Video

The simultaneous colonoscopic presence of serrated polyps and high-risk adenomas led to a fivefold increase in the odds of metachronous high-risk adenomas in a large population-based registry study reported in Gastroenterology (2017. doi: 10.1053/j.gastro.2017.09.011).

The data “support the recommendation that individuals with large and high-risk serrated lesions require closer surveillance,” said Joseph C. Anderson, MD, of White River Junction Department of Veterans Affairs Medical Center, Vt., with his associates. When discounting size and histology, the presence of serrated polyps alone was not associated with an increased risk for metachronous high-risk adenoma, they also reported. Although serrated polyps are important precursors of colorectal cancer, relevant longitudinal surveillance data are sparse. Therefore, the investigators studied 5,433 adults who underwent index and follow-up colonoscopies a median of 4.9 years apart and were tracked in the population-based New Hampshire Colonoscopy Registry. The cohort had a median age of 61 years and half of individuals were male.

SOURCE: AMERICAN GASTROENTEROLOGICAL ASSOCIATION

After adjusting for age, sex, smoking status, body mass index, and median interval between colonoscopies, individuals were at significantly increased risk of metachronous high-risk adenoma if their baseline colonoscopy showed high-risk adenoma and synchronous serrated polyps (odds ratio, 5.6; 95% confidence interval, 1.7-18.3), high-risk adenoma with synchronous sessile serrated adenomas (or polyps) or traditional serrated adenomas (OR, 16.0; 95% CI, 7.0-37.0), or high-risk adenoma alone (OR, 3.9; 95% CI, 2.8-5.4), vs. participants with no findings.

The researchers also found that the index presence of large (at least 1-cm) serrated polyps greatly increased the likelihood of finding large metachronous serrated polyps on subsequent colonoscopy (OR, 14.0; 95% CI, 5.0-40.9). “This has clinical relevance, since previous studies have demonstrated an increased risk for colorectal cancer in individuals with large serrated polyps,” the researchers wrote. “However, this increased risk may occur over a protracted time period of 10 years or more, and addressing variation in serrated polyp detection rates and completeness of resection may be more effective than a shorter surveillance interval at reducing risk in these individuals.”

The index presence of sessile serrated adenomas or polyps, or traditional serrated adenomas, also predicted the subsequent development of large serrated polyps (OR, 9.7; 95% CI, 3.6-25.9). The study did not examine polyp location or morphology (flat versus polypoid), but the association might be related to right-sided or flat lesions, which colonoscopists are more likely to miss or to incompletely excise than more defined polypoid lesions, the researchers commented. “Additional research is needed to further clarify the associations between index patient characteristics, polyp location, size, endoscopic appearance and histology, and the metachronous risk of advanced lesions and colorectal cancer in order to refine current surveillance recommendations for individuals undergoing colonoscopy,” they commented.

The study spanned January 2004 to June 2015, and awareness about the importance of serrated polyps rose during this period, they also noted.

The National Cancer Institute and the Norris Cotton Cancer Center provided funding. The researchers reported having no conflicts of interest.

The simultaneous colonoscopic presence of serrated polyps and high-risk adenomas led to a fivefold increase in the odds of metachronous high-risk adenomas in a large population-based registry study reported in Gastroenterology (2017. doi: 10.1053/j.gastro.2017.09.011).

The data “support the recommendation that individuals with large and high-risk serrated lesions require closer surveillance,” said Joseph C. Anderson, MD, of White River Junction Department of Veterans Affairs Medical Center, Vt., with his associates. When discounting size and histology, the presence of serrated polyps alone was not associated with an increased risk for metachronous high-risk adenoma, they also reported. Although serrated polyps are important precursors of colorectal cancer, relevant longitudinal surveillance data are sparse. Therefore, the investigators studied 5,433 adults who underwent index and follow-up colonoscopies a median of 4.9 years apart and were tracked in the population-based New Hampshire Colonoscopy Registry. The cohort had a median age of 61 years and half of individuals were male.

SOURCE: AMERICAN GASTROENTEROLOGICAL ASSOCIATION

After adjusting for age, sex, smoking status, body mass index, and median interval between colonoscopies, individuals were at significantly increased risk of metachronous high-risk adenoma if their baseline colonoscopy showed high-risk adenoma and synchronous serrated polyps (odds ratio, 5.6; 95% confidence interval, 1.7-18.3), high-risk adenoma with synchronous sessile serrated adenomas (or polyps) or traditional serrated adenomas (OR, 16.0; 95% CI, 7.0-37.0), or high-risk adenoma alone (OR, 3.9; 95% CI, 2.8-5.4), vs. participants with no findings.

The researchers also found that the index presence of large (at least 1-cm) serrated polyps greatly increased the likelihood of finding large metachronous serrated polyps on subsequent colonoscopy (OR, 14.0; 95% CI, 5.0-40.9). “This has clinical relevance, since previous studies have demonstrated an increased risk for colorectal cancer in individuals with large serrated polyps,” the researchers wrote. “However, this increased risk may occur over a protracted time period of 10 years or more, and addressing variation in serrated polyp detection rates and completeness of resection may be more effective than a shorter surveillance interval at reducing risk in these individuals.”

The index presence of sessile serrated adenomas or polyps, or traditional serrated adenomas, also predicted the subsequent development of large serrated polyps (OR, 9.7; 95% CI, 3.6-25.9). The study did not examine polyp location or morphology (flat versus polypoid), but the association might be related to right-sided or flat lesions, which colonoscopists are more likely to miss or to incompletely excise than more defined polypoid lesions, the researchers commented. “Additional research is needed to further clarify the associations between index patient characteristics, polyp location, size, endoscopic appearance and histology, and the metachronous risk of advanced lesions and colorectal cancer in order to refine current surveillance recommendations for individuals undergoing colonoscopy,” they commented.

The study spanned January 2004 to June 2015, and awareness about the importance of serrated polyps rose during this period, they also noted.

The National Cancer Institute and the Norris Cotton Cancer Center provided funding. The researchers reported having no conflicts of interest.

The simultaneous colonoscopic presence of serrated polyps and high-risk adenomas led to a fivefold increase in the odds of metachronous high-risk adenomas in a large population-based registry study reported in Gastroenterology (2017. doi: 10.1053/j.gastro.2017.09.011).

The data “support the recommendation that individuals with large and high-risk serrated lesions require closer surveillance,” said Joseph C. Anderson, MD, of White River Junction Department of Veterans Affairs Medical Center, Vt., with his associates. When discounting size and histology, the presence of serrated polyps alone was not associated with an increased risk for metachronous high-risk adenoma, they also reported. Although serrated polyps are important precursors of colorectal cancer, relevant longitudinal surveillance data are sparse. Therefore, the investigators studied 5,433 adults who underwent index and follow-up colonoscopies a median of 4.9 years apart and were tracked in the population-based New Hampshire Colonoscopy Registry. The cohort had a median age of 61 years and half of individuals were male.

SOURCE: AMERICAN GASTROENTEROLOGICAL ASSOCIATION

After adjusting for age, sex, smoking status, body mass index, and median interval between colonoscopies, individuals were at significantly increased risk of metachronous high-risk adenoma if their baseline colonoscopy showed high-risk adenoma and synchronous serrated polyps (odds ratio, 5.6; 95% confidence interval, 1.7-18.3), high-risk adenoma with synchronous sessile serrated adenomas (or polyps) or traditional serrated adenomas (OR, 16.0; 95% CI, 7.0-37.0), or high-risk adenoma alone (OR, 3.9; 95% CI, 2.8-5.4), vs. participants with no findings.

The researchers also found that the index presence of large (at least 1-cm) serrated polyps greatly increased the likelihood of finding large metachronous serrated polyps on subsequent colonoscopy (OR, 14.0; 95% CI, 5.0-40.9). “This has clinical relevance, since previous studies have demonstrated an increased risk for colorectal cancer in individuals with large serrated polyps,” the researchers wrote. “However, this increased risk may occur over a protracted time period of 10 years or more, and addressing variation in serrated polyp detection rates and completeness of resection may be more effective than a shorter surveillance interval at reducing risk in these individuals.”

The index presence of sessile serrated adenomas or polyps, or traditional serrated adenomas, also predicted the subsequent development of large serrated polyps (OR, 9.7; 95% CI, 3.6-25.9). The study did not examine polyp location or morphology (flat versus polypoid), but the association might be related to right-sided or flat lesions, which colonoscopists are more likely to miss or to incompletely excise than more defined polypoid lesions, the researchers commented. “Additional research is needed to further clarify the associations between index patient characteristics, polyp location, size, endoscopic appearance and histology, and the metachronous risk of advanced lesions and colorectal cancer in order to refine current surveillance recommendations for individuals undergoing colonoscopy,” they commented.

The study spanned January 2004 to June 2015, and awareness about the importance of serrated polyps rose during this period, they also noted.

The National Cancer Institute and the Norris Cotton Cancer Center provided funding. The researchers reported having no conflicts of interest.

If you haven’t started reporting quality data for the Merit-Based Incentive Payment System (MIPS), there’s still time to avoid a 4% cut to your Medicare payments.

Under the Pick Your Pace approach being offered this year, the Centers for Medicare & Medicaid Services allows clinicians to test the system by reporting on one quality measure for one patient through paper-based claims. Be sure to append a Quality Data Code (QDC) to the claim form for care provided up to Dec. 31, 2017, in order to avoid a penalty in payment year 2019.

Consider this measure:

Measure #111: Pneumococcal Vaccination Status for Older Adults

This measure is aimed at capturing the percentage of patients aged 65 years and older who have ever received a pneumococcal vaccine.

What you need to do: Review the medical record to find out if the patient has ever received a pneumococcal vaccine and if not, administer the vaccine.

Eligible cases include patients who were aged 65 years or older on the date of the encounter and a patient encounter during the performance period. Applicable codes include (CPT or HCPCS): 99201, 99202, 99203, 99204, 99205, 99212, 99213, 99214, 99215, 99341, 99342, 99343, 99344, 99345, 99347, 99348, 99349, 99350, G0402, G0438, G0439.

To get credit under MIPS, be sure to include a QDC that shows that you successfully performed the measure or had a good reason for not doing so. For instance, CPT II 4040F indicates that the pneumococcal vaccine was administered or previously received. Use exclusion code G9707 to indicate that the patient was not eligible because they received hospice services at any time during the measurement period.

CMS has a full list measures available for claims-based reporting at qpp.cms.gov. The American Medical Association has also created a step-by-step guide for reporting on one quality measure.

Certain clinicians are exempt from reporting and do not face a penalty under MIPS:

• Those who enrolled in Medicare for the first time during a performance period.

• Those who have Medicare Part B allowed charges of $30,000 or less.

• Those who have 100 or fewer Medicare Part B patients.

• Those who are significantly participating in an Advanced Alternative Payment Model (APM).


 

If you haven’t started reporting quality data for the Merit-Based Incentive Payment System (MIPS), there’s still time to avoid a 4% cut to your Medicare payments.

Under the Pick Your Pace approach being offered this year, the Centers for Medicare & Medicaid Services allows clinicians to test the system by reporting on one quality measure for one patient through paper-based claims. Be sure to append a Quality Data Code (QDC) to the claim form for care provided up to Dec. 31, 2017, in order to avoid a penalty in payment year 2019.

Consider this measure:

Measure #111: Pneumococcal Vaccination Status for Older Adults

This measure is aimed at capturing the percentage of patients aged 65 years and older who have ever received a pneumococcal vaccine.

What you need to do: Review the medical record to find out if the patient has ever received a pneumococcal vaccine and if not, administer the vaccine.

Eligible cases include patients who were aged 65 years or older on the date of the encounter and a patient encounter during the performance period. Applicable codes include (CPT or HCPCS): 99201, 99202, 99203, 99204, 99205, 99212, 99213, 99214, 99215, 99341, 99342, 99343, 99344, 99345, 99347, 99348, 99349, 99350, G0402, G0438, G0439.

To get credit under MIPS, be sure to include a QDC that shows that you successfully performed the measure or had a good reason for not doing so. For instance, CPT II 4040F indicates that the pneumococcal vaccine was administered or previously received. Use exclusion code G9707 to indicate that the patient was not eligible because they received hospice services at any time during the measurement period.

CMS has a full list measures available for claims-based reporting at qpp.cms.gov. The American Medical Association has also created a step-by-step guide for reporting on one quality measure.

Certain clinicians are exempt from reporting and do not face a penalty under MIPS:

• Those who enrolled in Medicare for the first time during a performance period.

• Those who have Medicare Part B allowed charges of $30,000 or less.

• Those who have 100 or fewer Medicare Part B patients.

• Those who are significantly participating in an Advanced Alternative Payment Model (APM).


 

If you haven’t started reporting quality data for the Merit-Based Incentive Payment System (MIPS), there’s still time to avoid a 4% cut to your Medicare payments.

Under the Pick Your Pace approach being offered this year, the Centers for Medicare & Medicaid Services allows clinicians to test the system by reporting on one quality measure for one patient through paper-based claims. Be sure to append a Quality Data Code (QDC) to the claim form for care provided up to Dec. 31, 2017, in order to avoid a penalty in payment year 2019.

Consider this measure:

Measure #111: Pneumococcal Vaccination Status for Older Adults

This measure is aimed at capturing the percentage of patients aged 65 years and older who have ever received a pneumococcal vaccine.

What you need to do: Review the medical record to find out if the patient has ever received a pneumococcal vaccine and if not, administer the vaccine.

Eligible cases include patients who were aged 65 years or older on the date of the encounter and a patient encounter during the performance period. Applicable codes include (CPT or HCPCS): 99201, 99202, 99203, 99204, 99205, 99212, 99213, 99214, 99215, 99341, 99342, 99343, 99344, 99345, 99347, 99348, 99349, 99350, G0402, G0438, G0439.

To get credit under MIPS, be sure to include a QDC that shows that you successfully performed the measure or had a good reason for not doing so. For instance, CPT II 4040F indicates that the pneumococcal vaccine was administered or previously received. Use exclusion code G9707 to indicate that the patient was not eligible because they received hospice services at any time during the measurement period.

CMS has a full list measures available for claims-based reporting at qpp.cms.gov. The American Medical Association has also created a step-by-step guide for reporting on one quality measure.

Certain clinicians are exempt from reporting and do not face a penalty under MIPS:

• Those who enrolled in Medicare for the first time during a performance period.

• Those who have Medicare Part B allowed charges of $30,000 or less.

• Those who have 100 or fewer Medicare Part B patients.

• Those who are significantly participating in an Advanced Alternative Payment Model (APM).


 

NATIONAL HARBOR, MD. – Laparoscopy offers advantages over laparotomy when performing nonobstetrical surgery on pregnant women, Yuval Kaufman, MD, said at the AAGL Global Congress.

“When we talk about advantages in referral to the pregnant patient, one of the most important things is early ambulation,” Dr. Kaufman, a gynecologic surgeon at Carmel Medical Center in Haifa, Israel, said in an interview. “These patients are in a hypercoagulable state; they are more likely to have DVT and PE. You need them up and running as soon as possible.”

Laparoscopy also tends to be better in terms of handling of the uterus, offering a field of view so that the uterus doesn’t need to be moved as much. In addition, laparoscopy is associated with a smaller, more easily healed scar, and usually requires fewer analgesics, which is better for the fetus, he said.

The Society of American Gastrointestinal and Endoscopic Surgeons recently issued guidelines for the use of laparoscopy during pregnancy, advising surgeons that these procedures can be safely performed during any trimester when the operation is indicated, he said.

“There was an older misconception that surgery has to be done in the second trimester only,” Dr. Kaufman said. “But they actually contradict that; they show that if you postpone surgery for this reason you might be doing much more damage to the mother and to the fetus.”

Dr. Kaufman reported having no relevant financial disclosures.

[email protected]

On Twitter @eaztweets

NATIONAL HARBOR, MD. – Laparoscopy offers advantages over laparotomy when performing nonobstetrical surgery on pregnant women, Yuval Kaufman, MD, said at the AAGL Global Congress.

“When we talk about advantages in referral to the pregnant patient, one of the most important things is early ambulation,” Dr. Kaufman, a gynecologic surgeon at Carmel Medical Center in Haifa, Israel, said in an interview. “These patients are in a hypercoagulable state; they are more likely to have DVT and PE. You need them up and running as soon as possible.”

Laparoscopy also tends to be better in terms of handling of the uterus, offering a field of view so that the uterus doesn’t need to be moved as much. In addition, laparoscopy is associated with a smaller, more easily healed scar, and usually requires fewer analgesics, which is better for the fetus, he said.

The Society of American Gastrointestinal and Endoscopic Surgeons recently issued guidelines for the use of laparoscopy during pregnancy, advising surgeons that these procedures can be safely performed during any trimester when the operation is indicated, he said.

“There was an older misconception that surgery has to be done in the second trimester only,” Dr. Kaufman said. “But they actually contradict that; they show that if you postpone surgery for this reason you might be doing much more damage to the mother and to the fetus.”

Dr. Kaufman reported having no relevant financial disclosures.

[email protected]

On Twitter @eaztweets

NATIONAL HARBOR, MD. – Laparoscopy offers advantages over laparotomy when performing nonobstetrical surgery on pregnant women, Yuval Kaufman, MD, said at the AAGL Global Congress.

“When we talk about advantages in referral to the pregnant patient, one of the most important things is early ambulation,” Dr. Kaufman, a gynecologic surgeon at Carmel Medical Center in Haifa, Israel, said in an interview. “These patients are in a hypercoagulable state; they are more likely to have DVT and PE. You need them up and running as soon as possible.”

Laparoscopy also tends to be better in terms of handling of the uterus, offering a field of view so that the uterus doesn’t need to be moved as much. In addition, laparoscopy is associated with a smaller, more easily healed scar, and usually requires fewer analgesics, which is better for the fetus, he said.

The Society of American Gastrointestinal and Endoscopic Surgeons recently issued guidelines for the use of laparoscopy during pregnancy, advising surgeons that these procedures can be safely performed during any trimester when the operation is indicated, he said.

“There was an older misconception that surgery has to be done in the second trimester only,” Dr. Kaufman said. “But they actually contradict that; they show that if you postpone surgery for this reason you might be doing much more damage to the mother and to the fetus.”

Dr. Kaufman reported having no relevant financial disclosures.

[email protected]

On Twitter @eaztweets

NATIONAL HARBOR, MD. – The biggest theme of the 2017 AAGL Global Congress was the importance of understanding anatomy, Charles E. Miller, MD, a minimally invasive gynecologic surgeon in Naperville, Ill., and past president of the AAGL, said at the meeting.

“It’s about doing surgery in the right place, in the right space,” he said.

One of the advantages of this year’s Congress is a greater emphasis on cadaveric dissections, Dr. Miller said during an interview. “Understanding how the nerves are placed, how the vessels are in place, the muscles and the different spaces, and how that all relates to our most complex dissections.”

In a presentation on neuropelveology, Michael Hibner, MD, and Mario Castellanos, MD, of St. Joseph’s Hospital and Medical Center, Phoenix, performed a live cadaveric dissection showing how to deal with a trapped pudendal nerve, working over the gluteus maximus and dissecting down.

In a video session, surgeons demonstrated a needleless robotic-assisted transabdominal cerclage. The nonneedle procedure used a unique, posterior placement of the cerclage knot, a technique which Dr. Miller said he plans to use in his own practice.

The incorporation of colleagues from around the country, and around the world, was another strength of this year’s Congress, said Dr. Miller, particularly a presentation from a Chinese ob.gyn. association on isthmoceles. “To be able to see that this transcends miles upon miles upon miles, but yet we’re seeing the same type of problems, is quite interesting,” he said.

[email protected]

On Twitter @eaztweets

NATIONAL HARBOR, MD. – The biggest theme of the 2017 AAGL Global Congress was the importance of understanding anatomy, Charles E. Miller, MD, a minimally invasive gynecologic surgeon in Naperville, Ill., and past president of the AAGL, said at the meeting.

“It’s about doing surgery in the right place, in the right space,” he said.

One of the advantages of this year’s Congress is a greater emphasis on cadaveric dissections, Dr. Miller said during an interview. “Understanding how the nerves are placed, how the vessels are in place, the muscles and the different spaces, and how that all relates to our most complex dissections.”

In a presentation on neuropelveology, Michael Hibner, MD, and Mario Castellanos, MD, of St. Joseph’s Hospital and Medical Center, Phoenix, performed a live cadaveric dissection showing how to deal with a trapped pudendal nerve, working over the gluteus maximus and dissecting down.

In a video session, surgeons demonstrated a needleless robotic-assisted transabdominal cerclage. The nonneedle procedure used a unique, posterior placement of the cerclage knot, a technique which Dr. Miller said he plans to use in his own practice.

The incorporation of colleagues from around the country, and around the world, was another strength of this year’s Congress, said Dr. Miller, particularly a presentation from a Chinese ob.gyn. association on isthmoceles. “To be able to see that this transcends miles upon miles upon miles, but yet we’re seeing the same type of problems, is quite interesting,” he said.

[email protected]

On Twitter @eaztweets

NATIONAL HARBOR, MD. – The biggest theme of the 2017 AAGL Global Congress was the importance of understanding anatomy, Charles E. Miller, MD, a minimally invasive gynecologic surgeon in Naperville, Ill., and past president of the AAGL, said at the meeting.

“It’s about doing surgery in the right place, in the right space,” he said.

One of the advantages of this year’s Congress is a greater emphasis on cadaveric dissections, Dr. Miller said during an interview. “Understanding how the nerves are placed, how the vessels are in place, the muscles and the different spaces, and how that all relates to our most complex dissections.”

In a presentation on neuropelveology, Michael Hibner, MD, and Mario Castellanos, MD, of St. Joseph’s Hospital and Medical Center, Phoenix, performed a live cadaveric dissection showing how to deal with a trapped pudendal nerve, working over the gluteus maximus and dissecting down.

In a video session, surgeons demonstrated a needleless robotic-assisted transabdominal cerclage. The nonneedle procedure used a unique, posterior placement of the cerclage knot, a technique which Dr. Miller said he plans to use in his own practice.

The incorporation of colleagues from around the country, and around the world, was another strength of this year’s Congress, said Dr. Miller, particularly a presentation from a Chinese ob.gyn. association on isthmoceles. “To be able to see that this transcends miles upon miles upon miles, but yet we’re seeing the same type of problems, is quite interesting,” he said.

[email protected]

On Twitter @eaztweets

SAN DIEGO – An advanced alternative payment model for rheumatoid arthritis will soon be submitted to the Centers for Medicare & Medicaid Services for evaluation, in order to provide rheumatologists with another payment pathway under Medicare’s new Quality Payment Program.

The draft version of the rheumatoid arthritis advanced alternative payment model (APM), prepared by the American College of Rheumatology and unveiled at its annual meeting, aims to give rheumatologists a more focused opportunity to participate in value-based care and potentially earn greater incentive payments. The model is geared not only to private practice rheumatologists, but also to those in academia.

The Quality Payment Program, including its advanced APM track, was established by the Medicare and CHIP Reauthorization Act of 2015 (MACRA).

Nick Piegari/Frontline Medical News

Other societies are working on or have submitted APMs for approval, Timothy Laing, MD, a member of the RA APM working group and also the ACR representative to the American Medical Association’s Relative Value Scale Update Committee and CPT Advisory Committee, said at the ACR meeting.

After presenting a draft of the RA APM at an AMA workshop in October, Dr. Laing came away encouraged by the attendees’ response to the usefulness and flexibility of the model to pay for services that rheumatologists are currently frustrated by in a fee-for-services system. “It’s a big if, but I think if we can make the money work, this will be a shift and it will have a lot of impact on how we practice, and I think it will be generalizable to more than one condition.”

The cochair of the RA APM working group, Kwas Huston, MD, presented the draft at the meeting. He noted that advanced APMs could be developed just for specific diseases, for all inflammatory arthritis, all types of vasculitis, or for all rheumatic diseases. RA was chosen first because the ACR is new to the development of APMs and “needed to start somewhere.”

“This model allows us to improve our ability to care for patients and is more sustainable over time for rheumatologists from a revenue standpoint,” Dr. Huston, a rheumatologist with Kansas City (Mo.) Physician Partners, said in an interview.

The RA APM helps to reduce barriers to good care by providing adequate reimbursement for cognitive services through monthly payments rather than relying on payment for separate office visits, Dr. Huston said. The model allows for more time spent in shared decision making, educational activities, and improving treatment adherence. It also builds in payment for non–face-to-face communication between rheumatologists, primary care physicians, and other specialists; interaction with patients via phone calls, email, and telemedicine; and using nurses or other staff to help with chronic disease management. It’s meant to be flexible for use in diverse settings by allowing comanagement of patients in rural areas and places where there is a shortage of rheumatologists or travel is difficult.

Why join an advanced APM?

Rheumatologists may want to join an advanced APM because of the potentially unsustainable, “zero-sum” nature of MACRA’s Merit-based Incentive Payment System (MIPS), in which the losers pay for the winners, said Angus Worthing, MD, chair of the ACR’s Government Affairs Committee and a member of the RA APM working group. In MIPS, there are expected over time to be fewer and fewer “losers” in the program, either because participants perform better or the losers drop out. In addition, advanced APM participants will receive a 5% bonus in 2019-2024 and Medicare payment updates will be higher for advanced APMs in 2026 and beyond than for MIPS (0.75% vs. 0.25%).

Beyond the financial practicalities of MACRA, it’s beneficial for rheumatologists to have their own advanced APM because it’s better than being stuck in one that’s “written by the government and doesn’t cater to other specialties; it’s specific to rheumatology, our patients, our work flow, and what we think is valuable,” said Dr. Worthing, a practicing rheumatologist in the Washington area.

The RA APM’s treatment pathway

Undergirding the whole model is a treatment pathway that takes a standardized approach to RA care, based on ACR 2015 guidelines, and will be updated regularly by the ACR, Dr. Huston said. Following the guidelines gives an opportunity to lower spending but increase the percentage that’s going to rheumatologists by reducing the variability in initiation of expensive medications. “Currently, we get about 2.5 cents on the dollar for every dollar that’s spent on rheumatoid arthritis care, and we want to increase the part that’s going to the rheumatologist to provide more services but decrease total spending,” he said.

The pathway requires the use of methotrexate and/or another disease-modifying antirheumatic drug (DMARD) before targeted therapy. However, the model also allows for treating unique patients by requiring only 75% adherence to the guidelines. Deviation from the guidelines is allowed if a patient has a contraindication, intolerance, or inadequate response to a DMARD, or if there are barriers outside of the rheumatologist’s control, such as insurance coverage. The ACR guidelines also specify the frequency and type of monitoring that’s needed for treatment.

Because the ACR guidelines will be followed, the model asks that payers make patients eligible for lower out-of-pocket costs for medications. Following the guidelines should also reduce the need for prior authorizations. Providers in the advanced APM would attest to 75% adherence to the pathway, which would be subject to audit. “We want to reduce the reporting burden. In MIPS, it’s very complicated. It’s hard to know how to report all of this. In the APM pathway, we’re trying to simplify reporting. You only have to report two things; one of them is following the treatment pathway 75% of the time” and the other is an outcome measure, he said.

The payments made under this RA treatment pathway are divided into four areas: diagnosis and treatment planning, support for primary care physicians in diagnosing joint symptoms, the initial treatment of RA patients, and continued care for RA.
 

Diagnosis and treatment planning

This step offers a one-time payment to support all the costs of evaluation, testing, diagnosis, and treatment planning for a patient who has symptoms that potentially indicate RA, has not been previously treated or diagnosed with RA, or has been treated unsuccessfully for RA by other physicians. It is not dependent on the number of visits.

This phase also covers basic lab testing and imaging, which if not done by the rheumatology practice, would then have a standardized amount deducted from the payment and be paid separately. Lab tests and imaging performed for other conditions would be paid separately as well.

The payment covers communication with other physicians, spending more time with patients in a shared decision-making process regarding treatment options, and developing a RA treatment plan.

“If you don’t end up diagnosing RA, you still get the payment. But there will be two different payments; one is a little lower if they don’t have RA. If they do have RA, then you spend more time with them developing this treatment plan, so that would be a higher payment,” Dr. Huston said.
 

Support for primary care physicians in diagnosing joint symptoms

This payment goes to a rheumatologist or a nurse practitioner or physician assistant who is working under the supervision of a rheumatologist for a patient who is under the care of a primary care physician who has an agreement to work collaboratively with the rheumatology practice. The payment, which is limited to one bill for one patient in a 1-year period, is for communication between the rheumatologist and the primary care physician about patients with symptoms that might indicate RA to determine the need for referral.

“This communication could be a phone call, an email, face-to-face, or some other form of communication ... to discuss how fast the patient may need to be seen or if there are other tests that need to be done before expediting referrals for patients who are higher risk,” Dr. Huston explained.

The payment would still be made if the patient does not require referral to a rheumatologist.
 

Initial treatment of RA patients

Payment for initial treatment can be made to a rheumatologist, a nurse practitioner or physician assistant under the supervision of a rheumatologist, or a team comprising the rheumatologist and a primary care physician who have a formal arrangement to support the early treatment of RA.

The latter scenario is intended for rural areas and other areas where there is a shortage of rheumatologists. The formal arrangement would specify how payments are shared and who is responsible for each of the accountability requirements and for treatment pathway, “but there is a lot of flexibility, and this can vary quite a bit, so what happens in rural Alaska where the primary care doctors might be more involved is not going to be the same as in a big city where the primary care doctors may not want to be involved at all. So there is no requirement for primary care doctors to be involved, but it just provides the resources in areas where that might make sense,” Dr. Huston noted.

The initial treatment payment would be made monthly for 6 months, replacing evaluation and management billing for office visits related to RA. It pays for typical lab tests and imaging and allows flexibility for non–face-to-face communications, and enhanced services to patients who need them. This payment is also stratified to adjust for sicker patients who have more comorbidities, he said.
 

Continued care for RA

This component of the payment structure also can be made to a rheumatologist, a nurse practitioner or physician assistant under the supervision of a rheumatologist, or the rheumatologist–primary care physician team. Continued care payments are made monthly and, just as with initial treatment payments, they are meant to replace E&M billing for office visits and pay for the same kinds of resources used in initial treatment, including stratified payments to adjust for patient characteristics.

Patients who come to a rheumatologist with established RA would enter this treatment pathway under this kind of payment.
 

RA APM’s accountability requirements

Participants in this model would be required to see a patient face-to-face at least every 6 months and to document their disease activity using a validated scale approved by the ACR for use in the RA APM, such as the RAPID-3 (Routine Assessment of Patient Index Data–3), the CDAI (Clinical Disease Activity Index), the SDAI (Simple Disease Activity Index), or the DAS28 (28-joint Disease Activity Score). Payment would also require keeping a written treatment plan that’s consistent with the ACR’s approved treatment pathway.

Changes in medication require communication with the patient within 2 weeks to help improve treatment adherence. Quality measures will still need to be recorded, such as a functional assessment, tuberculosis screening prior to starting biologics, and having a plan for steroid use, but they are not required to be reported. “You attest to that,” he said.

However, participants will need to report that they are following the treatment pathway for patients and an outcome measure for continued care of RA. These are necessary, Dr. Huston said, because “we are asking that we increase the money that’s going to the rheumatologist for managing patients with RA, so we have to show that we’re accountable and doing good with that money and that we’re taking care of our patients. ... and if we have an outcome measure, then we don’t have to report all those process measures that we do in MIPS.”

The outcome measure would be reporting:

• At least (some %) of patients with low disease activity remained in low disease activity.

• At least (some %) of patients with moderate disease activity stayed in the same or a lower disease activity category.

• At least (some %) of patients with a high disease activity had a lower disease activity category.

It’s unknown yet what the threshold percentage for each disease activity level would be, but it will be obtained from the ACR’s Rheumatology Informatics System for Effectiveness (RISE) Registry and will be refined over time from there. The outcome measure is not validated yet – none exists for RA for use in clinical practice – because it’s not yet known how to risk stratify patients in these disease activity levels for their comorbidities and socioeconomic factors. “Those are all things we need to learn over time,” Dr. Huston said, “but this is our good-faith effort at developing an outcome measure which we think will become more robust as we gather more and more data.”

Advantages of the RA APM

The RA APM’s advantages, according to Dr. Huston, stem from its payment for high-value services; the avoidance of the penalties and reporting burdens imposed by MIPS; a reduction in documentation requirements, allowing clinicians to take notes on history of present illness and review of systems however they want; a reduction in prior authorizations; and more control over performance measures.

Another big advantage of the RA APM is that participants “are not responsible for the price of drugs, whereas in MIPS you are responsible. When [the Centers for Medicare & Medicaid Services] calculates your cost category [in MIPS], that includes Part B drugs, and when the MIPS adjustment factor is applied to your revenue, that includes revenue from Part B drugs,” Dr. Huston said.

In addition, he noted that it will be possible for a rheumatologist to be a participant in just one or two APMs and still have the benefit of being out of MIPS.
 

Next steps

The next steps for the development of the RA APM include refining the treatment pathway, analyzing RISE data outcome thresholds, and modeling the financial impact on practices by running data from three to five practices across the country through the model to determine what the payment levels should be. Once those steps are completed, the RA APM can be submitted to the Physician-Focused Payment Model Technical Advisory Committee for approval, which will then send it to the CMS to run it through its Innovation Center to test the model in several practices to gather more data and refine the payment rates until it is ready to be expanded and implemented.

Dr. Huston, Dr. Worthing, and Dr. Laing had no relevant conflicts of interest to disclose.

[email protected]

SAN DIEGO – An advanced alternative payment model for rheumatoid arthritis will soon be submitted to the Centers for Medicare & Medicaid Services for evaluation, in order to provide rheumatologists with another payment pathway under Medicare’s new Quality Payment Program.

The draft version of the rheumatoid arthritis advanced alternative payment model (APM), prepared by the American College of Rheumatology and unveiled at its annual meeting, aims to give rheumatologists a more focused opportunity to participate in value-based care and potentially earn greater incentive payments. The model is geared not only to private practice rheumatologists, but also to those in academia.

The Quality Payment Program, including its advanced APM track, was established by the Medicare and CHIP Reauthorization Act of 2015 (MACRA).

Nick Piegari/Frontline Medical News

Other societies are working on or have submitted APMs for approval, Timothy Laing, MD, a member of the RA APM working group and also the ACR representative to the American Medical Association’s Relative Value Scale Update Committee and CPT Advisory Committee, said at the ACR meeting.

After presenting a draft of the RA APM at an AMA workshop in October, Dr. Laing came away encouraged by the attendees’ response to the usefulness and flexibility of the model to pay for services that rheumatologists are currently frustrated by in a fee-for-services system. “It’s a big if, but I think if we can make the money work, this will be a shift and it will have a lot of impact on how we practice, and I think it will be generalizable to more than one condition.”

The cochair of the RA APM working group, Kwas Huston, MD, presented the draft at the meeting. He noted that advanced APMs could be developed just for specific diseases, for all inflammatory arthritis, all types of vasculitis, or for all rheumatic diseases. RA was chosen first because the ACR is new to the development of APMs and “needed to start somewhere.”

“This model allows us to improve our ability to care for patients and is more sustainable over time for rheumatologists from a revenue standpoint,” Dr. Huston, a rheumatologist with Kansas City (Mo.) Physician Partners, said in an interview.

The RA APM helps to reduce barriers to good care by providing adequate reimbursement for cognitive services through monthly payments rather than relying on payment for separate office visits, Dr. Huston said. The model allows for more time spent in shared decision making, educational activities, and improving treatment adherence. It also builds in payment for non–face-to-face communication between rheumatologists, primary care physicians, and other specialists; interaction with patients via phone calls, email, and telemedicine; and using nurses or other staff to help with chronic disease management. It’s meant to be flexible for use in diverse settings by allowing comanagement of patients in rural areas and places where there is a shortage of rheumatologists or travel is difficult.

Why join an advanced APM?

Rheumatologists may want to join an advanced APM because of the potentially unsustainable, “zero-sum” nature of MACRA’s Merit-based Incentive Payment System (MIPS), in which the losers pay for the winners, said Angus Worthing, MD, chair of the ACR’s Government Affairs Committee and a member of the RA APM working group. In MIPS, there are expected over time to be fewer and fewer “losers” in the program, either because participants perform better or the losers drop out. In addition, advanced APM participants will receive a 5% bonus in 2019-2024 and Medicare payment updates will be higher for advanced APMs in 2026 and beyond than for MIPS (0.75% vs. 0.25%).

Beyond the financial practicalities of MACRA, it’s beneficial for rheumatologists to have their own advanced APM because it’s better than being stuck in one that’s “written by the government and doesn’t cater to other specialties; it’s specific to rheumatology, our patients, our work flow, and what we think is valuable,” said Dr. Worthing, a practicing rheumatologist in the Washington area.

The RA APM’s treatment pathway

Undergirding the whole model is a treatment pathway that takes a standardized approach to RA care, based on ACR 2015 guidelines, and will be updated regularly by the ACR, Dr. Huston said. Following the guidelines gives an opportunity to lower spending but increase the percentage that’s going to rheumatologists by reducing the variability in initiation of expensive medications. “Currently, we get about 2.5 cents on the dollar for every dollar that’s spent on rheumatoid arthritis care, and we want to increase the part that’s going to the rheumatologist to provide more services but decrease total spending,” he said.

The pathway requires the use of methotrexate and/or another disease-modifying antirheumatic drug (DMARD) before targeted therapy. However, the model also allows for treating unique patients by requiring only 75% adherence to the guidelines. Deviation from the guidelines is allowed if a patient has a contraindication, intolerance, or inadequate response to a DMARD, or if there are barriers outside of the rheumatologist’s control, such as insurance coverage. The ACR guidelines also specify the frequency and type of monitoring that’s needed for treatment.

Because the ACR guidelines will be followed, the model asks that payers make patients eligible for lower out-of-pocket costs for medications. Following the guidelines should also reduce the need for prior authorizations. Providers in the advanced APM would attest to 75% adherence to the pathway, which would be subject to audit. “We want to reduce the reporting burden. In MIPS, it’s very complicated. It’s hard to know how to report all of this. In the APM pathway, we’re trying to simplify reporting. You only have to report two things; one of them is following the treatment pathway 75% of the time” and the other is an outcome measure, he said.

The payments made under this RA treatment pathway are divided into four areas: diagnosis and treatment planning, support for primary care physicians in diagnosing joint symptoms, the initial treatment of RA patients, and continued care for RA.
 

Diagnosis and treatment planning

This step offers a one-time payment to support all the costs of evaluation, testing, diagnosis, and treatment planning for a patient who has symptoms that potentially indicate RA, has not been previously treated or diagnosed with RA, or has been treated unsuccessfully for RA by other physicians. It is not dependent on the number of visits.

This phase also covers basic lab testing and imaging, which if not done by the rheumatology practice, would then have a standardized amount deducted from the payment and be paid separately. Lab tests and imaging performed for other conditions would be paid separately as well.

The payment covers communication with other physicians, spending more time with patients in a shared decision-making process regarding treatment options, and developing a RA treatment plan.

“If you don’t end up diagnosing RA, you still get the payment. But there will be two different payments; one is a little lower if they don’t have RA. If they do have RA, then you spend more time with them developing this treatment plan, so that would be a higher payment,” Dr. Huston said.
 

Support for primary care physicians in diagnosing joint symptoms

This payment goes to a rheumatologist or a nurse practitioner or physician assistant who is working under the supervision of a rheumatologist for a patient who is under the care of a primary care physician who has an agreement to work collaboratively with the rheumatology practice. The payment, which is limited to one bill for one patient in a 1-year period, is for communication between the rheumatologist and the primary care physician about patients with symptoms that might indicate RA to determine the need for referral.

“This communication could be a phone call, an email, face-to-face, or some other form of communication ... to discuss how fast the patient may need to be seen or if there are other tests that need to be done before expediting referrals for patients who are higher risk,” Dr. Huston explained.

The payment would still be made if the patient does not require referral to a rheumatologist.
 

Initial treatment of RA patients

Payment for initial treatment can be made to a rheumatologist, a nurse practitioner or physician assistant under the supervision of a rheumatologist, or a team comprising the rheumatologist and a primary care physician who have a formal arrangement to support the early treatment of RA.

The latter scenario is intended for rural areas and other areas where there is a shortage of rheumatologists. The formal arrangement would specify how payments are shared and who is responsible for each of the accountability requirements and for treatment pathway, “but there is a lot of flexibility, and this can vary quite a bit, so what happens in rural Alaska where the primary care doctors might be more involved is not going to be the same as in a big city where the primary care doctors may not want to be involved at all. So there is no requirement for primary care doctors to be involved, but it just provides the resources in areas where that might make sense,” Dr. Huston noted.

The initial treatment payment would be made monthly for 6 months, replacing evaluation and management billing for office visits related to RA. It pays for typical lab tests and imaging and allows flexibility for non–face-to-face communications, and enhanced services to patients who need them. This payment is also stratified to adjust for sicker patients who have more comorbidities, he said.
 

Continued care for RA

This component of the payment structure also can be made to a rheumatologist, a nurse practitioner or physician assistant under the supervision of a rheumatologist, or the rheumatologist–primary care physician team. Continued care payments are made monthly and, just as with initial treatment payments, they are meant to replace E&M billing for office visits and pay for the same kinds of resources used in initial treatment, including stratified payments to adjust for patient characteristics.

Patients who come to a rheumatologist with established RA would enter this treatment pathway under this kind of payment.
 

RA APM’s accountability requirements

Participants in this model would be required to see a patient face-to-face at least every 6 months and to document their disease activity using a validated scale approved by the ACR for use in the RA APM, such as the RAPID-3 (Routine Assessment of Patient Index Data–3), the CDAI (Clinical Disease Activity Index), the SDAI (Simple Disease Activity Index), or the DAS28 (28-joint Disease Activity Score). Payment would also require keeping a written treatment plan that’s consistent with the ACR’s approved treatment pathway.

Changes in medication require communication with the patient within 2 weeks to help improve treatment adherence. Quality measures will still need to be recorded, such as a functional assessment, tuberculosis screening prior to starting biologics, and having a plan for steroid use, but they are not required to be reported. “You attest to that,” he said.

However, participants will need to report that they are following the treatment pathway for patients and an outcome measure for continued care of RA. These are necessary, Dr. Huston said, because “we are asking that we increase the money that’s going to the rheumatologist for managing patients with RA, so we have to show that we’re accountable and doing good with that money and that we’re taking care of our patients. ... and if we have an outcome measure, then we don’t have to report all those process measures that we do in MIPS.”

The outcome measure would be reporting:

• At least (some %) of patients with low disease activity remained in low disease activity.

• At least (some %) of patients with moderate disease activity stayed in the same or a lower disease activity category.

• At least (some %) of patients with a high disease activity had a lower disease activity category.

It’s unknown yet what the threshold percentage for each disease activity level would be, but it will be obtained from the ACR’s Rheumatology Informatics System for Effectiveness (RISE) Registry and will be refined over time from there. The outcome measure is not validated yet – none exists for RA for use in clinical practice – because it’s not yet known how to risk stratify patients in these disease activity levels for their comorbidities and socioeconomic factors. “Those are all things we need to learn over time,” Dr. Huston said, “but this is our good-faith effort at developing an outcome measure which we think will become more robust as we gather more and more data.”

Advantages of the RA APM

The RA APM’s advantages, according to Dr. Huston, stem from its payment for high-value services; the avoidance of the penalties and reporting burdens imposed by MIPS; a reduction in documentation requirements, allowing clinicians to take notes on history of present illness and review of systems however they want; a reduction in prior authorizations; and more control over performance measures.

Another big advantage of the RA APM is that participants “are not responsible for the price of drugs, whereas in MIPS you are responsible. When [the Centers for Medicare & Medicaid Services] calculates your cost category [in MIPS], that includes Part B drugs, and when the MIPS adjustment factor is applied to your revenue, that includes revenue from Part B drugs,” Dr. Huston said.

In addition, he noted that it will be possible for a rheumatologist to be a participant in just one or two APMs and still have the benefit of being out of MIPS.
 

Next steps

The next steps for the development of the RA APM include refining the treatment pathway, analyzing RISE data outcome thresholds, and modeling the financial impact on practices by running data from three to five practices across the country through the model to determine what the payment levels should be. Once those steps are completed, the RA APM can be submitted to the Physician-Focused Payment Model Technical Advisory Committee for approval, which will then send it to the CMS to run it through its Innovation Center to test the model in several practices to gather more data and refine the payment rates until it is ready to be expanded and implemented.

Dr. Huston, Dr. Worthing, and Dr. Laing had no relevant conflicts of interest to disclose.

[email protected]

SAN DIEGO – An advanced alternative payment model for rheumatoid arthritis will soon be submitted to the Centers for Medicare & Medicaid Services for evaluation, in order to provide rheumatologists with another payment pathway under Medicare’s new Quality Payment Program.

The draft version of the rheumatoid arthritis advanced alternative payment model (APM), prepared by the American College of Rheumatology and unveiled at its annual meeting, aims to give rheumatologists a more focused opportunity to participate in value-based care and potentially earn greater incentive payments. The model is geared not only to private practice rheumatologists, but also to those in academia.

The Quality Payment Program, including its advanced APM track, was established by the Medicare and CHIP Reauthorization Act of 2015 (MACRA).

Nick Piegari/Frontline Medical News

Other societies are working on or have submitted APMs for approval, Timothy Laing, MD, a member of the RA APM working group and also the ACR representative to the American Medical Association’s Relative Value Scale Update Committee and CPT Advisory Committee, said at the ACR meeting.

After presenting a draft of the RA APM at an AMA workshop in October, Dr. Laing came away encouraged by the attendees’ response to the usefulness and flexibility of the model to pay for services that rheumatologists are currently frustrated by in a fee-for-services system. “It’s a big if, but I think if we can make the money work, this will be a shift and it will have a lot of impact on how we practice, and I think it will be generalizable to more than one condition.”

The cochair of the RA APM working group, Kwas Huston, MD, presented the draft at the meeting. He noted that advanced APMs could be developed just for specific diseases, for all inflammatory arthritis, all types of vasculitis, or for all rheumatic diseases. RA was chosen first because the ACR is new to the development of APMs and “needed to start somewhere.”

“This model allows us to improve our ability to care for patients and is more sustainable over time for rheumatologists from a revenue standpoint,” Dr. Huston, a rheumatologist with Kansas City (Mo.) Physician Partners, said in an interview.

The RA APM helps to reduce barriers to good care by providing adequate reimbursement for cognitive services through monthly payments rather than relying on payment for separate office visits, Dr. Huston said. The model allows for more time spent in shared decision making, educational activities, and improving treatment adherence. It also builds in payment for non–face-to-face communication between rheumatologists, primary care physicians, and other specialists; interaction with patients via phone calls, email, and telemedicine; and using nurses or other staff to help with chronic disease management. It’s meant to be flexible for use in diverse settings by allowing comanagement of patients in rural areas and places where there is a shortage of rheumatologists or travel is difficult.

Why join an advanced APM?

Rheumatologists may want to join an advanced APM because of the potentially unsustainable, “zero-sum” nature of MACRA’s Merit-based Incentive Payment System (MIPS), in which the losers pay for the winners, said Angus Worthing, MD, chair of the ACR’s Government Affairs Committee and a member of the RA APM working group. In MIPS, there are expected over time to be fewer and fewer “losers” in the program, either because participants perform better or the losers drop out. In addition, advanced APM participants will receive a 5% bonus in 2019-2024 and Medicare payment updates will be higher for advanced APMs in 2026 and beyond than for MIPS (0.75% vs. 0.25%).

Beyond the financial practicalities of MACRA, it’s beneficial for rheumatologists to have their own advanced APM because it’s better than being stuck in one that’s “written by the government and doesn’t cater to other specialties; it’s specific to rheumatology, our patients, our work flow, and what we think is valuable,” said Dr. Worthing, a practicing rheumatologist in the Washington area.

The RA APM’s treatment pathway

Undergirding the whole model is a treatment pathway that takes a standardized approach to RA care, based on ACR 2015 guidelines, and will be updated regularly by the ACR, Dr. Huston said. Following the guidelines gives an opportunity to lower spending but increase the percentage that’s going to rheumatologists by reducing the variability in initiation of expensive medications. “Currently, we get about 2.5 cents on the dollar for every dollar that’s spent on rheumatoid arthritis care, and we want to increase the part that’s going to the rheumatologist to provide more services but decrease total spending,” he said.

The pathway requires the use of methotrexate and/or another disease-modifying antirheumatic drug (DMARD) before targeted therapy. However, the model also allows for treating unique patients by requiring only 75% adherence to the guidelines. Deviation from the guidelines is allowed if a patient has a contraindication, intolerance, or inadequate response to a DMARD, or if there are barriers outside of the rheumatologist’s control, such as insurance coverage. The ACR guidelines also specify the frequency and type of monitoring that’s needed for treatment.

Because the ACR guidelines will be followed, the model asks that payers make patients eligible for lower out-of-pocket costs for medications. Following the guidelines should also reduce the need for prior authorizations. Providers in the advanced APM would attest to 75% adherence to the pathway, which would be subject to audit. “We want to reduce the reporting burden. In MIPS, it’s very complicated. It’s hard to know how to report all of this. In the APM pathway, we’re trying to simplify reporting. You only have to report two things; one of them is following the treatment pathway 75% of the time” and the other is an outcome measure, he said.

The payments made under this RA treatment pathway are divided into four areas: diagnosis and treatment planning, support for primary care physicians in diagnosing joint symptoms, the initial treatment of RA patients, and continued care for RA.
 

Diagnosis and treatment planning

This step offers a one-time payment to support all the costs of evaluation, testing, diagnosis, and treatment planning for a patient who has symptoms that potentially indicate RA, has not been previously treated or diagnosed with RA, or has been treated unsuccessfully for RA by other physicians. It is not dependent on the number of visits.

This phase also covers basic lab testing and imaging, which if not done by the rheumatology practice, would then have a standardized amount deducted from the payment and be paid separately. Lab tests and imaging performed for other conditions would be paid separately as well.

The payment covers communication with other physicians, spending more time with patients in a shared decision-making process regarding treatment options, and developing a RA treatment plan.

“If you don’t end up diagnosing RA, you still get the payment. But there will be two different payments; one is a little lower if they don’t have RA. If they do have RA, then you spend more time with them developing this treatment plan, so that would be a higher payment,” Dr. Huston said.
 

Support for primary care physicians in diagnosing joint symptoms

This payment goes to a rheumatologist or a nurse practitioner or physician assistant who is working under the supervision of a rheumatologist for a patient who is under the care of a primary care physician who has an agreement to work collaboratively with the rheumatology practice. The payment, which is limited to one bill for one patient in a 1-year period, is for communication between the rheumatologist and the primary care physician about patients with symptoms that might indicate RA to determine the need for referral.

“This communication could be a phone call, an email, face-to-face, or some other form of communication ... to discuss how fast the patient may need to be seen or if there are other tests that need to be done before expediting referrals for patients who are higher risk,” Dr. Huston explained.

The payment would still be made if the patient does not require referral to a rheumatologist.
 

Initial treatment of RA patients

Payment for initial treatment can be made to a rheumatologist, a nurse practitioner or physician assistant under the supervision of a rheumatologist, or a team comprising the rheumatologist and a primary care physician who have a formal arrangement to support the early treatment of RA.

The latter scenario is intended for rural areas and other areas where there is a shortage of rheumatologists. The formal arrangement would specify how payments are shared and who is responsible for each of the accountability requirements and for treatment pathway, “but there is a lot of flexibility, and this can vary quite a bit, so what happens in rural Alaska where the primary care doctors might be more involved is not going to be the same as in a big city where the primary care doctors may not want to be involved at all. So there is no requirement for primary care doctors to be involved, but it just provides the resources in areas where that might make sense,” Dr. Huston noted.

The initial treatment payment would be made monthly for 6 months, replacing evaluation and management billing for office visits related to RA. It pays for typical lab tests and imaging and allows flexibility for non–face-to-face communications, and enhanced services to patients who need them. This payment is also stratified to adjust for sicker patients who have more comorbidities, he said.
 

Continued care for RA

This component of the payment structure also can be made to a rheumatologist, a nurse practitioner or physician assistant under the supervision of a rheumatologist, or the rheumatologist–primary care physician team. Continued care payments are made monthly and, just as with initial treatment payments, they are meant to replace E&M billing for office visits and pay for the same kinds of resources used in initial treatment, including stratified payments to adjust for patient characteristics.

Patients who come to a rheumatologist with established RA would enter this treatment pathway under this kind of payment.
 

RA APM’s accountability requirements

Participants in this model would be required to see a patient face-to-face at least every 6 months and to document their disease activity using a validated scale approved by the ACR for use in the RA APM, such as the RAPID-3 (Routine Assessment of Patient Index Data–3), the CDAI (Clinical Disease Activity Index), the SDAI (Simple Disease Activity Index), or the DAS28 (28-joint Disease Activity Score). Payment would also require keeping a written treatment plan that’s consistent with the ACR’s approved treatment pathway.

Changes in medication require communication with the patient within 2 weeks to help improve treatment adherence. Quality measures will still need to be recorded, such as a functional assessment, tuberculosis screening prior to starting biologics, and having a plan for steroid use, but they are not required to be reported. “You attest to that,” he said.

However, participants will need to report that they are following the treatment pathway for patients and an outcome measure for continued care of RA. These are necessary, Dr. Huston said, because “we are asking that we increase the money that’s going to the rheumatologist for managing patients with RA, so we have to show that we’re accountable and doing good with that money and that we’re taking care of our patients. ... and if we have an outcome measure, then we don’t have to report all those process measures that we do in MIPS.”

The outcome measure would be reporting:

• At least (some %) of patients with low disease activity remained in low disease activity.

• At least (some %) of patients with moderate disease activity stayed in the same or a lower disease activity category.

• At least (some %) of patients with a high disease activity had a lower disease activity category.

It’s unknown yet what the threshold percentage for each disease activity level would be, but it will be obtained from the ACR’s Rheumatology Informatics System for Effectiveness (RISE) Registry and will be refined over time from there. The outcome measure is not validated yet – none exists for RA for use in clinical practice – because it’s not yet known how to risk stratify patients in these disease activity levels for their comorbidities and socioeconomic factors. “Those are all things we need to learn over time,” Dr. Huston said, “but this is our good-faith effort at developing an outcome measure which we think will become more robust as we gather more and more data.”

Advantages of the RA APM

The RA APM’s advantages, according to Dr. Huston, stem from its payment for high-value services; the avoidance of the penalties and reporting burdens imposed by MIPS; a reduction in documentation requirements, allowing clinicians to take notes on history of present illness and review of systems however they want; a reduction in prior authorizations; and more control over performance measures.

Another big advantage of the RA APM is that participants “are not responsible for the price of drugs, whereas in MIPS you are responsible. When [the Centers for Medicare & Medicaid Services] calculates your cost category [in MIPS], that includes Part B drugs, and when the MIPS adjustment factor is applied to your revenue, that includes revenue from Part B drugs,” Dr. Huston said.

In addition, he noted that it will be possible for a rheumatologist to be a participant in just one or two APMs and still have the benefit of being out of MIPS.
 

Next steps

The next steps for the development of the RA APM include refining the treatment pathway, analyzing RISE data outcome thresholds, and modeling the financial impact on practices by running data from three to five practices across the country through the model to determine what the payment levels should be. Once those steps are completed, the RA APM can be submitted to the Physician-Focused Payment Model Technical Advisory Committee for approval, which will then send it to the CMS to run it through its Innovation Center to test the model in several practices to gather more data and refine the payment rates until it is ready to be expanded and implemented.

Dr. Huston, Dr. Worthing, and Dr. Laing had no relevant conflicts of interest to disclose.

[email protected]

If you haven’t started reporting quality data for the Merit-Based Incentive Payment System (MIPS), there’s still time to avoid a 4% cut to your Medicare payments.

Under the Pick Your Pace approach being offered this year, the Centers for Medicare & Medicaid Services allows clinicians to test the system by reporting on one quality measure for one patient through paper-based claims. Be sure to append a Quality Data Code (QDC) to the claim form for care provided up to Dec. 31, 2017, in order to avoid a penalty in payment year 2019.

Consider this measure:

Measure #181: Elder Maltreatment Screen and Follow-Up Plan

This measure aims to capture the percentage of patients aged 65 years and older who have a documented elder maltreatment screening and a follow-up plan, if appropriate.

What you need to do: Screen your elderly patients for maltreatment using an Elder Maltreatment Screening tool during the visit and if they screen positive, develop and document a follow-up plan at the visit.

Eligible cases include patients who were aged 65 years or older on the date of the encounter and a have patient encounter during the performance period. Applicable codes include (CPT or HCPCS): 90791, 90792, 90832, 90834, 90837, 96116, 96118, 96150, 96151, 96152, 97165, 97166, 97167, 97802, 97803, 99201, 99202, 99203, 99204, 99205, 99212, 99213, 99214, 99215, 99304, 99305, 99306, 99307, 99308, 99309, 99310, 99318, 99324, 99325, 99326, 99327, 99328, 99334, 99335, 99336, 99337, 99341, 99342, 99343, 99344, 99345, 99347, 99348, 99349, 99350, G0101, G0270, G0402, G0438, G0439 without telehealth modifiers GQ or GT.

To get credit under MIPS, be sure to include a QDC that shows that you successfully performed the measure or had a good reason for not doing so. For instance, G8733 indicates that an elder maltreatment screen was documented as positive and a follow-up plan was documented, while G8734 indicates that the screen was negative and a follow-up plan is not required. Use exception code G8535 if the screening was not documented because the patient is not eligible. For example, a patient is not eligible if they require urgent medical care during the visit and the screening would delay treatment.

CMS has a full list measures available for claims-based reporting at qpp.cms.gov. The American Medical Association has also created a step-by-step guide for reporting on one quality measure.

Certain clinicians are exempt from reporting and do not face a penalty under MIPS:

• Those who enrolled in Medicare for the first time during a performance period.
• Those who have Medicare Part B allowed charges of $30,000 or less.
• Those who have 100 or fewer Medicare Part B patients.
• Those who are significantly participating in an Advanced Alternative Payment Model (APM).

If you haven’t started reporting quality data for the Merit-Based Incentive Payment System (MIPS), there’s still time to avoid a 4% cut to your Medicare payments.

Under the Pick Your Pace approach being offered this year, the Centers for Medicare & Medicaid Services allows clinicians to test the system by reporting on one quality measure for one patient through paper-based claims. Be sure to append a Quality Data Code (QDC) to the claim form for care provided up to Dec. 31, 2017, in order to avoid a penalty in payment year 2019.

Consider this measure:

Measure #181: Elder Maltreatment Screen and Follow-Up Plan

This measure aims to capture the percentage of patients aged 65 years and older who have a documented elder maltreatment screening and a follow-up plan, if appropriate.

What you need to do: Screen your elderly patients for maltreatment using an Elder Maltreatment Screening tool during the visit and if they screen positive, develop and document a follow-up plan at the visit.

Eligible cases include patients who were aged 65 years or older on the date of the encounter and a have patient encounter during the performance period. Applicable codes include (CPT or HCPCS): 90791, 90792, 90832, 90834, 90837, 96116, 96118, 96150, 96151, 96152, 97165, 97166, 97167, 97802, 97803, 99201, 99202, 99203, 99204, 99205, 99212, 99213, 99214, 99215, 99304, 99305, 99306, 99307, 99308, 99309, 99310, 99318, 99324, 99325, 99326, 99327, 99328, 99334, 99335, 99336, 99337, 99341, 99342, 99343, 99344, 99345, 99347, 99348, 99349, 99350, G0101, G0270, G0402, G0438, G0439 without telehealth modifiers GQ or GT.

To get credit under MIPS, be sure to include a QDC that shows that you successfully performed the measure or had a good reason for not doing so. For instance, G8733 indicates that an elder maltreatment screen was documented as positive and a follow-up plan was documented, while G8734 indicates that the screen was negative and a follow-up plan is not required. Use exception code G8535 if the screening was not documented because the patient is not eligible. For example, a patient is not eligible if they require urgent medical care during the visit and the screening would delay treatment.

CMS has a full list measures available for claims-based reporting at qpp.cms.gov. The American Medical Association has also created a step-by-step guide for reporting on one quality measure.

Certain clinicians are exempt from reporting and do not face a penalty under MIPS:

• Those who enrolled in Medicare for the first time during a performance period.
• Those who have Medicare Part B allowed charges of $30,000 or less.
• Those who have 100 or fewer Medicare Part B patients.
• Those who are significantly participating in an Advanced Alternative Payment Model (APM).

If you haven’t started reporting quality data for the Merit-Based Incentive Payment System (MIPS), there’s still time to avoid a 4% cut to your Medicare payments.

Under the Pick Your Pace approach being offered this year, the Centers for Medicare & Medicaid Services allows clinicians to test the system by reporting on one quality measure for one patient through paper-based claims. Be sure to append a Quality Data Code (QDC) to the claim form for care provided up to Dec. 31, 2017, in order to avoid a penalty in payment year 2019.

Consider this measure:

Measure #181: Elder Maltreatment Screen and Follow-Up Plan

This measure aims to capture the percentage of patients aged 65 years and older who have a documented elder maltreatment screening and a follow-up plan, if appropriate.

What you need to do: Screen your elderly patients for maltreatment using an Elder Maltreatment Screening tool during the visit and if they screen positive, develop and document a follow-up plan at the visit.

Eligible cases include patients who were aged 65 years or older on the date of the encounter and a have patient encounter during the performance period. Applicable codes include (CPT or HCPCS): 90791, 90792, 90832, 90834, 90837, 96116, 96118, 96150, 96151, 96152, 97165, 97166, 97167, 97802, 97803, 99201, 99202, 99203, 99204, 99205, 99212, 99213, 99214, 99215, 99304, 99305, 99306, 99307, 99308, 99309, 99310, 99318, 99324, 99325, 99326, 99327, 99328, 99334, 99335, 99336, 99337, 99341, 99342, 99343, 99344, 99345, 99347, 99348, 99349, 99350, G0101, G0270, G0402, G0438, G0439 without telehealth modifiers GQ or GT.

To get credit under MIPS, be sure to include a QDC that shows that you successfully performed the measure or had a good reason for not doing so. For instance, G8733 indicates that an elder maltreatment screen was documented as positive and a follow-up plan was documented, while G8734 indicates that the screen was negative and a follow-up plan is not required. Use exception code G8535 if the screening was not documented because the patient is not eligible. For example, a patient is not eligible if they require urgent medical care during the visit and the screening would delay treatment.

CMS has a full list measures available for claims-based reporting at qpp.cms.gov. The American Medical Association has also created a step-by-step guide for reporting on one quality measure.

Certain clinicians are exempt from reporting and do not face a penalty under MIPS:

• Those who enrolled in Medicare for the first time during a performance period.
• Those who have Medicare Part B allowed charges of $30,000 or less.
• Those who have 100 or fewer Medicare Part B patients.
• Those who are significantly participating in an Advanced Alternative Payment Model (APM).

NATIONAL HARBOR, MD. – Moving hysterectomy and advanced gynecologic procedures to the ambulatory surgical environment is better for patients, surgeons, and the health care system, Richard B. Rosenfield, MD, who is in private practice in Portland, Ore., said at the AAGL Global Congress.

“We’ve been basically proving this model over the last decade by performing advanced laparoscopic surgery in the outpatient environment, and we do this for a number of reasons,” Dr. Rosenfield said in an interview. “The patients get to go home the same day, which they typically enjoy, we avoid the hospital-acquired infections, which is great, and in addition to that, the physicians tend to really appreciate the efficiency of an outpatient center.”

But with the focus on value-based payment under federal health programs, there should also be a greater focus on getting more high-volume surgeons to perform their procedures, he said. The idea is to lower the hospital readmissions, complications, and infections that could arise during procedures by less experienced surgeons and redirect the cost savings toward payments for surgeons with better outcomes, Dr. Rosenfield said. But this should be coupled with training and mentoring for lower-volume surgeons, he said.

Dr. Rosenfield reported having no relevant financial disclosures.

[email protected]

On Twitter @eaztweets

NATIONAL HARBOR, MD. – Moving hysterectomy and advanced gynecologic procedures to the ambulatory surgical environment is better for patients, surgeons, and the health care system, Richard B. Rosenfield, MD, who is in private practice in Portland, Ore., said at the AAGL Global Congress.

“We’ve been basically proving this model over the last decade by performing advanced laparoscopic surgery in the outpatient environment, and we do this for a number of reasons,” Dr. Rosenfield said in an interview. “The patients get to go home the same day, which they typically enjoy, we avoid the hospital-acquired infections, which is great, and in addition to that, the physicians tend to really appreciate the efficiency of an outpatient center.”

But with the focus on value-based payment under federal health programs, there should also be a greater focus on getting more high-volume surgeons to perform their procedures, he said. The idea is to lower the hospital readmissions, complications, and infections that could arise during procedures by less experienced surgeons and redirect the cost savings toward payments for surgeons with better outcomes, Dr. Rosenfield said. But this should be coupled with training and mentoring for lower-volume surgeons, he said.

Dr. Rosenfield reported having no relevant financial disclosures.

[email protected]

On Twitter @eaztweets

NATIONAL HARBOR, MD. – Moving hysterectomy and advanced gynecologic procedures to the ambulatory surgical environment is better for patients, surgeons, and the health care system, Richard B. Rosenfield, MD, who is in private practice in Portland, Ore., said at the AAGL Global Congress.

“We’ve been basically proving this model over the last decade by performing advanced laparoscopic surgery in the outpatient environment, and we do this for a number of reasons,” Dr. Rosenfield said in an interview. “The patients get to go home the same day, which they typically enjoy, we avoid the hospital-acquired infections, which is great, and in addition to that, the physicians tend to really appreciate the efficiency of an outpatient center.”

But with the focus on value-based payment under federal health programs, there should also be a greater focus on getting more high-volume surgeons to perform their procedures, he said. The idea is to lower the hospital readmissions, complications, and infections that could arise during procedures by less experienced surgeons and redirect the cost savings toward payments for surgeons with better outcomes, Dr. Rosenfield said. But this should be coupled with training and mentoring for lower-volume surgeons, he said.

Dr. Rosenfield reported having no relevant financial disclosures.

[email protected]

On Twitter @eaztweets

NATIONAL HARBOR, MD. – Innovative tools for vaginal hysterectomy were in the spotlight during a surgical demonstration at the AAGL Global Congress.

“I think it’s really compelling that we use the technologies that the AAGL is known for investigating and teaching each other,” said Charles Rardin, MD, director of the robotic surgery program at Women & Infants Hospital, Providence, R.I. “It’s nice to see a renewed interest in some newer technologies and applying them to vaginal hysterectomy.”

The presentation of new tools comes as the number of vaginal hysterectomies have decreased and laparoscopic procedures are on the rise. The rate of vaginal hysterectomy in the United States has fallen from 24.8% in 1998 to 16.7% in 2010, according to the Nationwide Inpatient Sample from the Agency for Healthcare Research and Quality.

Surgeons demonstrated new tools with the intent of showing physicians that the benefits some associate with laparoscopic procedures, such as having easier access or a better sense of the uterus, can be associated with vaginal hysterectomy as well.

Advanced tools, such as a self-retaining retractor and 3-D camera systems, could make it easier to teach students by allowing more mobility and easier visual access, Dr. Rardin said in a video interview.

The tutorial ended with a demonstration of the natural orifice transluminal endoscopic surgery tool that allows laparoscopic tools to be introduced through the vaginal pathway.

All the tools exhibited at AAGL are currently available.

Dr. Rardin reported having no relevant financial disclosures.

[email protected]

On Twitter @eaztweets

NATIONAL HARBOR, MD. – Innovative tools for vaginal hysterectomy were in the spotlight during a surgical demonstration at the AAGL Global Congress.

“I think it’s really compelling that we use the technologies that the AAGL is known for investigating and teaching each other,” said Charles Rardin, MD, director of the robotic surgery program at Women & Infants Hospital, Providence, R.I. “It’s nice to see a renewed interest in some newer technologies and applying them to vaginal hysterectomy.”

The presentation of new tools comes as the number of vaginal hysterectomies have decreased and laparoscopic procedures are on the rise. The rate of vaginal hysterectomy in the United States has fallen from 24.8% in 1998 to 16.7% in 2010, according to the Nationwide Inpatient Sample from the Agency for Healthcare Research and Quality.

Surgeons demonstrated new tools with the intent of showing physicians that the benefits some associate with laparoscopic procedures, such as having easier access or a better sense of the uterus, can be associated with vaginal hysterectomy as well.

Advanced tools, such as a self-retaining retractor and 3-D camera systems, could make it easier to teach students by allowing more mobility and easier visual access, Dr. Rardin said in a video interview.

The tutorial ended with a demonstration of the natural orifice transluminal endoscopic surgery tool that allows laparoscopic tools to be introduced through the vaginal pathway.

All the tools exhibited at AAGL are currently available.

Dr. Rardin reported having no relevant financial disclosures.

[email protected]

On Twitter @eaztweets

NATIONAL HARBOR, MD. – Innovative tools for vaginal hysterectomy were in the spotlight during a surgical demonstration at the AAGL Global Congress.

“I think it’s really compelling that we use the technologies that the AAGL is known for investigating and teaching each other,” said Charles Rardin, MD, director of the robotic surgery program at Women & Infants Hospital, Providence, R.I. “It’s nice to see a renewed interest in some newer technologies and applying them to vaginal hysterectomy.”

The presentation of new tools comes as the number of vaginal hysterectomies have decreased and laparoscopic procedures are on the rise. The rate of vaginal hysterectomy in the United States has fallen from 24.8% in 1998 to 16.7% in 2010, according to the Nationwide Inpatient Sample from the Agency for Healthcare Research and Quality.

Surgeons demonstrated new tools with the intent of showing physicians that the benefits some associate with laparoscopic procedures, such as having easier access or a better sense of the uterus, can be associated with vaginal hysterectomy as well.

Advanced tools, such as a self-retaining retractor and 3-D camera systems, could make it easier to teach students by allowing more mobility and easier visual access, Dr. Rardin said in a video interview.

The tutorial ended with a demonstration of the natural orifice transluminal endoscopic surgery tool that allows laparoscopic tools to be introduced through the vaginal pathway.

All the tools exhibited at AAGL are currently available.

Dr. Rardin reported having no relevant financial disclosures.

[email protected]

On Twitter @eaztweets

LAS VEGAS – Currently, there are available treatments that are effective in contouring the body, Christopher B. Zachary, MD, said in a video interview at Skin Disease Education Foundation’s annual Las Vegas Dermatology Seminar.

Some devices can help patients looking for reductions of trouble spots, such as around the abdomen, and are safe and effective, said Dr. Zachary of the University of California, Irvine. However, they are not a realistic option for obese or overweight patients, he added.

In addition, other treatments can be combined with body sculpting devices to optimize results, particularly when removing fat in the submental area, he noted.

Dr. Zachary disclosed relationships with Solta, Zeltiq, Sciton, DUSA, Zimmer, Cutera, Alma, and Amway.

SDEF and this news organization are owned by the same parent company.

LAS VEGAS – Currently, there are available treatments that are effective in contouring the body, Christopher B. Zachary, MD, said in a video interview at Skin Disease Education Foundation’s annual Las Vegas Dermatology Seminar.

Some devices can help patients looking for reductions of trouble spots, such as around the abdomen, and are safe and effective, said Dr. Zachary of the University of California, Irvine. However, they are not a realistic option for obese or overweight patients, he added.

In addition, other treatments can be combined with body sculpting devices to optimize results, particularly when removing fat in the submental area, he noted.

Dr. Zachary disclosed relationships with Solta, Zeltiq, Sciton, DUSA, Zimmer, Cutera, Alma, and Amway.

SDEF and this news organization are owned by the same parent company.

LAS VEGAS – Currently, there are available treatments that are effective in contouring the body, Christopher B. Zachary, MD, said in a video interview at Skin Disease Education Foundation’s annual Las Vegas Dermatology Seminar.

Some devices can help patients looking for reductions of trouble spots, such as around the abdomen, and are safe and effective, said Dr. Zachary of the University of California, Irvine. However, they are not a realistic option for obese or overweight patients, he added.

In addition, other treatments can be combined with body sculpting devices to optimize results, particularly when removing fat in the submental area, he noted.

Dr. Zachary disclosed relationships with Solta, Zeltiq, Sciton, DUSA, Zimmer, Cutera, Alma, and Amway.

SDEF and this news organization are owned by the same parent company.

LAS VEGAS – For those starting to use toxins and fillers, “my first advice is to get a good education,” Christopher B. Zachary, MD, said in a video interview at Skin Disease Education Foundation’s annual Las Vegas Dermatology Seminar.

“Know … how to evaluate your patient, know where the problems are, know what the danger zones are, understand your anatomy,” advised Dr. Zachary of the University of California, Irvine.

“In general, the upper face is an easier place to start,” when learning to work with toxins , he noted. Procedures on the upper face, such as the treatment for crow’s feet or a brow lift, can be “a home run,” while the lower face is much more complicated, he said in the video interview.

Dr. Zachary disclosed relationships with companies including Solta, Zeltiq, Sciton, DUSA, Zimmer, Cutera, Alma, and Amway.

SDEF and this news organization are owned by the same parent company.

LAS VEGAS – For those starting to use toxins and fillers, “my first advice is to get a good education,” Christopher B. Zachary, MD, said in a video interview at Skin Disease Education Foundation’s annual Las Vegas Dermatology Seminar.

“Know … how to evaluate your patient, know where the problems are, know what the danger zones are, understand your anatomy,” advised Dr. Zachary of the University of California, Irvine.

“In general, the upper face is an easier place to start,” when learning to work with toxins , he noted. Procedures on the upper face, such as the treatment for crow’s feet or a brow lift, can be “a home run,” while the lower face is much more complicated, he said in the video interview.

Dr. Zachary disclosed relationships with companies including Solta, Zeltiq, Sciton, DUSA, Zimmer, Cutera, Alma, and Amway.

SDEF and this news organization are owned by the same parent company.

LAS VEGAS – For those starting to use toxins and fillers, “my first advice is to get a good education,” Christopher B. Zachary, MD, said in a video interview at Skin Disease Education Foundation’s annual Las Vegas Dermatology Seminar.

“Know … how to evaluate your patient, know where the problems are, know what the danger zones are, understand your anatomy,” advised Dr. Zachary of the University of California, Irvine.

“In general, the upper face is an easier place to start,” when learning to work with toxins , he noted. Procedures on the upper face, such as the treatment for crow’s feet or a brow lift, can be “a home run,” while the lower face is much more complicated, he said in the video interview.

Dr. Zachary disclosed relationships with companies including Solta, Zeltiq, Sciton, DUSA, Zimmer, Cutera, Alma, and Amway.

SDEF and this news organization are owned by the same parent company.