Daily Archives: December 7, 2015


State CME Requirement Regarding Opiods

Gerald N. Yorioka, MD, SCMS President

There has been a little confusion regarding the Washington State requirement for CME to prescribe opiois, and particularly long-acting opioids for chronic pain.   The state website regarding this topic can be found here.

For M.D.s the requirement for prescribing opioids is completion of 12 hours within the past two years, as it is for ARNPs and podiatrists.  Osteopaths have a 3 year cycle requirement of 18 hours.

The requirement is for 12 hours of CME to  be exempt from the mandatory consultation requirement.  Of these 12 hours, 4 hours must be designated as dedicated towards long-acting opioid use.  Even for practitioners who do not prescribe long-acting or methadone, it is recommended that 4 hours (lifetime) be dedicated towards these medications.

The mandatory consultation requirement applies when a patient is being prescribed 120mg of “Morphine Equivalent Dose” (MED).  The state provides a calculator to convert other opioids to a MED.

At the federal level, there is the term REMS (Risk Evaluation and Mitigation Strategies).  The FDA has identified REMS education to be made available for opioid, and other, types of medications.

These are requirements imposed on manufacturers, rather than on prescribers, and a list of specific medications can be found here.

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Sea Mar Marysville Family Medicine Residency Update

Greg Sanders, MD, Developing Family Medicine Residency Director, Sea Mar Marysville

We are in the process of applying for ACGME accreditation for this Family Medicine Residency (FMR). In August, we received feedback from the ACGME which is helping us improve our application. This is not uncommon. We have just sent in our completed application and we are already scheduled for a site visit on December 8th.  Now we expect to receive accreditation this April, 2016. Once we are accredited we will begin recruiting six 4th year medical students for the first class, starting July, 2017.

We have been working hard on laying the groundwork for our  FMR. There are now 3 core faculty members, Dr. Jose Mata, Dr. Michael Kopec, and Dr. Kaeli Caldwell. They are all family physicians who have done obstetrical fellowships. I am in the middle of a UW Faculty Development Fellowship, and I completed an AAFP Program Director Fellowship last Spring. We have been working on faculty development, curriculum development, didactics, simulation training, etc. After accreditation we will be offering training for everyone involved with the residents, via various modalities. Our governing Graduate Medical Education Committee is functioning well, with Sea Mar and PRMCE leadership as members of this committee.

Recently, Dr. Matt Hansen, our internal medicine hospital FMR champion, and I attended the annual Providence/Swedish GME summit. This meeting had representatives from the many residencies and Fellowship programs in the Providence/Swedish system. We discussed various local and national issues related to GME training at our institutions. It was enlightening and the networking component was quite valuable as well. The power of all of these programs collaborating will enhance each of our programs, and give an organized voice for common issues.

We really appreciate the strong support we have received from the physicians working in the community and at PRMCE. This is a CHC sponsored residency, so you all are vital to this community based endeavor. We will keep everyone updated on our progress. Please contact me if you want to work with our FMR, the first in Snohomish county.

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Reading the Future in the Alphabet Soup of the Present

Gerald N. Yorioka, MD, SCMS President

In October 2007 the Institute of Healthcare Improvement (IHI) under the leadership of Donald Berwick launched the “Triple Aim” for the improved future of health care.  The components are 1) Contain costs, 2) Improve quality, and 3) Population health.  They are to be attained simultaneously, rather than achieving one at a time, at the expense of the other.

Meanwhile the National Committee of Quality Assurance (NCQA) established a task force in2011 to create an accreditation process  for Accountable Care Organizations (ACOs) which would be tasked with achieving the Triple Aim, and in 2013, these criteria were published.  The NCQA since the 1990’s had been working with Healthcare Effectiveness Data and Information Set (HEDIS) quality standards, which was generated in the 1980’s by think tanks of large employers and health experts.

In June 2015 the Center for Medicaid and Medicare Services (CMS) published the Final Rule in the Federal Register that outlined the Medicare Shared Savings (MSS) Program and its companion definition of the Accountable Care Organization (ACO) needed for its implementation. The initial proposed rule had been published in December of 2014.  The origins of this Medicare Shared Savings Program can be traced back to the Affordable Care Act (ACA) of 2010. ACOs will share in the achieved savings, and are an integral and essential part of the Shared Savings Program.

Dr. Burwick, a pediatrician, was placed as head of the CMS by President Obama in a “pocket-appointment” in June of 2010, when the Senate was in recess. As a result, he was never confirmed by the Senate and eventually resigned in December of 2011. During his tenure the ACO was codified and written into federal rules and into the NCQA certification process.

Superimposed on these concepts is another entity, the Accountable Communities of Health (ACH).  While the ACO’s are generally coalition of health providers, the ACH’s have a broader base within the community as a whole. Washington State is implementing  this concept in its Medicaid program design and has divided the state into nine  geographical areas called Regional Service Areas (RSAs) that will cover the entire state, each with an exclusive territory.  CMS awarded the state an innovation grant in December 2014 to launch this process.  At this point only three are “certified,” and Snohomish County is included in one of these as the five county North Sound ACH.

In summary of all these interrelated terms, we see the “Triple Aim” leading to the Medicare Shared Savings, enacted in the Affordable Care Act. This in turn, gave rise to the ACO’s for Medicare and then the initial ACH’s in Medicaid.  While each of these two has a different domain, they do converge through one federal agency, CMS.  It is quite likely that the ACOs and ACHs will spread into other sectors of health care. Furthermore, all of this ties to payment reform, which pulls in new goals of population outcomes and Patient Centered Medical Homes.  Here also, the NCQA had codified criteria for a PCMH.

A specific purpose for this article is to urge you, as an individual in the medical community, to willingly engage in the Accountable Communities of Health process when the opportunities arise.  These opportunities may take the form of committees, boards, task forces, focus groups, or hearings.  Your voice is needed to define the health goals for our community.

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Medicare Cut?

Gerald N. Yorioka, MD, SCMS President

Do you remember the recent physician victory in Congress with the repeal of the dreaded Sustained Growth Rate (SGR) that was scheduled to impose a Medicare payment rate reduction? That new law was supposed to swap a 23% reduction with a 0.5% increase. The ink has barely dried on signing this into law April 16th and now we see the final result … a 0.3% pay cut! The DC-speak explanation is that the Affordable Care Act (ACA) and laws related to Medicare reimbursement trumps the new Medicare Access and CHIP Reauthorization Act (MACRA) of 2015.

The expression “you can’t win for losing” never seemed to make sense, but it is coming into focus. We have been dealt a blow, but we still have some remaining dignity as in the lyrics of the Bobby Bare song, “The Winner” which ends:

So I stumbled from that barroom, not so tall and not so proud
And behind me I still hear the hoots of laughter of the crowd
But my eyes still see and my nose still works and my teeth’re still in my mouth
And you know I guess that makes me the winner…

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