October 27, 2011 Home|Journals & Publications|  AGA eDigest
AGA eDigest

News from the Literature | Practice | Policy | Awards | Research | Education & Meetings | GI Fellows


How Will ACO Final Rule Impact Your Practice?

AGA experts have reviewed the accountable care organization (ACO) rule released last week by CMS and offer important insights about the implications for specialists. It is essential that gastroenterologists keep track of this issue since ACOs have the potential to shape the future health-care system. AGA is pleased that CMS considered our comments to the proposed rule and included many of our recommendations in the final rule. Compare CMS’ changes to the ACO rule in response to AGA’s comments.

The Medicare Shared Savings Program (MSSP) establishing ACOs provides incentives for participating health-care providers who agree to work together to achieve measured quality improvement and reductions in the rate of spending growth. Although the focus of the MSSP still centers on the provision of primary care services, specialists can participate in the MSSP as either an owner, an ACO CEO, an ACO participant, a member of the ACO governing body, a senior level medical director, or part of the physician-directed quality assurance and improvement program.

Through several modifications in the final rule, CMS addressed the role of specialty physicians under ACOs, including:

  • Adding a stepwise beneficiary assignment process. CMS acknowledges that specialists appropriately provide primary care services for beneficiaries with serious and/or chronic conditions. As a result, CMS will implement a “stepwise” beneficiary assignment that will allow patients to be assigned to specialists, as long as they have not received a primary care service from a primary care physician during the most recent year.
  • Maintaining key quality measures that emphasize the need for specialty care and the creation of an “access to specialists” module. As a result of comments, CMS reduced the number of quality measures from 65 to 33. Of the 33 measures, two measures have a direct impact on GI care. They are consumer assessment of health providers and systems: access to specialists, and colorectal cancer screening. CMS also announced its intent to add an “access to specialists” module to emphasize the importance of specialist care in ACOs.
  • Clarifying referral relationships. While the MSSP maintains the beneficiary's freedom under the Medicare fee-for-service program to choose any participating Medicare provider, CMS acknowledged that there will be an incentive for ACOs to require that referrals be retained among the ACO, ACO participants and ACO providers/suppliers. CMS’ initial proposal restricted any specific referral arrangements. However, CMS modified its proposal to provide limited exceptions for referrals permitted under the physician self-referral law. CMS will monitor the actions of ACOs to determine whether an ACO, its ACO participants or its ACO providers/suppliers are interfering with the beneficiary's freedom of choice by improperly limiting or restricting referrals and care to ACO participants or ACO providers/suppliers in the same ACO.

Read more about the role that specialty physicians can play in ACOs.

AGA will continue to review and analyze the final ACO rule and how it will affect the practice of gastroenterology and patient care. Continue to read AGA eDigest to learn more.


Doctors Caution about Overinterpretation of Symptom Indexes

Symptom index (SI) and symptom-association probability (SAP) are indexes used to analyze data collected from ambulatory pH and/or impedance monitoring, and quantify the association between symptoms and reflux events. However, their characteristics are not well defined. According to study results in Clinical Gastroenterology and Hepatology, SI or SAP indexes can be overinterpreted, unless patients with GERD who are refractory to PPI therapy have high rates of reflux.

Clinical Gastroenterology and Hepatology 2011; 9(10): 868-874

Which Factors Predict Pain Relief after Cholecystectomy?

Upper abdominal pain (UAP) in patients with gallstones is often treated by cholecystectomy, but it frequently persists. In a study in Clinical Gastroenterology and Hepatology, doctors reported that UAP features and concomitant GERD, IBS and somatization determine the odds for relief from UAP after cholecystectomy.

Clinical Gastroenterology and Hepatology 2011; 9(10): 891-896

Early Mucosal Healing Associated with Improved Outcomes

In Active Ulcerative Colitis Trial (ACT)-1 and ACT-2, patients with ulcerative colitis treated with infliximab were more likely than those given placebo to have a clinical response, undergo remission and have mucosal healing. In a study published in Gastroenterology, the degree of mucosal healing after eight weeks of infliximab was correlated with improved clinical outcomes, including colectomy. Similar trends were observed for all outcomes except colectomy among the subgroup with clinical response at week eight. The degree of mucosal healing at week eight among those in clinical remission did not predict subsequent disease course.

Gastroenterology 2011; 141(4): 1194-1201

Submucosal Cushion Does Not Improve Evaluation of Polyps

Although the “submucosal cushion” technique or injection-assisted polypectomy (IAP) is often used to resect colon polyps, little is known of the influence of this technique on histologic interpretation. In this study appearing in Clinical Gastroenterology and Hepatology, the utilization of IAP did not result in a better margin evaluability of the resected polyp. Overall, IAP does not result in a better histologic polyp evaluability.

Clinical Gastroenterology and Hepatology 2011; 9(10): 910-913


Own a GI Pathology Lab? We Need to Hear From You!

In the 2012 Medicare physician fee schedule proposed rule, CMS requested that the AMA/Specialty Society Relative Value Update Committee (RUC) review the practice expense for Current Procedural Terminology® code 88305 level IV — surgical pathology, gross and microscopic examination. This is the most common pathology code reported by GI practices that also provide anatomic pathology services. The AGA participates in the RUC process and will be working with the College of American Pathologists and other specialty societies to survey members who perform this service.

To prepare for the survey process, we need to hear from you if your practice owns a GI pathology lab where you prepare the tissue specimen for examination by a pathologist. Please complete this short survey to provide us with your practice name, pathology services your practice offers and contact information.

Your participation in the RUC survey process is an important part of ensuring adequate and fair reimbursement for GI services.

eRx Payment Adjustments Begin Jan. 1; Are You Affected?

Beginning Jan. 1, 2012, eligible professionals who have not successfully met the requirements of the electronic prescribing (eRx) incentive program (or, alternately, qualify for a significant hardship exemption) will be subject to the 2012 eRx payment adjustment. The adjustment will reduce Medicare payment rates by 1 percent of the provider’s allowable Medicare Part B charges. The deadline to request a hardship exemption for the 2012 eRx payment adjustment is Nov. 1.
Eligible professionals and group practices should determine if they are subject to the payment adjustment and determine if they meet any of the hardship exemption categories specified by CMS. A quick reference guide is available to help understand the changes that the eRx final rule made to the 2011 Medicare eRx incentive program.
To request an exemption, submit your hardship exemption requests through the quality communications support page. Group practices participating under the group practice reporting option must submit hardship exemption requests via a letter to CMS.

To be considered for an exemption under the significant hardship exemption category, an eligible professional must:

  • Have registered for either the Medicare or Medicaid electronic health record (EHR) incentive program.
  • Show that they adopted certified EHR technology no later than Oct. 1, 2011, and provide identifying information about the certified EHR technology.

Eligible professionals wishing to register for the Medicaid EHR incentive program in states that have not yet launched their respective programs may initiate the registration process at the CMS registration and attestation system and obtain a registration number, even though they will not be able to successfully complete registration.
To initiate registration, please visit https://EHRincentives.CMS.gov/hitech/login.action. Obtaining a CMS registration number, even if the registration is not successfully completed, suffices for the purposes of applying for a significant hardship exemption.

PCPI Approves Adult IBD Measures

The AGA IBD measures were approved by the AMA’s Physician Consortium for Performance Improvement® (PCPI) last week. This approval adds to the credibility of the measures as the AGA prepares to submit them to the National Quality Forum for endorsement early next year.

A subset of these measures has been included as an IBD measures group in the proposed 2012 Physician Quality Reporting System. The proposal calls for this measures group to be reported only via a CMS qualified registry, not via claims.

The AGA adult IBD measures focus on transitioning patients to corticosteroid-sparing therapy and preventive care. The side effects of long-term corticosteroid steroid use, other immunosuppressants and anti-TNF agents make these patients especially vulnerable to preventable illnesses. The preventive care measures address immunizations and smoking assessment and cessation.

Gastroenterology practices managing the complex care needs of IBD patients need to understand their preventive care status and intervene accordingly. These measures are intended to decrease the variability in transitioning patients to steroid-sparing therapy and provide preventive care services to IBD patients as documented in the literature.

Comment on Draft Report on Bariatric Surgery, Nonsurgical Therapy

The following new report is available and open for comment on the Agency for Healthcare Research and Quality Effective Health Care (EHC) Program website until Nov. 16:

  • Comparative Effectiveness of Bariatric Surgery and Nonsurgical Therapy in Adults with Metabolic Conditions and a Body Mass Index of 30.0 to 34.9 kg/m². View and comment.

View all EHC program products that are currently available for comment. Also, learn how you can personalize your interactions with and share what you learn on the EHC program website.

If you have any comments on the EHC program website, please use their contact form.

HHS Holds Public Meeting on Essential Health Benefits

AGA attended an HHS-sponsored public listening session for providers to share their thoughts on essential health benefits. This meeting was in response to the release of the Institute of Medicine (IOM) report, “Essential Health Benefits: Balancing Coverage and Cost,” which provided HHS with recommendations on the essential health benefits package. AGA provided oral and written comments to HHS, based upon comments previously submitted to IOM.

AGA’s oral comments focused on criteria that should be used to define and update essential health benefits. Specifically, AGA believes that HHS and CMS should consider guidelines written and disseminated by national physician medical societies, in addition to recommendations made by entities such as the U.S. Preventive Services Task Force, when determining the essential health benefits package.

HHS is expected to issue a proposal on what benefits must be covered by the end of the year. AGA will continue to monitor this important provision and will advocate for patient access to treatments that are not solely based on cost-effectiveness.


What Is the RUC Process … and Why Should I Care?

There is nothing intuitive about the process by which Medicare determines payments for physicians. The AMA/Specialty Society Relative Value Scale Update Committee or “RUC” is an advisory group of “expert” physicians who provide recommendations on relative value units for physician work, practice expenses and liability insurance for particular physician services.

Jaya Agrawal, MD, first became involved in AGA’s efforts with the RUC nearly a year ago and has developed a new perspective on how this effort has a direct impact on reimbursement for GI services. Read why she thinks we have reached a critical juncture, the outcome of which will likely impact every gastroenterologist in the country.


AGA Member Is Honored with Lifetime Achievement Award

Francis M. Giardiello, MD, AGAF, was awarded the 2011 Lifetime Achievement Award from the Collaborative Group of the Americas on Inherited Colorectal Cancer (CGA-ICC) at a dinner banquet in his honor on Oct. 10 in Montreal, Canada during CGA-ICC’s annual meeting. Dr. Giardiello is the Johns G. Rangos senior professor of medicine, oncology and pathology at Johns Hopkins University School of Medicine in Baltimore, MD and director of the Johns Hopkins division of gastroenterology. He is also the program director of their gastrointestinal fellowship and director of the Johns Hopkins Colorectal Cancer Registry and colon cancer risk assessment clinic.

The award is presented to an individual who has had an important and lasting impact on the understanding and/or treatment of hereditary colorectal cancer. Dr. Giardiello’s accomplishments in genotype-phenotype correlations of polyposis syndromes, chemoprevention in polyposis syndromes, and genetic testing and understanding of hereditary syndromes is well known throughout the community. “If not the father of chemoprevention for familial polyposis, Frank is at least the godfather,” said Paul E. Wise, MD, associate professor of surgery at Vanderbilt University Medical Center, director of the Vanderbilt Hereditary Colorectal Cancer Registry and president of the CGA-ICC at the time he presented Dr. Giardiello with the award.

Prior to receiving the award, Dr. Giardiello presented a talk on his philosophy on becoming successful through the support of teachers, mentors, colleagues and loved ones, while naming many of those instrumental to his lifetime of success. Past winners of the award include Henry Lynch, MD; Patrick Lynch, MD, JD; Bert Vogelstein, MD; James Church, MD; and Randall W. Burt, MD.

The CGA-ICC is a non-profit, multidisciplinary organization established in 1995 to improve the understanding of the basic science of inherited colorectal cancer and the clinical management of affected families.

Call for Nominations: Member Recognition Prizes

Each year, the AGA honors a number of individuals for their outstanding contributions to the field of gastroenterology. Nominations are due Nov. 11 for the following awards:

  • The William Beaumont Prize in Gastroenterology, which recognizes an individual who has made a major contribution (a single accomplishment or series of accomplishments) that has significantly advanced gastroenterological basic or clinical research.
  • The Distinguished Clinician Awards, which recognize two individuals, one in private practice and one in clinical academic practice, who have exemplified leadership and excellence in the practice of gastroenterology.
  • The Distinguished Educator Award, which recognizes an individual for his or her achievements as an outstanding educator over a lifelong career.
  • The Distinguished Mentor Award, which recognizes an individual for his or her achievements as an outstanding mentor over a lifelong career.
  • The AGA Research Service Award, which recognizes an individual who has dedicated an extraordinary effort to advocacy for the advancement of gastroenterological science and research.

Complete nomination instructions, selection criteria and more information about each award are available on AGA's website. Please contact awards@gastro.org with questions about the nomination process


Connect with Colleagues Using AGA’s Researcher Directory

As part of the AGA’s mission to support multiple aspects of research, AGA has developed the directory of GI researchers, a free, online tool designed to help members connect with others who perform GI and liver disease research.

As a benefit of AGA membership, the directory is open to all members who perform research at no cost. You can use the directory to identify potential collaborators, identify resources that may be shared among fellow researchers, identify potential mentors and indicate interest in participating in pharmaceutical or device clinical trials.

To begin, watch this short instructional video that describes how the directory works and how to search participants' profiles; then, create your profile.

 To access the directory, visit http://gastro.org/ResearcherDirectory.

Your AGA Research Foundation Gifts Support ...

 … Ashwin Ananthakrishnan, MD, MPH, who received an AGA Research Scholar Award in 2011.

"It is truly an honor to be a recipient of the AGA Research Scholar Award (RSA). My research proposal aims to improve our understanding of environmental risk factors for the development of Crohn's disease and ulcerative colitis (UC), focusing in particular on diet. To generate high-quality epidemiologic evidence for specific dietary triggers of disease onset, I propose to examine the relationship between prospectively collected information on diet and risk of incident Crohn's disease and UC among women enrolled in the Nurses' Health Study I and II. This proposal specifically aims to examine the association of dietary fiber, intake of n-3 and n-6 poly-unsaturated fatty acids, and incidences of Crohn's disease or UC. We hope that the results from our proposal will provide compelling evidence of causality, offering a bridge to clinical translation of dietary interventions for Crohn's disease and UC. In addition, the RSA will offer me the opportunity for invaluable mentorship and training within new areas of nutritional and genetic epidemiology, and comes at a critical next step in my development into a leader in clinical and translational IBD research."

To make a donation, visit http://www.gastro.org/contribute.


Modules Focus on Optimal Diagnosis, Management Strategies

The AGA Institute, through a partnership with Medscape, has developed two free online modules to increase awareness among gastroenterologists and other health-care professionals of the need for a well-planned, multidisciplinary approach for the optimal management of patients with gastrointestinal stromal tumors (GISTs):

Because the symptoms of GIST — frequently found during an endoscopic procedure for another GI condition — are often related to the GI tract, gastroenterologists can be involved in the diagnosis. Therefore, the entire clinical care team needs to be aware of the best strategies for diagnosing and managing GIST patients.

Each module offers AMA PRA Category 1 Credits™.

This program is supported by an independent educational grant from Pfizer.

Screening for Hereditary Pancreatic Cancer Syndromes

Family history is a recognized risk factor for pancreatic cancer. Familial pancreatic cancer has been used to describe families with at least two first-degree relatives with pancreatic cancer without a known genetic defect. Hereditary pancreatic cancer cases are those where there are three or more pancreatic cancers in family or those due to a known genetic defect. These certain high-risk subgroups that have a significantly elevated lifetime risk of pancreatic cancer may benefit from screening and ongoing surveillance with the aim of detecting early pancreatic lesions.

Screening studies in high-risk cohorts have demonstrated that early pre-invasive pancreatic lesions can be detected and then treated using a number of currently available pancreatic cancer imaging modalities, including CT, endoscopic ultrasound and MRI/ magnetic resonance cholangiopancreatography.

More on this topic will be covered at the AGA Clinical Congress, which will be held Jan. 20 and 21, 2012, in Miami, FL. Sapna Syngal, MD, from the Dana-Farber Cancer Institute, will review the epidemiology and genetic basis of hereditary pancreatic cancer and discuss the emerging strategies for the detection of early pancreatic neoplasms in high-risk individuals. Learn more about this session and others at www.gilearn.org/clinicalcongress.


Here's What You're Retweeting

Here is what our Twitter followers retweeted most often last week:

  • FDA reform legislation introduced in Congress to streamline process for approving medical devices: ow.ly/74M2c.
  • Check out this free, must-read CGH article on chronic liver disease in the US Hispanic population. ow.ly/74GZm.
  • Incidence of CRC among adults in the US drops 10% in 5 years according to CDC data; page 1. GI & Hep News: ow.ly/710PO.
  • The most effective treatment for patients w/ microscopic colitis? Find out in today's post from The AGA Journals Blog ow.ly/70O2u.
  • Great interview w/ Dr. Douglas Dieterich, who was infected w/ hep C while a med student; eventually became hep C expert ow.ly/6ZSAJ.
  • Identifying Operational Metrics For Your Practice: ow.ly/6WFfX.

Have any news that you would like us to share with our AGA members? Please send them to communications@gastro.org or share them on our social media channels:

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Place GI Position Listings and Activity Announcements

For as little as $82.50, you can place a classified ad of 100 words or less in AGA's weekly e-mail newsletter, AGA eDigest, or AGA's bi-monthly magazine, AGA Perspectives. If you place ads in both AGA Perspectives and AGA eDigest, you will receive a 10 percent discount. Advertising in either includes a free online classified listing. Learn more.

North Carolina
Gastroenterologist Opportunities — Charlotte, NC

The division of gastroenterology at Carolinas Medical Center (CMC) has recently established a new and growing GI fellowship program and is seeking two full-time faculty members who have a commitment to excellence in clinical care and teaching. One of the candidates should have a strong interest and expertise in EUS, and while not required, additional experience with ERCP would be desirable. The other candidate should have strong general GI skills along with an interest in clinical research related to an additional area of focus such as esophageal disease, pancreatic disease, IBD, motility or QI.

CMC is one of the most comprehensive acute care hospitals in the Carolinas, and the largest hospital in Carolinas HealthCare System (CHS), which comprises more than 30 affiliated hospitals. With 874 beds and the region’s only level one trauma center, CMC treats patients from a widespread geographic area. Each year, CMC has more than 50,000 inpatient discharges, more than 6,500 newborn deliveries, more than 31,000 surgical procedures, and more than 110,000 emergency department visits.

We offer award-winning facilities, excellent benefits and a quality of life second to none. CHS is committed to being the leading provider of health-care services and sponsor of educational programs.

For more information or to submit a CV for consideration, please contact:

Geri Deutschman at geri.deutschman@carolinashealthcare.org.

704-355-6931 Office / 800-847-5084 Toll Free / 704-355-5033 Fax


North Dakota
Procedure-Oriented Practice

Sanford Health Fargo has immediate openings for BC/BE gastroenterologists in a procedure-oriented practice. Call 1:8. 100 percent hospitalist coverage; hospital consults only. Procedures performed include: ERCP, EUS and capsule endoscopy. ERCP and EUS skills are desirable, but not necessary. Opportunity to teach medical students and IM residents. Level II 583-bed trauma center with electronic medical records and PACS. Sanford Health Fargo consists of 585+ physicians located in Fargo and 32 regional primary care clinics.

Fargo, ND, with a metro population of 190,000, is a diverse, stimulating and family-oriented city with all the amenities that make for a satisfying and fulfilling life. We offer exceptional K-12 and higher education systems, world-class health care, affordable housing, low cost of living, and myriad cultural and entertainment opportunities.

Jean Keller, physician recruiter
Sanford Physician Placement
Phone: 701-280-4853
E-mail: jean.keller@sanfordhealth.org