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Medicaid Primer 2012: Avoiding the Office RAC
All legislation passed by our government has seemingly good intentions, and so it goes with the Affordable Care Act. However, with all legislation comes unintended consequences, and this has proven true with the ACA.
Tucked into the reams of legislation were provisions for tightening antifraud and abuse efforts in state Medicaid programs via the Recovery Audit Contractor (RAC) program. RACs are independent contractors using professionally trained coders under the authority of the Centers for Medicare and Medicaid Services (CMS) who perform focused chart audits on physician CPT coding outliers in an attempt to identify and recoup improper overpayments and underpayments made to providers. From an audit of charts, a statistical analysis is done to estimate total overpayments and the physician or group is assessed a fine. A contingency fee of up to 10% is paid to the RAC upon recovery of monies.
I have spent many hours at the American Medical Association House of Delegates listening to physicians’ complaints of arbitrary, capricious, and even egregious behavior by these RAC companies preying upon Medicare practices to collect their contingency fees. Lack of timely response to physician grievances, lack of physician oversight of the coders, systematic overestimation of overpayments and underrecognition of underpayments, and lack of due process appeal procedures are just some of the litany of complaints aired.
The RAC is akin to an IRS audit, and the financial consequences, as well as costs to one’s business reputation, are to be avoided at all costs. Modest changes have been made by the CMS in response to concerns, and since 2005, the Medicare trust funds have recovered over a billion dollars in overpayments.
Beginning Jan. 1, permanent RAC audits will be implemented in state Medicaid programs as part of routine compliance and audit procedures, thanks to the ACA, so the RAC soon may be coming to your office.
What can you expect, and how can you avoid getting wrecked by RAC?
Based on comments from the Health and Human Services Department Office of Inspector General, (OIG 2012 audit Work Plan) and past Medicare and Medicaid audits, it seems for now the low-hanging fruit is the 99214/99215, and modifier –25 outliers will be likely targeted.
It appears that initial Medicaid RAC audits by states may or may not offer sufficient due process as the auditors stumble out of the starting gates. Rules of engagement, including an appeals mechanism and timely response to physician grievances, have yet to be implemented in most states, even at this late date. Unfamiliarity with state Medicaid rules and regulations, and in particular pediatric workflow and procedures, may also interfere with a smooth transition of this program into Medicaid.
On an individual level, I recommend becoming immediately familiar with the AMA CPT 2012 manual, which interprets the AMA CPT rules and regulations. Establish office consensus on your coding procedures. Document all the work that you do. Self audit your level 4 and 5 E & M codes and your modifier –25s to ensure you comply with all the necessary documentation.
If you have EMR, make sure your code level, despite enough documentation, is appropriate for the level of medical decision making. If you are in a large group, establish a coding and compliance committee that routinely does chart audits, sets group policy, and implements yearly group education on CPT coding, along with a group policy manual.
Remember, if your community codes level 99214s at an average of 24% and you are at 60%, "you’ve got some ’splainin’ to do!"
If the community average for modifier 25s is 4% of health supervision visits and you are at 25%, you will be audited. The cost to your practice and the mental anguish to you and your staff may not be worthwhile, so consider taking a hard look at your internal billing and coding practices now.
On a macro level, I suggest several actions. First, work with your state medical society general council to monitor state implementation of the RAC. Ensure appropriate procedures, due process including a formal appeals mechanism, professional coders under physician oversight, timely response to provider concerns, and avoidance of flawed statistical analysis, as well as overlooking of underpayments.
Second, have your state medical society advocate for a managed care Medicaid waiver for RAC - the managed care plans already have extensive compliance and audit procedures that need not be duplicated by the RAC.
Finally, monitor the audit and compliance procedures of the commercial health plan you work with. They often copycat Medicare and could perhaps view fraud and abuse recovery as a way to enhance their revenue, so implement all the above tactics with your commercial health plan patients as well.
We are entering a new milieu of CPT coding and compliance. Higher coding may not be as desirable as ‘more accurate’ coding. Hiding below the radar by not entering CPT outlier territory may be more preferable than being a well-reimbursed CPT outlier with your office serving as a bull’s eye for target practice by your friendly neighborhood state RAC auditor.
Dr. Cohen is is vice chair of the American Academy of Pediatrics, District 9 and president of the San Diego County Medical Society Foundation. He has represented the American Academy of Pediatrics at the American Medical Association for many years. He said he had no relevant financial disclosures.
I strongly urge all my colleagues to take heed of the warnings and advice in this missive. There are many gems of information that should help us stay out of harm's way. I am especially concerned that many vascular practices will be inadvertently caught in reviews of the .25 modifier. We use this modifier every time we perform a non-invasive vascular lab test and see the patient for a valid office visit the same day.
| Dr. Samson |
The .25 modifier is applied to the office visit. This would be considered a valid use of the modifier, since the information gathered by that test should help in the management of the patient on that day. It also is a convenience for the patient in that they do not have to return for another visit on another day. So if scrutinized it should not pose an issue.
Unfortunately, as crazy as it may seem, some carriers have issued, or are considering, mandates against same day testing. So this general review of that modifier may result in heavy penalties even if the tests were performed on the same day for imperative clinical reasons. Importantly, it is likely that as vascular surgeons ordering tests in our labs, we may exceed the local norm for use of that modifier causing review of our practice patterns.
Probably there wouldn't be any repercussions, but we would still have to defend our actions and this would be time consuming and would involve unnecessary expense. I do not know what the alterative is, but I do suggest that we stay aware of this potential issue.
If anyone gets caught up in this mess, please notify the SVS so that it can defend their use of the modifier and so that we can all learn from their unfortunate experience. Hopefully, it will never happen but who knows?
Russell H. Samson, MD, is a Clinical Associate Professor of Surgery (Vascular) at Florida State University Medical School and a member of Sarasota Vascular Specialists.
I strongly urge all my colleagues to take heed of the warnings and advice in this missive. There are many gems of information that should help us stay out of harm's way. I am especially concerned that many vascular practices will be inadvertently caught in reviews of the .25 modifier. We use this modifier every time we perform a non-invasive vascular lab test and see the patient for a valid office visit the same day.
| Dr. Samson |
The .25 modifier is applied to the office visit. This would be considered a valid use of the modifier, since the information gathered by that test should help in the management of the patient on that day. It also is a convenience for the patient in that they do not have to return for another visit on another day. So if scrutinized it should not pose an issue.
Unfortunately, as crazy as it may seem, some carriers have issued, or are considering, mandates against same day testing. So this general review of that modifier may result in heavy penalties even if the tests were performed on the same day for imperative clinical reasons. Importantly, it is likely that as vascular surgeons ordering tests in our labs, we may exceed the local norm for use of that modifier causing review of our practice patterns.
Probably there wouldn't be any repercussions, but we would still have to defend our actions and this would be time consuming and would involve unnecessary expense. I do not know what the alterative is, but I do suggest that we stay aware of this potential issue.
If anyone gets caught up in this mess, please notify the SVS so that it can defend their use of the modifier and so that we can all learn from their unfortunate experience. Hopefully, it will never happen but who knows?
Russell H. Samson, MD, is a Clinical Associate Professor of Surgery (Vascular) at Florida State University Medical School and a member of Sarasota Vascular Specialists.
I strongly urge all my colleagues to take heed of the warnings and advice in this missive. There are many gems of information that should help us stay out of harm's way. I am especially concerned that many vascular practices will be inadvertently caught in reviews of the .25 modifier. We use this modifier every time we perform a non-invasive vascular lab test and see the patient for a valid office visit the same day.
| Dr. Samson |
The .25 modifier is applied to the office visit. This would be considered a valid use of the modifier, since the information gathered by that test should help in the management of the patient on that day. It also is a convenience for the patient in that they do not have to return for another visit on another day. So if scrutinized it should not pose an issue.
Unfortunately, as crazy as it may seem, some carriers have issued, or are considering, mandates against same day testing. So this general review of that modifier may result in heavy penalties even if the tests were performed on the same day for imperative clinical reasons. Importantly, it is likely that as vascular surgeons ordering tests in our labs, we may exceed the local norm for use of that modifier causing review of our practice patterns.
Probably there wouldn't be any repercussions, but we would still have to defend our actions and this would be time consuming and would involve unnecessary expense. I do not know what the alterative is, but I do suggest that we stay aware of this potential issue.
If anyone gets caught up in this mess, please notify the SVS so that it can defend their use of the modifier and so that we can all learn from their unfortunate experience. Hopefully, it will never happen but who knows?
Russell H. Samson, MD, is a Clinical Associate Professor of Surgery (Vascular) at Florida State University Medical School and a member of Sarasota Vascular Specialists.
All legislation passed by our government has seemingly good intentions, and so it goes with the Affordable Care Act. However, with all legislation comes unintended consequences, and this has proven true with the ACA.
Tucked into the reams of legislation were provisions for tightening antifraud and abuse efforts in state Medicaid programs via the Recovery Audit Contractor (RAC) program. RACs are independent contractors using professionally trained coders under the authority of the Centers for Medicare and Medicaid Services (CMS) who perform focused chart audits on physician CPT coding outliers in an attempt to identify and recoup improper overpayments and underpayments made to providers. From an audit of charts, a statistical analysis is done to estimate total overpayments and the physician or group is assessed a fine. A contingency fee of up to 10% is paid to the RAC upon recovery of monies.
I have spent many hours at the American Medical Association House of Delegates listening to physicians’ complaints of arbitrary, capricious, and even egregious behavior by these RAC companies preying upon Medicare practices to collect their contingency fees. Lack of timely response to physician grievances, lack of physician oversight of the coders, systematic overestimation of overpayments and underrecognition of underpayments, and lack of due process appeal procedures are just some of the litany of complaints aired.
The RAC is akin to an IRS audit, and the financial consequences, as well as costs to one’s business reputation, are to be avoided at all costs. Modest changes have been made by the CMS in response to concerns, and since 2005, the Medicare trust funds have recovered over a billion dollars in overpayments.
Beginning Jan. 1, permanent RAC audits will be implemented in state Medicaid programs as part of routine compliance and audit procedures, thanks to the ACA, so the RAC soon may be coming to your office.
What can you expect, and how can you avoid getting wrecked by RAC?
Based on comments from the Health and Human Services Department Office of Inspector General, (OIG 2012 audit Work Plan) and past Medicare and Medicaid audits, it seems for now the low-hanging fruit is the 99214/99215, and modifier –25 outliers will be likely targeted.
It appears that initial Medicaid RAC audits by states may or may not offer sufficient due process as the auditors stumble out of the starting gates. Rules of engagement, including an appeals mechanism and timely response to physician grievances, have yet to be implemented in most states, even at this late date. Unfamiliarity with state Medicaid rules and regulations, and in particular pediatric workflow and procedures, may also interfere with a smooth transition of this program into Medicaid.
On an individual level, I recommend becoming immediately familiar with the AMA CPT 2012 manual, which interprets the AMA CPT rules and regulations. Establish office consensus on your coding procedures. Document all the work that you do. Self audit your level 4 and 5 E & M codes and your modifier –25s to ensure you comply with all the necessary documentation.
If you have EMR, make sure your code level, despite enough documentation, is appropriate for the level of medical decision making. If you are in a large group, establish a coding and compliance committee that routinely does chart audits, sets group policy, and implements yearly group education on CPT coding, along with a group policy manual.
Remember, if your community codes level 99214s at an average of 24% and you are at 60%, "you’ve got some ’splainin’ to do!"
If the community average for modifier 25s is 4% of health supervision visits and you are at 25%, you will be audited. The cost to your practice and the mental anguish to you and your staff may not be worthwhile, so consider taking a hard look at your internal billing and coding practices now.
On a macro level, I suggest several actions. First, work with your state medical society general council to monitor state implementation of the RAC. Ensure appropriate procedures, due process including a formal appeals mechanism, professional coders under physician oversight, timely response to provider concerns, and avoidance of flawed statistical analysis, as well as overlooking of underpayments.
Second, have your state medical society advocate for a managed care Medicaid waiver for RAC - the managed care plans already have extensive compliance and audit procedures that need not be duplicated by the RAC.
Finally, monitor the audit and compliance procedures of the commercial health plan you work with. They often copycat Medicare and could perhaps view fraud and abuse recovery as a way to enhance their revenue, so implement all the above tactics with your commercial health plan patients as well.
We are entering a new milieu of CPT coding and compliance. Higher coding may not be as desirable as ‘more accurate’ coding. Hiding below the radar by not entering CPT outlier territory may be more preferable than being a well-reimbursed CPT outlier with your office serving as a bull’s eye for target practice by your friendly neighborhood state RAC auditor.
Dr. Cohen is is vice chair of the American Academy of Pediatrics, District 9 and president of the San Diego County Medical Society Foundation. He has represented the American Academy of Pediatrics at the American Medical Association for many years. He said he had no relevant financial disclosures.
All legislation passed by our government has seemingly good intentions, and so it goes with the Affordable Care Act. However, with all legislation comes unintended consequences, and this has proven true with the ACA.
Tucked into the reams of legislation were provisions for tightening antifraud and abuse efforts in state Medicaid programs via the Recovery Audit Contractor (RAC) program. RACs are independent contractors using professionally trained coders under the authority of the Centers for Medicare and Medicaid Services (CMS) who perform focused chart audits on physician CPT coding outliers in an attempt to identify and recoup improper overpayments and underpayments made to providers. From an audit of charts, a statistical analysis is done to estimate total overpayments and the physician or group is assessed a fine. A contingency fee of up to 10% is paid to the RAC upon recovery of monies.
I have spent many hours at the American Medical Association House of Delegates listening to physicians’ complaints of arbitrary, capricious, and even egregious behavior by these RAC companies preying upon Medicare practices to collect their contingency fees. Lack of timely response to physician grievances, lack of physician oversight of the coders, systematic overestimation of overpayments and underrecognition of underpayments, and lack of due process appeal procedures are just some of the litany of complaints aired.
The RAC is akin to an IRS audit, and the financial consequences, as well as costs to one’s business reputation, are to be avoided at all costs. Modest changes have been made by the CMS in response to concerns, and since 2005, the Medicare trust funds have recovered over a billion dollars in overpayments.
Beginning Jan. 1, permanent RAC audits will be implemented in state Medicaid programs as part of routine compliance and audit procedures, thanks to the ACA, so the RAC soon may be coming to your office.
What can you expect, and how can you avoid getting wrecked by RAC?
Based on comments from the Health and Human Services Department Office of Inspector General, (OIG 2012 audit Work Plan) and past Medicare and Medicaid audits, it seems for now the low-hanging fruit is the 99214/99215, and modifier –25 outliers will be likely targeted.
It appears that initial Medicaid RAC audits by states may or may not offer sufficient due process as the auditors stumble out of the starting gates. Rules of engagement, including an appeals mechanism and timely response to physician grievances, have yet to be implemented in most states, even at this late date. Unfamiliarity with state Medicaid rules and regulations, and in particular pediatric workflow and procedures, may also interfere with a smooth transition of this program into Medicaid.
On an individual level, I recommend becoming immediately familiar with the AMA CPT 2012 manual, which interprets the AMA CPT rules and regulations. Establish office consensus on your coding procedures. Document all the work that you do. Self audit your level 4 and 5 E & M codes and your modifier –25s to ensure you comply with all the necessary documentation.
If you have EMR, make sure your code level, despite enough documentation, is appropriate for the level of medical decision making. If you are in a large group, establish a coding and compliance committee that routinely does chart audits, sets group policy, and implements yearly group education on CPT coding, along with a group policy manual.
Remember, if your community codes level 99214s at an average of 24% and you are at 60%, "you’ve got some ’splainin’ to do!"
If the community average for modifier 25s is 4% of health supervision visits and you are at 25%, you will be audited. The cost to your practice and the mental anguish to you and your staff may not be worthwhile, so consider taking a hard look at your internal billing and coding practices now.
On a macro level, I suggest several actions. First, work with your state medical society general council to monitor state implementation of the RAC. Ensure appropriate procedures, due process including a formal appeals mechanism, professional coders under physician oversight, timely response to provider concerns, and avoidance of flawed statistical analysis, as well as overlooking of underpayments.
Second, have your state medical society advocate for a managed care Medicaid waiver for RAC - the managed care plans already have extensive compliance and audit procedures that need not be duplicated by the RAC.
Finally, monitor the audit and compliance procedures of the commercial health plan you work with. They often copycat Medicare and could perhaps view fraud and abuse recovery as a way to enhance their revenue, so implement all the above tactics with your commercial health plan patients as well.
We are entering a new milieu of CPT coding and compliance. Higher coding may not be as desirable as ‘more accurate’ coding. Hiding below the radar by not entering CPT outlier territory may be more preferable than being a well-reimbursed CPT outlier with your office serving as a bull’s eye for target practice by your friendly neighborhood state RAC auditor.
Dr. Cohen is is vice chair of the American Academy of Pediatrics, District 9 and president of the San Diego County Medical Society Foundation. He has represented the American Academy of Pediatrics at the American Medical Association for many years. He said he had no relevant financial disclosures.
Surgeons Decry Latest Duty-Hour Restrictions
SAN FRANCISCO -- The American College of Surgeons could consider taking over resident training from the Accreditation Council of Graduate Medical Education to avoid the council's latest duty-hour restrictions, which went into effect in July.
In considering strategies to address the unwelcome restrictions, "we haven't taken anything off the table," said Dr. L.D. Britt, immediate past president of the American College of Surgeons (ACS) and chair of the ACS Task Force on Resident Duty Hours. "We shouldn't allow any entity to destroy our training programs."
At least one College official later said the College has no plans to take over accreditation of residency programs, but the mere mention of this possibility as an option drew cheers at an emotional, standing-room-only session on resident duty hours during the annual Clinical Congress of the American College of Surgeons.
Dr. Britt and a panel of ACS leaders described their efforts thus far to modify the new duty-hour requirements before and after they went into effect. The session was the first time surgeons had gathered in large numbers since the new rules went into effect, and many of them vented their frustrations.
They objected most to the 16-hours/day limit on first-year residents. "The 16-hour day is an enemy to education," said Dr. Britt, an ACS Fellow and Brickhouse Professor of Surgery and Chairman at Eastern Virginia Medical School, Norfolk.
Limitations on the work hours of surgical trainees in England, Switzerland, and other European countries have been "devastating" to the quality of education there, he said. "Why aren't they looking at the international experience?" Dr. Britt asked in a lengthy discussion session after the formal presentations.
He and others emphasized that there are no data showing that reduced hours lead to better patient outcomes. On the contrary, the limits could hurt patients by increasing the risk for errors because the new schedule leads to an increased number of patient hand-offs and gives residents less experience, they suggested.
Dr. Ajit K. Sachdeva, an ACS Fellow, director of the ACS Division of Education, and moderator of the session, said in a phone interview afterward that there has been "a lot of chatter" on ACS listservs about the duty-hour restrictions, but the ACS "has no plans" to take over residency program accreditations.
"There's a prevailing sense in the surgical community that the 16 hours a day is not going to be good for surgical training and actually will do harm, because you will have less well-trained people in the future," said Dr. Sachdeva, adjunct professor of surgery at Northwestern University, Chicago. The ACS will continue to try to get the Accreditation Council of Graduate Medical Education (ACGME) to expand the daily 16-hour limit for first-year residents and to keep the 80-hour weekly limit from shrinking.
Under the 2011 regulations, residents must break the rules to get needed experience in continuity of care, said Dr. Thomas V. Whalen, an ACS Fellow and chief medical officer, department of surgery, Lehigh Valley Health Network, Allentown, Pa.
Dr. Whalen, who served on the ACGME task force that reviewed and revised the 2003 regulations, said that pressure for tighter limits on resident duty hours came largely from sleep scientists such as Dr. Charles A. Czeisler, professor and director of the division of sleep medicine, Harvard University, and chief of the division of sleep medicine at Brigham and Women's Hospital, Boston.
Dr. Czeisler said in an interview that he is an advocate of patient safety and evidence-based medicine. "In fact, this year is the 40th anniversary of the first study demonstrating that extended-duration shifts double the rate of errors that interns make when detecting cardiac arrhythmias," he said. Since then, his research has shown that work shifts longer than 24 hours lead to a 460% increase in serious diagnostic mistakes made by resident physicians caring for critically ill patients in the ICU, a 73% increase in the risk of percutaneous injuries, and a 168% increase in the odds of a resident being in a motor vehicle crash while driving home, among other adverse consequences.
An Institute of Medicine (IOM) consensus statement in December 2008 recommended, among other things, that 5 hours of sleep be allowed after any shift longer than 16 hours, and that this sleep time be counted toward the 80-hour/week limit, averaged over 4 weeks.
The ACS published a detailed response to the IOM report, arguing that the 16 hours/day limit "is entirely unworkable in the surgical environment" (Surgery 2009;146:398-409).
The ACGME rules don't go as far as the IOM recommendations because the ACGME applied the 16 hours/day limit only to interns and not to other residents, Dr. Czeisler has noted in previously published statements.
Limiting duty shifts for surgical residents will not necessarily hurt the quality of education or increase the number of years of training needed, according to Dr. Czeisler. He pointed out that "surgeons in New Zealand have been training with a 16-hour shift limit since 1985, without needing a longer training program."
Dr. Mark L. Friedell, an ACS Fellow and president of the Association of Program Directors in Surgery, suggested that the fourth year of medical school could be used to prepare students for surgical residency. Dr. Sachdeva said that the ACS is working with other organizations to develop a surgery "boot camp" for fourth-year medical students.
Another helpful alternative would be to develop a "milestone" for first-year residents that might make the ACGME feel comfortable in letting them work 24 consecutive hours, like other residents, said Dr. Friedell, who directs the residency program in general surgery at Orlando Health, a network of hospitals.
Reports from five residency programs on their experience thus far with duty-hour restrictions suggest that surgery interns now are working 6 days/week, and "golden weekends" have disappeared. Patient hand-offs have increased in many programs. Faculty and senior residents are under more stress as more of the workload shifts to them. Many programs have hired additional nurse practitioners and physician assistants to help handle the work residents no longer do.
First-year residents report that they do not feel blamed for the restrictions, but many feel they are being shortchanged by not having the same duty hours as other residents, Dr. Friedell said.
"Part of the reason we're in the mess we're in is because we didn't pay enough attention to what residents did in the pre-80-hour era," said Dr. Joshua M.V. Mammen, assistant professor at the University of Kansas, Kansas City, and past chair of the ACS Resident and Associate Society (RAS). He echoed a theme suggesting that enhanced supervision of residents -- rather than limiting duty hours -- is the key to safe practice.
In a 2006 Internet-based survey of RAS members, approximately 60% said that, ideally, residents should work less than 80 hours/week, and 40% favored more than 80 hours/week, said Dr. Mammen. In an ongoing survey of current RAS members with 841 respondents so far, it's more of a 50-50 split, he said. In all, 48% said that residents should work 60-80 hours/week, 47% believed 61-100 hours/week would be ideal, 2% favored fewer than 60 hours/week, and 3% wanted residents working more than 100 hours/week.
The speakers had no conflicts.
This newest version of ACGME work hour regulation has created significant challenges for program directors, faculty and residents alike, unfortunately without any evidence that it will be of benefit to trainees, patients, or the educational process. While the overall number of hours per week is unchanged at 80, there are numerous new restrictions which create logistical difficulties for both programmatic management and patent care.
These center around the length of time that residents can work consecutively, as well as the number of hours required to be off duty between duty periods. Specifically, first year residents may not spend more than 16 hours on duty at a time (compared to 24 hours previously and for more senior trainees); in addition, eight hours between duty periods is now mandatory, compared to the "suggested" ten hours previously indicated, and lastly there is added regulation around time off following a 24-hour shift and night float.
| Dr. Shortell |
Such restrictions, which at first glance may seem fairly minor, create additional difficulties in scheduling, but perhaps more importantly, have the potential to impact continuity of care for patients in significant ways. Consider that with every new restriction on duty hours, more hand-offs are required, with each hand-off having the potential to affect continuity of care. In addition, each hand-off takes time - time which could be otherwise devoted to educational experiences and care of patients. Astonishingly, despite placing all these additional restrictions around resident work hours, moonlighting, an activity which provides no educational opportunities, remains an acceptable activity for trainees.
Ultimately, we must ask whether the potential (but unproven) benefits noted above gleaned from duty hour restrictions are worth the loss of opportunity to patients and residents that is afforded by continuous care by an individual physician.
It is important to note that the addition of physician extenders, which has been a strategy utilized to reduce service requirements in the past, would not address the above concerns, as hand-offs would still be required. Regardless of the validity of these changes, they are here to stay for the foreseeable future, and it will be our responsibility as surgeons and educators to develop ways to maximize patient care and resident education in the face of these new regulations.
Cynthia K. Shortell, MD, is a professor of surgery and chief of vascular surgery and program director, vascular residency at Duke University Medical Center, Durham, N.C.
This newest version of ACGME work hour regulation has created significant challenges for program directors, faculty and residents alike, unfortunately without any evidence that it will be of benefit to trainees, patients, or the educational process. While the overall number of hours per week is unchanged at 80, there are numerous new restrictions which create logistical difficulties for both programmatic management and patent care.
These center around the length of time that residents can work consecutively, as well as the number of hours required to be off duty between duty periods. Specifically, first year residents may not spend more than 16 hours on duty at a time (compared to 24 hours previously and for more senior trainees); in addition, eight hours between duty periods is now mandatory, compared to the "suggested" ten hours previously indicated, and lastly there is added regulation around time off following a 24-hour shift and night float.
| Dr. Shortell |
Such restrictions, which at first glance may seem fairly minor, create additional difficulties in scheduling, but perhaps more importantly, have the potential to impact continuity of care for patients in significant ways. Consider that with every new restriction on duty hours, more hand-offs are required, with each hand-off having the potential to affect continuity of care. In addition, each hand-off takes time - time which could be otherwise devoted to educational experiences and care of patients. Astonishingly, despite placing all these additional restrictions around resident work hours, moonlighting, an activity which provides no educational opportunities, remains an acceptable activity for trainees.
Ultimately, we must ask whether the potential (but unproven) benefits noted above gleaned from duty hour restrictions are worth the loss of opportunity to patients and residents that is afforded by continuous care by an individual physician.
It is important to note that the addition of physician extenders, which has been a strategy utilized to reduce service requirements in the past, would not address the above concerns, as hand-offs would still be required. Regardless of the validity of these changes, they are here to stay for the foreseeable future, and it will be our responsibility as surgeons and educators to develop ways to maximize patient care and resident education in the face of these new regulations.
Cynthia K. Shortell, MD, is a professor of surgery and chief of vascular surgery and program director, vascular residency at Duke University Medical Center, Durham, N.C.
This newest version of ACGME work hour regulation has created significant challenges for program directors, faculty and residents alike, unfortunately without any evidence that it will be of benefit to trainees, patients, or the educational process. While the overall number of hours per week is unchanged at 80, there are numerous new restrictions which create logistical difficulties for both programmatic management and patent care.
These center around the length of time that residents can work consecutively, as well as the number of hours required to be off duty between duty periods. Specifically, first year residents may not spend more than 16 hours on duty at a time (compared to 24 hours previously and for more senior trainees); in addition, eight hours between duty periods is now mandatory, compared to the "suggested" ten hours previously indicated, and lastly there is added regulation around time off following a 24-hour shift and night float.
| Dr. Shortell |
Such restrictions, which at first glance may seem fairly minor, create additional difficulties in scheduling, but perhaps more importantly, have the potential to impact continuity of care for patients in significant ways. Consider that with every new restriction on duty hours, more hand-offs are required, with each hand-off having the potential to affect continuity of care. In addition, each hand-off takes time - time which could be otherwise devoted to educational experiences and care of patients. Astonishingly, despite placing all these additional restrictions around resident work hours, moonlighting, an activity which provides no educational opportunities, remains an acceptable activity for trainees.
Ultimately, we must ask whether the potential (but unproven) benefits noted above gleaned from duty hour restrictions are worth the loss of opportunity to patients and residents that is afforded by continuous care by an individual physician.
It is important to note that the addition of physician extenders, which has been a strategy utilized to reduce service requirements in the past, would not address the above concerns, as hand-offs would still be required. Regardless of the validity of these changes, they are here to stay for the foreseeable future, and it will be our responsibility as surgeons and educators to develop ways to maximize patient care and resident education in the face of these new regulations.
Cynthia K. Shortell, MD, is a professor of surgery and chief of vascular surgery and program director, vascular residency at Duke University Medical Center, Durham, N.C.
SAN FRANCISCO -- The American College of Surgeons could consider taking over resident training from the Accreditation Council of Graduate Medical Education to avoid the council's latest duty-hour restrictions, which went into effect in July.
In considering strategies to address the unwelcome restrictions, "we haven't taken anything off the table," said Dr. L.D. Britt, immediate past president of the American College of Surgeons (ACS) and chair of the ACS Task Force on Resident Duty Hours. "We shouldn't allow any entity to destroy our training programs."
At least one College official later said the College has no plans to take over accreditation of residency programs, but the mere mention of this possibility as an option drew cheers at an emotional, standing-room-only session on resident duty hours during the annual Clinical Congress of the American College of Surgeons.
Dr. Britt and a panel of ACS leaders described their efforts thus far to modify the new duty-hour requirements before and after they went into effect. The session was the first time surgeons had gathered in large numbers since the new rules went into effect, and many of them vented their frustrations.
They objected most to the 16-hours/day limit on first-year residents. "The 16-hour day is an enemy to education," said Dr. Britt, an ACS Fellow and Brickhouse Professor of Surgery and Chairman at Eastern Virginia Medical School, Norfolk.
Limitations on the work hours of surgical trainees in England, Switzerland, and other European countries have been "devastating" to the quality of education there, he said. "Why aren't they looking at the international experience?" Dr. Britt asked in a lengthy discussion session after the formal presentations.
He and others emphasized that there are no data showing that reduced hours lead to better patient outcomes. On the contrary, the limits could hurt patients by increasing the risk for errors because the new schedule leads to an increased number of patient hand-offs and gives residents less experience, they suggested.
Dr. Ajit K. Sachdeva, an ACS Fellow, director of the ACS Division of Education, and moderator of the session, said in a phone interview afterward that there has been "a lot of chatter" on ACS listservs about the duty-hour restrictions, but the ACS "has no plans" to take over residency program accreditations.
"There's a prevailing sense in the surgical community that the 16 hours a day is not going to be good for surgical training and actually will do harm, because you will have less well-trained people in the future," said Dr. Sachdeva, adjunct professor of surgery at Northwestern University, Chicago. The ACS will continue to try to get the Accreditation Council of Graduate Medical Education (ACGME) to expand the daily 16-hour limit for first-year residents and to keep the 80-hour weekly limit from shrinking.
Under the 2011 regulations, residents must break the rules to get needed experience in continuity of care, said Dr. Thomas V. Whalen, an ACS Fellow and chief medical officer, department of surgery, Lehigh Valley Health Network, Allentown, Pa.
Dr. Whalen, who served on the ACGME task force that reviewed and revised the 2003 regulations, said that pressure for tighter limits on resident duty hours came largely from sleep scientists such as Dr. Charles A. Czeisler, professor and director of the division of sleep medicine, Harvard University, and chief of the division of sleep medicine at Brigham and Women's Hospital, Boston.
Dr. Czeisler said in an interview that he is an advocate of patient safety and evidence-based medicine. "In fact, this year is the 40th anniversary of the first study demonstrating that extended-duration shifts double the rate of errors that interns make when detecting cardiac arrhythmias," he said. Since then, his research has shown that work shifts longer than 24 hours lead to a 460% increase in serious diagnostic mistakes made by resident physicians caring for critically ill patients in the ICU, a 73% increase in the risk of percutaneous injuries, and a 168% increase in the odds of a resident being in a motor vehicle crash while driving home, among other adverse consequences.
An Institute of Medicine (IOM) consensus statement in December 2008 recommended, among other things, that 5 hours of sleep be allowed after any shift longer than 16 hours, and that this sleep time be counted toward the 80-hour/week limit, averaged over 4 weeks.
The ACS published a detailed response to the IOM report, arguing that the 16 hours/day limit "is entirely unworkable in the surgical environment" (Surgery 2009;146:398-409).
The ACGME rules don't go as far as the IOM recommendations because the ACGME applied the 16 hours/day limit only to interns and not to other residents, Dr. Czeisler has noted in previously published statements.
Limiting duty shifts for surgical residents will not necessarily hurt the quality of education or increase the number of years of training needed, according to Dr. Czeisler. He pointed out that "surgeons in New Zealand have been training with a 16-hour shift limit since 1985, without needing a longer training program."
Dr. Mark L. Friedell, an ACS Fellow and president of the Association of Program Directors in Surgery, suggested that the fourth year of medical school could be used to prepare students for surgical residency. Dr. Sachdeva said that the ACS is working with other organizations to develop a surgery "boot camp" for fourth-year medical students.
Another helpful alternative would be to develop a "milestone" for first-year residents that might make the ACGME feel comfortable in letting them work 24 consecutive hours, like other residents, said Dr. Friedell, who directs the residency program in general surgery at Orlando Health, a network of hospitals.
Reports from five residency programs on their experience thus far with duty-hour restrictions suggest that surgery interns now are working 6 days/week, and "golden weekends" have disappeared. Patient hand-offs have increased in many programs. Faculty and senior residents are under more stress as more of the workload shifts to them. Many programs have hired additional nurse practitioners and physician assistants to help handle the work residents no longer do.
First-year residents report that they do not feel blamed for the restrictions, but many feel they are being shortchanged by not having the same duty hours as other residents, Dr. Friedell said.
"Part of the reason we're in the mess we're in is because we didn't pay enough attention to what residents did in the pre-80-hour era," said Dr. Joshua M.V. Mammen, assistant professor at the University of Kansas, Kansas City, and past chair of the ACS Resident and Associate Society (RAS). He echoed a theme suggesting that enhanced supervision of residents -- rather than limiting duty hours -- is the key to safe practice.
In a 2006 Internet-based survey of RAS members, approximately 60% said that, ideally, residents should work less than 80 hours/week, and 40% favored more than 80 hours/week, said Dr. Mammen. In an ongoing survey of current RAS members with 841 respondents so far, it's more of a 50-50 split, he said. In all, 48% said that residents should work 60-80 hours/week, 47% believed 61-100 hours/week would be ideal, 2% favored fewer than 60 hours/week, and 3% wanted residents working more than 100 hours/week.
The speakers had no conflicts.
SAN FRANCISCO -- The American College of Surgeons could consider taking over resident training from the Accreditation Council of Graduate Medical Education to avoid the council's latest duty-hour restrictions, which went into effect in July.
In considering strategies to address the unwelcome restrictions, "we haven't taken anything off the table," said Dr. L.D. Britt, immediate past president of the American College of Surgeons (ACS) and chair of the ACS Task Force on Resident Duty Hours. "We shouldn't allow any entity to destroy our training programs."
At least one College official later said the College has no plans to take over accreditation of residency programs, but the mere mention of this possibility as an option drew cheers at an emotional, standing-room-only session on resident duty hours during the annual Clinical Congress of the American College of Surgeons.
Dr. Britt and a panel of ACS leaders described their efforts thus far to modify the new duty-hour requirements before and after they went into effect. The session was the first time surgeons had gathered in large numbers since the new rules went into effect, and many of them vented their frustrations.
They objected most to the 16-hours/day limit on first-year residents. "The 16-hour day is an enemy to education," said Dr. Britt, an ACS Fellow and Brickhouse Professor of Surgery and Chairman at Eastern Virginia Medical School, Norfolk.
Limitations on the work hours of surgical trainees in England, Switzerland, and other European countries have been "devastating" to the quality of education there, he said. "Why aren't they looking at the international experience?" Dr. Britt asked in a lengthy discussion session after the formal presentations.
He and others emphasized that there are no data showing that reduced hours lead to better patient outcomes. On the contrary, the limits could hurt patients by increasing the risk for errors because the new schedule leads to an increased number of patient hand-offs and gives residents less experience, they suggested.
Dr. Ajit K. Sachdeva, an ACS Fellow, director of the ACS Division of Education, and moderator of the session, said in a phone interview afterward that there has been "a lot of chatter" on ACS listservs about the duty-hour restrictions, but the ACS "has no plans" to take over residency program accreditations.
"There's a prevailing sense in the surgical community that the 16 hours a day is not going to be good for surgical training and actually will do harm, because you will have less well-trained people in the future," said Dr. Sachdeva, adjunct professor of surgery at Northwestern University, Chicago. The ACS will continue to try to get the Accreditation Council of Graduate Medical Education (ACGME) to expand the daily 16-hour limit for first-year residents and to keep the 80-hour weekly limit from shrinking.
Under the 2011 regulations, residents must break the rules to get needed experience in continuity of care, said Dr. Thomas V. Whalen, an ACS Fellow and chief medical officer, department of surgery, Lehigh Valley Health Network, Allentown, Pa.
Dr. Whalen, who served on the ACGME task force that reviewed and revised the 2003 regulations, said that pressure for tighter limits on resident duty hours came largely from sleep scientists such as Dr. Charles A. Czeisler, professor and director of the division of sleep medicine, Harvard University, and chief of the division of sleep medicine at Brigham and Women's Hospital, Boston.
Dr. Czeisler said in an interview that he is an advocate of patient safety and evidence-based medicine. "In fact, this year is the 40th anniversary of the first study demonstrating that extended-duration shifts double the rate of errors that interns make when detecting cardiac arrhythmias," he said. Since then, his research has shown that work shifts longer than 24 hours lead to a 460% increase in serious diagnostic mistakes made by resident physicians caring for critically ill patients in the ICU, a 73% increase in the risk of percutaneous injuries, and a 168% increase in the odds of a resident being in a motor vehicle crash while driving home, among other adverse consequences.
An Institute of Medicine (IOM) consensus statement in December 2008 recommended, among other things, that 5 hours of sleep be allowed after any shift longer than 16 hours, and that this sleep time be counted toward the 80-hour/week limit, averaged over 4 weeks.
The ACS published a detailed response to the IOM report, arguing that the 16 hours/day limit "is entirely unworkable in the surgical environment" (Surgery 2009;146:398-409).
The ACGME rules don't go as far as the IOM recommendations because the ACGME applied the 16 hours/day limit only to interns and not to other residents, Dr. Czeisler has noted in previously published statements.
Limiting duty shifts for surgical residents will not necessarily hurt the quality of education or increase the number of years of training needed, according to Dr. Czeisler. He pointed out that "surgeons in New Zealand have been training with a 16-hour shift limit since 1985, without needing a longer training program."
Dr. Mark L. Friedell, an ACS Fellow and president of the Association of Program Directors in Surgery, suggested that the fourth year of medical school could be used to prepare students for surgical residency. Dr. Sachdeva said that the ACS is working with other organizations to develop a surgery "boot camp" for fourth-year medical students.
Another helpful alternative would be to develop a "milestone" for first-year residents that might make the ACGME feel comfortable in letting them work 24 consecutive hours, like other residents, said Dr. Friedell, who directs the residency program in general surgery at Orlando Health, a network of hospitals.
Reports from five residency programs on their experience thus far with duty-hour restrictions suggest that surgery interns now are working 6 days/week, and "golden weekends" have disappeared. Patient hand-offs have increased in many programs. Faculty and senior residents are under more stress as more of the workload shifts to them. Many programs have hired additional nurse practitioners and physician assistants to help handle the work residents no longer do.
First-year residents report that they do not feel blamed for the restrictions, but many feel they are being shortchanged by not having the same duty hours as other residents, Dr. Friedell said.
"Part of the reason we're in the mess we're in is because we didn't pay enough attention to what residents did in the pre-80-hour era," said Dr. Joshua M.V. Mammen, assistant professor at the University of Kansas, Kansas City, and past chair of the ACS Resident and Associate Society (RAS). He echoed a theme suggesting that enhanced supervision of residents -- rather than limiting duty hours -- is the key to safe practice.
In a 2006 Internet-based survey of RAS members, approximately 60% said that, ideally, residents should work less than 80 hours/week, and 40% favored more than 80 hours/week, said Dr. Mammen. In an ongoing survey of current RAS members with 841 respondents so far, it's more of a 50-50 split, he said. In all, 48% said that residents should work 60-80 hours/week, 47% believed 61-100 hours/week would be ideal, 2% favored fewer than 60 hours/week, and 3% wanted residents working more than 100 hours/week.
The speakers had no conflicts.
Duty Hours: Now Versus Then
The 2011 "Resident Duty Hours in the Learning and Working Environment" replaced 2003 regulations from the ACGME. Here is a comparison of some of the 2003 and 2011 standards:
• Maximum Hours Per Week
2003: Duty hours limited to 80/week, averaged over a 4-week period, inclusive of in-house call activities.
2011: Also counts moonlighting hours in the 80-hour limit.
• Exceptions
2003: A review committee may grant exceptions for up to 10% or a maximum of 88 hours to individual programs.
2011: Same.
• Moonlighting
2003: Internal moonlighting must be counted toward the 80-hour limit.
2011: Also counts external moonlighting hours toward the limit.
• Maximum Duty Period
2003: Continuous on-site duty must not exceed 24 consecutive hours. Residents may remain on duty for up to 6 additional hours for didactic activities, transfer care of patients, outpatient clinics, or to maintain continuity of care. No new patients may be accepted after 24 hours of continuous duty.
2011: Maximum 16 consecutive hours for first-year residents. For second-year residents and above, in-hospital duty periods must not exceed 24 consecutive hours. Strategic napping is strongly suggested, especially after 16 hours of duty and between 10 p.m. and 8 a.m. Residents may remain on-site for up to 4 more hours for essential transitions of care but must not be assigned additional clinical responsibilities after 24 hours of continuous in-house duty. In unusual circumstances, residents may take the initiative to stay beyond the duty period to care for a single patient.
• Time Off
2003: One day in 7 free of responsibilities, averaged over 4 weeks, inclusive of call. Ten hours off between duty periods and after in-house call should be provided.
2011: Time off between duty periods must be at least 8 hours and should be 10 hours. Intermediate-level residents must have at least 14 hours free after 24 hours of in-house duty. No more than 6 consecutive nights of night float allowed.
The 2011 "Resident Duty Hours in the Learning and Working Environment" replaced 2003 regulations from the ACGME. Here is a comparison of some of the 2003 and 2011 standards:
• Maximum Hours Per Week
2003: Duty hours limited to 80/week, averaged over a 4-week period, inclusive of in-house call activities.
2011: Also counts moonlighting hours in the 80-hour limit.
• Exceptions
2003: A review committee may grant exceptions for up to 10% or a maximum of 88 hours to individual programs.
2011: Same.
• Moonlighting
2003: Internal moonlighting must be counted toward the 80-hour limit.
2011: Also counts external moonlighting hours toward the limit.
• Maximum Duty Period
2003: Continuous on-site duty must not exceed 24 consecutive hours. Residents may remain on duty for up to 6 additional hours for didactic activities, transfer care of patients, outpatient clinics, or to maintain continuity of care. No new patients may be accepted after 24 hours of continuous duty.
2011: Maximum 16 consecutive hours for first-year residents. For second-year residents and above, in-hospital duty periods must not exceed 24 consecutive hours. Strategic napping is strongly suggested, especially after 16 hours of duty and between 10 p.m. and 8 a.m. Residents may remain on-site for up to 4 more hours for essential transitions of care but must not be assigned additional clinical responsibilities after 24 hours of continuous in-house duty. In unusual circumstances, residents may take the initiative to stay beyond the duty period to care for a single patient.
• Time Off
2003: One day in 7 free of responsibilities, averaged over 4 weeks, inclusive of call. Ten hours off between duty periods and after in-house call should be provided.
2011: Time off between duty periods must be at least 8 hours and should be 10 hours. Intermediate-level residents must have at least 14 hours free after 24 hours of in-house duty. No more than 6 consecutive nights of night float allowed.
The 2011 "Resident Duty Hours in the Learning and Working Environment" replaced 2003 regulations from the ACGME. Here is a comparison of some of the 2003 and 2011 standards:
• Maximum Hours Per Week
2003: Duty hours limited to 80/week, averaged over a 4-week period, inclusive of in-house call activities.
2011: Also counts moonlighting hours in the 80-hour limit.
• Exceptions
2003: A review committee may grant exceptions for up to 10% or a maximum of 88 hours to individual programs.
2011: Same.
• Moonlighting
2003: Internal moonlighting must be counted toward the 80-hour limit.
2011: Also counts external moonlighting hours toward the limit.
• Maximum Duty Period
2003: Continuous on-site duty must not exceed 24 consecutive hours. Residents may remain on duty for up to 6 additional hours for didactic activities, transfer care of patients, outpatient clinics, or to maintain continuity of care. No new patients may be accepted after 24 hours of continuous duty.
2011: Maximum 16 consecutive hours for first-year residents. For second-year residents and above, in-hospital duty periods must not exceed 24 consecutive hours. Strategic napping is strongly suggested, especially after 16 hours of duty and between 10 p.m. and 8 a.m. Residents may remain on-site for up to 4 more hours for essential transitions of care but must not be assigned additional clinical responsibilities after 24 hours of continuous in-house duty. In unusual circumstances, residents may take the initiative to stay beyond the duty period to care for a single patient.
• Time Off
2003: One day in 7 free of responsibilities, averaged over 4 weeks, inclusive of call. Ten hours off between duty periods and after in-house call should be provided.
2011: Time off between duty periods must be at least 8 hours and should be 10 hours. Intermediate-level residents must have at least 14 hours free after 24 hours of in-house duty. No more than 6 consecutive nights of night float allowed.