Summer 2019 e-Newsletter
In This Issue:
- President’s Message
- ACMS Happenings
- Ask Glenn: Answers to Your Mohs Coding & Billing Questions
- Viewpoints: Dr. George Hruza Discusses Unity of the Specialty
- Hot Topic: A Brief Interview with Dr. Len D'Avolio
- Practice Tips and Efficacy: Mohs Surgeons’ Favorites - Part 2
- Highlights from the Literature: What is the Most Effective Treatment for Actinic Keratosis? A Head-to-Head Comparison of 4 Field Treatments
- Fellow-in-Training Perspectives: Complexities Surrounding Use of Streaming Music Services in the Office Setting
Dear Colleagues –
August is the time of summer vacations, the last garden produce, outdoor fun, and a time of anticipation as fall is about to begin. There is something so special about this time of year – students are preparing to return to school and those that have recently completed their trainings are preparing themselves for the next step of their professional journey. Dr. Goldman and the Membership Committee have received and are reviewing both Associate and Fellow applications for 2020. The Board and I are looking forward to reviewing and approving the new Associates and Fellows that will be recommended for membership at the Annual Meeting in Nashville. We welcome the incoming Fellows-in-Training, and offer our continued support to the dedicated Program Directors – thank you for continuing Dr. Mohs’ legacy and guaranteeing the continued successful growth of our subspecialty.
Last month I encouraged you consider supporting the College through volunteering – both internally and externally, and your responses have been truly inspiring. Many thanks to those of you that have shown an interest in serving on Committees and Task Forces. Continue to share your desire to serve by visiting the Committees and Volunteer Opportunities page.
2020 Board Elections
The 2020 Board Nominations process has started, and you are invited to recommend candidates for the 2020 election. Use this link to suggest ACMS Fellows to fill the four (4) coming vacancies on the ACMS Board of Directors – self nominations are accepted as well. Nominations close on September 23, 2019; please take a moment and submit your candidates today.
2020 Annual Meeting
The ACMS 2020 Annual Meeting abstract submission site is open. Consider submitting an abstract for consideration of an oral or poster presentation at the 52nd American College of Mohs Surgery Annual Meeting in Nashville, Tennessee. As members of the College, we serve as the voice of our specialty, and it is through our efforts that the specialty will continue to succeed – and the research that you do contributes to our collective accomplishments. This will be a fantastic meeting – I encourage you to participate!
MDS Subspecialty Certification Examination
I would like to take this opportunity to clarify the situation for some College members that did not meet the initial eligibly requirements. As you know, current certification by the American Board of Dermatology is a prerequisite for taking the new certification exam in Micrographic Dermatologic Surgery. For those who have completed a Mohs fellowship and are certified by the ABMS Boards in Plastic Surgery or Otolaryngology-Head and Neck Surgery, but not by the American Board of Dermatology, the ABMS is considering approving ABPS and ABOHNS as qualifying boards. Under the proposed terms only individuals who are board-certified by ABPS or ABOHNS and have completed an ACMS fellowship or an ACGME fellowship will be eligible for MDS Board Certification. In addition to the Micrographic Dermatologic Surgery exam, these individuals will have to pass exams in dermatology and dermatopathology prepared by the ABD to obtain certification. The ABMS COCERT will consider this proposal in September. Please visit the ABMS website for updates. While our members who are certified by the American Osteopathic Board of Dermatology, but not the ABD, still cannot take the new MDS exam, they remain eligible to take the long existing subspecialty exam in Mohs Micrographic Surgery under the AOBD.
Below is the most recent member e-Newsletter; please take time to review this issue for updates on ACMS Happenings, as well as an update on the subspecialty examination, an interview with AAD President and Fellow ACMS member Dr. George Hruza, the conclusion of Mohs surgeons' favorite resources and tips, and much more. Thank you to Dr. Leshin and the members of the Newsletter Committee for providing such quality content.
Elizabeth M. Billingsley, MD, FACMS
ACMS President, 2019-20
2020 Annual Meeting Call for Abstracts
You are cordially invited to submit an abstract for consideration of an oral or poster presentation at the 52nd ACMS Annual Meeting in Nashville, Tennessee taking place April 23-26, 2020 at the Gaylord Opryland Resort. Scientific, Clinical Pearl or Rapid Pearl abstract submissions can be made via the meeting website, where full criteria and submission guidelines are found. The submission deadline is Monday, January 6, 2020.
In addition to abstract submissions, beginning November 15, 2019, Fellows-in-Training are invited to submit a case for the Clinicopathologic Case Competition that includes slides and photographs of Mohs cases that have uncommon or rare pathology or that illustrate prototypical diagnostic challenges and keys to diagnosis or tumor detection. These case submissions must be received by Friday, February 7, 2020.
Honor Your ACMS Mentor Through the ACMS Foundation's Lineage Fund
In the past year, the Foundation has made tremendous strides towards the launch goal of $2.5 million. While many ACMS members continue to faithfully contribute to this fund, the opportunity remains for additional growth and financial expansion.
The Linage Fund affords members the opportunity to contribute to the ACMS Foundation, while honoring the instructional inheritance and professional training provided by the Program Director that so dutifully shared the legacy that Dr. Frederic Mohs began so many years ago. Consider making a contribution to the ACMS Fund today in honor of the Program Director that guided your professional journey as a Mohs surgeon.
2019 Advocacy Conference
It was a great pleasure to have the opportunity to join the College’s public policy experts and members of our executive committee at the 2019 ACMS Advocacy Conference.
Several of us arriving early had a special treat. Dr. Brent Moody’s daughter Claire (who had spent the summer as an intern in Senator Rand Paul’s office) gave us an inspired tour of the Capitol. Off the beaten path, we were treated to visits of the original venues of the House of Representatives and the Supreme Court, and regaled with stories from an insider.
The Conference kicked off on Tuesday evening with a dinner meeting at the Hart Health Strategies office. We participated in active discussions with an expert on the current political landscape, and received an overview on the issues facing the College presently.
On Wednesday morning in the Russell Senate Office Building, we enjoyed interactive discussions with three physicians (including dermatologist Dr. John Joyce) who serve in the House of Representatives, and are members of the GOP Doctors Caucus. We covered important topics such as access to skin cancer care and treatment, physician in-office compounding, drug costs, and pending legislation on surprise billing and prior authorizations.
The centerpiece of the Advocacy Conference is the afternoon visits to Capitol Hill. Our policy experts at Hart Health prepared us well with talking points as we as constituents engaged our Representatives and Senators.
I have much greater insight to the public policy issues that impact us, and a keen perspective on how to advocate for our patients. I found this to be a fantastic experience, and strongly encourage you to be part of this vital mission.
Keyvan Nouri, MD, FACMS
Micrographic Dermatologic Surgery (MDS) Subspecialty Certification Examination Update
by Kelly Park, MD, MSL
In October 2018, the American Board of Dermatology (ABD) announced that the American Board of Medical Specialties (ABMS) Board of Directors approved the creation of subspecialty certification in Micrographic Dermatologic Surgery (MDS).
ACMS members who have completed an ACGME-accredited MSDO fellowship are eligible to take the examination. Also eligible for the exam during an initial five-year practice pathway eligibility period are those who attest to the active practice of micrographic surgery as part of one’s patient care activities. The ABD has released a projected Fall 2021 date for the initial examination. The exam will be administered at Pearson VUE testing centers, and will be approximately 200 questions.
In order to prepare our members for the examination, the ACMS has created a Board Certification Preparation Task Force chaired by Dr. Sumaira Aasi. Currently, the Task Force is planning a three-pronged approach to prepare members for the examination:
- Email self-test questions late Summer/early Fall 2019
- Create a list of references annotated with a summary of key points that will be available to members on the College's website.
- The Scientific Program Committee and the Board Certification Preparation Task Force will develop a board preparation session at the 2020 ACMS Annual Meeting in Nashville.
A very special thank you to Dr. Sumaira Aasi and Dr. Allison Vidimos in the preparation of this update.
The American College of Mohs Surgery has a rich tradition of dedicated members that work hard to uphold the legacy of excellence initiated by Dr. Frederic Mohs. It is fitting that current members are able to showcase their ACMS membership by adding either of these marks to their professional profile. To acquire the newly designed Member Mark, please complete the no-fee License Agreement. You'll be prompted to log in using your member username and password. Once you have submitted the agreement, you will reach a screen with three Member Mark variations (see image). Select the image that is most appropriate for your preferred use.
Please remember that you may not, in any way, alter, manipulate or change the graphic. Contact email@example.com should you have any questions about proper use.
August 1, 2019 Marks One Year of MohsAIQ
Since the August 1, 2018 launch of MohsAIQ, more than 34,500 cases have been entered by the 135 members currently enrolled. The ACMS Executive Committee announced in July that Associates and Fellows practicing abroad have been granted access to MohsAIQ and are invited to participate. In January of 2019, MohsAIQ was approved as a Qualified Clinical Data Registry by the Centers for Medicare and Medicaid Services for the 2019 reporting year under the Merit-based Incentive Payment System. MohsAIQ is the only reporting solution designed exclusively for Mohs surgeons to fulfill MIPS requirements.
For members considering enrolling in MohsAIQ, a recording of the webinar hosted by Dr. Howard Rogers is available online. Topics covered in the 30-minute webinar include data sheets and tools to allow data entry by staff, maximizing efficiency, ensuring data completeness, and more. Visit www.mohscollege.org/registry for more information and a link to the recording (member login required).
The registry will help the ACMS members demonstrate the value of Mohs surgery as patient-centered and highly effective. Learn more about MohsAIQ here or contact Tammy O'Connell, CEHRS at firstname.lastname@example.org.
Send Your Tech to Advanced Mohs Technician Training
Do your histotechs need help in reaching a higher level of slide preparation or reinforcing their skills? The American Society for Mohs Histotechnology offers customized, hands-on instruction through its ongoing Mohs Technician Training Program. Offered exclusively to technicians with at least six months experience cutting tissue, registration is now open for the next training session taking place October 11-12, 2019 at Avantik Academy Mohs Training Campus, in Springfield, NJ. Topics include mapping and inking, embedding, staining, cryosectioning, CLIA regulations and troubleshooting.
Non-member registration will include ASMH membership through 2020 for qualified techs. Upon completion, trainees can claim 12 CEUs through the National Society for Histotechnology and will receive a certificate of completion from the ASMH/ACMS.
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Answers to Your Mohs Coding & Billing Questions
Responses provided by Glenn D. Goldman, MD, FACMS
Many ACMS members have questions about proper coding and billing for Mohs surgery. This reinforces a need for ongoing education to ensure the College meets its goal of integrity and ethics in all aspects of Mohs practice. The College's Vice President, Dr. Glenn Goldman answers these coding and billing questions submitted to email@example.com. Responses are included in the e-Newsletter for the benefit of all members.
Dr. George Hruza Discusses Unity of The Specialty
by Ramona Behshad, MD, FACMS
ACMS member Ramona Behshad, MD, FACMS presents a video interview, in this issue of ACMS Viewpoints. Enjoy this comprehensive discussion about a variety of topics relevant to ACMS members.
A Brief Interview with Dr. Len D'Avolio
by Barry Leshin, MD, FACMS
Editor’s Note: Our featured guest in this interview, Dr. Len D’Avolio delivered the featured keynote lecture at our recent Annual Meeting. Dr. D’Avolio is an assistant professor at Brigham and Women’s Hospital and Harvard Medical School. Through CYFT, the company he founded, he has brought a fresh perspective and a sense of meaning and purpose in making the learning healthcare system a reality. His recent address to the College focused on opportunities and threats facing all of us in this era of evolution to value based reimbursement. In the article that follows, Dr. D’Avolio responds to questions developed by Drs. Scott Collins, Howard Rogers, Brent Moody, and Brett Coldiron.
Q: In the eyes of payers, do Appropriate Use Criteria (AUC), and specialty-generated benchmarks (such as those from Improving Wisely) count as measures of Mohs Surgery value? If so, how much?
Dr. D’Avolio: I think each payer (and even different departments in payers) are wrestling with the challenge of defining value. What typically happens is CMS takes the lead with the definition of value, sometimes on a per-specialty basis, and payers follow suit. The opportunity now is to take the lead in defining value - with payers, CMS, etc. Compelling evidence in support of your case is best presented on the offensive, not defensive in response to proposed measures you disagree with. With compelling evidence ACMS can take a leadership role in bringing payers to the table to discuss definitions of value that work for all parties (payer, provider, and patient).
Q: Having learned something about our organization, how would you define “quality” for us? In addition to Mohs surgery AUC and the Improving Wisely program, what should we be focusing on so that we define this for ourselves? Data on appropriate use of reconstruction? Outpatient vs. facility based site of service issues? Development of a patient self-reported satisfaction or other surveys?
Dr. D’Avolio: I was grateful to learn more about your surgery and organization but I’m not knowledgeable enough to suggest how Mohs surgeons should define the quality of Mohs surgery. I do believe that there is a pathway for arriving at specific definitions.
I’d start where your payers / regulators are likely to focus - unexplained variance. Wherever the same services are used with different frequency, for different reasons, and with different prices attached, you can expect scrutiny. I would also give serious thought to incorporating patients’ perspectives. There is growing support within CMS for measures such as a patient’s response to the question, “Knowing what you know now, would you still have had this procedure?”
Once I had collected the data and understood the variance I’d create data-driven value arguments to a selected group of payer representatives and work toward a pilot with a few high performers. This is what we are doing now in the orthopedic surgical space and though it’s not easy work, I remain convinced that it’s quite doable.
Q: You mentioned “Centers of Excellence” in your recent keynote. If the ACMS established parameters for COE (thereby defining quality), would that be a meaningful resource to our members seeking to prove their value to payers? Are you aware of any other professional medical organizations that have done this?
Dr. D’Avolio: The Center of Excellence model as a contracting mechanism is still a relatively new concept. It’s being explored mostly by large, influential employers (e.g., GE, Walmart, etc.). To date the employers have either attempted to define value or have asked their potential partners to define value.
I’m not sure the ACMS is in a position to define the parameters of a Center of Excellence in an enforceable way, since it is ultimately the decision of the payer as to what qualifies. However, I do think that the timing and need for said models is such that ACMS could play an influential role.
For example, if ACMS led the way in the collection of data that could be used to both negotiate and define the terms of value with a payer then they would provide a distinct advantage to their fellowship-trained membership over clinicians without this level of insight. In effect, they would define the terms of the debate. If ACMS dedicated individuals to support physician groups in the negotiation of COEs those individuals would become quite valuable. If they carried their learnings to the next group and the group after that as they negotiated contracts, the ACMS can become indispensable to both sides of the debate.
As said programs mature, and ACMS continues to collect data, they can become the arbiters of value empowering them to make data-driven arguments to the most influential payers (CMS). Of course, it raises the issue of dealing with negative outliers in order to defend the value of the many. “With great power comes great responsibility!” -Uncle Ben Parker.
Q: We talk about quality as being cure rates and safety, and insurers pay that only lip service. So how do we switch the conversation with insurers who are ingrained to believe that “quality = cost”? What combination of concepts can we present to insurers that allows us to redefine their industry term? Is it possible or is cost all that really matters?
Dr. D’Avolio: Too often this is framed as benevolent doctor versus greedy insurer. As far as I can tell, both sides are at the negotiating table to protect their economic interests. Neither has given the other useful alternatives.
What else do you have to offer besides cheaper rates that is of value to the payer? Do your patients recover more quickly? Prove it. Do you ensure the most appropriate level of care based on need? Let’s see the data. Do your patients get back to work faster than those treated elsewhere? Until you can make the case - with data - you have little recourse but to retreat to good doctor versus evil insurer.
With mutually agreed upon definitions of value and the data to support said value, one can begin to negotiate on more than procedure cost alone.
Q: You now know us—give us two things that we should do NOW.
Dr. D’Avolio: First, decide if there’s urgency. Change is hard and frankly impossible without proper motivation. Without urgency, don’t waste your valuable time.
If urgency exists, step two is to begin creating a data-driven culture. We have learned that with a plan, it’s absolutely possible to achieve this.
First, get a handle on your data. Begin to understand your own variance - positive and negative. Begin sharing that data. Start small and with anonymized results and move toward transparency. Involve your surgeons in the definition of value and quality. Begin collecting patient reported outcomes. What are they telling you?
Once this foundation of information is laid and a data-driven culture begins to foment, you’ll find there are not enough hours in the day to begin addressing all of the opportunities for improvement and value definition.
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Mohs Surgeons’ Favorites - Part 2
by Mark Russell, MD, FACMS
During their career medical professionals learn from multiple sources including formal and informal training, conferences, independent study, and experience. Education by colleagues represents another learning resource.1 The purpose of this article is to present favorite practice tips from some of our experienced colleagues. The data in this report was collected in a survey sent to a limited number of Mohs surgeons in private and academic practice.
I would like to thank those Mohs surgeons who were willing to share their wisdom and respond to the survey. They represent over 500 years of collective practice experience. The second of this two-part report is linked below.
What is the Most Effective Treatment for Actinic Keratosis? A Head-to-Head Comparison of 4 Field Treatments
by Emily Newsom, MD
Jansen, Kessels, Nelemans, et al. Randomized Trial of Four Treatment Approaches for Actinic Keratosis. N Engl J Med 2019; 380:935-946. DOI: 10.1056/NEJMoa1811850
Actinic keratosis (AK) is an extremely common pre-cancerous skin lesion caused by ultraviolet radiation exposure. Cryosurgery is typically used for focal lesions, while field therapy is used for more extensive ill-defined actinic keratoses in a continuous area. There is no consensus on which field therapy is preferred.
A group out of the Netherlands has published a multi-center, single-blind, randomized controlled trial to compare treatment success at 12 months of 4 treatment modalities: fluorouracil 5% cream, imiquimod 5% cream, ingenol mebutate 0.015% gel, and methyl aminolevulinate PDT (MAL-PDT) in 624 patients with actinic keratoses. No commercial support was provided for the trial.
The treatment protocols are as follows: fluorouracil was applied twice daily for 4 weeks; imiquimod was applied once daily 3 times a week for 4 weeks. For ingenol, one 0.47 g tube was applied once a day for 3 days to an area of 25 cm2. For MAL-PDT, a thin layer of MAL cream was applied, covered with aluminum foil for 3 hours, and illuminated with LED light at a wavelength of 635 nm for 7.23 minutes. Some patients received a 2nd treatment in case of insufficient treatment response. Treatment success was defined as a 75% or more reduction of AKs. The number and extent of AKs was measured at baseline, 3 months and 12 months after treatment by a blinded investigator.
Complexities Surrounding Use of Streaming Music Services in the Office Setting
By Thomas Bander, MD • 2018-19 FIT Board Observer
Ensuring patient comfort before, during, and after Mohs surgery is an important part of our daily practice. We know from previous studies that the patient experience is improved with intraoperative music, especially if it can be tailored to individual tastes. Studies have noted improved patient satisfaction and reduced anxiety, particularly in the setting of a patient’s first cutaneous procedure. Management of anxiety may also lower blood pressure and reduce risk of surgical complications like bleeding. Streaming music services, such as Spotify, Pandora, Google Play Music, Apple Music, Amazon Music, Tidal, YouTube, and SoundCloud, allow us to access many different genres of music at the click of a button. But what are the implications of logging into your favorite streaming service in the clinic setting?
The following discussion ought to be prefaced with the disclaimer that I am not an expert in copyright law. You may wish to consult a lawyer to evaluate your specific situation.
As a general rule, music purchased by an individual, regardless of the medium—CD, downloaded mp3, or streaming subscription service—has been licensed to the customer for personal use. In contrast, a public performance is defined by United States copyright law as music performed in a “place open to the public or at any place where a substantial number of persons outside of a normal circle of a family and its social acquaintances is gathered.” This definition generally includes commercial settings; however, there are some gray areas. Does a small gathering of friends at a backyard cookout count as a public performance? How about playing music in your cubicle or the break room where coworkers can hear it? Or a procedure room where only your assistant and patient can hear it? Are a small group of patients in your office waiting room considered “the public”?
SAVE THE DATE
Mohs Surgery Career Center
Visit careers.mohscollege.org to search, apply for, and post open Mohs-related positions
The ACMS/ASMH Mohs Surgery Career Center is a resource for surgeons, histotechs, physician assistants, dermatopathologists, practice managers, administrative staff and others to search for job openings, post resumes, and connect with employers. The Career Center includes positions in multiple categories, expanded national reach, and the ability to search by position type, work setting, and state.
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