The second annual ACR Division Directors’ Conference took place in Chicago on March 10–11. The conference opened with a presentation on the use of the ACR’s Rheumatology Informatics System for Effectiveness (RISE) Registry in academic medical centers by Salahuddin “Dino” Kazi, MD, from UT Southwestern Medical Center, and Jinoos Yazdany, MD, MPH, from the University of California San Francisco. Dr. Kazi reviewed the mechanics of the registry and how it is designed to retrieve relevant medical data from electronic medical record systems without the need for significant clinician involvement. A number of community physicians have enrolled in RISE, but many implementation barriers remain for academic medical centers, which the committee is currently addressing. Dr. Yazdany emphasized how this registry can be used to improve quality of care in clinical rheumatology practice and may serve as an important resource for rheumatology fellow quality projects.
Daniel F. Battafarano, DO, from the San Antonio Medical Military Center, presented highlights from the 2015 ACR Workforce Study.
The education of fellows in rheumatology was presented by Douglas W. White, MD, PhD, chair of the ACR’s Committee on Rheumatologic Care, and Maria I. Danila, MD, MSc, MSPH, a rheumatologist at the University of Alabama at Birmingham (UAB). Dr. White presented data from a survey completed by rheumatology fellows, the majority of whom thought it was important to teach the business of rheumatology during fellowship, but not in the first year. The fellows expressed support for interaction with community clinicians and administrators familiar with billing procedures and best practices in the rheumatology setting. Dr. Danila discussed how UAB prepares fellows to enter rheumatology practice with educational sessions on contract negotiation, finance, clinic work flow, human resource management and marketing.
Angus Worthing, MD, chair of the ACR’s Government Affairs Committee, discussed ACR advocacy strategies and Congressional healthcare reform efforts. He also reviewed the two pathways, Merit-Based Incentive Payment System and Alternate Payment Models, that are available under MACRA. He addressed the key rheumatology issues related to MACRA, including the reduction in cost-attribution risk, the potential importance of the RISE Registry for clinical practice improvement and development of quality measures, along with opportunities for rheumatologists to comment on rule updates. He also mentioned workforce issues and the importance of RheumPAC for building relationships with members of Congress.
Lilly Marks, vice president for health affairs at the University of Colorado, discussed medical school economics and the many challenges facing the academic mission. She emphasized that understanding the risks, rewards and nuances of leverage is critical to understanding the financial aspects of academic medicine. Medical schools have successfully built and financed their missions through leveraging of primary revenue sources derived largely from clinical income, which has grown precipitously over the past 20 years.
In contrast, funding from state and local agencies has been flat, and funding for NIH research has declined when adjusted for inflation. Resistance to growing tuition and fees, another important revenue source, is increasing. Ms. Marks reviewed the challenges related to managing NIH resources and maintaining adequate funding in academic medical centers. She also discussed the probability that clinical revenues will decline due to changing physician employment models, the increasing view of healthcare as a commodity, and the shift of costs to consumers.
Ms. Marks also reviewed the political, economic and demographic forces that will profoundly affect academic medical centers across all three missions. Political interventions to address the rising costs of medical care will profoundly impact the economic, demographic and market forces that support academic medical centers. She stressed that external sources may be unwilling to subsidize fundamental principles of the academic medical center, particularly education and research, and we must be creative in addressing these challenges.
Members from Vizient discussed how relative value units (RVUs) are developed and applied to compensate physician productivity. Recently Vizient merged with the Faculty Practice Solutions Center (FPSC) to serve many academic medical centers and acute care hospitals across the country through provision of data on RVUs, patient charges and evaluation and management coding distribution. They discussed how RVUs were developed and applied to measure clinical productivity. Data were presented that revealed a decrease in earned work RVUs in rheumatology practices, from 5,126 in 2011 to 4,256 in 2015. Moreover, a five-year trend suggests a 17% overall decrease in the work RVU production. Explanations for this decrease are unclear but may relate, in part, to the use of electronic medical records.
Timothy Laing, MD, senior associated chair of clinical programs at the University of Michigan, and Musty Habhab, chief administrator in the Department of Internal Medicine at the University of Michigan, discussed the use of RVUs in managing rheumatology divisions. They described how the total RVU comprises the work RVU plus the practice expense RVU, plus the malpractice expense RVU. The work RVU includes time, technical skill, physical effort, mental effort, along with judgment and psychological stress. RVUs can be applied to manage a rheumatology division, to assess productivity, to deliver provider compensation and for billing reviews. Details regarding the use of RVUs in provider compensation and billing reviews were presented.
Richard Siegel, clinical director at NIAMS, closed the meeting with a discussion of the rheumatology training pipeline. Data from the FIT Survey revealed a paucity of trainees interested in basic, translational or clinical research. The survey also found that clinical educator and clinical investigator tracks were preferred among women and that one of the major factors influencing career decisions is the high student debt carried by many U.S. medical school graduates.
The third annual Division Directors’ Conference will take place March 9–10, 2018, in Chicago. The Division Directors’ Special Committee encourages all rheumatology division directors to attend.
