate fair RVU systems. Finally, they end the episode by discussing concrete ways to demonstrate value as a urologist. Generally, minimizing complications and maximizing RVUs is helpful. Dr. Simhan advises urologists who are joining a new system to build their name and referral network to earn a long term contract. Usually, there is no RVU requirement in the first employment contract. In the later years, he recommends putting in the effort to understand productivity metrics and downstream costs and revenues in order to maximize earnings and potential.

This is a conversation about physician compensation, which is often oddly misaligned from the way that the whole physician or provider organization is getting paid. Now, first thing to point out: There are lots of different kinds of physicians doing all kinds of different things. As with most everything in healthcare, lumping everybody together and making general proclamations about what is best is a really cruddy idea. With that disclaimer, if you think about the main models of physician compensation, there are two; and this is oversimplified, but let's call one fee for service (FFS), which is really getting paid for generating RVUs (relative value units)—in short, getting paid for volume. The more you do (especially the more expensive things you do), the more you get paid. And then we have getting some kind of capitation payment. A capitated payment is some kind of per member per month-ish flat payment to ideally keep patients healthy, and you will make the most money if you can figure out how to have the least volume of expensive stuff. As an individual doc getting a salary to care for a patient panel of a certain size, let's just consider commensurate with that. These incentive models obviously have a big impact on any given doctor's ability to get paid to do things that they think they should be doing. For example, the current fee-for-service RVU fee schedule frequently rewards those doing the stuff a lot of specialists do much more than those doing primarily cognitive work, including those doing work for patients who aren't sitting in the exam room at the time—like a PCP arranging for a patient to go to hospice or answering patient portal questions. In my opinion, the goal here should be to pay docs and others fairly for providing high-value care. These payments also should actually be proven to actually incent that high-value care. Here's the obvious problem: Neither of these two things, either the quantifiable definition of high-value care and/or the best way to pay for it, has any kind of canon. There are no rules which are considered to be particularly authoritative and definitive here, really. So, what is the downside of not aligning physician compensation models to what good looks like, meaning to the kind of care that patients really need in that particular community? A couple of downsides for you: One is moral injury. Not the only reason, but a reason for moral injury is getting paid in misalignment with what is best for patients. That sucks. You want to help your patients as best you can, and then you can't earn a living and/or you get in trouble with the boss if you do what you think is right. This can cause real mental anguish for especially PCPs but also others who see the need to do anything that doesn't have a billing code. Here's another downside to not worrying about physician compensation, and it's for plan sponsors (employers, maybe) who are trying to get integrated care or a medical home for their employees. I was talking to Katy Talento about this. She was telling me that in ASO (administrative services only) contracts, there are often line items for value-based care and for capitated payments. So, good news? Well, let's follow the dollar here, because we wind up with a disconnect that doesn't help patients but certainly can earn a nice little kitty for those who can get away with it. Here's where that dollar goes: This VBC (value-based care) or capitated payment kitty may go to a health system that the ASO says is to be a medical home for employees or plan members. But the PCPs mainly who are treating members in those medical homes are getting paid, it often turns out, fee for service with maybe some quality kickers. So, the plan is paying a value-based care payment, but the PCPs are getting paid FFS. Is anyone shocked when the members report that they don't actually feel like they are getting integrated care, that they are getting rushed in and out because maximizing throughput becomes a thing when you're getting paid for volume? Dan O'Neill also talks about this at length in episode 359, because IPAs (independent physician associations) are doing kinda the same thing. Getting so-called value-based care contracts with MA (Medicare Advantage) plans or CMS or employer groups, I'd imagine, and then paying all the individual practices or the solo practitioners fee for service and scooping up the excess payments themselves, most docs manage to provide high-enough-quality care that the contract holder can scoop up the profit off the capitation without actually having to share the capitation to achieve this high-enough-quality care. In this healthcare podcast, I am digging into all of this physician compensation ballyhoo with Rachel Reid, MD, MS. She was an author on a study at the Center of Excellence on Health System Performance at RAND. This study specifically set out to look at how health systems and provider organizations (POs) affiliated with those health systems incentivize and compensate the physicians who work there. Short version: Yeah, it's confirmed. Most docs are paid using the classic RVU productivity measures representing a big chunk of their compensation, even PCPs. There's frequently some kickers or extra payments to achieve some kind of quality metric, but this is the icing, not the cake. The cake is still very fee for service-y. This is true regardless of how the physician organizations, the provider organizations themselves are getting paid by payers. I asked Dr. Rachel Reid a bunch of questions about this, but one of them was (this seems weird, a weird misalignment), Why is this happening? And Dr. Reid listed out five reasons beyond the macro existential question of what is value and do we even know how to change human behavior to get it. 1. The payment is not big enough from the payer for the physician organization to go through all the time and trouble and risk frankly of changing the whole comp model. 2. The value-based payment arrangements that do exist at the organizational level often have a fee-for-service chassis with an icing of quality payments or some kind of value payment on top of it. So, maybe there's actually more alignment than we might think. 3. It's hard to try to change comp models—it's a thing. And there is risk in messing it up. 4. Inertia. The ever-present inertia. 5. We know what we want to move from, but what exactly are we moving to? And this “What do we want to move to?” is going to change for PCPs and for every single different specialty and could even vary by patient population. I then also asked Dr. Reid what could be done by plan sponsors, for example, to pay docs in alignment with the goals of the contract; and she said, write physician comp expectations into the contract. Something to think about. We dig into all of this today. Shows that you should, for sure, listen to for additional insights include the one with Dan O'Neill (EP359) as aforementioned. Also the show with Brian Klepper, PhD (AEE16), where we dig into how the RUC is behind some of these FFS rates. Also episode 391 with Scott Conard, MD. My guest today is Rachel Reid, MD, MS. She is a physician policy researcher at RAND Corporation and a primary care physician at Brigham and Women's Hospital.   You can learn more about Dr. Reid, her publications, and the work she has done on the RAND Web site.     Rachel Reid, MD, MS, is a physician policy researcher at the RAND Corporation. Also a practicing primary care physician, her research focuses on measuring cost, quality, and value in healthcare. She has particular interest in the primary care delivery system, physician payment and compensation, and delivery and payment system reform. Dr. Reid has been engaged in the RAND Center of Excellence on Health System Performance, assessing health systems' compensation and incentives for physicians, leading work related to assessing low-value healthcare delivery, and measuring primary care spending. She is the principal investigator on an NIH-funded grant assessing novel Medicare billing codes for transitional care provided after hospital discharge. Prior to joining RAND, Dr. Reid worked in the Research and Rapid Cycle Evaluation Group at the Centers for Medicare & Medicaid Services' Innovation Center. Her clinical work has included ambulatory primary care and hospital-based internal medicine. She is an associate physician at Brigham and Women's Hospital and an instructor in medicine at Harvard Medical School. Dr. Reid received her AB in biochemical sciences from Harvard University and her MD and MS in clinical research from the University of Pittsburgh School of Medicine.   07:13 What did Dr. Reid's recent study show about how doctors are currently being paid and incentivized? 08:11 Why Dr. Reid decided to do the study in the first place. 09:49 What are the main foundations of what doctors are paid on? 10:31 Why is value-based compensation still just the “icing” on the cake? 13:08 What is the biggest value add for doctors, and does it vary between specialties? 14:32 Why wouldn't a physician organization change their comp models? 19:55 Are we at a moment of evolution? 20:20 “Tying dollars to measured quality gaps doesn't necessarily produce results.” 20:42 EP295 with Rebecca Etz, PhD. 22:04 “I don't think there's a current gold standard for how to pay doctors.” 25:37 Job one: What are we trying to incent? 31:28 From the payer or insurer perspective, what's the leverage they have to change doctor compensation?   You can learn more about Dr. Reid, her publications, and the work she has done on the RAND Web site.   Rachel Reid, MD, MS, of @RANDCorporation discusses on our #healthcarepodcast how doctors get paid. #healthcare #podcast   Recent past interviews: Click a guest's name for their latest RHV episode! Dr Amy Scanlan, Peter J. Neumann, Stacey Richter (EP400), Dawn Cornelis (Encore! EP285), Stacey Richter (EP399), Dr Jacob Asher, Paul Holmes, Anna Hyde, Dea Belazi (Encore! EP293), Brennan Bilberry

In this episode of BackTable ENT, Dr. Varun Varadarajan speaks with Michael Johnson, a business lawyer, about advice for negotiating academic and hospital employment contracts. --- EARN CME Reflect on how this Podcast applies to your day-to-day and earn free AMA PRA Category 1 CMEs: https://earnc.me/0aliK0 --- SHOW NOTES First, the doctors talk about the RVU system of compensation used by many hospitals and academic centers. They discuss what the price per RVU means and additional bonuses after the expected RVU goal is met. Michael adds that it may be beneficial to negotiate for more resources to earn more RVUs instead of negotiating more compensation, as the former strategy can lead to higher compensation. Additionally, he notes that subspecialty clinicians and surgeons have more leverage to negotiate their contracts if they are the first subspecialists in a large system. He recommends that physicians start negotiating at least a year in advance of their anticipated start date. They also discuss the compensation models based on productivity versus a flat salary. Then, the doctors explain how to handle verbal offers from academic centers. Michael recommends talking to multiple employers at a time when starting the hiring process in order to weigh multiple options. However, he recommends physicians to be upfront about where they are interviewing with each employer. He notes that some academic institutions will send a letter of appointment, and not an employment contract, but physicians can still negotiate for firm deal breakers in the letter of appointment. He then explains different clauses in the contracts, such as restrictive covenants (non-compete and non-solicit clauses), non-disclosure agreements, and malpractice tail insurance. He advises against comparing salary offers to the MGMA compensation data, as different jobs require different obligations. Instead, he recommends making sure that the compensation matches the job obligations. Finally, the doctors end the episode with reviewing common employer tactics, such as pressuring doctors to sign contracts quickly and only offering negotiation on the base salary and signing bonus. Michael explains that it is worthwhile to engage in higher levels of administration in the negotiation process if necessary. --- RESOURCES Michael Johnson's Website: https://www.michaeljohnsonlegal.com/physician-contracts/ Michael Johnson's Instagram: https://www.instagram.com/physiciancontracts/ Episode 45- Private Equity: Savior or Existential Threat? https://www.backtable.com/shows/ent/podcasts/45/private-equity-savior-or-existential-threat

The early 1970's saw the start of the medical specialty we now know as oncology. How does one create standards and practices for patient care during that time? Dr. John Glick is a pioneer during the dawn of oncology. He says that early work involved humanity, optimism, and compassion, all of which were the foundation of his career. Dr Glick describes the clinical experiences that drove him to oncology (4:28), his rapport with patients, which was portrayed in Stewart Alsop's book Stay of Execution (9:21), and his groundbreaking work developing the medical oncology program at the University of Pennsylvania (12:22). Speaker Disclosures Dr. David Johnson: Consulting or Advisory Role – Merck, Pfizer, Aileron Therapeutics, Boston University Dr. Patrick Loehrer: Research Funding – Novartis, Lilly Foundation, Taiho Pharmaceutical Dr. John Glick: None More Podcasts with Oncology Leaders    Oncology, Etc. – In Conversation with Dr. Richard Pazdur (Part 1) Oncology, Etc. – HPV Vaccine Pioneer Dr. Douglas Lowy (Part 1) Oncology, Etc. – Rediscovering the Joy in Medicine with Dr. Deborah Schrag (Part 1)  If you liked this episode, please follow the show. To explore other educational content, including courses, visit education.asco.org. Contact us at education@asco.org.   TRANSCRIPT Disclosures for this podcast are listed in the podcast page. Pat Loehrer: Welcome to Oncology, Etc. This is an ASCO education podcast. I'm Pat Loehrer, Director of Global Oncology and Health Equity at Indiana University. Dave Johnson: And I'm Dave Johnson, a medical oncologist at the University of Texas Southwestern in Dallas, Texas. If you're a regular listener to our podcast, welcome back. If you're new to Oncology, Etc., the purpose of our podcast is to introduce listeners to interesting people and topics in and outside the world of oncology. Today's guest is someone well-known to the oncology community. Dr. John Glick is undoubtedly one of oncology's most highly respected clinicians, researchers, and mentors. I've always viewed John as the quintessential role model. I will add that for me, he proved to be a role model even before I met him, which hopefully we'll talk about a little bit later.   To attempt to summarize John's career in a paragraph or two is really impossible. Suffice it to say, he is to the University of Pennsylvania Cancer Center what water is to Niagara Falls. You can't have one without the other. After completing his fellowship at NCI in Stanford, John joined the Penn faculty in 1974 as the Ann B. Young Assistant Professor. Some five decades later, he retired as the director of one of the most highly respected comprehensive cancer centers in the nation. Among his many notable accomplishments, I will comment on just a few. He established the Medical Oncology program at Penn and subsequently directed the Abramson Cancer Center from 1985 to 2006. Interestingly, he established the Penn Medicine Academy of Master Clinicians to promote clinical excellence in all subspecialties across the health system. He's been a driving force in philanthropy at Penn Medicine, culminating in his role as Vice President Associate Dean for Resource Development.  Over the past several decades, he has helped raise over half a billion dollars for Penn Med. We need you on our team, John. As a clinician scholar, John's research has helped shape standards of care for both breast cancer and lymphomas. For example, he pioneered the integration of adjuvant chemotherapy and definitive breast irradiation for early-stage breast cancer. In 1985, he chaired the pivotal NCI Consensus Conference on adjuvant chemotherapy for breast cancer. He also was a driving force in a clinical landmark study published in The New England Journal some 20 or so years ago about the role of bone marrow transplant for advanced breast cancer. Most impressive of all, in my opinion, is John's legacy as a mentor to multiple generations of medical students, residents, and fellows.   So, John, we want to thank you for joining us and welcome. Thought we might start by having you tell us a little about your early life, your family, your parents, where you grew up, and how you got into medicine. Dr. John Glick: Well, thank you for having me on the podcast, Pat and David, it's always a pleasure to be with you and with ASCO. I grew up in New York City in Manhattan. My father was a well-known dermatologist. He was my role model. And from the age of eight, I knew I wanted to be a doctor. Nothing else ever crossed my mind. But having seen my father's many interests outside of medicine, I realized from very early that there was much more to medicine than just science. And that really induced me, when I went to college, to major in the humanities, in history, art history, and I actually took the minimum number of science courses to get into medical school. That probably wouldn't work today, but it was the start of my interest in humanism, humanities, and dealing with people outside of the quantitative sciences.  Dave Johnson: So that's reflected in how we all view you, John. You're one of the most humanistic physicians that I know personally. I wonder if you could tell us about your interest in medical oncology, and in particular, as one of the pioneers in the field. I mean, there wasn't really even a specialty of medical oncology until the early 1970s. So, how in the world did you get interested in oncology and what drew you to that specialty? Dr. John Glick: Well, I had two clinical experiences that drove me into oncology. The first, when I was a third year medical student at Columbia PNS, my first clinical rotation in internal medicine, I was assigned a 20-year-old who had acute leukemia, except he was not told his diagnosis. He was told he had aplastic anemia, receiving blood and platelets, and some form of chemotherapy. And I spent a lot of time just talking to him as an individual, not just taking care of him. And we became friends. And he was then discharged, only to be readmitted about two weeks later. And in the elevator, the medical assistant had his admission sheet, and unfortunately, it was facing the patient, and it had his diagnosis, acute leukemia. So he came into the ward and he confronted me. "Why didn't you tell me I had acute leukemia?" Well, I couldn't say the attendees forbade me to do that. So I took what today we would call ‘the hit', and apologized. But it stimulated me to reflect that honesty with patients was extremely important, and that oncology was just in its infancy. We knew nothing about it. It was not considered even a specialty. I don't think we used the word "oncology."  But that inspired me to take an elective in my fourth year at PNS, at an indigent cancer hospital called the Francis Delafield Hospital. It only took care of indigent cancer patients, and there were wards, twelve patients in a ward, six on each side, and nobody would go see the patients. It was almost as if they were afraid that if they were to touch the patient, they would get cancer. And I started talking to the patients, and they were human beings, but nobody had told them their diagnosis. Nobody had told them if they were terminal. And there were a few patients who were getting a new drug at that time for multiple myeloma called melphalan, and they actually had relief of some of the symptoms, of their bone pain. But I realized that there was a huge void in medicine that I could possibly help to fill.  And that was the era of Vietnam, and so I applied to the National Cancer Institute to become a commissioned officer in the Public Health Service to avoid the draft, to be on a service with, at that time, some very notable oncologists Vince DeVita, Ed Henderson, Paul Carbone. I had read some of their papers, and I was lucky to be accepted. And I was a clinical associate at the National Cancer Institute. And that was life-changing because there every patient was considered to be potentially curable. The advances at that time using MOPP for Hodgkin's disease, C-MOPP for lymphoma, some treatments for leukemia. George Canellos pioneered the use of CMF for metastatic breast cancer. It was an amazing, amazing experience. That was in 1971 to ‘73. Oncology did not become a true specialty till ‘73, but my two years at NCI were formative.  However, I realized that there was something missing in my training. Everybody was considered curable, but I had never seen a patient with metastatic colon cancer, metastatic lung cancer. The radiotherapists there did not like to teach clinical associates, and I knew that there was a place called Stanford. And Stanford had Saul Rosenberg in medical oncology for lymphomas and Henry Kaplan in radiotherapy. So, everybody was going to California, and my wife and I packed up and went to California and spent a year at Stanford, which, combined with my training at the NCI, led me to the principles that guided my career in oncology; humanity, optimism, reality, compassion, and a love for clinical trials.  I was very, very fortunate to be there at the dawn of medical oncology shortly after I decided to go to Penn, which at that time did not have a medical oncologist. In fact, I was the only medical oncologist at Penn for four years and did every consult in the hospital for four years, much to the chagrin of my wife. But I was fortunate to have great mentors in my career: Paul Carbone, Vince DeVita, Saul Rosenberg, Henry Kaplan, among many, many others. And that impressed me about the importance of mentorship because my career would never have been where it was or is without these mentors. Pat Loehrer: John, just to echo what Dave said, you've been such a tremendous mentor for us. Dave and I particularly, you took us under your wings when you didn't know who we were. We were people in the Midwest. We weren't from any place shiny, but we really appreciate that. Dave Johnson: So, John, I mentioned at the very beginning that I met you before I met you, and the way I met you was through Stewart Alsop's book, Stay of Execution. He portrayed you as an extraordinarily caring individual, and it tremendously impacted me. It was one of the reasons why I chose oncology as a specialty. I realize it's been 50 or more years ago and most of our listeners will have no idea who Stewart Alsop was. And I wonder if you might share with us a little bit of that experience interacting with someone who was particularly well-known in that time as a columnist for The New York Times.  Dr. John Glick: His brother Joe Alsop and Stu Alsop were two of the most famous columnists at that time. Joe Alsop was a hawk right-winger who lived in the Vietnam War. Stewart was charming, was a centrist Democrat, wrote the back page for Newsweek for years. He and I had very similar educational backgrounds and interests. And we functioned on two different levels—one as a physician-patient, and then we became friends. And he and his wife adopted us into the Georgetown set.  And I received a lot of criticism for socializing with a patient. But over the years, I've been able to become friends with many of my patients, and I've been able to compartmentalize their medical care from our friendship. And I use the analogy if I was a doctor in a small town and I was the only doctor,  I'd be friends with people in town, with the pastor and likely the mayor. But I have always believed that patients can become your friends if they want it and if they initiated it.   Taking care of Stewart Alsop was an amazing, amazing experience. We didn't know what he had. People initially thought he had acute leukemia. In reality, he had myelodysplastic syndrome, but that hadn't been described yet. He had a spontaneous remission, which I rarely see, probably due to interferon released from a febrile episode, all his blasts went away in his marrow. One of my children's middle name is Stewart. But professionally and personally, it was an incredible experience. It taught me the importance of being available to patients. They had my home phone number. We didn't have cell phone numbers in those days. We had beepers, but they didn't work. And from that point on, I gave my home phone number to patients, and I actually trained my children how to answer the phone. “This is Katie Glick. How can I help you? My father's not home. You need my father? Can I have your phone number? I'll find him and he'll call you back.” Patients still remember my children and their way of answering the phone. Pat Loehrer: One of the things you did do is create this medical oncology program at Penn, which has graduated some incredible fellows that have become outstanding leaders in our field. But can you reflect a little bit about the process of creating something that was never created before, like a medical oncology program? Dr. John Glick: Well, I came to Penn, my first day. Person who recruited me was on sabbatical. I asked where my office was and there was no office. There was an exam room. There was a clinic for indigent patients which we scrubbed by hand. There was another office for patients who paid. Within two months, I had abolished that. We had one– I hate to use the word clinic, people still use the word clinic today, but one office that took care of all patients, irregardless of means.   I saw every oncology consult in the hospital for four years. But I had a mentor, not only Buz Cooper, but fortunately, Jonathan Rhoads was Chairman of Surgery, and he was also Chairman of the President's Cancer panel. And what he said at Penn in surgery became the law. And then when we introduced lumpectomy for breast cancer and radiotherapy, he endorsed it immediately. All the other surgeons followed suit. I don't think there's any hospital in the country that adopted lumpectomy and radiotherapy for breast cancer as quickly. And the surgeons were instrumental in my career.  Now, I was taking care of gliomas, head and neck cancers, and it was difficult. If I had a colorectal patient, I'd call Charles Moertel at Mayo Clinic and say, “What do I do?” I was there when Larry Einhorn in 1975 presented his data on testicular cancer with the platinum. Unbelievably inspiring, transformational. It also showed the importance of single-arm studies. You didn't have to do randomized studies because the results were so outstanding. And so in my career, I did both single-arm studies, proof of principle studies, and then many randomized trials through the cooperative groups.  But the first four years were very difficult. I didn't know what the word ‘work-life balance' meant in those days. If somebody was sick, I stayed and saw them. It was difficult introducing new principles. When I first mentioned platinum after Larry's presentation, I was laughed out of the room because this was a heavy metal. When patients were dying, they died in the hospital, and I wanted to hang up morphine to assist them. The nurses reported me to the administration. I had to fight to get the vending machines for cigarettes out of the hospital. So there were a lot of victories along the way and a lot of setbacks.  It took me several years to have an oncology unit of six beds, and now I think we have 150 or 160 beds and need more. So it was an interesting and, in retrospective, a wonderful experience, but I didn't know any better. Fortunately, I had a great wife who was working at Penn and then at Medical College of Pennsylvania, and she was incredibly understanding, never complained. And I think my kids knew that on Tuesdays and Thursdays, don't bring up anything difficult with dad because he's had a really tough day in clinic. Dave Johnson: We were not in that era, but we were very close. And many of the struggles that you had were beginning to dissipate by the time we were completing our training. But it was still a challenge. I mean, all those things. I gave my own chemotherapy for the first few years I was in practice. I don't know that our colleagues today who have trained in the last, say, 10 or 15 years, actually realize that that was what we did. Most of the chemo was given in the hospital. It was not uncommon in the early days to have 20, 30, 40 inpatients that you would round on because there just wasn't an outpatient facility. But the corporate mind made a big difference, allowing us to give drugs like platinum in the outpatient arena. You span all of that era, and so you've seen the whole panoply of change that has taken place.  John, the other thing you did that has impressed me, in part because of my time as a Chair of Medicine, is you created this Academy of Master Clinicians. Can you tell us a bit about that and what was the motivation behind that?  Dr. John Glick: Ben had a strategic plan, and one of the pillars was talking about valuing clinical medicine and clinical excellence. But there was no implementation plan. It was sort of just words and left in the air. And I was no longer director of the cancer center, and I realized we had a lot of awards for research, awards for education, and no awards for clinical excellence. So I created the idea of having an academy and master clinician spend six months talking to all constituencies, chairs of various departments, directors of centers to get a buy-in. Wrote a three-page white paper for the dean, who approved it immediately. And then, as typical at Penn, I raised all the money for it. I went to one of my patients who was an executive at Blue Cross. I said I need $500,000 to start this program. And then subsequently, I raised $4 million to endow it. Today, it is the highest honor that a Penn clinician can receive.  You could be on any one of our multiple tracks. You have to see patients at least 60% of the time. You not only have to be a great doctor, you have to be a humanist. So the world's best thoracic surgeon who has a demeanor in the operating room that is not conducive to working with a nurse as a team doesn't get in. We emphasize professionalism, mentorship, citizenship, teaching, national reputation, local reputation, and clinical excellence. And so we've elected over 100 people, maybe 3% of the Penn faculty. We give an honorarium. We have monthly meetings now by Zoom. We have monthly meetings on various topics. We never have a problem getting any dean or CEO to come talk to us.  We were the first to do Penn's professionalism statement. The school subsequently adopted, and it's become the highest honor for a Penn clinician. It's very competitive. It's peer-reviewed. The dean has no influence. And we're very proud that 40% of the members of the academy are women. We have a high percentage of diversity compared to the numbers on our faculty, but you really have to be elected on merit, and some people that you might expected to be members of the academy aren't. It's one of the things I'm proudest of. It will go on in perpetuity because of the money we've raised. I think many of my accomplishments as a researcher will fade, as they typically do, but I'm very proud of the Academy, and I'm very proud of the people that I've mentored. Dave Johnson: It speaks to your values, John, and I think it's one of the reasons why you're so widely admired. Thank you for creating that. It proved to be a model for other institutions. I know that for a fact. One would think that valuing clinical care would be preeminent in medical schools, but in fact, it's often ignored. So again, I know that your colleagues at Penn appreciate your efforts in that regard.  Tell us a little about your term as ASCO president. What are you most proud about and what were your most difficult challenges? Dr. John Glick: Well, the most difficult challenge was that ASCO was in transition. I had to fire the company that ran the meeting. We had to decide that ASCO was going to hire a CEO. We hired John Durant, made a small headquarters, tiny staff, and did a lot of the work as being chief operating officer myself. It was the year that email was just getting started, and ASCO wasn't using it. So every Saturday from 8:00 to 6:00, I came into the office and my secretary wrote letters inviting people to be on the program committee or various committees. But it was a society in transition. The growth of membership was huge. The meeting sites had to be changed. We emphasized science. Some of the things that we did are still in existence today.  We formed the ASCO ACR Clinical Research Methods course. It's still given. That's one of our real highlights. We forged relationships with other societies, the National Coalition for Survivorship. We made the ASCO guidelines much more prominent. And I remember that we were going to publish the first guidelines on genetic testing for breast cancer, and the MCI went up in absolute arms, so I arranged a meeting. I was at the head of the table. On my right were Francis Collins, Richard Klausner, Bob Wittes, and a few other people. Then the ASCO people who wrote the guideline were on the left, and they didn't want us to publish it. They thought it was premature to have a guideline about genetic testing. And what I learned from that meeting is that you can agree to disagree with even the most prominent people in oncology and still maintain those relationships. But we did what's right, and we published a guideline on the JCO. There were so many wonderful things that happened at ASCO that I can hardly restate all that happened I guess 27 years later. It was exciting. ASCO was still young. There was a lot we had to do, and we could do it. You could just go ahead and do it. It was exciting. It was gratifying. It was one of the most fun years of my life. Dave Johnson: I mean, that transition from an outside company in many respects, controlling the premier activity of ASCO, its annual meeting to ASCO, taking that on, that defined ASCO, and that's what I remember most about your time as president. It was a bold move, and the hiring of John Durant was brilliant. I mean, he was such an incredible individual, and it was great that you guys were able to pull that off. Pat Loehrer: Thank you for what you've done.  You've had a number of your mentees if you will, and colleagues that have gone on to prominent positions, including, I think, at least three directors of NCI Cancer Centers. Can you just talk briefly how you would describe your mentoring style because you've been so successful? Dr. John Glick: First, there are two aspects. One is when people come to you, and then when you go to people, you sense they're in need. The key aspect of mentoring is listening. Not talking, listening. Looking for the hidden meanings behind what they're saying, not telling them what to do, presenting options, perhaps giving them clues on how to weigh those options in pros and cons, being available for follow-up. Mentoring is never a one-time exercise. Not criticizing their decisions. You may disagree with their decision, but it's their decision, especially if they've considered it. Being proud of the mentee, being proud of their accomplishments, following them over the years. And when they've gotten in trouble or failed to get the job that they wanted, always be there for them, not just in the good times, but in the times that are difficult for them professionally. I think that's one of the most important things.  Even today, I mentor three or four clinical department chairmen, and people ranging from full professors to newly appointed assistant professors. Now that I'm retired, mentoring is the one activity that I've really retained. It's extraordinarily satisfying, and I'm proud of the people that I've mentored. But it's their accomplishments, and the key aspect of mentoring is never to take credit. Dave Johnson: I'll give you credit for mentoring me, and I appreciate it. You were very instrumental at a very decisive point in my career when the old Southeast Cancer Group disbanded, and we were looking for a new cooperative group home. And you were instrumental in helping my institution come into the ECOG fold, and not just as a very junior member, but really as a player. And I'll never forget that, and we'll always appreciate that very much. Pat Loehrer: Ditto on my side, too. Dave Johnson: John, you mentioned that you're retired. What do you like to do in your "free time” if you're not mentoring? Dr. John Glick: Life is good. My daughter says I have a disease, O-L-D. My grandson says, “He's not old; he's almost 80. Look how well he's done.” “Here's $20.” I'm having fun. We are fortunate to have homes in different places. We spend the summer up in the Thousand Islands on the St. Lawrence River, spring and fall down in Charleston, then lots of time in Philadelphia. We travel. I play golf poorly. I'm getting a chance to read history again, go back to one of my great loves. I'm with my children and grandchildren more. I lost my first wife. I've been remarried for about twelve years, and I'm enjoying every moment of that. I'm not bored, but I do wake up in the morning with no anxiety, no realization that I have to herd sheep or herd cats. I have no metrics, I have no RVUs,  not behind of the EMR.  Dave Johnson: You're making it sound too good, John.  Dr. John Glick: We're having fun. And I have not been bored. I've not been down in the dumps. Each day brings a different aspect. We see a lot more of our friends. I exercise. I deal with the health problems that people get when they get older, and I have plenty of those. Seeing doctors takes a lot of time, but I'm grateful that I'm having these few years of retirement. I'm one of the people who is most fortunate to have attained everything they wanted to do in their professional life, and now I'm trying to do some of the same in my personal life. Dave Johnson: John, Pat and I both love to read. We love history. You mentioned that you're reading some history. Is there a book that you've read recently that you might recommend to us? Dr. John Glick: “the Last of the Breed” {With the Old Breed} It's about a private in the Pacific campaign who was not a commissioned officer; it's just a grunt on the ground. It brings the horrors of the Pacific island campaigns to life. But there's a huge number of books, some historical fiction. I'm a great fan of Bernard Cornwell, who's written about the Medieval times, Azincourt, 1356. I'll read two or three books a week. I'm devoted to my Kindle. Dave Johnson: If you could go back in time and give your younger self a piece of advice, what would that advice be?   Dr. John Glick: Try and achieve more of a work-life balance. I didn't have any choice. If I didn't do the consult, it didn't get done. That's not the situation today. But I have a second piece of advice, don't treat medicine as a 9 to 5 job. If a patient is sick, stay with the patient. Give the patient your home or cell phone number. Remember, medicine is not just a profession, but it can be a calling. Too few of our physicians today regard medicine as a calling. And even if you're employed, as most of us are by an academic or other institution, do what's right for the patient, not just what's right for your timesheet or the EMR. Remember that the patient is at the center of all we do and that medicine is a calling for some people, as it was for me. Dave Johnson: Great advice, John. Great advice.  Well, I want to thank Dr. Glick for joining Pat and me. This has been a delight. You're one of our role models and heroes.  I want to thank all of our listeners of Oncology, Etc., which is an ASCO educational podcast where we will talk about oncology medicine and other topics. If you have an idea for a topic or a guest you'd like us to interview, please email us at education@asco.org. To stay up to date with the latest episodes and explore other educational content of ASCO, please visit education.asco.org. Thanks again. Pat, before we go, I've got an important question for you. I've been trying to school you recently, and you've failed miserably. So I'm going to ask you, why is it that McDonald's doesn't serve escargot? Pat Loehrer: I can't do it. I don't know. I give up.  Dave Johnson: It's not fast food. Pat Loehrer: I like that. It's good.  The purpose of this podcast is to educate and to inform. This is not a substitute for professional medical care and is not intended for use in the diagnosis or treatment of individual conditions.   Guests on this podcast express their own opinions, experiences, and conclusions. Guest statements on the podcast do not express the opinions of ASCO. The mention of any product, service, organization, activity, or therapy should not be construed as an ASCO endorsement.    

How do you get paid for what you do, and why is it so complicated? Healthcare more than any other industry has a huge amount of complexity in how its professionals get paid for services they have rendered. Join me for this episode on reimbursement where we break down exactly how you get paid through your insurance contracts, and how your work is valued by payers.Link to CMS site referenced in this episode: https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeeSched/PFS-Relative-Value-FilesPurchase your copy of Jill's book here: Physician Heal Thy Financial Self Join our Medical Money Matters Facebook Group here: https://www.facebook.com/groups/3834886643404507/ Original Musical Score by: Craig Addy at https://www.underthepiano.ca/ Visit Craig's website to book your Once in a Lifetime music experience Podcast coaching and development by: Jennifer Furlong, CEO, Communication Twenty-Four Seven https://www.communicationtwentyfourseven.com/

Dr. Shannon Westin and Dr. Stephanie Graff discuss a revision to the famous "Simone's Maxims" and the broader nature of intersectionality. TRANSCRIPT The guest on this podcast episode has no disclosures to declare. Dr. Shannon Westin: Hello, everyone, and welcome to another episode of JCO After Hours, where we get in-depth on articles that have been published in the Journal of Clinical Oncology. I am your host, Shannon Westin, a GYN Oncologist, and Professor at MD Anderson Cancer Center, and I'm honored to serve as the Social Media Editor of the Journal of Clinical Oncology. Today, we're going to be discussing the very important work called “Understanding Modern Medical Centers: Beyond Simone—Intersectional Maxims for a New Era.” And this was published online in the JCO on September 27th, 2022. And joining me to discuss this important work is Dr. Stephanie Graff, who is the Director of Breast Oncology at the Lifespan Cancer Institute at the Warren Alpert Medical School, Brown University. Welcome, Dr. Graff. Dr. Stephanie Graff: Thanks so much for having me. It's going to be fun to talk about this piece with everyone. Dr. Shannon Westin: Yeah. It's a great piece of work. And before we start, I will just note that all participants have noted no conflict of interest for this manuscript. So, let's get down to it. I want to level set. What were Simone's Maxims, that you just revised, and why did they matter? Dr. Stephanie Graff: Yeah. So, Dr. Joseph Simone, who is a legend in oncology, and our revision of his work is truly in respect of what he did, not in any way meant to be anything less than that. So, in 1999, Dr. Simone published, in Clinical Cancer Research, this piece that would famously come to be known as Simone's Maxims, and the official title was, “Understanding Academic Medical Centers.” And that list of, you know, sayings and circulated truths have really sort of been this commonly quoted list of things that people talk about in medicine as just the truth of what it takes to sort of cut it, if you will, in the world, especially in academic medicine, but just medicine in general. Like, one of the famous ones is "Institutions don't love you back." And I think that you've probably heard these and maybe not even realized that you were quoting or hearing Simone's Maxims, but they're pretty ubiquitous in the world of academic medicine and, in particular, oncology, because Joseph Simone was an oncologist. He actually went on to write a book. There's a text called Simone's Maxims as well that's much longer than the Clinical Cancer Research piece. We didn't have a book in us yet, so we just started with updating the original manuscript. Dr. Shannon Westin: That's so great. And it's so funny when I was younger--I don't know if I'm still young or not, but there was things that we said, and I had no idea where they came from. So, I bet that a lot of our listeners are saying the same things, like, "Oh, that's a Simone's Maxim." So, I guess the question is now why did your group set out to update these? Dr. Stephanie Graff: I think if you look at the list of authors, a bunch of the authors have had recent career changes. And so, it actually started as just sort of this casual conversation about how for many of us who have recently undergone career changes, that some of these maxims don't hold true for us. The list of authors is a group of very intersectional physicians in our identities--and I know you'll ask me a question in a moment here about what exactly intersectional means. But, you know, I think that Dr. Simone wrote Simone's Maxims at a time when Medicine was more homogeneous, and so, some of the Maxims that he wrote represent the more traditional values of medicine, what medicine looked like in 1980, in 1990. And I think medicine in 2022, 2023, 2033 is just continuing to evolve and change shape. And so, it's important that we reframe the truths of what it takes to foster a successful career, create successful working environments for the modern workforce. Dr. Shannon Westin: I think this is so critical, and we're seeing it across a number of different fields, not just medicine. We're seeing it in politics and policy and other places. So, why don't you just make sure that all our listeners do understand this concept of intersectionality and how it applies, you know, in medicine and feminism and other areas? Dr. Stephanie Graff: Yeah. And that--shout out to our co-author Edith Mitchell. Dr. Mitchell very quickly said, "Well, we have to start the manuscript by defining intersectionality if we're going to include it in the title because a lot of the readers won't even be familiar with the concept of intersectionality." So, it's included there in the maxims. Intersectionality was first introduced in 1989, and the definition is this nature of social categories, like race and class and sex and gender and the way that they overlap, so that I'm not just white or Christian or a farmer's daughter or a woman, but I'm all those different things, and that creates my intersectional identity. And obviously, there are millions of different intersectional identities, because we have all of these different facets of our personality, of our identity, that come together. And as medicine gets more diverse, which I believe makes us stronger, we'll see more and more complexity in the intersectional personalities, intersectional identities, of the people working in healthcare. Dr. Shannon Westin: Thank you. I couldn't have said it better myself. You know, the other question that comes up as we start seeing more diversity in our workforce, and I mean, frankly, in our patient population, how do you think that that understanding about diversity and the accentuation of our diversity helps improve the success of medical organizations? Dr. Stephanie Graff: Oh, gosh. There's like a million examples. I think that-- ah, Shannon, there's so many different examples I can quote. So, I think that you know, there's a study that looked at patients coming into the emergency department having heart attacks. And if they were female patients cared for by female doctors or female patients cared for by male doctors, that had an impact on their risk of death. Not surprisingly, it was the women patients cared for by male doctors that were the most likely to die and the female patients cared for by the female doctors that were the most likely to live, telling us that when there's this concordance, this understanding between patient and physician, that it improves outcome. But that could be corrected if the male physicians had more female partners. So, just that understanding of relationships, that exposure to more people, more female physicians, increased male physicians' ability to care for female patients or communicate with female patients, it just increased confidence, our collective confidence. And that's been proven in other settings too. But that's just one sort of great example. The McKinsey group has shown how financial performance improves with gender diversity and ethnic diversity. And that's been shown, not just in healthcare, but in numerous different business environments. And if we think about, you know, as an oncologist, as a clinical researcher, if I imagine that innovation is improved by diversity, imagine that translating into better clinical trial outcomes with a more diverse workforce. And the outcomes that the McKinsey group show, ethnic diversity drove a 35% improvement in financial performance, which is huge. And again, that's at a time when the oncology workforce is really struggling with everything from, you know, recruitment to trials, staffing, revenues. That would be enormous if we could derive that sort of performance. So, I think that there's a million different ways to illustrate what diversity could do, whether it's make us better or stronger or more confident or provide better care, and it's been shown in a million different ways, in a million different contexts. Dr. Shannon Westin: Well, you're convincing everyone, I know. I think we'll get into some of the kind of more nitty-gritty details of the manuscript. I want to be very clear; I think all our listeners should absolutely 100% read the entire manuscript because it's so critical. But let's try to hit some of the major high points. And I say this all the time, and I'm going to take your line, but which one's your favorite? What do you think is the most important one? Just like you would totally tell me which of your children is your favorite, right? Dr. Stephanie Graff: I can't possibly pick a favorite. That's completely impossible. I really like--one of the Maxims that we have is, "Everyone's time and voice is valuable. Institutional leaders must respect time and encourage diversity of thought." Originally, Dr. Simone had a maxim that said, "Members of most institutional committees consist of about 30% of people who work despite other pressures and 20% who are idiots, status seekers, and troublemakers." And we changed that to say, again, "Everyone's time and voice is valuable. Institutional leaders must respect time and encourage diversity of thought," as a way of saying that, you know, I think that in 2022 and beyond, we're getting to a place where it's important that we find better labels for people than idiot and troublemaker and that we reach beyond that to identify how we can help everyone find an environment to be successful and that we fill the working corners of our cancer centers, the working corners of our hospitals, healthcare systems, clinics, with the people that are excited about the work that needs to be done. And, you know, not all of us are gonna want to run clinical trials. Not all of us are going to want to do quality improvement projects. Not all of us are going to want to do five straight days of clinic. Not all of us are going to want to do--insert the day-to-day grind of whatever it is that needs to get done to make a cancer center function. But somebody somewhere loves that little thing. And it's important that we work together to accomplish what needs to be done for best care of the patients that we're honored to take care of. And so, we have to respect that time, respect that voice, and work to connect people with the thing that drives them. Dr. Shannon Westin: I think that one, how you just ended there, kind of touches on one of the ones that really grabbed my attention, which was the original maxim that was, "Leaders are often chosen primarily for characteristics that have little or no correlation with successful tenure as a leader." And instead, as an intersectional maxim, you all changed it to, "Leaders should be chosen for their ability to inspire." That really spoke to me because it's exactly what you said.  That leader has to work to inspire people to do what they love within each piece of that, you know, department or division or hospital or organization or whatever. You can't expect everybody to do the same cookie-cutter thing, but help inspire people to be behind the mission and do what they love as part of moving that hospital organization forward. I thought that was really perfect. Dr. Stephanie Graff: Yeah. And we've too often seen, you know, in academic medicine especially, that we equate a really high h-index or a really successful history of grant funding with leadership. And those aren't the same skills, right? Like, you could be a really fantastic researcher and not a really great person at organizing a team of people to run a cancer center. And you might have both skills, in which case, wow, congratulations. But I think that it's important that we look at the job in front of us and select for that, rather than assuming that all of the same skills fill every single job because that's just not true. Dr. Shannon Westin: I think that, again, I know I said this already, listeners, but please, please run, don't walk, to read the whole paper and get more information. On our last note, one of the things I really loved about this paper was you really provided some clear reforms really to help improve physician wellness. Can you maybe summarize some of those reforms that could improve intersectionality within healthcare organizations? Dr. Stephanie Graff: Yeah. Those are all in Table 2. So, again, I hope you guys all grab the paper and give it a download and pin them up somewhere and think about them. I think that some examples are, you know, to really promote intersectionality, which means that you've got a lot of diversity in characteristics across your cancer center, which is going to be things like gender, race, introverts, extroverts, researchers, clinicians. You really have to have very clear metrics that are shared and discussed. And so, you might need to publish benchmarks for things like median RVUs or come up with a group incentive structure, so that whether you're a person who is in clinic less and publishing more or in clinic all the time and publishing less, you can work together to be flexible collectively, and then everybody can be contributing to that greater team environment. I think it's really important that if you want to grow intersectionality, that your search committees and your leadership interview strategy undergoes unconscious bias training. There's still not really great strategies to make sure that we're 100% pursuing a no-bias environment in our workplace, but there is evidence that unconscious bias training can be effective to help us recruit a more diverse workforce. And that's the simplest strategy - is if you're going to be putting a search committee together, have everybody do an implicit bias training and work together to select candidates that don't necessarily fit what feels like your traditional mold, and then find strategies, once you've hired into your organization, to partner your new employee, new physician, new hire, for maximum success in that workplace. Another important thing is, as you're growing diversity in your organization, is to make sure that you're creating opportunities to give everybody a voice. You should be looking at who's being invited to speak and making sure that that's representative and diverse. You should be considering changing up strategies. One of the examples I often give is that, when we have a problem and we do brainstorming, where you bring everybody in a room and they shout out, "This is what I think we should do," what happens is you get the loudest extrovert or the most powerful person at the table who just gets their way. And it's far more effective to do brain writing, where you have everybody write down the three or five or 10 things that they think might work, and then you read those out in a neutral way, because then, everybody's voice and everybody's idea gets equal play in a neutral way that allows you to elevate those ideas independent of the other bizarre, irrelevant hierarchies that may exist in your system and can really elevate some of those diverse voices and ideas in your organization. Those are just some of the examples that are listed. Dr. Shannon Westin: Yeah. Listeners, there's a ton of very clear frameworks that you could potentially implement tomorrow in your organization if you want to strive to improve the intersectionality. Well, the time always goes so fast. It has been so great to speak with you, Dr. Graff. Thank you so much for being here. Dr. Stephanie Graff: It's such an honor. I hope everyone gives it a read and comes up with the next iteration and update together with us. Dr. Shannon Westin: Perfect. So, again, readers and listeners, this was, “Understanding Modern Medical Centers: Beyond Simone—Intersectional Maxims for a New Era,” published online in the Journal Clinical Oncology, on September 27th, 2022. And we are so thrilled that you came to listen to JCO After Hours. Please go check us out on the website and see what other podcasts you've missed.   The purpose of this podcast is to educate and to inform. This is not a substitute for professional medical care and is not intended for use in the diagnosis or treatment of individual conditions. Guests on this podcast express their own opinions, experience, and conclusions. Guest statements on the podcast do not express the opinions of ASCO. The mention of any product, service, organization, activity, or therapy should not be construed as an ASCO endorsement.  

October 28, 2022Mark and Scott discuss the Day 1 agenda for the Urology Coding and Reimbursement Seminar what we included and why it's important right now. Urology Advanced Coding and Reimbursement Seminar Day 1 Agenda8:00 PreService/Front Office: Strategies to promote, maintain, and enhance optimal front office workflow - How to make the Front Office work for you.10:15 E/M 2023 Interactive Session: Making sense of the new rules to maximize efficiency and productivity.12:00 Lunch - Optimizing patient place of service-clinic, ASC and inpatient1:00 Annual Update - Medicare Policy: How upcoming Medicare changes will affect your practice operations and revenue.2:00 Global Package and Modifiers: Getting paid more for what you already do3:15 The Business of Urology: Coding, Billing, and Business Metrics, RVUs, Productivity Measurement, Market Trends, Contracting, Private Equity, QHP CompensationUrology Advanced Coding and Reimbursement Seminar  - Registration OpenLas Vegas, NV - December 2-3, 2022New Orleans, LA - January 27-28, 2023Register NowCompliance PlansQuestions or need help, please send us an email: info@prsnetwork.comJoin the discussion:Urology Coding and Reimbursement Group - Join for free and ask your questions, and share your wisdom.Click Here to Start Your Free Trial of AUACodingToday.com 

We all know that there is a tension between being the empathetic physician that you want to be and getting your charts done so you don't stay at the office until 9pm. We also know that patients hate it when their doctor never looks up from the computer. Is there anything we can do?We can't get rid of RVUs or fix the whole healthcare system (at least not today), but there are a few very effective techniques for fostering connection with our patients without upending our whole schedule. Here are six techniques that will supercharge your connection with your patients without adding time to your visits.Reach out anytime!Dr. Chiaramontewww.integrativepalliative.com Do you wish that you had more tools to give great care to your patients with complex or serious illness? A new CME program will be starting soon that will give you the skills and confidence that you're looking for to help your most challenging patients. Sign up and I'll let you know when the next course is open: https://trainings.integrativepalliative.com/tiipm-keep-in-touch. Programs will also be starting soon for loved ones of people with serious illness. Sign up at the link above if you'd like to know when registration is open.Please review this podcast wherever you listen and forward your favorite episode to a friend! Thanks for helping me spread the word about heart-centered care for people with complex and serious illness.

This episode discusses how neurologists are undervalued in academic and non-academic settings when their compensation is predicated on RVUs alone. Neurologists, particularly in certain disciplines, generate enormous economic advantages for their institutions that need to be recognized, appraised, and valued.

Show Notes - All Things Afib - Episode 17 (16) - Medicare Cuts!!!! with Dr. Brett Gidney Medicare is slashing reimbursement for AFib procedures during a time of record-setting inflation and an increasing number of patients (currently 6 million) suffering from AFib. From an RVU (Relative Value Unit) of 26.44 in 2021, the payment is being reduced by FORTY PERCENT to 15.88 in 2023. AFib is becoming more and more widespread, in fact, there are predicted to be 20 Million AFib patients by 2050. Afib can often be fixed very easily, REDUCING the burden on the healthcare system, as likelihood of stroke, dementia, and other morbidities are reduced by AFib management. There are only 1500 EPs in the U.S. right now, and Medicare cuts are actually DE-INCENTIVIZING more doctors from entering this specialty, because they cannot get fairly compensated for their work. Did you know Medicare pays the same amount for an EP to sit in their office and read 3 echocardiograms, as they would get to do a complex AFib procedure/operation?! Join me and my guest Dr. Brett Gidney to discuss how and why these cuts are happening, and what you can do today to join the fight to reform these Medicare payments. Dr. Brett Gidney is a cardiac electrophysiologist leading the charge to reform Medicare payments to EPs. He practices throughout the central coast of California from Thousand Oaks up to Santa Maria. He is board certified in clinical cardiac electrophysiology focusing on complex cardiac arrhythmia management. Dr. Gidney spends the majority of his time in the hospital setting performing procedures, such as cardiac ablation, to treat abnormal heart rhythms. He is particularly interested in very low or no radiation exposure facilitated by 3D mapping and ultrasound technologies. All Things Afib is hosted by me, Dr. Armin Kiankhooy. As a board-certified cardiothoracic surgeon, my focus is on advanced treatments for heart and lung failure and minimally-invasive surgical treatments for atrial fibrillation such as the Hybrid Maze procedure. You can find me on staff at Adventist Health Heart and Vascular Institute in St. Helena California. Discussion points: ● Dr. Brett Gidney introduction● The reduction of RVUs– 2021 to 2023 – reduced 40% - bundling/cuts● EP is a tiny specialty, only 1500 in the US today● AFib procedures REDUCE the burden on the system● Who is advocating for these cuts? The RUC and it's role● Affect on caseloads/day to day practice● De-valuing physician services vs. equipment costs● Will this be the spark that leads to the formation of lobbying groups?● 501(c)6 vs. 501(c)3● Reduced access to underserved populations● The EPAdvocacy.org foundation will soon be up and running● Reach out to your congressperson and senator, let them know we need reform! Resources: Dr. Brett Gidney LinkedIn Dr. Brett Gidney Twitter Find Your Representatives Dr. Kiankhooy LinkedIn All Things AFib Website All Things AFib Twitter All Things AFib YouTube Channel

Matt Spraker joins us to talk about details of what an actual attending job in Radiation Medicine looks like, RVUs, medical director roles, etc. Earn free CME by reflecting on the content of this episode: https://earnc.me/E9XHPi www.becktamd.com Twitter: @drbeckta --- Support this podcast: https://podcasters.spotify.com/pod/show/radmed/support

In part two of this two-part ASCO Education podcast episode, host Dr. Jeremy Cetnar (Oregon Health & Science University) continues the conversation with Drs. Lauren Abrey and Jason Faris, whose careers have criss-crossed academia and industry. They share words of advice for trainees today. If you liked this episode, please subscribe. Learn more at https://education.asco.org, or email us at education@asco.org. TRANSCRIPT Dr. Jeremy Cetnar: Hello, and welcome to Part 2 of the ASCO Educational Podcast episode focused on career choices and transitions. My name is Jeremy Cetnar. I'm a Medical Oncologist and Associate Professor of medicine at Oregon Health and Science University in Portland. In Part 1, Dr. Lauren Abrey and Dr. Jason Faris about their motivations for pursuing medicine, and how they arrived at the different positions they've had. Today, we'll further explore career fulfillment, maximizing impact on patient care, and differences between working in academia and industry. Dr. Faris, what have you learned from the different roles you have had, and what aspects of your current work do you find most rewarding? Dr. Jason Faris: So, there's a lot to discuss here. In my academic and patient care roles, I felt extremely privileged to forge strong bonds with patients and their families, to offer support, counseling and hope in the context of making really difficult, challenging decisions... to rejoice in the individual victories, whether that was clean scans and normal tumor markers after adjuvant therapy for Stage III colon cancer, using the neoadjuvant therapy in locally advanced pancreatic cancer and watching them go to resection, helping to maintain quality of life by addressing key symptoms that a cancer patient unfortunately must endure, and providing emotional support when things do not go as hoped. Whereas the latter times in GI cancer patients are unfortunately all too common. And the moments or clinic visits where the cancer has recurred, or the treatments aren't working really do take their emotional toll on clinicians. I'll just say I took many of those losses personally. And as a general rule in medicine, I tend to wear my heart on my sleeve, which can be a mixed blessing. But that shared sense of purpose and the many times where you were able to offer something meaningful to patients and families provided real fulfillment and joy. I think at the time of the two transitions I've had, this was fundamentally the most difficult part for me, which was relinquishing these direct patient care interactions. So, another highly rewarding part of my role in academia was working with colleagues to open clinical trials or conduct clinical research. I had opportunities to be mentored by or collaborate with multiple people Ted Hong, Dave Ryan, Chin Wu, Jeff Clark, David Ting, and others at Mass General, as well as Lionel Lewis, Konstantin Dragnev, and Steve Leach at Dartmouth. Treating patients on clinical trials was always a stressful enterprise but highly rewarding, and I had the chance to be part of some really amazing groundbreaking trials at MGH, in some cases witnessing breathtaking responses in patients who were out of treatment options, in some cases for many months. Another highly rewarding aspect of my role in academia or my roles in academia involved all of the many opportunities to engage in teaching and mentoring, whether that's with medical students, residents, or fellows, where the enthusiasm for helping patients and learning was always infectious. Finally, I'd be remiss not to mention the wonderful nurse practitioners that I've worked with like Patty Tammaro at Mass General, with whom I cared for many GI cancer patients for years, and Elizabeth McGrath at Dartmouth, whose wisdom and dedication to patient care was really inspiring. On the industry side, on the NIBR side, I've had the opportunity to work on novel therapeutics that are making a bench to bedside transition from a drug candidate to a first in human Phase 1 trial, which to me is a thrilling, complex, and highly fulfilling endeavor that contributes critical knowledge to advance the field. And in the best of cases, identifies therapies that has the potential, that have the potential to alter the prognosis for thousands of future patients. As a clinician or clinical investigators, those times where your patients are responding to their treatment, whether it's on or off a clinical trial are wonderful and so incredibly rewarding. And I would argue that there's a similar phenomenon in running trials in industry, where there's nothing quite as magical as having a cadre of patients who had run out of treatment options, enrolled to a clinical trial designed based on compelling science, go on to experience sustained and significant responses. I absolutely love the commitment to patients and to follow the science, the collaborations among our teams, and interactions with our academic colleagues which I really treasure. I'm part of a team whose responsibility is to ensure the development of a clinical protocol to safely evaluate the potential of that therapeutic, carefully monitor for adverse events, evaluate the emerging pharmacokinetic and pharmacodynamic data, and most fulfilling of all, begin to observe responses in patients whose cancers had progressed on standard of care therapies. So I think the chance to have an opportunity to explore new therapeutics that might impact the eventual treatment of thousands of people with cancer is what keeps me engaged and fulfilled. It's been a wonderful opportunity and applies the clinical skills and patient focus from my prior roles and combines this with the resources and expert teams to run and analyze clinical trials. Dr. Jeremy Cetnar: If I can opine a little bit and ask you guys some philosophical questions. I think what I'm hearing today and what I've heard from other folks who have made that transition is that in industry versus academics, you work in a team, and you're evaluated as a team. And that's very different than in academics. You're very much rewarded for, whether it's patient volume or number of papers or leadership. That seems to me like a very big difference in terms of academic versus industry. And I'm wondering if you guys can comment on that a little bit more. Then you guys also mentioned, at least you just mentioned this, Dr. Faris, is that some will also say that when you go into industry, you're able to just impact a much bigger population of folks rather than typically in an academic setting where you are working one on one with patients. And yes, you have your IETs and whatnot, but there's just a bigger vision. Would you say that those are two accurate differences that are fairly significant, Dr. Abrey? Dr. Lauren Abrey: Yes. You are certainly part of a team. But I think if we're honest, you're part of a team when you're in the hospital. So I ran the team of research nurses. I ran the fellowship program. I needed people to manage the patients who were in-patient and to help me look after the clinical trial conduct paperwork, etc. and so I think that does translate into the setup that you find when you move to industry. It may be a little bit that your personal success, and industry can get very sometimes focused on metrics, like what have you contributed? What has the team been successful? So you do need to think about how to set yourself up for success. If you're leading the team, how do you set the team up for success? To me, that doesn't feel terribly different than academic medicine, but I could see where it could be a change depending on what your role was in the academic world. So I think that's reasonable. The other part of what you said, I struggle with that sometimes. I feel like we tell ourselves, that we're impacting more patients. And I think that's true. If we get a drug approved, and potentially that drug is used, not only in the US, but across western countries, in Europe, potentially in China, you get a sense of that. But it's like how do you feel that? You feel the story of an individual patient. Sensing the scale can be hard. News media know this well. They often tell the story of a particular person in the Ukraine right now to try to help us understand the scale of the war, because otherwise, it's a little impossible to digest. So for me, that doesn't always resonate. I think it resonates when I go out and talk to the different physicians practicing in different parts of the world. And I think that has been an incredibly eye-opening experience for me being in the global organization, is seeing the impact well beyond the US, because I think most companies are very indexed on the US. And we understand US practice well, but I think understanding the impact we can have across the world is also really inspiring, humbling, challenging, and something I think we all have to contend with because it's not the same everywhere. So yes, no, and in between, that's where philosophical lives, so thank you. Dr. Jeremy Cetnar: Yeah. Well, that's a fascinating perspective, the international perspective. Very interesting. Dr. Faris, how about you? Dr. Jason Faris: I completely agree with Lauren. I think on the team question, I definitely feel like we worked on teams in academia as well, whether we're talking about the multidisciplinary groups that are needed to take care of GI cancer patients, which always involves multiple specialties. I think at MGH, in particular, we would tend to go see the patient as a group, which is a bit unusual, to try to get everyone's schedules aligned, to be able to go into the room together. But it really presented an opportunity for the patient and the families to ask questions of us as a group and hear any disagreement that's in the room between the providers right there. There's absolutely a ton of teamwork that goes into taking care of patients. But what you were alluding to, I think, is also right, which is your promotion, your opportunities for advancement are sometimes couched on or developed from accomplishments on the individual side. And I would say more so than is true in industry. I think that's correct as well. I mean, certainly there are multidisciplinary grants that I was a part of, of course, publications that had multiple authors to which I was a contributing author. Sometimes I was first or last author, sometimes I was in the middle, but contributing to the paper. So there was teamwork there, but no question that there's an element of individual accomplishment. How many first- and last-author publications do you have? What's the grant situation look like in terms of ability to supplement the RVUs that you need to generate your clinical…? There's no question that there's an element of that that's not a present to the same degree in an industry role. And I just wanted to speak to the impact side, because I also agree with what Lauren said here. I think the idea and the hope is that in industry, we have an opportunity to potentially affect the lives of many, many, many patients, thousands of patients potentially, with a given cancer type if a new therapy is a homerun and takes off and is approved. That's a huge draw and I think something that motivates all of us is to be a part of something like that. But of course, not every drug, far from it, unfortunately, is going to end up as an approved drug that impacts thousands of patients. So I think it requires some recognition of that fact and patience and continuing to work on multiple projects, and always under the prism of doing the right thing for the patients while those trials are open. And I think that's the key, as well as working on scientifically exciting projects, really proud to say in NIBR that we follow the science. If there's an indication to be explored, based on the science, it may not be the most common indication in cancer, but if the science leads us to that place, that's what we work on. I think that decision making gets tougher, obviously, as you move through the system into a later stage, more commercially informed decision. But I think and certainly on the early phase trials side, that's something that's really exciting. I think on the academic side, taking direct care of patients, you have incredible impact on individual patients, and there's a lot of individual patients. I think you have tremendous opportunity for impact there as well, and your impact can be measured by those that you mentor and teach as well, the committees that you serve on influencing other trials that may be open at your institution. So I would in no way suggest that the impact is less in academia. I don't think that's true at all. I think it's just a different approach. And it is true that if you're lucky enough to work on a program in industry that ends up being an approved drug, you can help thousands of future patients or your team has helped thousands of future patients. That's also true when you're on the academic setting, serving as a PI, contributing safety data and efficacy data, really giving the best information back to the sponsor that you can or maybe you're running your own investigator-initiated study that can change a standard of care down the road. So that's the homerun. That's kind of the Grand Slam of situations that might develop as a medical oncologist on either side of the divide. Dr. Jeremy Cetnar: Thank you. I'd like to shift gears just a little bit and ask you, for people who are deciding for a transition in their career, what are some characteristics or skills or other attributes that you think would make one successful in industry? What are some things that are really, really important to be successful? And that might be different than in an academic situation or not? I'm not sure. And maybe that's another question is, you know, what are some of the things that make people successful in a career in industry? Dr. Abrey? Dr. Lauren Abrey: So I think there are so many things that you can do in industry that depending on what your strength is, I think you have the opportunity to play to that. So again, I think if you are very entrenched in the science, and that is really what makes you want to get out of bed in the morning, being in the early research group, whether it's Novartis, Roche, other companies or small biotech, you can really dig in and spend time thinking and contributing in incredible ways. And if you're the person who is much more interested, perhaps in finding out, what's influencing the patterns of care and why people are using certain drugs or certain treatment paradigms, you could absolutely work on the absolute other end and work in medical affairs and be the person who's out there, who's the critical partner to whether folks at MGH, OHSU, major cancer centers around the world, to figure out how do we bring those two together. And I think the group in the middle typically, like the drug development group that's getting the approval, so running the large Phase 3 studies, that requires people who are in it a little bit for the long haul. Those tend to be large studies. They run over several years, you're constantly looking at the incoming data, and yet you're blind to the results. So you have to be pretty diligent while you're in that space and willing to just buckle down and work hard. But I think there are things for everyone. And I think it's a little bit similar to what I discovered when you went into medicine. Not everybody's going to be a cardiothoracic surgeon. Only a few of us end up in this weird oncology space. But I think it does give you the chance to reinvent yourself and explore a few things. So I wouldn't say you have to have something. I think probably what you should do is talk to a lot of people. I think people make a lot of assumptions about what a change to a career in industry is or means. And you probably don't know what you don't know. So call people like me or Jason or someone who's done it and talk to people, because I think that's probably the best way you can make an informed choice. Dr. Jeremy Cetnar: What do you think, Dr. Faris? Dr. Jason Faris: Can I offer some advice? So are we in this kind of advice section? Dr. Jeremy Cetnar: Absolutely. Please do. Dr. Jason Faris: Yeah. So I would say my advice to oncology trainees would be to keep an open mind and stay flexible. I've got a Wayne Gretzky quote that I'd like to bring into this here, which is 'You miss 100% of the shots that you never take'. And I feel like I've probably taken that flexibility to a bit of an extreme with my career path and transitions. But ultimately, it's really enabled me to experience diverse career opportunities that I might otherwise not have had the chance to really experience. I think sometimes there can be assumptions or negative stereotypes about moves from academia to industry. But my own personal experience, now twice, at NIBR has been overwhelmingly positive. I've learned a tremendous amount from both environments, which I think provides me with a different perspective on design, conduct, and analysis of clinical trials and allows me to bring a patient-centric view into clearer focus in my industry role. I think it's also really critical to recognize that there are significant stressors and positives to each of these career paths. And they're not necessarily one way. I know multiple colleagues who have made a transition from academia to industry. Other colleagues like me who did return to clinical practice in a clinical investigator role or returning from industry to an academic lab, I've seen that happen multiple times, and multiple colleagues, of course, that have transitioned to other industry roles. So regardless of which path someone ultimately pursues, the real critical thing to me is to remember what brought us to medical school in the first place, which is a commitment and focus to patients above all else. I believe this can be achieved in many career options, direct patient care, teaching and mentoring, clinical investigator roles in the academic setting, or in industry by collaborating with academic colleagues and patient groups, focusing on programs that have high potential to advance treatment options for diseases with high unmet medical need. I happen to think GI cancers are the poster child for that, but you know, I'm a bit biased, and designing trials that are as patient-centric as possible. So that's the kind of advice that I would offer to people is not to think of these as mutually exclusive or there's only one way forward or if I make this decision, it's irreversible. I don't think any of those things are true. And I feel like I'm living proof. Dr. Jeremy Cetnar: Dr. Abrey, back to you. Any advice? Dr. Lauren Abrey: I can only agree with Jason, and I know a number of people who've gone in both directions, including some who have been in pharma for quite a long time, and then make a decision to go back to patient care. Sometimes, I'm going to say, like as a final career chapter, but it has been a bit like that, including in countries where it's quite difficult to return to practice, that they need to go back and redo some training. So I think, move forward, do things that make you want to get out of bed in the morning, and that probably will change over the course of your career. But I think don't be afraid to try something because the worst thing that could happen—that's always a good question to ask yourself, right? What is the worst thing that could happen? If it doesn't work out, you can probably make another choice. I also think you should, you know, I already said talk to lots of people. But pay attention to that network that you have and nurture it, cultivate it, because some of those people in your network might become mentors at some point, might become advocates or sponsors at some point. And always, always, always take the opportunity to mentor somebody else, including if you're young, do some reverse mentoring. I have gotten some of my best mentoring from somebody that I agreed to mentor, but he really ended up reverse mentoring me. And he's actually now leading a very small biotech and you could argue has leapfrogged part of my career. And that's a fantastic dialogue that I get to have. So, great fun. We only go around this once. So have some fun while you're doing good things, too. Dr. Jeremy Cetnar: Ain't that the truth? And I'll tell you, this is a small world. It does feel like the more people you talk to, all of a sudden, we all are connected. And so I just want to thank you, Dr. Abrey, Dr. Faris, for your time today, for your perspective, your interesting stories. And to all the listeners, we appreciate you tuning into this episode of the ASCO Education podcast. Dr. Jason Faris: Thank you very much.   Thank you for listening to the ASCO Education podcast. To stay up to date with the latest episodes, please click subscribe. Let us know what you think by leaving a review. For more information, visit the Comprehensive Education Center at education.asco.org. The purpose of this podcast is to educate and to inform. This is not a substitute for professional medical care and is not intended for use in the diagnosis or treatment of individual conditions. Guests on this podcast express their own opinions, experience, and conclusions. Guest statements on the podcast do not express the opinions of ASCO. The mention of any product, service, organization, activity, or therapy should not be construed as an ASCO endorsement.  

Sara Schaefer gets into the details of relative value units (RVUs)- where they come from, how they are calculated, and how they are used in billing, insurance reimbursement, and physician compensation- with Marc Nuwer, Neurophysiology Department Head at UCLA and member of the CPT and Relative Value Update Committee (RUC) Advisory Panels, and Rohit Marawar, Assistant Professor of Neurology at Wayne State University.

How ChenMed is Changing the Currency of Primary Care Dr Faisel Syed, National Director for Primary Care at ChenMed, shares some provocative thinking about addressing primary care from outside the fee-for-service model. The currency of healthcare delivery right now is billing more in order to generate more RVUs. Learn how ChenMed's full-risk model and moral vision are leading them to honor seniors with affordable VIP care. All that, plus the Flava of the Week about the lessons that Jared learned from the Creator Economy Expo. What can healthcare learn from content entrepreneurs? Find all of our network podcasts on your favorite podcast platforms and be sure to subscribe and like us. Learn more at www.healthcarenowradio.com/listen/

Dr Faisel Syed, National Director for Primary Care at ChenMed, shares some provocative thinking about addressing primary care from outside the fee-for-service model. The currency of healthcare delivery right now is billing more in order to generate more RVUs. Learn how ChenMed's full-risk model and moral vision are leading them to honor seniors with affordable VIP care. All that, plus the Flava of the Week about the lessons that Jared learned from the Creator Economy Expo. What can healthcare learn from content entrepreneurs?  Thanks to Persado for spreading the awesome, yo! Persado provides healthcare organizations with pre-developed, pre-optimized marketing messaging focused on improving health goals and business objectives. (#214)  See omnystudio.com/listener for privacy information.

Do you ever feel like the medical system is gaslighting you? “Thanks for being a healthcare hero – now go generate more RVUs!” We need to change the martyr physician culture that we all grew up in that taught us that we don't need to eat or pee or sleep. We need to nurture ourselves out loud! We need to take our vacation proudly and support our peers when they prioritize their own wellness.  Let's change this crazy culture together.Come join our community! Sign up at www.tiipm.orgWhen your patient is crying do you know just what to do? Can you confidently help patients manage anxiety or pain without controlled medications? Come learn with Dr. Chiaramonte and improve your integrative symptom management skills!- evidence supported patient care skills- self care for you- patient resources for your office- group case-based discussionswww.integrativepalliative.com/training

Last week's show was with Wayne Jenkins, MD, from Centivo; and we talked about how insurance design, when not done well, can lead, in a nutshell, to mental and physical health problems for employees. This is a great lead-in to the conversation in this healthcare podcast with Dan O'Neill. And before I get into why it's a great lead-in, let me just start here—and don't roll your eyes. What is value-based care? Consider this delineation: There's value-based payments, and then there's the type of care that these payments incentivize. You would hope that a value-based payment would result in care that was of value (ie, great patient outcomes and patient satisfaction at a fair total cost of care). But those are two distinct things—the payment and the care. If we change the payment model but the provider behavior doesn't change in a way that actually improves patient outcomes and care, then what are we doing here? Or the converse: If we do not change the payment model, then how does anyone expect the care paid for is going to change? Employers or carriers who just meander along with the broad PPO network happily paying as much for low-value care as for high-value care and happily paying centers of excellence as much as non–centers of excellence … how is a provider who wants to spend time and money building out a practice to deliver better patient outcomes, how can they do that without overcoming some pretty fundamental business model challenges? This whole concept is one that my guest today, Dan O'Neill, has talked about and will talk about in this episode. Dan says the first step is for insurers, IPAs, managed care organizations to take an absolute chainsaw to their network management bureaucracy. There must be a clear door to a value-based payment model. It must be that if you're a provider or you're a physician practice (primary care practice, in particular), and you want to go down a value-based care path, there has to be a clear door and a pathway for you. I think I have a non-perfect litmus test for anybody with a value-based payment program who wants a heuristic to check if their value-based payment program is actually meaningfully impacting models of care in the marketplace: If most of the provider organizations who are part of that value-based program still incentivize and pay their doctors using FFS incentives like RVUs (relative value units), I'd step back and think about that for a piece. Contemplate that doctors, who are responsible for care decisions, still have every incentive to do everything that they would have done had the provider organization just been paid FFS. What's the point of value-based payments that extract exactly zero behavior change? And that is not a rhetorical question. So, back to the conversation from last week with Dr. Wayne Jenkins citing all of the things that can go horribly wrong when an employer's benefit designs are misaligned with the financial realities of their workforce. You get what you pay for, and I don't just mean that in terms of the dollars outlaid, since we all know in healthcare prices and quality have nothing to do with each other—I mean, in terms of what you choose to pay for and how you choose to pay for it. That's the macro of this whole thing, but indulge me as I get into the micro for just one sec. Let me just remind everybody about Goodhart's Law: “When a measure becomes a target, it ceases to be a good measure.” More on the why of this in the interview with Rishi Wadhera, MD, MPP, on the hospital readmission reduction program (EP326) and also what happens when we don't adhere to Goodhart's Law as we evaluate PCPs, which Rebecca Etz, PhD, talks about in EP295.   In this episode with Dan O'Neill, we go through where we're at on the continuum of value-based payments and how those payments are impacting the care, value-based or otherwise, that is incentivized by those payments. We tick through four gradations of value-based payments: A pure volume contract (otherwise known as FFS [fee for service]) A clinician bonus for achieving quality measures A piece of the savings (ie, MSSP [Medicare Shared Savings Program]) Global risk My guest, Dan O'Neill, is chief commercial officer over at Pine Park Health. Besides over a decade in healthcare tech and services, he was a policy fellow at the National Academy of Medicine and worked in the Senate on the Senate Health Committee. You can learn more at dponeill.com or connect with Dan on LinkedIn. Daniel O'Neill, MA, MS, currently serves as chief commercial officer for Pine Park Health, a value-based primary care group that delivers on-site care in senior living communities. Prior to that, Dan was a health policy fellow at the National Academy of Medicine, working primarily in the US Senate on legislation focused on surprise billing, anti-competitive contracting practices in the commercial market, and price transparency. Dan has also worked as a senior vice president with Change Healthcare and as an advisor to venture-stage healthcare services and technology firms. At Pine Park, Dan is responsible for risk-based contracting with IPAs and insurers and for the group's participation in CMS value-based care models, including direct contracting. Dan's research is available in NEJM Catalyst and on the Health Affairs blog, and he holds graduate degrees from Johns Hopkins University and Stanford University.   05:06 What is the spectrum of value-based contracts? 07:24 Why don't value-based contracts at the organizational level always trickle down to the provider level? 11:25 What are the two things that need to happen to drive outcomes in value-based healthcare? 15:24 How do insurers play into improving value-based contracts? 19:46 “There's a strong case to actually clamp down on prices.” 23:47 “Right now, we're still in a place where if you want to do something other than fee for service … you have to fight like hell.” 24:03 What's the first step to making value-based contracts more accessible? 24:27 What's the second step to making value-based contracts accessible? 25:23 Why are the incentives to change American healthcare pretty weak? 27:10 “Organizational change is just exceedingly difficult.” 28:45 What should you do if you want to start pushing organizations toward value-based contracts? 32:42 EP351 with Eric Bricker, MD.  You can learn more at dponeill.com or connect with Dan on LinkedIn. @dp_oneill discusses #vbc on our #healthcarepodcast. #healthcare #podcast #valuebasedpayments #digitalhealth What is the spectrum of value-based contracts? @dp_oneill discusses #vbc on our #healthcarepodcast. #healthcare #podcast #valuebasedpayments #digitalhealth Why don't value-based contracts at the organizational level always trickle down to the provider level? @dp_oneill discusses #vbc on our #healthcarepodcast. #healthcare #podcast #valuebasedpayments #digitalhealth What are the two things that need to happen to drive outcomes in value-based healthcare? @dp_oneill discusses #vbc on our #healthcarepodcast. #healthcare #podcast #valuebasedpayments #digitalhealth How do insurers play into improving value-based contracts? @dp_oneill discusses #vbc on our #healthcarepodcast. #healthcare #podcast #valuebasedpayments #digitalhealth “There's a strong case to actually clamp down on prices.” @dp_oneill discusses #vbc on our #healthcarepodcast. #healthcare #podcast #valuebasedpayments #digitalhealth “Right now, we're still in a place where if you want to do something other than fee for service … you have to fight like hell.” @dp_oneill discusses #vbc on our #healthcarepodcast. #healthcare #podcast #valuebasedpayments #digitalhealth What's the first step to making value-based contracts more accessible? @dp_oneill discusses #vbc on our #healthcarepodcast. #healthcare #podcast #valuebasedpayments #digitalhealth What's the second step to making value-based contracts accessible? @dp_oneill discusses #vbc on our #healthcarepodcast. #healthcare #podcast #valuebasedpayments #digitalhealth Why are the incentives to change American healthcare pretty weak? @dp_oneill discusses #vbc on our #healthcarepodcast. #healthcare #podcast #valuebasedpayments #digitalhealth “Organizational change is just exceedingly difficult.” @dp_oneill discusses #vbc on our #healthcarepodcast. #healthcare #podcast #valuebasedpayments #digitalhealth What should you do if you want to start pushing organizations toward value-based contracts? @dp_oneill discusses #vbc on our #healthcarepodcast. #healthcare #podcast #valuebasedpayments #digitalhealth   Recent past interviews: Click a guest's name for their latest RHV episode! Dr Wayne Jenkins, Liliana Petrova, Ge Bai, Nikhil Krishnan, Shawn Rhodes, Pramod John (EP353), Pramod John (EP352), Dr Eric Bricker, Katy Talento, Stacey Richter (INBW33), Stacey Richter (INBW32), Dr Steve Schutzer (Encore! EP294), Lisa Trumble, Jeb Dunkelberger, Dr Ian Tong, Mike Schneider, Peter Hayes, Paul Simms, Dr Steven Quimby, Dr David Carmouche (EP343), Christin Deacon, Gary Campbell, Kristin Begley, David Contorno (AEE17), David Contorno (EP339), Nikki King, Olivia Webb, Brandon Weber  

Alex Kirkland and Matt Jensen join Mark to talk about the latest evaluation and management code updates to the Medicare Physician Fee Schedule. The Centers for Medicare and Medicaid Services (CMS) decreased the conversion factor for evaluation and management (E/M) codes for 2022.     Podcast Information Follow our feed in Apple Podcasts, Google Podcasts, Spotify, Audible, or your preferred podcast provider. Like what you hear? Leave a review! We welcome all feedback from our listeners. Email us questions on any of the topics we discuss or questions about issues that interest you. You can also provide recommendations on matters for future episodes.  Please email us: feedback@cokergroup.com Connect with us on LinkedIn: Coker Group Company Page Follow us on Twitter: @cokergroup Follow us on Instagram: @cokergroup Follow us on Facebook: @cokerconsulting   Episode Synopsis CMS increased the RVUs for which they reimburse outpatient E/M services and decreased the conversion factor to remain budget neutral. The conversion factor cuts will affect reimbursement for all services in the fee schedule to increase reimbursement for more cognitive E/M services. Organizations with RVU-based compensation plans need to revalue their wRVU rates to remain economically aligned with the fee schedule, especially if their provider compensation plans tie to wRVU values in the most recent Medicare Physician Fee Schedule. Click to listen to the episode.   Extras 2022 E/M Coding Calculator How the CY 2022 PFS Final Rule Affects Split/Shared Visits and Critical Care Services

In part one of a two-part conversation, Oncology, Etc. hosts Patrick Loehrer (Indiana University) and David Johnson (University of Texas) have a blast speaking with two physician astronauts. Hear the incredible stories of Drs. Robert L. Satcher (MD Anderson), Ellen Baker (MD Anderson), and their lives on and off this planet. If you liked this episode, please subscribe. Learn more at https://education.asco.org, or email us at education@asco.org. TRANSCRIPT Patrick Loehrer:  Hi, I'm Patrick Loehrer. I'm Director of Global Oncology and Health Equities at Indiana University. Dave Johnson: My name's Dave Johnson. I'm at UT Southwestern in Dallas. Patrick, we're excited to be back for another segment of ASCO's Educational Podcast, Oncology, Etc. We have two very special guests today, Drs. Ellen Baker and Robert Satcher, oncologist and former astronauts. So I predict this will be an out of this world segment. Patrick Loehrer: It's starting out pretty slow right now, with that one. Thank you though.  Dave Johnson:  Well, listen, this should be a great segment. But before we get started, do you have a favorite astronaut book?  Patrick Loehrer:  Well, the one I read this summer was called American Moonshot by Douglas Brinkley, and it basically took the story of John F. Kennedy and how the space race happened from 1960 and actually earlier than that, into getting onto the moon. It was really, I thought very extraordinary.  Dave Johnson:  So, I haven't read that yet. My favorite would be Rocket Boys by Homer Hickam. I thought that was a fantastic book about his life growing up in West Virginia and ultimately, becoming a NASA engineer and rocket scientist. So that was really great. Patrick Loehrer:  I read that several years ago after you recommended it. They made a movie out of that.  Dave Johnson:  Yeah, I think October Sky was the name of the movie. Yeah. >Patrick Loehrer: Yeah, it's a terrific book. Dave Johnson: Well, why don't we introduce our guests? You want to start with Dr. Baker?  Patrick Loehrer: Oh, sure. It's my pleasure to introduce Dr. Ellen Baker. I have known Ellen over the years through interactions in global oncology. She was born in Fayetteville, North Carolina, graduated from Bayside High School in New York, got a bachelor of arts degree in geology from the State University at Buffalo. A doctorate in medicine for Cornell, masters in public health at UT Public Health, and then trained in internal medicine at UT San Antonio. And during her residency, she decided to join in the NASA program as a medical officer. And it was actually, she did a residency around the same time I did, and I remember the space call for astronauts at that time. She was selected as an astronaut in may of 1984, had a variety of jobs. She's logged more than 680 hours in space and has been a mission specialist. She retired from NASA in 2011 and is Director of the MD Anderson project, Echo Program in which he does projects in rural Texas, as well as Zambia, Mozambique, in Central and South America. It's such a great pleasure to have you here today, Ellen.  Dr. Ellen Baker:  Thank you, Patrick.  Dave Johnson:  Our other guest is Dr. Robert Satcher, currently an Associate Professor in the Department of Orthopedic Oncology Division of Surgery at MD Anderson, as well. Dr. Satcher grew up in Hampton, Virginia. He's the son of a university professor and English teacher, so I'm sure they made him do all of his homework. He received a bachelor degree, as well as a PhD in chemical engineering from the Massachusetts Institute of Technology and received his MD degree from Harvard. By the way Patrick, Dr. Satcher enrolled at MIT at age 16 and graduated at the top of his class. Later, we'll find out what you were doing at age 16? Patrick Loehrer: I do have to interject that I was a mechanical engineer at Purdue, and it's like being in high school compared to chemical engineers. Dave Johnson: Yeah, there's a hierarchy in the engineering world for sure. Dr. Satcher's medical degree was followed by internship and residency in orthopedic surgery at the University of California, San Francisco. In addition, he did a post doc research fellowship again at MIT and University of California, Berkeley. And completed a fellowship in muscular skeletal oncology at the University of Florida, before joining the faculty at Northwestern in Chicago. You guys have a lot of connections it seems? Not satisfied with that massive amount of education and training, Dr. Satcher went on to NASA to train as an astronaut, culminating in a flight aboard the space shuttle Atlantis in November of 2009. Apparently, he got a little bored cooped up in the shuttle because he took a couple of space walks, which I'd like to know more about. In fact, I read on NASA's website that he did some lubricating on one of his walks. I'm not sure what that's about, but I assume there's not a lot of gas stations in space. I also read that he repaired one of the robotic arms, which seems perfect appropriate for an orthopedic surgeon. You'll have to tell us more. Anyway, while these achievements would be enough for most people, it only begins to scratch the surface of the many accomplishments of Dr. Satcher's career to date.  I really can't cover it all, but our audience should know that Dr. Satcher's has been involved in a number of community activities, as well, ranging from his involvement in Big Brother for Youths at Risk, counseling program, to serving as a lay minister in his church. He's also undertaken a number of medical mission trips to underserved areas in countries, such as Nicaragua, Venezuela, Nigeria, and Gabon, where he once served as a Schweitzer fellow at the Albert Schweitzer Hospital in Lambaréné. Dr. Satcher, welcome to Oncology, Etc., we very much appreciate your joining us. Dr. Robert Satcher: Thanks Dave. Glad to be here. Dave Johnson: Perhaps I'll start by asking the two of you, if you could give us just a little bit about your background, other than what we've stated and what got you interested in medicine and how you got interested in space? Dr. Baker, maybe we'll start with you? Dr. Ellen Baker: I've always been interested in space. I was a child of the '60s, and I think one of the very memorable parts of the '60s was the US Space Program. It was a fairly tumultuous decade in the US, I think otherwise, and the space program was really literally a shining star. However, there were no girls in the space program at that time. Right? There were no girl astronauts and so I thought about it, but it didn't seem like it was even possible. I come from a family of medical people. My mother was a nurse, my father was a doctor, my brother is a doctor, and so that had a lot of influence, I think, in my choosing to go into medicine. And in fact, my brother is an oncologist and though I am actually not an oncologist, I've been hanging around with him long enough that some people think I'm an oncologist. So I think that's what got me pointed in that direction. Dave Johnson: Your brother is Larry Schulman, by the way, right? Humanitarian of the Year Award from ASCO, a couple years ago. Dr. Ellen Baker: It is, yes, and he is a great humanitarian. I was actually at my last year of medical school when I saw a little article in the New York Times that NASA was selecting new astronauts and women and minorities were urged to apply. And I kind of filed that away and went off to do my medicine residency and at the end of my residency, I applied to work for NASA as a physician. And that's how I got to Houston and to Johnson Space Center. Dave Johnson: Dr. Satcher, what about yourself? Dr. Robert Satcher: I got interested in space and being an astronaut when I was a kid too, and I was watching astronauts land on the moon. And I was sitting there listening what Ellen was saying and yeah, it was a time where all the astronauts were of course, white males and I didn't see myself there walking on the moon, but I knew it was something that I would really like to do, but didn't really see a way either, at the time. So it really was with the shuttle era that women, people from underrepresented groups finally had the opportunity to become astronauts. And right around the same time too, was when I was starting as an undergraduate at MIT and had the good fortune of meeting Ron McNair, who got his PhD from MIT. And that was the first time I ever saw someone who looked like me, who was an astronaut and that planted the seed that maybe I could do that one day. I also come from, as you mentioned, a family that values education and we've got a number of physicians in our family. Most famously my uncle, Dr. David Satcher, who was Surgeon General of the Clinton Administration. And I always remember, this is a funny story I like to tell if he's listening. When I was going around getting advice on whether or not I should stick with medicine or think about applying to become an astronaut, he advised me just to stick with medicine. So didn't take his advice, this is the one time I didn't, but I did take his advice, in terms of going to medical school. And I wound up applying to become an astronaut, right actually, before the Columbia accident and so they actually paused taking astronauts for a number of years. And in those years, actually that's when I went to Northwestern and was on faculty there. So they opened it up again and that's when I submitted my application and I was in Chicago and was selected from there. Dave Johnson: There's a number of questions that spill off from that. You guys may know David Wolf, who's an astronaut, who's from Indiana University. I had him in my clinic when he was a medical student and as I always do, I basically say, "What do you want to do when you grow up?" And he said, "I want to be an astronaut." And I just smiled and I don't think I ever went back in the room with him, I just figured, "This guy is a flake, what's going on with him?" And I think he's logged more space miles than just about anybody, he's an incredible human being. And again, if he's listening, you're terrific. David. Patrick Loehrer: I just have to ask this as a boyhood thing, because I did contemplate being an astronaut because I was an engineer and MD just like you were Ellen and so were you Bobby. But it hit me, one is, you have not to be afraid of heights, I think. And then, you have to be willing to go around in a circle a thousand times a minute and not throw up. But in the training there, did any of that stuff bother you or was this no big deal? Dr. Ellen Baker: That sounds a little like Hollywood and not so much like the real thing, actually. In the early days of the space program, they did put astronauts in rotating chairs. I'm not exactly sure why? But we don't do that anymore. I would say that the training is rigorous, but it's not unreasonable. I don't know what you think, Bobby? It's fairly predictable. And I will put a little shout out for Purdue, which maybe has one of the highest number of astronauts of any university outside the military academies. I don't know if that's true now, but 10 or 15 years ago, we just had a large number of engineers from Purdue who were in the astronaut office. Dr. Robert Satcher: I agree, the training is not quite how it's portrayed sometimes in the media. The question I get asked from my doctor friends a lot, "I guess you can't be claustrophobic going into space because you're in the space capsule." And that really does deter a significant number of people, probably more than myself or Ellen appreciate because I'm always surprised when I get that question. Dave Johnson: But I'm 100% sure I couldn't be an astronaut if claustrophobia is an issue because I can't stand to be in an elevator. Dr. Ellen Baker: Let me step back a little, I don't want anybody to get discouraged. But you'd be surprised at how many pilots have a fear of heights if they're not encased in an airplane. So fear of heights is not necessarily something that you might worry about if you're an astronaut. And I disagree with you Bobby, I don't think space vehicles are claustrophobic. It's not like being in a submarine, which I would find very claustrophobic. Particularly in the shuttle because we actually had great windows and great views and we didn't feel confined. I don't know what you think Bobby, but I didn't think it was like being in a cave or closet or a submarine. Dr. Robert Satcher: Yeah, I definitely agree with that, the views are spectacular. Patrick Loehrer: So William Shatner just went up and had a brief stint in space and is now considered an astronaut, but he came back with such a sense of awe. Can you describe a little bit what it's like, the view from up there and how does it leave you, particularly your first time up in space? Dr. Robert Satcher: The words don't completely capture it. The colors are so vivid, the view is so breathtaking. It's really impressive seeing the Earth, not only at daytime, but at nighttime and it goes beyond. It's one of a few things I always tell people, that really exceeded my expectation, in terms of what my preconceived notion of what it would be. And ever since going, that's what's so addictive about going into space, it makes you want to go back just to see that again and experience it again. The closest that I've come to seeing anything like that is, they have these new virtual reality experiences, where they actually got footage that they shot in high-def on the space station, outside the space station. It comes close, in terms of the look but it still doesn't fully capture it because the colors and everything, aren't as clear and crisp as it is when you're there. Because you're in the vacuum of space and there's nothing interfering with it and it's just spectacular. Dr. Ellen Baker: Yeah. I'll jump in here too and I absolutely agree with Bobby. And the other thing is, you orbit the Earth every 90 minutes, so you cover a lot of ground and you see a lot of the planet and in that one orbit, you get a sunrise and a sunset. So you orbit the Earth 16 times a day and get 16 sunrises and sunsets, so every 45 minutes the sun is either coming up or going down. It's really hard to know what time of day it is, in terms of your work day in orbit, but it's just magnificent. And it did give me a sense that we're all from the same planet and of course, it makes me wonder why we can't all get along better? Patrick Loehrer: I think people our age remember a few things, we remember the day Kennedy was shot. We remember the landing on the moon with Neil Armstrong. We also sadly, also remember the Challenger disaster and where we all were at that point in time. Ellen, you were an astronaut at that time. Dr. Ellen Baker: I was. Patrick Loehrer:> Can you reflect a little bit about that, if you can? I'm not sure I could do it without getting emotional, if I was there. Dr. Ellen Baker: Yeah, I was actually at work of course, and watching the launch and it was just devastating. Obviously, I knew everybody on board, I knew their families very well. And I have to say, we knew flying in space was risky, but we were still pretty unprepared for Challenger and for Columbia. It is something that I still think about. As weird as it might sound, I actually rescued the plant from Dick Scobee's office. He was the Commander of Challenger and I still have it growing. So it's a reminder that he was a good friend and a good colleague, it was a terrible blow, as was the Columbia accident. In that same tradition, I have African violets by my sink that were in Laurel Clark's office and Laurel was a physician who was aboard the Columbia, as well as Dave Brown, who was also a physician on the Columbia. Dave Johnson: That's an amazing tribute to both of your colleagues. It's very touching to hear that. I wonder if the two of you could share with us, what you actually did on your missions scientifically? How did you use your medical knowledge, if at all? And Robert, what about your oncologic knowledge, was that useful at all? Dr. Robert Satcher: Fortunately, no use for the oncology training in space. I got to use the orthopedic training. One of the most common problems is back pain the first few days when you're in space. We attribute it to, you're going into weightlessness and all of a sudden, there's these fluid shifts, you get more fluid in your inner discs, everybody gets taller. Dave Johnson: Well, let's send Patrick to space. Patrick Loehrer: We need to get up there soon, Dave. Dr. Robert Satcher: Yeah. Actually, during our visit, we measured everybody's height just so that we know what that change was and we did do a experiment actually, that my background came very useful for. We were looking at the effects of bisphosphonate on bone loss. So bisphosphonates, well, everybody knows, this is ASCO, a class of drugs, anti-absorptives, used in patients with bone metastasis. It was actually being tested in rats, thinking about countermeasures for keeping people from losing bone in long duration, space trips. Unfortunately, bisphosphonates come with a lot of effects. But it did seem to work, in terms of the bone mass, which is induced by weightlessness in rats. And then finally, I was the crew medical officer for my group because I was the only MD up there in our crew. Ellen probably was the same in hers. So, what that involves is, NASA was one of the first places to pioneer use of telemedicine. So, you're basically, communicating with the flight surgeons on the ground every day, talking about what sort of medical issues there are with the crew and getting their recommendations for dealing with whatever it is. So yeah, being a doctor actually came very much handy. Dave Johnson: I was going to ask both of you. During your flights, did you encounter any medical emergencies without violating HIPAA? I mean, did you have to do an appendectomy? Dr. Ellen Baker: No appendectomies and fortunately, no emergencies, astronauts are pretty well scrutinized and examined before flights. And I think the best insurance against a medical problem in space is to send crews that are really fit and really healthy. And of course, there's always the risk of things like trauma, but the risk is actually fairly low. So no emergencies on my flight. Patrick Loehrer: There's no RVUs up there are there, that you have to worry about billing or no? Dr. Robert Satcher: No, we didn't have to deal with third-party payers. Patrick Loehrer: This is looking more and more like a job I want to pursue here, I'm going to be taller and there's no billing. This is great. Dave Johnson: I want to hear from Ellen, what sort of experiments she was involved in and how her medical background helped her assist with that? Dr. Ellen Baker: Yeah. People think, "Gee, if you're a doctor and you're an astronaut, they selected you to be a doctor in space." But in fact, astronauts are selected sort of generically. So once you come into the office, you're trained as an astronaut and Bobby and I were both mission specialists, as opposed to astronaut pilots. And so we received training on all sorts of different things. Bobby did a space walk. I trained for space walks, but never did one. We trained on the remote arm. We trained how to fix things when they were broken. I was actually a flight engineer on one of my flights. But that aside, I was also the crew medical officer and on every flight astronauts participate in medical experiments, because we are trying to gather lots of information from very few people on the physiologic effects of space flight, particularly looking towards longer flights, perhaps back to the moon or to Mars. So I did participate as a subject, I was an operator in a few medical experiments, but the bulk of my responsibilities actually were not medical. And I think Bobby, maybe you would agree with that? We did have some flights that were designated as what I would call, space life sciences flights, but there was only a handful of them and I was not a crew member on any of those flights. Patrick Loehrer: Boy, I could spend another three hours on this and would love to hear more stories. Dave Johnson: This concludes part one of our interview with former NASA astronauts, Drs. Ellen Baker and Robert Satcher. Please be sure to tune in to part two of the interview, where we will learn more about the incredible work they're doing in their post NASA careers. Thank you for tuning in to Oncology, Etc., an ASCO Educational Podcast. If you have an idea for a topic or guest you would like us to interview, please email your suggestion to education@asco.org. Thank you for making Oncology, Etc. a part of your day. Announcer: Thank you for listening to the ASCO Education Podcast. To stay up to date with the latest episodes, please click subscribe, let us know what you think by leaving a review. For more information, visit the Comprehensive Education Center at education.asco.org. Announcer 2: The purpose of the as podcast is to educate and to inform. This is not a substitute for professional medical care and is not intended for use in the diagnosis or treatment of individual conditions. Guests on this podcast express their own opinions, experience and conclusions. Guests statements on the podcast do not express the opinions of ASCO. The mention of any product, service, organization, activity or therapy, should not be construed as an ASCO endorsement.

Maxillomandibular advancement (MMA) surgery is highly effective in curing moderate to severe obstructive sleep apnea (OSA). But how does that surgery impact a patient's facial profile? Are we inadvertently beating people with an ugly stick in the name of better breathing? On this episode of Dentist Brain Candy, I cover two thought-provoking articles from recent editions of the Journal of Oral and Maxillofacial Surgery, sharing the findings from a study on the impact of MMA surgery for OSA on facial profile esthetics. I also discuss a paper identifying the trends in work relative value units (or RVUs) among oral and maxillofacial surgeons participating in Medicare from 2013 to 2017. Listen in to understand why I find the RVU system so frustrating and learn why the free market is a far better way of determining reimbursement rates for a given dental procedure. Key Takeaways How the physician fee schedule based on relative value units or RVUs came to be Why I find the RVU system incredibly frustrating and offensive Why so few maxillofacial surgeons participate in the Medicare system How a recent study uncovered an increase in productivity of OMSs and a decrease in the number of Medicare patients served by OMSs in the period from 2013 to 2017 Why the free market is a far better way of determining reimbursement rates for a given dental procedure than the RVU system The high success rate of maxillomandibular advancement (MMA) surgery in curing obstructive sleep apnea (OSA) How a recent study found that MMA surgery for OSA does not have a negative impact on facial profile esthetics Why I'm an advocate of building wealth through cashflowing real estate How I earn cashflow from owning a portion of the building my practice occupies Connect with Dr. Bryan McLelland Dentist Brain Candy Dentist Brain Candy on Facebook Dentist Brain Candy on YouTube Dentist Brain Candy Podcast Dentist Brain Candy App Dentist Brain Candy Continuing Education About Dr. Bryan McLelland Dr. Jawbreaker on YouTube Email bryanmclelland@hotmail.com Call (509) 922-2273 Resources Liberty Oral Surgery February Event Nobel Biocare ‘Trends in Work Relative Value Unit Production in Oral and Maxillofacial Surgery' in the Journal of Oral and Maxillofacial Surgery Omnibus Budget Reconciliation Act of 1989 American Medical Association RVS Update Committee ‘Evaluation of Facial Profile Esthetics After Maxillomandibular Advancement Surgery for the Treatment of Obstructive Sleep Apnea' in the Journal of Oral and Maxillofacial Surgery Chris Salazar on DBC S2EP3 Arsenal Capital

Today we featurer Dr. Barbara Levy and welcome back our wonderful Med-Ed extraordinaire Dr. Ashley Comfort as our moderator! We discuss coding and payments for Ob/Gyn, how to maximize payment, and make sure that you are being paid for the work you do. We discuss using coding principles to maximize payment and how to Identify how RVUs for codes are determined and recognize how to achieve parity. How to identify and differentiate the health policy related to Pay for Performance (P4P) and the P4P measures for incorporation into practice. We also dive into Dr. Levy's experience with coding and how she became such an expert.

EMRs contribute to HCW burnout, are disruptive to workflows, contribute to alarm fatigue, decrease patient contact time, and are a way for hospitals to bill. But also... EMRs are better at trending care, reduce prescribing errors, measure social determinants of health. Do Laura and Abby like the EMR? Do they hate the EMR? is the EMR Laura and Abby's frenemy? No one knows, but they definitely have a lot of questions like: Is the EMR a billing software? Do scribes increase RVUs? Should there be price transparency in the EMR? Should patients get immediate access to results? Definitely good that patients can carry their records around with them.. right? Healthcare systems don't have the infrastructure to do counselling, so do patients get results and then not have a provider to talk to them about it? Is it paternalism to think all doctors break bad news well? What if a patient finds out they have cancer from checking their MRI reports at home? New season, new cohost.⁣ I

Krish is joined by Dr. Lynn Rapsilber, owner of NP Business Consultants, LLC. As the owner of NP Business Consultants, LLC, she provides dissemination of information regarding reimbursement for nurse practitioner and other health care provider services. Dr. Rapsilber is an author and educator of NP students and seasoned NPs. She is also the co-founder and CEO of the National Nurse Practitioner Entrepreneur Network helping NPs build and sustain practices. The two discuss RVUs, credentialing and business brain development.

Specialty care should be rewarded when efficiently coordinated with Primary Care. The goal should be to improve health, not generate more RVUs. This week, Dr. Scott Tromanhauser joins Faisel & Friends to discuss the role of specialists in value-based care.Being a doctor is your calling because you couldn't imagine doing anything else. Let's talk about your career goals in medicine. Connect with us and tell us how you dream of practicing medicine. Want to learn more about how we do healthcare? Visit our resource center and check out how we are transforming healthcare. Don't forget to subscribe to ChenMed Rx to receive the latest news and articles from ChenMed.

What can you expect, and how should you prepare, when leaving your current position?  Most of you will be in the following situation: Working for a medical group or healthcare system.  You find clinical medicine to be frustrating and unrewarding for a variety of reasons, including: lack of respect, understaffing, poorly designed or slow EMRs, long hours, churning of patients to maintain worked RVUs, entitled, angry patients, endless paperwork, lack of control over your hours, staffing, vacations, etc. You've checked out emotionally and you realize that something must change. You may envision the following scenario: You're going to find something else to do, either clinical or nonclinical, or both, Once that's locked in, or you have a really good plan, you will give your separation notice to your employer, You will leave in a few weeks to a few months from now, and that will be that! Problem solved. Unfortunately, that is not how it usually goes. If not fully prepared, what follows are a series of unexpected financial, legal, and/or psychosocial consequences that can slow or complicate your departure.  Financial Issues Any pivot will have financial consequences. If there is a gap between jobs, you'll need a nest egg to get you through the time when income temporarily stops. This is ameliorated if you have passive income from other sources or a spouse's income can cover expenses while you're in the process of transitioning. Legal Issues This leads us right into the legal ramifications. An employment contract is typically a long and complicated document, with many provisions that are forgotten until separation is imminent. And some of them will prevent, postpone or complicate your departure. Psychosocial Issues You may observe a common behavioral pattern in colleagues and employers when leaving. That pattern is Kubler-Ross's 5 Stages of Death and Dying. You may go through the stages of denial, anger, bargaining, depression, and acceptance once you come to the realization that you can no longer tolerate working in the current healthcare environment. But you may not be prepared for those very same steps occurring in your colleagues and employer. The denial and anger of those around you can be particularly disconcerting. You may intend to be completely professional and deliberate as you wrap things up. But prepare yourself for others to be oppositional, upset, angry, or in denial. This may manifest as passive-aggressive or overtly hostile behavior. Your managers may avoid you, even though there are issues to take care of. They may try to involve you in matters that are no longer of your concern. And they may attempt to burden you with more than your share of on-call duties. Oftentimes, you're leaving an employer because it is dysfunctional. It may not be run like a business: no regular meetings, problems are ignored, strategic planning is nonexistent. It is naïve to think that a business that is dysfunctional is going to respond to your departure in a functional way. Listen to the complete episode to learn how to prepare for these challenges. Remain calm, deal with the chaos logically, follow the advice of your accountant and attorney, and move on. To access the show notes and the links for this episode, go to nonclinicalphysicians.com/get-ready. If you'd like to join my Nonclinical Mastermind Group, you can learn about it at nonclinicalphysicians.com/mastermind. Get an updated edition of the FREE GUIDE to 10 Nonclinical Careers at nonclinicalphysicians.com/freeguide. Get a list of 70 nontraditional jobs at nonclinicalphysicians.com/70jobs. Check out a FREE WEBINAR called Best Options for an Interesting and Secure Nonclinical Job at nonclinicalphysicians.com/freewebinar1

This conversation starts out talking about the RUC, which is a committee run by the AMA, who has the sole source contract with CMS to figure out how many RVUs any given procedure or service is worth. There are roughly four times as many specialists on this RUC committee as PCPs. You might be able to see where this is going, but let me let our guest in this healthcare podcast, Brian Klepper, explain how primary care got trampled by the goings-on. Brian Klepper is a longtime healthcare analyst and former CEO of the National Business Coalition on Health. You can learn more by emailing Brian at bklepper@worksitehealthadvisors.com. Brian Klepper, PhD, is a healthcare analyst, commentator, and entrepreneur. He is a Principal of Healthcare Performance Inc, a healthcare strategy and business development practice, and CEO/Principal of Worksite Health Advisors, a benefits consultancy focused on linking high-performance/high-impact healthcare organizations with purchasers. He founded and moderates a popular professional healthcare Listserv, Healthcare Hackers, which is a discussion forum on healthcare high performance and value and which has about 850 participating benefits managers, benefits advisors, and innovative vendors. An active author and speaker, Dr. Klepper has provided healthcare commentary to CBS Evening News, the Wall Street Journal, the New York Times, and the Washington Post. He has published widely in healthcare trade and academic publications and in newspapers nationally. Brian is a regular contributor to Employee Benefit News, the Health Affairs Blog, The Health Care Blog, The Doctor Weighs In, Kevin MD, and other expert healthcare blogs. He is a reviewer for Health Affairs and The Journal of Ambulatory Care Management. He is an advisor to the Lundberg Institute and to several for-profit healthcare organizations. In his spare time, Brian is an offshore sailor. 01:00 What is the RUC? 03:18 What is the goal of the specialists in the RUC? 04:32 Why health plans and not health systems? 06:55 “All this time, the hospital community was waging war against the HMO community.” 07:59 “The incentives that have been at play have been very formidable.” 08:23 “Primary care has developed a reputation for being the easy specialty … and it's just not so.” You can learn more by emailing Brian at bklepper@worksitehealthadvisors.com. @bklepper1 discusses #primarycare on our #anexpertexplains #healthcarepodcast. #healthcare #podcast #digitalhealth #pcp What is the RUC? @bklepper1 discusses #primarycare on our #anexpertexplains #healthcarepodcast. #healthcare #podcast #digitalhealth #pcp What is the goal of the specialists in the RUC? @bklepper1 discusses #primarycare on our #anexpertexplains #healthcarepodcast. #healthcare #podcast #digitalhealth #pcp Why health plans and not health systems? @bklepper1 discusses #primarycare on our #anexpertexplains #healthcarepodcast. #healthcare #podcast #digitalhealth #pcp “All this time, the hospital community was waging war against the HMO community.” @bklepper1 discusses #primarycare on our #anexpertexplains #healthcarepodcast. #healthcare #podcast #digitalhealth #pcp “The incentives that have been at play have been very formidable.” @bklepper1 discusses #primarycare on our #anexpertexplains #healthcarepodcast. #healthcare #podcast #digitalhealth #pcp “Primary care has developed a reputation for being the easy specialty … and it's just not so.” @bklepper1 discusses #primarycare on our #anexpertexplains #healthcarepodcast. #healthcare #podcast #digitalhealth #pcp Recent past interviews: Click a guest's name for their latest RHV episode! Brian Klepper (EP335), Sunita Desai, Care Plans vs Real World (EP333), Dr Tony DiGioia, Al Lewis, John Marchica, Joe Connolly, Marshall Allen, Andrew Eye, Naomi Fried, Dr Rishi Wadhera, Dr Mai Pham, Nicole Bradberry and Kelly Conroy, Lee Lewis, Dr Arshad Rahim, Dr Monica Lypson, Dr Rich Klasco, Dr David Carmouche (AEE15), Christian Milaster, Dr Grace Terrell, Troy Larsgard, Josh LaRosa, Dr David Carmouche (EP316), Bob Matthews, Dr Douglas Eby (AEE14), Dr Sheldon Weiss, Dan Strause and Drew Leatherberry, Dr Douglas Eby (EP312)

As I am on the road moving from the east coast to the west, I wanted to review an old topic that we've discussed here before. This week's episode is part 2 in our series about RVUs and income benchmarking to help pain physicians understand the link between RVUs and compensation. This is a very broad topic which we will continue to discuss in the coming weeks and the purpose of this series is to provide some context to the topic. Learn more: https://apmsuccess.com/110 Watch the video: https://apmsuccess.com/110v

As I am on the road moving from the east coast to the west, I wanted to review an old topic that we've discussed here before. In today's podcast we cover the topic of RVUs in the context of an interventional pain practice.  We talk about the history of RVUs, how they work with reimbursement between medicare and commercial payors, the different components that make up an RVU calculation, and what pain doctors should consider when they think about their own clinical productivity. Learn more: https://apmsuccess.com/108 Watch the video: https://apmsuccess.com/108v

"Mid-career colleagues: it's time to go back to the future. Time to learn again. Time to build professional and social networks at work. Take a lunch break. Bring home a few fewer RVUs. I recently started a monthly journal club for our small section of gastroenterologists as a way to recreate some of what I loved about residency. A case conference to discuss difficult cases is next. While the rewards of these diversions are not quantifiable, they are still valuable. I hope my colleagues feel the same way. Maybe I'll throw in some free movie tickets, as well." Anish Sheth is a gastroenterologist. He shares his story and discusses his KevinMD article, "Attention mid-career physicians: Let's find our ikigai." (https://www.kevinmd.com/blog/2021/04/attention-mid-career-physicians-lets-find-our-ikigai.html)

Physician compensation is often based on RVUs. But, in reality, RVUs actually have no monetary value.  So in order to understand productivity and revenue you have to know what an RVU is, how it's determined and how to determine what it's worth. In this episode, you'll get all this info and more.RVU stands for relative value units and are basic component of the Resource-Based Relative Value Scale (RBRVS.) RVUs define the value of a service or procedure relative to all services and procedures. It's based on the extent of physician work, the clinical and nonclinical resources needed and the expertise required to deliver the service to the patient.When you are actually coding and billing for a service, you do not assign an RVU code. You assign a CPT code. And each and every CPT code has a dollar amount assigned to it by CMS. When your practice receives reimbursement from Medicare or a commercial payor, they pay you according to the CPT code. There is no direct payment for any service based on an RVU. Key point: You need to be able to convert back and forth between CPT codes and RVUs—it's nothing more than a formula. Here's a link that will allow you to  convert from CPT to RVU.Under the RBRVS, payment for physician services is determined by: Total RVUsGeographic Practice Cost Indices (GPCIs)A conversion factorThere are actually 3 types of RVUs that go into the calculation of the total RVU. Work RVU Practice expense RVUMalpractice RVUKey Point: The place of service significantly factors into reimbursement. CMS makes a distinction and organizes all places of service into 2 categories: ·   Non-facility- usually refers to the physician's office ·   Facility - inpatient hospital—even if its an outpatient clinic in an inpatient hospital, ambulatory surgery center or skilled nursing facilityIf you go to the CMS physician fee schedule lookup you'll notice that for each CPT code there's one amount of payment if done in your office (the non-facility) and another for the facility. Essentially CMS compensates you more if you perform the service in your office because you are incurring the overhead. An RVU has to be multiplied by a dollar conversion factor (CF) to become a payment. The conversion factor converts the value expressed in RVUs to dollars and you can see the conversion factor on the CMS physician lookup schedule. The final Medicare payment for each CPT code is the sum of the 3 geographically weighted RVU types multiplied by the Medicare CF.[(work RVU x work GPCI) + (PE RVU x PE GPCI) + (MP RVU x MP GPCI)] x CF = final paymentFor a full searchable copy of the transcript, https://www.thepracticebuildingmd.com/podcastIf you'd like to hear more tips on how to start, run and grow your practice and related medical businesses, please sign up for my newsletter at https://www.thepracticebuildingmd.com.    And, be sure to join my FB group, The Private Medical Practice Academy. Enroll in my course,  How To Start Your Own Practice and get the ste

Listen to pearls of wisdom from Dr. Brian Herrmann as he takes us through what questions you should ask when selecting a practice, as well as RVUs, buy-ins, contract clauses, and more!

Did you know that as a PA, there are several different ways that you can be compensated? Your income may not be as clearcut as getting paid via hourly pay or via a salary. In this episode, the various compensation models that physician assistants can get paid will be reviewed as well as some of the pros and cons of each, so that you can have an understanding of these options when you are interviewing for PA jobs as a new grad or throughout your PA career!  This episode will review different compensation models such as salary, hourly, RVUs, or bonus structures.  Additionally, I'm going to share which types of compensation models that I have experienced over my almost 7 years of practicing as a PA, along with some detailed income numbers. I decided to do this simply because I think sharing income information is helpful for other PAs, and I don't think it's done enough. However, income is clearly based on so many factors including the following: years of experience as a PA, medical specialty, state and even city or county within a state, as well as total compensation package including benefits.  Read blog posts: pathefiway.com Prefer to pin the posts that you found informative? Follow along on Pinterest: https://www.pinterest.com/pathefiway  Follow along on Instagram: @pathefiway   https://www.instagram.com/pathefiway/ Join the private Facebook group only for current and future PAs on their journey to financial independence: https://www.facebook.com/groups/pathefiway  Like the Facebook page to follow along: https://www.facebook.com/pathefiway

Did you know that as a PA, there are several different ways that you can be compensated? Your income may not be as clearcut as getting paid via hourly pay or via a salary. In this episode, the various compensation models that physician assistants can get paid will be reviewed as well as some of the pros and cons of each, so that you can have an understanding of these options when you are interviewing for PA jobs as a new grad or throughout your PA career! This episode will review different compensation models such as salary, hourly, RVUs, or bonus structures. Additionally, I'm going to share which types of compensation models that I have experienced over my almost 7 years of practicing as a PA, along with some detailed income numbers. I decided to do this simply because I think sharing income information is helpful for other PAs, and I don't think it's done enough. However, income is clearly based on so many factors including the following: years of experience as a PA, medical specialty, state and even city or county within a state, as well as total compensation package including benefits. Learn more here: https://www.pathefiway.com/blog/an-overview-of-various-physician-assistant-compensation-models Website: pathefiway.com Prefer to pin the posts that you found informative? Follow along on Pinterest: https://www.pinterest.com/pathefiway Follow along on Instagram: @pathefiway https://www.instagram.com/pathefiway/ Join the private Facebook group only for current and future PAs on their journey to financial independence: https://www.facebook.com/groups/pathefiway Like the Facebook page to follow along: https://www.facebook.com/pathefiway

This week on Roetzel’s HealthLaw HotSpot, Roetzel attorneys Ericka Adler and David Hochman are joined by Lucy Zielinski, Managing Partner at Lumina Health Partners, for a discussion on the changing landscape of physician compensation and reimbursement. This year, many health care organizations are looking to redesign their compensation models. Our panel explores these developments, which, while being driven in large part by the overall industry trend towards value-based compensation, are accelerating this year due to changes to RVUs in the 2021 Medicare fee schedule.

Today we tackle how you can stress test incentives in compensation so that you can understand likely outcomes based on what a professional (whether an advisor, or a physician) is incentivized to do.  I discuss AUM, flat fees, commissions, RVUs, salaries, and everything in between. Learn more: http://anesthesiasuccess.com/85 Watch the video: http://anesthesiasuccess.com/85v

Most physicians are expected to see in an increase in payments from Medicare, thanks to the latest COVID-19 relief bill. But with good news always comes some caution.First of all, the more that is paid, the more can be recouped during an audit. And with respect to provider compensation models that rely on relative value units (RVUs), it is possible that the increase in work RVUs may exceed the increase in the total RVUs – meaning that a provider may make more than what is proportional to overall practice revenue. This could have implications with respect to fair-market value, and should be watched very closely.Reporting our lead story on this timely matter during the next live edition of Monitor Mondays will be Frank Cohen, senior healthcare analyst and director of business intelligence at DoctorsManagment.Other segments to be featured during the live broadcast include the following:Social Determinants of Health: Ellen Fink-Samnick, a nationally recognized expert on the social determinants of health (SDoH), will report on the latest news that’s occurring at the intersection of healthcare and socioeconomics. Ellen will also conduct the Monitor Mondays Listeners Survey.Risky Business: Healthcare attorney David Glaser, shareholder in the law offices of Fredrikson & Bryon, will join the broadcast with his trademark segment, reporting on legal implications facing healthcare providers.Monday Rounds: Ronald Hirsch, MD, vice president of R1 RCM, will be making his Monday Rounds with another installment of his popular segment.RAC Report: Healthcare attorney Knicole Emanuel, a partner at the law firm of Practus, will file the Monitor Mondays RAC Report.Legislative Update: Former Centers for Medicare & Medicaid Services (CMS) official Matthew Albright, now chief legislative affairs officer for Zelis, will report on the status of healthcare legislation associated with the current COVID-19 pandemic.

Presented by Patrick Wallace, DO, a resident at University of Nevada, Las Vegas and member of the AAEM/RSA Education Committee, and Jorge Antonio Fernandez, MD, Assistant Professor of Clinical Emergency Medicine at Los Angeles County + USC Medical Center. Intro music by Akashic Records, Key to Success - Discover the Possibility from the album Corporate Presentation - Key to Success, powered by JAMENDO.

Presented by Patrick Wallace, DO, a resident at University of Nevada, Las Vegas and member of the AAEM/RSA Education Committee, and Jorge Antonio Fernandez, MD, Assistant Professor of Clinical Emergency Medicine at Los Angeles County + USC Medical Center. Intro music by Akashic Records, Key to Success - Discover the Possibility from the album Corporate Presentation - Key to Success, powered by JAMENDO.

*DISCLAIMER* There were some technical audio difficulties with this show, we hope that it doesn't impact your listening experience too much.   In this episode, we welcome John Canion to the show.  John is a nurse practitioner in Texas with a wealth of information and knowledge and we pick his brain about a hodge podge of topics.  We discuss RVUs, John's Pillars of Practice, contracts, and the education of nurse practitioners and ways that we'd improve it.  It's a fun filled episode, and 5 questions we learn more about Dublin Dr. Peppers, Skittles, and depositions. In our "Story You May Have Missed", we discuss a CEO working outside the bounds of his training and education.  You can find John on Youtube at JC the NP Just Some Podcast Social Media Facebook Twitter Instagram YouTube

The Centers for Medicare & Medicaid Services (CMS) will reimburse a greater number of relative value units (RVUs) associated with office-based evaluation and management (E&M) visits, the agency announced recently.In order to achieve budget neutrality, CMS will reduce the payment per RVU. With this change, CMS is allocating a larger proportion of its total spending to office-based physicians, at the expense of surgeons and hospital-based physicians.Here’s the rub: organizations that utilize RVUs in their physician compensation arrangements and continue to pay the same 2020 rates per RVU on the increased number of 2021 RVUs will experience a dramatic decline in operating income. Reporting our lead story during this edition of Monitor Mondays is Adam J. Klein, who heads ECG’s Financial Services practice.Other segments to be featured during the live broadcast include the following:Whistleblower Update: Famed whistleblower Mary Inman, partner in the law office of Constantine Cannon, returns to the broadcast to report on two whistleblower cases that have dropped from the radar screen, but nevertheless are essential for re-examination.RAC Report: Healthcare attorney Knicole Emanuel, a partner at the law firm of Practus, will file the Monitor Mondays RAC Report.SDoH Report: Ellen Fink-Samnick, a nationally recognized expert on the social determinants of health (SDoH), will report on the news that’s happening at the intersection of COVID-19 and the SDoH. Ellen will also conduct the Monitor Mondays Listeners Survey.Legislative Update: Former CMS official Matthew Albright, now chief legislative affairs officer for Zelis, will report on the status of healthcare legislation associated with the current COVID-19 pandemic.Risky Business: Healthcare attorney David Glaser, shareholder in the law offices of Fredrikson & Bryon, will join the broadcast with his trademark segment, reporting on legal implications during the pandemic.Monday Rounds: Ronald Hirsch, MD, vice president of R1 RCM, will be making his Monday Rounds with another installment of his popular segment.

Justin Chamblee, Alex Kirkland, and Amit Vaishampayan join Mark Reiboldt to discuss the proposed changes to the Medicare Physician Fee Schedule (MPFS). There are three noteworthy changes proposed, including evaluation and management (E/M) coding and payment changes, permanent telehealth changes implemented in response to the pandemic, and updates to the Quality Payment Program (QPP). Contact Information Subscribe to our feed in Apple Podcasts, Google Podcasts, Spotify, or your preferred podcast provider. Like what you hear? Leave a review! Not there? Let us know! We welcome all feedback from our listeners. Email us questions on any of the topics we discuss or questions about issues that interest you. You can also provide recommendations on matters for future episodes.  Please email us: feedback@cokergroup.com Connect with us on LinkedIn: Coker Group Company Page Follow us on Twitter: @cokergroup Follow us on Instagram: @cokergroup Like us on Facebook: @cokerconsulting   Episode Synopsis E/M Coding and Payment Changes Due to increasing RVU amounts, the statutory budget neutrality mandate comes into play to reduce the conversion factor by $3.83 to $32.2605 to prevent an increase in healthcare costs. The Budget Neutrality Act requires that increases or decreases in RVUs may not cause the value of expenditures for the year to change more than $20 million in the absence of changes. If this threshold is exceeded, adjustments are made to preserve budget neutrality.   Telehealth Changes The Centers for Medicare and Medicaid Services (CMS) are adding several telehealth CPT codes that are similar to existing consultations and office visits. They also added temporary codes during the pandemic that will continue to be evaluated. CMS is seeking comments to determine future usage as well as additional temporary codes.   QPP Updates We see ACO scoring and policy changes to acknowledge that providers will not immediately recover from COVID-19, and they will need support throughout their recovery. The Merit-based Incentive Payment System (MIPS) category weightings will shift to reduce the quality weight by five percent (to a total weight of 40 percent) and increase cost by five percent (to a total weight of 20 percent).   Extras Three Quick Tips to Get You Started with the New E/M Guidelines Is Telehealth Past the Tipping Point? Episode 71: The Ongoing Battle of Site Neutral Payments Episode 70: Major E/M Coding Changes Coming in 2021: Here’s What You Need to Know

Mark outlines the proposed rule and the 8 items that will have the most impact on the Urology practice.Final rule posting late this yearConversion factor decreasing by 10.6%E&M 2021 changes being adopted and will include increased RVUs for the E&M codesRVUs for non-facility codes increasing enough to offset conversion factor decreaseRVUs for facility procedures are all decreasingASC payments are set to increaseMIPs has a couple of changes but they are not major changes to the current programTelehealth is going to continue with the same rules during the Public Health Emergency. Once the PHE is over then covered codes will change and be separated into 3 categories of covered codes

Episode #10, recorded April 16, 2020.Many thanks to Andy Fadenholz, a physician recruiter at RosmanSearch, Inc., for joining me today. Andy specializes in placing neurologists and neurosurgeons. We discussed the advantages of using a recruitment firm that specializes in a specific market and is aware of all the subspecialty areas within that specialty, such as an academic role, EMG specialist, neurohospitalist, neurointerventionalist, or outpatient-only neurologist. Andy mentioned that his firm pre-screens potential employers and won't contract with employers who don't meet their professional standards. Andy also makes site visits to employers and residency training programs, recently visiting the University of Tennessee. He helps educate residents on aspects of the business of medicine, such as RVUs, salary structure, and competitive salaries for the various subspecialties. Andy explained that “hand-holding” is part of his job. Agents at his firm act as a bridge between the physician applicant and the hiring facility. He encouraged physicians to reach out to program directors who may not even be advertising a position because there might be an unmet need for a new faculty member. His group has created a document of best practices for “Zoom interviews,” which are now replacing in-person interviews during the COVID-19 pandemic. To contact Andy, please check the website: www.rosmansearch.com or email: afadenholz@rosmansearch.com. 

This week's episode is part 2/2 in our series talking about RVUs and income benchmarking to help pain physicians specifically understand what is the link between RV use and compensation. This is a very broad topic which we will continue to discuss in the coming weeks, so the purpose of this series is to provide some context to the topic. Learn more: https://anesthesiasuccess.com/50 Check out our Youtube channel: https://www.youtube.com/watch?v=RLzen3QThSI&feature=youtu.be

Today's episode is a bit different. I am going to be doing a 2-part series helping pain management positions, especially this is also true in anesthesiology to a lesser degree, understand productivity compensation specifically as it relates to RVUs use. Today we're going to do a deep dive on what our views are, how they are determined, how it functions in the context of a practice. Learn more: https://anesthesiasuccess.com/49

UCR 008: RVUs - Overview and How They Can Help YouMark discusses RVUs and why they are important to the urology practice. Not only are they important for reimbursement but they can also be used as a tool to assess practice productivity and efficiency.Learn why not understanding the RVU basics could be costing you in many aspects of your practice.

Having the right number of staff at the top of their license is an ongoing challenge for every CV program, but it is vital to patient care, operational efficiency, and the bottom line. We talked with MedAxiom members from Sanger Heart & Vascular Institute, Bart Reeves and Dr. Geoffrey Rose, about their data-driven approach to rightsizing staff that has boosted physician productivity, created transparency, and achieved organizational success.

Session 110 Geriatric medicine is both stimulating and satisfying for Dr. Shannon Tapia. We’ll talk about housecalls, mortality, and the importance of having a sense of humor. Meanwhile, be sure to check out all our other resources on Meded Media for more help as you journey along this awesome field of medicine! Listen to this podcast episode with the player above, or keep reading for the highlights and takeaway points. [01:20] Interest in Geriatrics Having a father who's a geriatrician was Shannon's first exposure to medicine. Growing up, medicine was different back then but she got to witness how it was being a physician. She liked the cognitive aspects of medicine. She could do procedures but she just never really got stoked about it. Being exposed to it early on and realizing how cognitively challenging geriatrics is, she was essentially drawn to it. Shannon compares geriatrics with being the Sherlock Holmes of doctors. Aside from a huge kinetic variability if they live long enough, they also have a lifetime of choices. With geriatric patients, many of them could be suffering from dementia and other cognitive issues, making it difficult for them to express how they feel. So geriatricians have to get a collaborative history from their family and know the environment.  Shannon finds this to be very interesting, challenging, and satisfying. Half the time, it's med side effects from the specialists. They throw a med at them which they should never have been on. You will also realize there's not an answer so you need to be working with the patient and their family. It basically covers all aspects of medicine. You have to be constantly thinking of options and navigate it with your patients and their families. [05:00] Types of Patients The majority of 30-50-year-olds are rare diagnoses but most of them present pretty similar cases. They come in and the doctor asks appropriate questions and they give an accurate history for the most part. This excludes people who are actively psychotic. In the older population, you have to expand your differential in what they say because a lot of things present differently. They have dampened immune systems. They have neuropathy and they don't feel pain in the same way. Until you spend a lot of time with your geriatric patients, it's hard to truly describe the extent of how different it is. You're essentially dealing with a variety of factors when you're trying to approach a problem. Then there are a lot more limitations on what the achievable goals are. So you have to reconcile those to arrive at a realistic outcome and that people can be comfortable with. [07:19] Traits that Lead to Being a Good Geriatrician Shannon says that having a healthy sense of humor is good. You have to be patient and not afraid to get into the thick of things. You never know what you're going to walk into half of the time. Don't take things too seriously otherwise you're going to end up missing what the patient really needs and that of their family. Being empathic and being comfortable with mortality are two other important traits of a good geriatrician. Shannon believes that if you're not someone who can stop doing things to people, you should not be a geriatrician. There's this mentality in medicine where doctors intervene when there's a problem and they're going to fix it. As patients get older, the only truth is we all die. There's always more we could do but you have to be able to step back. Think about the quality of life and prognosis for the patient if you did it. How would it look like not only after they recover but also in two years down the road? Essentially, you have to take it one patient at a time and take their goals and preferences at a time. Have your opinions but separate yourself from that. Moreover, there's a lot of misinformation even for geriatric patients and their families as to what's achievable in medicine. You have to get to know both the patient and their family. Be honest with them about what you think and whatever intervention they're considering. If it's a treatment situation, you have to be able to take their goals and translate what the realistic prognosis would be for them, knowing what their wishes are. That's not easy always because there's a lot of misinformation about what the medical community can achieve at a certain point." [11:00] A Typical Bread and Butter Day Shannon explains how geriatrics is struggling in terms of how they're under Medicare plans. But it's a cognitive field. It's not a procedure that they can always do and can rack up reimbursement for.  Especially if you're in private practice, it's really hard to pay off your student loans and do it well.  Unfortunately, there are very few private practice geriatricians anymore because it's tough and the pressures in the private practice world are hard. Not to mention that there are only a few great academic institutions that have great geriatric support programs.  Shannon describes her typical day as being different from an academician. It's basically different depending on what realm you practice in. If you're in academic geriatrics, you're going to do a mixture of geriatric consult service at a hospital you're affiliated with. You will be on service with heavy clinic and lots of didactics. It's hard for academic institutions to do long-term care providing. It's a whole different set of private regulations that tend to be challenging in an academic setting. As a private practice geriatrician, your day is variable depending on whether you're clinic-based or when you're doing house-based care. When Shannon's new job starts, her practice will be in one geographic area with the goal to see 10 patients a day. Four will be in one assisted living facility and the other four from another assisted living facility, and then two independent homes within the same geographic region. Moreover, Shannon has done some expert witness and chart reviews. There is so much chat vomit in terms of what they're required to put in the medical records. So much of it is just completely useless information. [14:50] Doing House Calls Before Shannon moved to Denver, she used to do direct primary care house calls. She was fortunate in her geriatrics fellowship to get good exposure to it. The problem with geriatric fellowships is they're hugely variable. Some are more research-focused, some are more clinical. Shannon did it for a year but it was clinically focused on every level.  While Shannon loved her fellowship training, she also saw how bad what you walk into could get. But part of why she loves doing this is that because of the patient population they serve. Just because you're Medicare age does not mean you need a geriatrician. It's really based on your physiology and the individual patients. Shannon explains that doing house calls could be best for the majority of the patients. This way, you also get to figure out what's going on with them. Whether it's physical debility or even a mile cognitive debility, getting them to the doctor is a huge deal. This also gives Shannon as their physician so much more information. Plus, the relationship you're able to build with them goes to another higher level. Being invited to their home, you kind of become part of their family. There is a much more intimate relationship with your patients. There is a lot more trust involved. Whereas just receiving patients in your clinic and you only have to go on the face with what they say that they're taking their medicines or they're eating. But it's different when you walk into their homes and see how they're taking their medications. So you get this unique perspective when you get to go to their home. [17:45] Work-Life Balance and Geriatrics Being a Low-Reimbursement Field Shannon says there's a potential to have a very good work-life balance as a geriatrician but it depends on how much money you need for your life balance. Again, it's a low-reimbursement field. So if you are one of those people that wants to take extravagant vacations, it is not for you. As a single mom and not having to be tied to an office, Shannon says this is really huge for her. When you're doing house calls or going to a long term care facility or nursing home, there's a timeframe. There's that flexibility of time that comes with having children but still being able to go out and do clinical work. The only challenge is the documentation requirements that put a lot of pressure on you so you end up taking more work home. Medicare sets the fees even for private insurances. So everything in medicine is all based on trying to figure out how much they're going to pay you and how many RVUs (relative value unit) you've got for a visit. The way the system works out is that time gets very few RVUs unless you do a ton of volume. But procedures get a ton. It's inherent that it's highly cognitive and diagnostic but it's not like you should be ordering tons of tests because usually, those tests are bad for the patients. People who do nursing home care sometimes do pretty well because they can do high volume as they're able to see a ton of people in one place.  Also, the reimbursement system is different in nursing homes than in an assisted living or even in house calls. In nursing home care, how reimbursement works is that it's not just face-to-face visits but it works like at a hospital where it's billed for all the time you spent on the patient. If you're in an outpatient clinic or in a house call, your time is all face-to-face time with them.  [21:35] The Training Path You can either do internal medicine or family practice to become a geriatrician. She was originally going to do internal medicine. Then she had great mentors in family medicine that told her that geriatrics is really an outpatient field and that if your patients are in the hospital, it's not good. Because of this, Shannon wanted to go to a field that emphasizes outpatient and she got a sense in medical school that family medicine did this. So she decided to do family medicine the last minute. After residency, you have to go through either a one or two-year fellowship thereafter. Whichever one you choose, you have to take both boards.  Since she did family medicine, she would have to take a family medicine board every ten years and the geriatrics board. She also has to do a ton of things that family medicine requires that are focused on peds and women's health, which are not related to what she's currently doing. In terms of subspecialty, there really isn't that much. You can do geriatrics/psychiatry but you would have to also go into psychiatry residency. [24:04] Bias Against DOs There is apparently no bias against DOs. Geriatricians are badly needed. Unfortunately, there are people who do fellowships just for filler because they can but they don't really have intention of really practicing the specialty. [25:33] Working with Primary Care and Other Specialties Shannon wishes to say to internal medicine and family medicine physicians that geriatrics is a specialty. This has been her biggest frustration with some family doctors. There are some that think that they've got it all and they don't need help from geriatricians. But they are trained to recognize a lot of things that can help their patients out. Geriatricians are very good at recognizing and helping treat dementia, Alzheimer's, and most vascular dementias.  They're actually better suited to treat it than neurologists because they are also generalists in the whole area. They're able to take a more big-picture approach. They can stay involved with the families and get them connected to the resources they need, more than just do a cognitive evaluation once a year and give them medicine. For family medicine or internal medicine physicians that have patients that are of the geriatric population or have geriatric syndromes such as Parkinson's disease and certain types of early-onset dementia, you would benefit from a geriatrician. Other specialties they work the closest with include cardiology, ophthalmology, and neurology, and gastroenterology. She also works with nephrology but not as much. They also work closely with trauma surgeons because so much of the geriatric trauma are related to unrecognized geriatric syndromes. Getting a geriatrician involved can medicate delirium and help the patients get on the right track. [30:30] Special Opportunities Outside of Clinical Medicine One opportunity is being an expert witness. Shannon only does defense. There's a lot of physicians, especially academic physicians that are on the plaintiff side. For instance, if a geriatric person had a fall in a nursing home and a bad outcome, the family goes and sues. So she does the defense and expert witness if she's asked to. [31:45] Most and Least Liked Things What Shannon wished she knew about the specialty that she knows now is that the system is not great for geriatric patients. And Shannon thinks it's even gotten a lot worse. If she had to do it all over again, she would still have gone into geriatrics. She just wished she had known how things would change in the system for the worse.  For her, it would have been easier to accept things if she knew about it going in, sort of like an informed consent process. Just like when she didn't know she had to take the family medicine boards every ten years that doesn't even apply to geriatric patients. So she was really frustrated about it. And had she known it, it would have been a different story. There's a disconnect between the general population's understanding of how the medical system works and how the system actually works. What she likes the most about being a geriatrician is the patient population. It's fun to be dealing with people. You get to know them and their families. She likes how these people have a lot of wisdom. If you go into it with a sense of humor, you can have a lot of fun with it. On the flip side, what she likes the least about her specialty is the system. She really believes how detrimental the system is to the patient population. It's a growing population and it's costly.  Eventually, she wants to get involved in advocacy for changing the system because she really doesn't think we can sustain the way we do things now. [37:08] Major Changes in the Field Shannon admits that she stopped subscribing to the Journal of American Geriatrics Society as she didn't see it necessary. She doesn't think there are major changes in the field but she hopes that there will be changes in terms of the system and Medicare.  On a side note, Shannon also does hospice, which a lot of geriatricians do because of a similar mentality. And she really hopes politics will recognize the need for qualified geriatricians. [39:15] Final Words of Wisdom It's one of the most fascinating medical fields you can go into. You have to constantly use your mind and be an expert at pharmacology and psychiatry in some ways. The physiology is fascinating as well as the pathophysiology. So if you love to think and you love relationships, it's a great field for you.  But be aware that everybody is different in terms of their student debt burden and the kind of support systems. That being said, it's not the field that's going to make you the most money the fastest. Links: Meded Media

In this podcast, Dave reviews over Dennis Hursh's book "The Final Hurdle". Dave shares the following: - The highlights of RVUs and what every resident & fellow should consider - How physicians considering private practice can avoid pitfalls - What benefits can be negotiated and not negotiated Finally, he is giving away ONE free copy! The first person to e-mail dave@daviddenniston.com with your name & address will get a free copy! For all the show notes, transcription and more, check out the podcast website at www.doctorfreedsompodcast.com

Bad things have a propensity to occur in health care when patients are placed on a trajectory and then simply follow the yellow brick road—to an Oz potentially filled with unnecessary surgeries, MRIs that cost 10 times what they should, low-quality providers chasing RVUs (relative value units) like their paychecks depended on it … I could go on. Today I speak with Derek Winn, cofounder at Distilled Concepts and consultant at the Business Benefits Group. His distilled advice is to recognize that every transaction with the health care system is a waypoint on a larger journey—and also an opportunity to pause and ask questions. Payers of health care have a profound opportunity and perhaps growing obligation to help employees/members/patients, first of all, to recognize that a “look both ways before you cross the street” modus operandi is safer from both a monetary as well as an actual patient safety standpoint. Derek and I discuss the ways to make this happen, when/if it will become standard operating procedure, and the likely impact on providers and insurance carriers and Pharma if employers choose to take this route. By the way, BUCA stands for Blue Cross, United, Cigna, Aetna, and Anthem. We use this acronym in the interview. You can learn more by contacting Derek on LinkedIn atDerekWinn or by visiting distilled-concepts.com. Derek Winn is a lead consultant at the Business Benefits Group, where he has consulted clients regarding employer-sponsored benefit programs for nearly the past decade. More recently he is a cofounder of Distilled Concepts, a newly created organization that is purpose built to provide more advanced advisory and consulting exclusively for employers of intention and also to counsel on solutions from the industry as a whole. When supporting health plans for clients, they work exclusively with self-insured employers or serving as a bolt-on adviser for the eventual transition to a self-funded health plan, providing distilled client education and strategy. Derek has been recognized as a Rising Star in Advising by Employer Benefit Adviser magazine and interviewed in Managed Care magazine, and he has also been a contributor to BenefitsPRO magazine. When it comes to social media, he is most active on LinkedIn. When not addressing and tackling health care concerns for employers, Derek enjoys spending time with his wife and children at home, which doubles as a hobby farm, in Virginia. 02:13 How employers can intervene to get their employees to the right doctors and health system. 04:10 “Health care’s a journey.” 04:25 How Derek connects with employees and employers at waypoints. 05:35 Finding ways to reconnect with the patient. 06:11 What a concierge approach looks like. 08:38 What this model looks like. 11:53 Fixed costs vs variable costs. 13:59 What health plans think about employers taking this initiative. 15:22 “Who has leverage?” 19:18 “Where’s the incentive for an insurance company to … [stand] with [the] patients?” 23:10 “Change takes a long time for a hospital, but … employers can move pretty quickly.” 24:43 Showing where the value is vs setting price points. 26:58 HTA—Health Transformation Alliance. 27:17 P&T committee—Pharmacy and Therapeutics committee. 28:26 “Are we causing undue harm?” 29:29 The spectrum of pharmacy benefit managers (PBMs) and the ones to consider. You can learn more by contacting Derek on LinkedIn atDerekWinn or by visiting distilled-concepts.com. How #employers can intervene to get their #employees to the right #doctors and #healthsystem. @BBGDerek of #distilledconcepts discusses on our #healthcarepodcast. #healthcare #podcast #digitalhealth “Health care’s a journey.” @BBGDerek of #distilledconcepts discusses on our #healthcarepodcast. #healthcare #podcast #digitalhealth Connecting #employers and #employees at #health waypoints. @BBGDerek of #distilledconcepts discusses on our #healthcarepodcast. #healthcare #podcast #digitalhealth Finding ways to reconnect the #patient. @BBGDerek of #distilledconcepts discusses on our #healthcarepodcast. #healthcare #podcast #digitalhealth What does a #healthconcierge approach look like? @BBGDerek of #distilledconcepts discusses on our #healthcarepodcast. #healthcare #podcast #digitalhealth #Fixedcosts vs #variablecosts. @BBGDerek of #distilledconcepts discusses on our #healthcarepodcast. #healthcare #podcast #digitalhealth What do #healthplans think when #employers take this initiative? @BBGDerek of #distilledconcepts discusses on our #healthcarepodcast. #healthcare #podcast #digitalhealth “Who has leverage?” @BBGDerek of #distilledconcepts discusses on our #healthcarepodcast. #healthcare #podcast #digitalhealth “Where’s the incentive for an insurance company to … [stand] with [the] patients?” @BBGDerek of #distilledconcepts discusses on our #healthcarepodcast. #healthcare #podcast #digitalhealth “Change takes a long time for a hospital, but … employers can move pretty quickly.” @BBGDerek of #distilledconcepts discusses on our #healthcarepodcast. #healthcare #podcast #digitalhealth Showing #value when setting #pricepoints in #healthsystems. @BBGDerek of #distilledconcepts discusses on our #healthcarepodcast. #healthcare #podcast #digitalhealth “Are we causing undue harm?” @BBGDerek of #distilledconcepts discusses on our #healthcarepodcast. #healthcare #podcast #digitalhealth The spectrum of #PBMs and which ones you should consider. @BBGDerek of #distilledconcepts discusses on our #healthcarepodcast. #healthcare #podcast #digitalhealth

written post at https://healthy-skeptic.com/2019/07/10/the-rvs-may-not-accurately-reflect-actual-physician-work-time/

In this bonus episode, Dr. Jackson explains the important role RVUs play in compensation and payment for Hospitalists and Employed Physicians. Have feedback or suggestions for future topics? Email us at:healtheconomics@acog.org Additional links:Have a coding question? Submit a ticket into ACOG's FreshDesk Ticket Database:https://www.acog.org/About-ACOG/ACOG-Departments/Coding/New-Ticket-Database-for-Coding-Questions Practice Management Ticket Database:https://www.acog.org/About-ACOG/ACOG-Departments/ACOG-Practice-Management-Ticket-Database Additional links to coding resources:https://www.acog.org/About-ACOG/ACOG-Departments/Coding ACOG Legal Disclaimer: Information contained in this podcast should not be construed as legal advice. As always, practitioners should consult their personal attorney about legal requirements in their jurisdiction and for legal advice on a particular matter. The information presented in this podcast is for guidance purposes only. ACOG makes no representations and/or warranties, express or implied, regarding the accuracy of the information contained in this podcast. ACOG assumes no liability for any consequences resulting from or otherwise related to any use of, or reliance on, this podcast. Inclusion of any product, procedure, or method of practice in this presentation does not constitute endorsement by the College. Music Attribution: Our intro and outro music is a derivative of “Golden Sunrise (Instrumental Version)” from the album The Wake by Josh Woodward, used under a Creative Commons Attribution 4.0 International LicenseFree Download: https://www.joshwoodward.com/ Album: The WakeCreative Commons Attribution 4.0 International License Support the show (https://www.acog.org/Practice-Management)

What is the best model for compensating physicians, and what is your process for implementing change in physician compensation? Two MedAxiom member programs highlight their respective answers to these questions, showcasing unique compensation models for cardiology in these challenging times. Joseph Goeke, MD, is Chairman of Operations and Finance Committee at Saint Luke's Physician Group. Arie Szatkowski, MD, FACC, is Director of Cardiovascular Services for Baptist Memorial Healthcare Corporation, Baptist Desoto Hospital, Stern Cardiovascular Clinic. Joel Sauer, MBA, is Executive Vice President of MedAxiom Consulting.

A quick run-through of the basic terminologies and concepts associated with physician payment.Have feedback or suggestions for future topics? Email us at:healtheconomics@acog.org Additional links: Have a coding question? Submit a ticket into ACOG's FreshDesk Ticket Database:https://www.acog.org/About-ACOG/ACOG-Departments/Coding/New-Ticket-Database-for-Coding-Questions Have a practice management question? Submit a ticket into ACOG's Practice Management Ticket Database:https://www.acog.org/About-ACOG/ACOG-Departments/ACOG-Practice-Management-Ticket-Database Additional links to coding resources and publications:https://www.acog.org/About-ACOG/ACOG-Departments/Coding ACOG Legal Disclaimer: Information contained in this podcast should not be construed as legal advice. As always, practitioners should consult their personal attorney about legal requirements in their jurisdiction and for legal advice on a particular matter. The information presented in this podcast is for guidance purposes only. ACOG makes no representations and/or warranties, express or implied, regarding the accuracy of the information contained in this podcast. ACOG assumes no liability for any consequences resulting from or otherwise related to any use of, or reliance on, this podcast. Inclusion of any product, procedure, or method of practice in this presentation does not constitute endorsement by the College. Music Attribution: Our intro and outro music is a derivative of “Golden Sunrise (Instrumental Version)” from the album The Wake by Josh Woodward, used under a Creative Commons Attribution 4.0 International LicenseFree Download: https://www.joshwoodward.com/ Album: The Wake Creative Commons Attribution 4.0 International License Definition from external source:Principles of Healthcare Reimbursement, by Anne B. Casto and Elizabeth Forrestal, American Health Information Management Association, 2013, pp. 155Support the show (https://www.acog.org/Practice-Management)

The new podcast from MedPage Today is for physicians and clinicians, all about the narrative side of medicine. With the demise of doctors lounges and increasing feeling of isolation and burnout, we believe that the power of shared story can help heal the healers. To re-calibrate and remind us all of why we do what we do. The new podcast will honor and highlight the humanity and soul of caring for people. The victories, the lessons learned, heartache and jubilation. We're digging past RVUs and satisfaction scores towards empathy as a way to connect, attach, and encourage. We have a great first season lined up and in production. We're launching next month, so subscribe and stay tuned! So, if you have stories and music to share, we'd love to hear more. Email us: anamnesis@medpagetoday.com Thanks for joining us, and we look forward to getting started and hearing from you soon.

Session 87 Dr. Jairo Barrantes joins Ryan to talk about Academic Sleep Medicine including what he loves about it, what call looks like, and why he chose academia. For more resources, be sure to check out all our other podcasts on the MedEd Media Network. [01:24] Interest in Sleep Medicine Jairo's interest in sleep medicine sparked during his pulmonary critical care fellowship, where their director was the head of the American Academy of Sleep Medicine. That being said, a pulmonary physician has too little exposure to what sleep medicine really is including the different diseases you come across. Sleep medicine involves 80%-90% of sleep apnea. While the training you get as a pulmonologist is the sleep apnea part and not so much exposure to all other diseases that sleep medicine entails. This opened up different doors such as narcolepsy, parasomnia, and insomnia, which may up the main problems of sleep medicine today– but there are more others apparently, especially in children. Jairo describes sleep medicine as a very fine specialty where you get the opportunity to see all patients. [03:31] Traits that Lead to Being a Good Sleep Medicine Specialist Jairo says that most people choose this specialty for being gentle in terms of not having any calls and you only get to work from Monday to Friday. You infrequently get phone calls from the sleep lab at night time. So many people choose this because of the lifestyle. However, what makes you a good physician is to have a good understanding of the pulmonary and brain physiology. We sleep 33% of our life so we sleep for many years. And that's part of the time that no one really cares about. That period of time, a lot of changes happen during our sleep. Metabolism slows down as well as your brain function and this has that recovery and immunology component. Jairo explains that the reason many people die during their sleep is due to surges of stress once your metabolism goes down and when your body is already deconditioned, this can cause a heart attack. [05:40] Types of Patients You may choose to do only adults or only pediatrics, or both as what Jairo does. For the children, the most common concern would be sleeping difficulties. Childhood insomnia composes 80% of his consults. The rest would be children with sleep apnea. Interestingly, sleep apnea in children is often misdiagnosed as ADHD by primary care physicians and pediatricians and they prescribe the medication like stimulants to keep them awake and focused during the day. But the reality is that these kids are sleep-deprived and have got poor quality of sleep. That could be sleep apnea that hasn't been treated for years and have been in medication to keep them awake. Suddenly, you go ahead to treat the sleep apnea and the kid's behavior improves. In fact, about 40% of children that have been diagnosed with ADHD were actually suffering sleep apnea. The rest of the patients would then be dealing with parasomnias, which are irregular behaviors during sleep time such as banging of the head or entire body during sleep. Obesity and narrow airways may cause sleep apnea and this is easier to notice among adults. However, there are other multiple solutions for this such as medication to help them sleep. Jairo also likes to use common devices like fitness trackers to help patients with insomnia so they can develop better sleep patterns. The key is to sleep right at the wrong time. For instance, teens go to sleep at around 1-2 am and wake up at 11 am. People think they're lazy, but they just have a different sleep pattern. Unfortunately, this is causing disrupting in schools. In fact, in Minnesota, people are having their children start school later at 9am-10am and they scored better in their standardized test because they perform better when not sleep-deprived. Some people with parasomnia may act their dreams and they think they're playing karate in the middle of the night. That can be dangerous for the bed partner, or they can injure themselves since they're pretty much asleep when they're acting their dreams. And they could hurt themselves with sharp objects in the house, or fall off the mattress. Hence, these disorders should be treated. [10:55] Taking Calls and the Golden Age of Sleep Medicine Jairo admits to never having been back to the lab. The only time he needed was during their pulmonary fellowship. Most of the centers are outpatient sleep facilities. This makes it very convenient for people. In pediatric medicine, most of the fellowship are three years. So it's very attractive for them to have a one-year fellowship. Moreover, Jairo describes the salary is not bad at all for the amount of extra training you do after your internal medicine, pediatrics, or psychiatry, so it's very similar to primary specialties. Depending on where you work, they bill time for sleep interpretation and you have your schedule close for a couple of hours so you can do the sleep studies for the night. Jairo also points out that many people stay away from sleep medicines due to economical reimbursement. It was better during its golden years some 20 years ago but Medicare adjusted the prices and now, you get a glorified internist salary without calls. Not bad at all, however, it wasn't as good as it used to be back then. That being said, still, it's a very mellow specialty to go through and the number of diseases is limited with about 20-25 conditions with different subdivisions compared to doing general internal medicine where you have to treat thousands of conditions. [13:30] Typical Day and Work-Life Balance Jairo would usually go to the office and most of the patients prefer to schedule their sleep studies early in the morning. So you do a sleep study interpretation from 8-11am. Then after the clinic from 11-12 for lunch, you go back to the clinic and finish at about 4 pm. You wrap up and then go home. This happens Monday to Friday. He still has enough time for his family as he still gets to take his daughter to ballet classes and other activities. [14:55] Academic vs Community Setting As to why he chose the academic setting, there are opportunities for research available. This is one area in the specialty where you can develop your career. And there are also plenty of areas to do research. Alternatively, you don't get the opportunity to do research in the private sector and you focus more on sleep apnea as that's where money is generated. So you need to be linked to an academy to be able to develop sleep research. There is plenty of themes or areas that you can do it, but in order to develop that, you need a little bit of protected time, access to key people doing statistics and interpretation. You also need people to help coach you how to write articles properly. While the academic centers get more complicated cases. Hence, case reports are easier for them to make when from the academic side. Additionally, Jairo loves to teach. He finds being attached to a center that has Sleep Fellowship as very gratifying. [16:35] The Training Path and Getting Getting Monetary Compensation There are different ways down the Sleep Medicine path. Initially, you have to have a base specialty and then you can apply for sleep medicine from there. You can become a sleep physician from being a general internalist or from general pediatrics. You can also come from pulmonary critical care, psychiatry, psychology, and neurology. So finish your basic specialty then do sleep medicine fellowship thereafter. You take the board for sleep medicine and become a Diplomate. Jairo says that it's easy to find a job in sleep medicine because, in the last ten years, the doctors who were practicing sleep medicine weren't board-certified. Hence, they didn't have any formal training. And when the boards came, it was very difficult for those physicians practicing without formal training to pass the board. Those people shied away and they haven't studied again to be able to take the boards. Nevertheless, people don't realize it's a good specialty since it's easy to work with the schedule because it gives you a lot of flexibility. Plus, he gets to have weekends off.  Also, the amount of RVU they can generate from the sleep is significantly higher than what you can generate from being a primary pulmonologist. This means they give you more forgiveness in time and still receive the same expectations from the hospital without working extended hours. Or if you're paid by incentive and reach a certain amount of RVUs a year, you're able to reach those RVUs with the sleep part which you will never reach just with the pulmonary part alone or psychiatry work, whichever specialty you have. Matching into sleep medicine is not competitive at all. People don't even know what sleep medicine is. But Jairo thinks it's going to surge once people getting paid with these RVUs. There are about 60 programs that are eligible and out of those, about 60% get filled. [21:00] Special Opportunities to Subspecialize There isn't much opportunity to subspecialize once you get into sleep medicine. You basically choose your niche of practice usually depending on your background. For instance, if your background is neurology, you usually focus on circadian rhythm disorders, seizures, and movement disorders during the sleep compared to doing sleep apnea. In Jairo's case, he does mostly sleep apnea and uses of non-invasive positive pressure ventilation at night. He also does what he calls as special populations like children who have facial malformations or other conditions that leave them with very narrow airways and have severe sleep apnea that requires tracheostomies, advanced ventilators, or non-invasive positive pressure ventilation at nighttime, especially patients with APS who become dependent on those during both nighttime and daytime. [22:25] Working with Primary Care and Other Specialties Jairo wishes primary care physicians would realize that sleep medicine is more than a sleep apnea. But that's not what just the sleep medicine entails. It's more than just prescribing the CPAP or the BIPAP. A lot of knowledge is involved and a lot of different opportunities to treat the patient better. Additionally, there are many diseases that are preventable or better treated when you have a better sleep pattern at night. For example, if you have diabetes and your sleep apnea is controlled thereby giving you good sleep, your insulin requirements go down by 30-40%. The same happens to people with hypertension where they notice some drop in the amount of medication required for hypertension when they're treated for sleep apnea or insomnia. If they're able to understand this, primary care physicians would be more enticed to know more about sleep medicine so they can do basic practice in their practice, says Jairo. As a general internist, you can prescribe the CPAP and sleep study. But if you have the basic knowledge and interest in that, then you won't have to refer to a sleep specialist, which can be very difficult to find these days. In fact, it may take up to 6-8 months to get a sleep specialist available. This actually discourages patients to pursue any longer since they can't find anybody to see them. Other specialties they work the closest with are mostly pulmonologist, bariatric surgeons, psychiatrists, and child psychiatrists. They also work with neurologists for patients with ALS or spinal trauma. They do work with cardiologists as well as endocrinology. They're trying to get better control of irregular heartbeat at nighttime or daytime and this decreases the frequency of relapses of atrial fibrillation after ablation when sleep apnea is being treated. [25:22] Special Opportunities Outside of Clinical Medicine One area would be commercial devices. They're looking for people developing new technologies. If you get to work with one of the companies that develop non-invasive positive pressure ventilation, there are opportunities to go into the commercial or research side. You would now be part of the protocol. But if your center is standardized and needs to forfeit all of the conditions of the American Academy of Sleep Medicine, you will be able to get research going on in your lab. There are private doctors who decide to devote all of their time or 80% of their practice to do the case being paid by the research study. [26:26] Most and Least Liked About Sleep Medicine When he did his residency in internal medicine as an intern, one of the sleep doctors gave them a talk about sleep medicine and didn't mention about it and he was making good money at that time. Today, the population they work with include patients that are very gratifying as it enhanced their quality of life. Although there are some that complain, the majority are still grateful for what you do for them. Interestingly, you don't need to see your sleep patients very frequently. You may only seem them every year and they can do very well with that. What he likes the most about his specialty is the schedule. Interestingly, Jairo doesn't find anything that he doesn't like about his specialty. He enjoys every single minute he's at work. Maybe, having patient with insomnia that is very difficult to treat can be upsetting for him so you can end up being a dispenser of control medications for them. But as far as you do your job right, most of your patients get well. [29:20] Major Changes in Sleep Medicine People are becoming more aware of the wellness and lifestyle so sleep medicine is going to start growing more and more. And perhaps in the next 10-20 years, physicians are going to be very aware of the benefits of having a good quality of sleep. Hopefully, there will be more physicians coming to learn what sleep medicine is and practice it. This will lead to better reimbursement and more opportunity to treat other people. If he had to do it all over again, he'd still do it. In fact, he would even do it first over the pulmonary part if he'd just have to take sleep medicine. Although he loves pulmonary, he finds sleep medicine as more gratifying. [30:33] Final Words of Wisdom Jairo says that sleep medicine is a wonderful field where you can achieve many personal goals in relation to your career. Career is significantly easier when you do it from the sleep part because there is a blank canvas to be painted compared to other specialties. So this is a fine specialty to pursue. Links: MedEd Media Network

Host Brian Fortenberry and guest Jackie Boswell discuss the ins and outs of Relative Value Units (RVUs), how they work, and how they're calculated. They discuss how important it is for physicians to be educated when it comes to RVUs, especially for compensation purposes. RVUs have a wider reach as well, being used to evaluate specialties, compare physicians, and assess practices across the nation. To see this episodes show notes or to get more information, go to SVMIC.com.

Brandt Jewell and Alex Kirkland join Mark to discuss the final rule from CMS last month announcing changes to the physician fee schedule for 2019. Brandt and Alex provide their input on the changes that have been announced and what it means for physician practices. Contact Information Subscribe to our feed in Apple Podcasts, Google Podcasts, Spotify, or your preferred podcast provider. Like what you hear? Leave a review! Not there? Let us know! We welcome all feedback from our listeners. Please submit questions on any of the topics we discuss or questions about issues in which you have an interest. You can also provide recommendations on topics for future episodes.  Email us: feedback@cokergroup.com Connect with us on LinkedIn: Coker Group Company Page Follow us on Twitter: @cokergroup Follow us on Instagram: @cokergroup Episode Synopsis On November 1, 2018, the Centers for Medicare & Medicaid Services (CMS) issued a final rule that includes updates to payment policies, payment rates, and quality provisions for services furnished under the Medicare Physician Fee Schedule (PFS) on or after January 1, 2019. Key Points from the Final Rule One of the payment provisions announced involved streamlining evaluation and management payment and reducing clinician burden. Beginning in CY 2021, payment for E/M office/outpatient visits will be simplified and payment would vary primarily based on attributes that do not require separate, complex documentation. After consideration of concerns raised by commenters in response to the proposed rule, CMS is not finalizing aspects of the proposal that would have: Reduced payment when E/M office/outpatient visits are furnished on the same day as procedures; Established separate coding and payment for podiatric E/M visits; Standardized the allocation of practice expense RVUs for the codes that describe these services. Brandt and Alex will also be hosting a webinar on January 24, 2019 that will cover, in part, the potential ramifications for physicians and healthcare organizations. Learn more and sign-up for the live event today! Extras Final Policy on Payment and Quality Provision Changes to the Medicare Physician Fee Schedule for CY 2019 Follow Brandt on Twitter Connect with Brandt on LinkedIn Follow Alex on Twitter Connect with Alex on LinkedIn

A 9921..what? Ben & Tom jump deep into the sewers of medical billing to break it all down for you. How do you know what code to bill? Do I get a consent form or not? Is there an ICD-10 code for this? What are RVUS and how are they calculated? All those questions and more are answered in this episode. The guys break it down into three sections. First, is determining the appropriate coding for your office visits. We look at what needs to go into the HPI, ROS, and PE for each code. Next, they examine the transition from ICD-9 to ICD-10 and why we had to make that change. What is ICD-10 good for and they find some VERY interesting ICD-10 codes. Lastly, (and a highly requested topic) the boys jump into CPT codes, consent forms, and RVUs. An in-depth explanation of calculating RVUs occurs in this episode. If you are negotiating a RVU contract in the future, you don't want to miss this. And after the show ends, we get the guys back on for a short explanation of next week's episode. Amazon Affiliate Link:https://www.amazon.com/?tag=justsomepodca-20&linkCode=ur1

On this episode of the NP Dude podcast I explain my logic how PAs are “mid-level”!  I am not debating our PA brothers and sisters aren’t good providers but how their license and expectation in practice is inherently so.  I also mention an experienced listener’s comments about a side hustle he does which got me […] The post Episode 115 – Why I Feel PAs are “Mid-level”, More Side Hustles, and RVUs! first appeared on The NP Dude.

Listen NowIn 1997 the Congress reformed how it pays physicians under Medicare.  The new formula was termed the "sustainable growth rate" (SGR).   The impetus for the reform was to control better Medicare cost growth.   (Medicare physician payments now exceed $100 billion annually).   Largely because of the concern physicians would limit seeing Medicare patients if their Medicare reimbursement rates were cut, the Congress has not enforced the SGR since 2002.   Despite the realization the SGR is unalterably broken, the Congress has been unable or unwilling to amend the law.  Though the upaid SGR tab is presently $138 billion this amount is substantially less than previous calculations that approached  $300 billion (due to a recent decline in Medicare utilization).  With debt and deficit reduction talks expected to re-emerge over the next few months will the Congress finally find the wherewithal to fix the docs?    The podcast begins with Dr. Berenson addressing the genesis of the SGR and then proceeding to explain why Congress has routinely ignored enforcing the SGR since 2002.  The discussion proceeds to explain why/how doing away with the SGR would currently cost $138 billion.   What effect the SGR has (still) had and what recent MedPAC and a bipartisan House proposal (Reps. Schwartz and Heck) call for in creating a new payment method while offsetting the accumulated $138 billion.  Dr. Berenson next discusses his recent Congressional testimony where he identified ways to improve or mend Medicare fee for service payments, e.g., reducing distortions in, or improving the accuracy of, physician service relative value units (RVUs), improving payment for evaluation and management services.  He argues in sum for global payment or partial capitation.  Dr. Berenson concludes by noting current Congressional bi-partisan support for SGR reform though noting reform proposals would have to identify some mechanism/s to control for volume growth and an indication that quality and efficiency would be improved.           Dr. Robert Berenson is currently a Fellow at the Urban Institute where his research work concerns health care policy, particularly Medicare.  From 1998-2000, Dr. Berenson was in charge of Medicare payment policy and private health plan contracting in the Centers for Medicare and Medicaid Services (CMS). Previously, he served as an Assistant Director of the Carter White House Domestic Policy Staff.  Dr. Berenson became a Commissioner of the Medicare Payment Advisory Commission (MedPAC) in 2009 and in 2010 became MedPAC's Vice Chair.  Dr. Berenson is a board-certified internist, for the last twelve years practicing in Washington, D.C.  He is Fellow of the American College of Physicians and the author of numerous research publications.  He is a graduate of the Mount Sinai School of Medicine and on the faculty at the George Washington University Schools of Medicine and Public Health and the Fuqua School of Business at Duke.Dr. Berenson's February 2013 Energy and Commerce Committee testimony can be found at:  http://democrats.energycommerce.house.gov/sites/default/files/documents/Testimony-Berenson-Health-SGR-Medicare-Payment-2013-2-14.pdfDr. Berenson's (et al.) March 2013 Urban Institute paper, "Can Medicare Be Preserved While Reducing the Deficit?" is available at:http://www.rwjf.org/en/research-publications/find-rwjf-research/2013/03/can-medicare-be-preserved-while-reducing-the-deficit-.html This is a public episode. If you would like to discuss this with other subscribers or get access to bonus episodes, visit www.thehealthcarepolicypodcast.com