north carolina dermatology association 2019 summer meeting · 2019. 7. 18. · tubifast •light...

NORTH CAROLINA DERMATOLOGY ASSOCIATION

2019 Summer Meeting

JULY 26-28, 2019 | MARRIOTT RESORT & SPA | HILTON HEAD ISLAND, SC

This continuing medical education activity is jointly provided by theNorth Carolina Dermatology Association and Southern Regional Area Health Education Center

FRIDAY PRESENTATIONS

HILTON HEAD ISLAND

What should I treat that with? A collection of wound care cases

Ashley Group, MDAssociate Professor of DermatologyUniversity of Texas Medical Branch

• I have no conflicts of interest to disclose.

• I will be discussing brand name products in this presentation, which I have found helpful.

Department of Dermatology

Case 1A


Case 1A

• 74 year old male with PMH of venous leg ulcers, now with 6 week history of new leg ulcer

• Previous doctor had cultured 4+ Pseudomonas

• S/p treatment with Cipro x 1 week and Unna boot


Case 1A

• Does it need debridement?

• Is it infected?

• How much drainage is there?

• Is it safe to compress?

• PVD? • CHF?


Case 1A

1. Sharp debridement

2. Collagenase (Santyl) ointment

3. Foam dressing (Mepilex)4. Unna boot

Wear compression on unaffected leg!


Foam Dressings

• Absorb exudate• “Lite” versions

• Don’t use on dry wounds

• Can stay in place for up to 7 days

• Ok to cut

• Needs secondary dressing

• Works well under compression

Mepilex Foam

Mepilex Lite Foam

**Mepilex has soft silicone backing ‐ won’t stick to wounds

Foam Dressings


Case 1B


Case 1B

• 55 year old CM with recurrent leg ulcers

• Problems began after a ski injury in 2004, requiring multiple surgeries to right ankle/leg

• Previous wound care with compression in CA


Case 1B

1. Impetiginized• Wound culture• Empiric Doxycycline x 1 week• Silver dressing

2. Venous stasis dermatitis• Triamcinolone 0.1% ointment

3. Venous stasis ulcers• Very oozy alginate dressing (Melgisorb Ag) • Foam dressing (Mepilex)• Unna boot


What are Alginates?

• Derived from various types of seaweed and algae

• Used for highly exudative wounds

• Don’t use on dry wounds!

• Absorb up to 20x its weight

• Forms yellow‐brown gel don’t confuse with purulent drainage

• Needs secondary dressing

• Change after several days


Alginates


Nanocrystalline Silver

• Broad spectrum against G‐ and G+ organisms (including MRSA)

• Silver ions are bactericidal

• Comes in a variety of dressings

• Almost no evidence of bacterial resistance

• Extremely rare for patients to be allergic to it

• No evidence of cytotoxicity


Case 2

Case 2

• 14 year old female who presented 4 days after burn injury to forehead and left hand

• Injury occurred when she poured gasoline on a grill

• She had been applying silver sulfadiazine cream 4‐5 times daily, as prescribed by ER

Case 2

• No evidence of infection

• Silver sulfadiazine cream was discontinued

• Started on collagenase ointment daily with foam (Mepilex) dressing, secured with tube gauze

1 week later

Case 2

• For hand, instructed to continue collagenase ointment with non‐stick dressing, secured with tubular dressing

• Counseled on photoprotection

Tubular Dressings

Tubular Dressings

Tubifast• Light weight elastic tubular dressing• Holds dressings securely, without compression or constriction• No need for tape• Also comes in garment forms

Tubular Dressings

Tubigrip• Elastic tubular dressing• Gives light compression

• When applied in a double layer to appropriate size limb, exerts 10‐15 mmHg

Tubular Dressings

Se Pro Net• Elastic net tubular bandage• Help secure dressings in place, without compression or constriction• No need for tape

Case 3

57 year old Caucasian female with PMH of SLE, rheumatoid arthritis, and chronic inflammatory demyelinating polyneuropathy

• Methylprednisolone• IL‐6 inhibitor Sarilumab (Kevzara)• IVIg

• 5/27/10 – left total knee arthroplasty (TKA) due to RA complications• 8/3/17 – left TKA revision due to instability ‐ polyethylene liner exchange

• Complicated by concern for deep infection

• 11/27/17 – left knee irrigation and debridement with polyethylene liner exchange for infection of joint prosthesis

• Infection was due to Staphylococcus epidermidis• Surgical complication – skin tear

2 days post-op 11/29/17

Per operative report: “A skin tear from the distal aspect of the wound was noted. Attempted repair was performed, but the skin was too friable to hold suture material. An area of 1.5 cm x 2 cm was seen in the tear.”

Case 3

• Wound was initially treated with Xeroform and dry gauze.

• Intraoperative culture from knee infection grew 1+ Staph epidermidis

• Empiric treatment with Vancomycin• ID consulted – started Daptomycin IV for at least 6 weeks (12/1/17)

What is Xeroform?

• Petrolatum fine mesh gauze dressing

• Contains 3% Bismuth Tribromophenate (deodorizer)

• Bacteriostatic

Case 3

• Saw dermatology on 12/12/17

• Wound was worsening• Biopsy sent for H&E

• PG?

• Tissue sent for culture• Bacteria, AFB, fungal

• Started Mupirocin cream TID and Domeboro soaks

Case 3

• Biopsy results:

• Tissue culture grew:

Case 3

• At 1 week follow up with derm

• Recently febrile • Knee was warm• Erythema around incision site

• Per ID, started Ciprofloxacin 500 mg PO BID x 14 days

Case 3

• Patient presented to Wound Care clinic on 12/21/17

• Infection was improved• Wound worsened• Treatment:

• Sharp debridement• Performed weekly• Superior portion was 1.2 cm deep!

• Collagenase ointment• Applied/packed wounds with Dakin’s 0.25% moistened packing strips, dry gauze, Kerlix

Case 3

Wound care follow up on 1/4/18 – much improved

Case 3

• Ortho follow up 1/9/18• Patient c/o worsening pain

• Concerning for infection

• 1/16/18 ‐ left knee arthroscopy, synovectomy, irrigation• Much improvement in symptoms following surgery

• Switched to Erythromycin 400 mg PO QID x 6 weeks, per ID

Case 3

Pre‐debridement Post‐debridement

•Wound care follow up 1/25/18•Much improved

Case 3

Fully healed on 2/8/18

Case 4

Case 4

Arm Left upper thigh

Case 4

69 year old Indian male with 2 month history of itchy rash, now with extensive tense bullae

Case 4

• Started Prednisone 60 mg PO daily

• Started Doxycycline 100 mg PO BID

• Wound care:

Mepilex Ag and Kerlix gauze

• Phone call 5 days later – still getting new bullae so increased Prednisone to 80 mg PO daily.

Case 4

1.5 weeks later ‐ improving 3 weeks later – much betterStarted MTX 10 mg PO weekly

Case 4

• 4 weeks later

• No new bullae

• Started Prednisone taper

• C/w MTX 10 mg PO Qweek

• Stopped dressings

• Moisturize

Case 5

11/7/17

Case 5

• 74 year old Caucasian female with PMH of CHF, HTN, Sjogren's Syndrome, and membranoproliferative glomerulonephritis with cryoglobulins

• History of leg ulcers 7 months prior diagnosed with VLE

• New ulcers occurred 1 week ago

• Seen by NP at Wound Clinic

• Wound culture

• Treated with Collagenase ointment and Mepilex Border dressing

• On exam, petechiae were noted around the wound and on the posterior leg

Foam Border Dressings

• Foam dressing with adherent border • Lite versions available

• Can stay in place for up to 7 days• Water resistant• Do NOT cut• Soft silicone backing

Foam Border Dressings

Case 5

Wound culture grew 3+ Staph aureus

Started PO Clindamycin x 10 days

Case 5

Case 5

Wounds were worsening• size• pain• drainage ‐ “heavy exudate”

• Dressings changed – KerraContact Ag, KerraMax Care, Kerlix, Tubigrip

Contact Dressings

• What are they?

• Thin, non‐adherent sheets ‐ protect tissue from direct contact with additional dressings

• Porous – allows exudate to pass through to secondary dressing

Contact Dressings

KerraContact Ag Mepitel, Mepitel One

Curity Contact Layer

KerraMax Care

• Super absorbent dressing• Wicks and retains exudate• Prevents maceration• Needs secondary dressing• Very thin ‐ works great under compression

Case 5

• Quantitative tissue culture ‐ negative• Vascular studies

• ABI’s – normal• Venous duplex – no superficial or deep venous reflux

• NP requested dermatology evaluation at Wound Clinic

Case 5

Initial Derm evaluation at Wound Care clinic – 12/7/17

Left medial leg Left lateral leg

Case 5

Case 5

• Started work up for vasculitis

• Started Prednisone 40 mg QD

• Sharp debridement

12/21/18

Labs

• Cryoglobulins: absent (x 2)• ANCA Titer: <1:20 (normal)• Sed rate: 78 (elevated)• CRP: 2.2 (elevated)• C3: 67 (low)• C4: <2 (low)• ANA, HCV, HIV, HBV – negative• UA: showed UTI but otherwise normal

Case 5

• Seen by Rheumatology

• Vasculitis attributed to her Sjogren’s Syndrome

• Started Azathioprine 50 mg PO daily

• Started Prednisone taper

• Wound care:

• Weekly sharp debridement• Collagenase ointment, Melgisorb Ag, ABD pad,

Kerlix, Coban changed 3x/week

Case 5

• 1/18/18• Wounds were starting to improve• Added in Timolol 0.5% solution to wound edges

Case 1:

• 80 year old patient with venous stasis ulcers >1 year• Treated with standard therapy – compression, foam dressings, skin substitutes, STSG

• Applied Timolol 0.5% solution, 1 drop every 2 cm of wound edge weekly, allowed to dry x 2 min, then covered with foam and compression

• Wounds fully epithelialized after 8 weeks

Braun LR; Lamel SA; Richmond NA; Kirsner RS. Topical timolol for recalcitrant wounds. JAMA Dermatology. 149(12):1400-2, 2013 Dec.

Case 2:

• Patient in 70’s with venous insufficiency• Ulcer on dorsal foot x 3 months not improving with standard tx• Treated with Timolol fully healed w/in 7 weeks


• B2‐Adrenergic receptor antagonists (ie. Timolol) have been reported to promote wound healing• B‐Adrenergic receptors are present on keratinocytes, fibroblasts, and melanocytes• Potential mechanisms:

• Via keratinocyte migration ‐‐ induces a promigratory pathway in keratinocytes

• B2AR antagonists have been found to promote angiogenesis, dermal fibroblast migration, and epidermal differentiation

• This was found in chick chorioallantoic membrane assays and in vivo murine wound models


Case 5

• 1/25/18

• Still with edema started Unna Boots (cautiously)

Case 5

• 2/22/18• Doing well, but developed hypergranulation tissue• Added in Triamcinolone 0.1% ointment

Case 5

• 3/1/18 – Eeek!

Also with significantly worsening edema.

Case 5

Case 5

• Performed IL Kenalog 3 mg/mL to areas of erythema

• Increased Azathioprine to 100 mg PO daily

• Restarted Prednisone 20 mg PO daily x 1 week, then 10 mg PO daily x 1 week

Case 5

1 week follow up MUCH improved!

• No erythema• No hypergranulation tissue

Discontinued alginate

Continued local wound care

Case 5

• She continued to have flares of vasculitis

• Azathioprine was D/C’d

• Started on Mycophenolate mofetil 500 mg BID

• Ulcers completely healed

Case 6

Right hand Left 5th finger

Case 6

L 2nd finger

Right Elbow Right wrist

Case 6

• 61 year old African American male with new diagnosis of scleroderma, also with HTN, CKD, CAD, CHF, atrial fibrillation, and HCV

• Wounds were noted to be impetiginized• Treatment:

• Doxycycline 100 mg PO BID x 10 days• Vashe cleanser• Hydrocolloid dressing ‐ DuoDERM extra thin changed Q2‐3 days

• Mycophenolate mofetil 500 mg PO BID, per Rheumatology

Hydrocolloid Dressings

• Good for little or no drainage• Yellow‐brown gel can be mistaken for

purulent drainage

• Promote autolytic debridement• Easy for patients to use:

• Adherent – no secondary dressing needed• Water resistant• Can stay in place for 2‐3 days at a time

• Ok to cut

Case 6

What is Vashe Cleanser?

• Contains hypochlorous acid

• Non‐cytotoxic

• pH neutral to skin

• Rapidly kills wound pathogens

• Including MRSA, Pseudomonas, Proteus, Candida, etc.

Case 6

Left hand

2 week hospital follow up

2 week follow up• Much improved• Sharp debridement performed• Continued Doxycycline 100 mg BID x

10 additional days• Continued Vashe cleanser and

DuoDERM thin

3 week follow up

3 week follow up

• Much improved• Sharp debridement performed• Continued Vashe cleanser and DuoDERM thin• Instructed to finish course of Doxycycline

8 week follow up

8 week follow up

• Much improved• All wounds fully healed except right elbow• Continued wound care with DuoDERM thin

What other wounds do I like to use hydrocolloids on?

Neurotic Excoriations

More neurotic excoriations

Shallow Pressure Ulcers

Heel Buttock

Digital Ulcers - Scleroderma

Cat Wounds?!

Questions?

Pain Management in Medical Dermatology

Robert G. Micheletti, MDAssistant Professor of Dermatology and MedicineDirector, Cutaneous Vasculitis Clinic, Penn Vasculitis CenterChief of Hospital DermatologyUniversity of Pennsylvania

DISCLOSURE OF RELEVANT RELATIONSHIPS WITH INDUSTRY:

I have no relevant relationships with industry to disclose

3

Overview

1) Philosophical points

2) Practical points

3) Being systematic

4) Knowing your limits

5) Case examples

Philosophical Points

5

Dermatologist’s role in pain management

Disclosure:

I am not a pain specialist……but I do take care of people who have pain

6


As dermatologists, we are the experts when it comes to treating certain conditions which are characteristically painful:• Pyoderma gangrenosum• Hidradenitis suppurativa• Calciphylaxis• Vasculitis and vasculopathy• Post‐herpetic neuralgia• Post‐surgical pain• Others…

7


When treating these conditions, we should be willing to treat the pain that goes with them, at least within our scope of practice

It isn’t really fair to the primary care physician or patient to defer pain management to the PCP• Inefficiency of care• Pain is less likely to be addressed in a timely fashion• PCP is not the expert in the condition

– Won’t know whether it is supposed to be painful– Or when it is improving and should no longer be

8


So, as experts caring for painful skin disease, sometimes it falls to us to address pain as an important component of that disease

9


At the same time, we know that:• Prescribing opioids for acute pain increases the likelihood of

long‐term opioid use• Higher dose and duration of exposure increases risk of long‐

term use and overdose• Overprescription leads to leftover pills which can be abused

Opioids should be prescribed only when necessary, at the lowest effective dose, and for the shortest possible duration

10


So, with the current opioid epidemic, we must be careful…

…But not recognizing and addressing pain is not the answer; this does not make the problem disappear

…Patients are going to seek relief somewhere; ideally, this is a knowledgeable and responsible medical provider

(and there aren’t enough pain specialists to go around)

Practical Points

12

Appropriate selection of pain strategy

1) Know your patient and his / her medical situation before prescribing:

• Patient Age, Gender, Weight• Hepatic, Renal, or Respiratory impairment• History of prior opioid use• History of depression, substance abuse, or psychiatric issues• Other medications

– Drug‐drug interactions– Co‐administration with other CNS depressants

Cannot always predict how someone will respond, soproceed and titrate slowly (less is more)

34yo man seen in ER for swollen, painful, rapidly expanding purple‐gray necrotic plaque

Diagnosed with pyoderma gangrenosum and started on 60mg/day prednisone and clobetasol ointment

Case Example

What should be done for pain?

1) Know your patient:• Young, otherwise healthy• No prior opioid or substance use• No other medications

Case Example

15


2) Assess the need:– Degree and duration of expected pain– Expectation for planned follow‐up and reassessment

Acute Pain• Pain medicine should be a temporary

solution to a temporary problem– Want to choose agent commensurate

with pain severity– Set expectation that need will be

temporary

Chronic Pain• Some amount of ongoing pain is

expected– Find ways to optimize the use of

alternative analgesic agents– Address contributing medical and

psychosocial issues


1) Know your patient:• Young, otherwise healthy• No prior opioid or substance use• No other medications

2) Assess the need:• Expect acute needs to decrease

rapidly with effective medical management

Case Example

17


3) Know your options (mild to moderate pain):• NSAIDs and Acetaminophen (Tylenol)

– More effective when scheduled than when taken as‐needed– More effective in combination than alone– Generally safe and well‐tolerated

• Peptic ulcer disease, renal impairment (NSAIDs)• End‐stage liver disease (Tylenol)

Alternate Tylenol and ibuprofen every 4‐6 hours,

scheduled (not PRN)

18


3) Know your options (moderate to severe pain):• Oxycodone (5mg every 4‐6 hours; 3‐4 pills per day)

– Common choice (comfort with dosing, reliability)

• Tramadol (50mg every 4‐6 hours; 3‐4 pills per day):– Opioid agonist that is also a serotonin and norepinephrine reuptake

inhibitor, so may better address features of neuropathic pain– Need to be aware of risk of serotonin syndrome with other SSRIs

Most patients require less pain medicine for shorter duration than we think they doA script for 20 or fewer tabs may be reasonable, with plan to reassess

19


Optimize non‐opioid analgesics

Ice, heat, rest, elevation

Topical pain relief

Prescribe opioids only when necessary and for shortest duration needed

Considering our patient, his pain, and the available options, what should be done for pain?

• Rest, elevation

• Ibuprofen and acetaminophen alternating every 4‐6 hours

• If necessary, can provide a short oxycodone script (e.g., 5mg q6 hours; 12 total pills)

• Close follow‐up from ER (1 week)

Case Example

76yo woman with pyoderma gangrenosum occurring at the site of preceding herpes zoster

Started on prednisone and clobetasol

Case Example

Case Example


1) Know your patient:• No renal or hepatic impairment• Not taking CNS depressants• Opioid naïve; age is a factor

2) Assess the need:• We expect with proper medical

management acute PG will improve rapidly, with decreasing pain and inflammation

• However, she complains of a burning sensation as well

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3) Know your options (chronic or neuropathic pain):• Alternatives to opioids, like gabapentin or duloxetine for

neuropathic pain (burning, tingling pain)– Be aware of potential drug interactions and initiate / titrate slowly to ensure tolerability

– Must also taper slowly to discontinue


• Ibuprofen and acetaminophen alternating every 4‐6 hours may be sufficient

• Consider adding gabapentin for symptoms of post‐herpetic neuralgia

• Can consider short script of oxycodone, but carefully consider age, comorbidities, risk of polypharmacy

• Follow‐up in 1‐2 weeks

Case Example

Don’t forget about local wound care options:

• Lidocaine patch or lidocaine ointment can be helpful around chronic wounds or for neuropathic pain

• Domeboro (aluminum acetate) soaks are astringent and soothing for wet, weepy dermatoses

• Sitz baths may also be helpful

Case Example

70yo man with end‐stage renal disease, not yet on dialysis

Onset of extremely painful retiformpurpura on the lower legs following aortic valve replacement and starting warfarin

Biopsy supports the clinical impression of calciphylaxis

Case Example

Case Example


1) Know your patient:• Renal failure• Not taking CNS depressants• Age is a factor

2) Assess the need:• Calciphylaxis causes severe pain, and that

pain is ischemic (mixed nociceptive and neuropathic)

• It is also chronic in the sense that the resulting wound will not heal quickly


• Initiation of appropriate medical therapy (e.g, sodium thiosulfate, pentoxifylline) may help

• Rest, elevation, local wound care

• Acetaminophen every 6 hoursavoid NSAIDs in renal insufficiency

• Because of the neuropathic component of ischemic pain, gabapentin can be added

Case Example


• If these are insufficient, tramadol could be considered (mixed nociceptive / neuropathic)

• All dosing should be done with care due to renal insufficiency and risk of CNS depression

• Can be titrated during hospital admission to provide a sense of need

• Close follow‐up

Case Example

Understanding when opioid analgesia may no longer be indicated

Remember, we are the experts in dermatologic diseases and should be able to understand, to a point, when something should or should no longer be painful…

As the medical provider treating and following the disease, note improvement, when present, and set clear expectations for decreasing pain medication (particularly opioids)

Set clear expectations for the patient If things are not improving medically, change therapies (if appropriate) If pain is going to be chronic / ongoing, optimize strategies for chronic

pain (e.g., duloxetine, gabapentin), or enlist the help of a pain specialist

50yo man with severe hidradenitis suppurativa

Complains of swelling, drainage, bleeding, and pain

Reasonable to prescribe opioids as part of a multi‐modal pain strategy while waiting for medical therapies to take effect

Case Example

Significant objective improvement on infliximab

Still asking for opioid refills, however, despite not being seen for reassessment

Give patients the benefit of the doubt to an extent, but set clear limits and trust your clinical judgement

Either things are doing better, and there is no longer a need for opioidsOr, if disease is uncontrolled, we need to do something different medically

Case Example

33


Address other contributing factors:• Depression and anxiety can contribute significantly to the

perception of chronic pain

• Psychosocial factors can significantly affect adherence and engagement in medical care

• Such issues are not uncommon in diseases like hidradenitis, calciphylaxis, etc.

• Be prepared to acknowledge and address them; refer to psychiatry or primary care for assistance

• Do not underestimate the psychosocial benefit of offering hope in treating the medical condition and addressing other issues affecting the patient

23yo woman with hidradenitis

Has previously had painful flares, but now relatively inactive on spironolactone

Before the exam is performed, she complains of significant pain and is asking for pain medication

Pain characterized as burning / throbbing

Case Example

Hidradenitis can be severe and painful and may require non‐opioid and opioid analgesia

However, sometimes we see patients who are doing well medically but have pain out of proportion to the clinical exam

Case Example


1) Know your patient:• Otherwise healthy, no other medications• Depressed and anxious (strongly associated

with hidradenitis)

2) Assess the need:• Understand the contribution of depression

and anxiety to pain perception • It is important to address those factors for

successful management

Case Example


• Appropriate medical therapies for HS

• Topicals and local wound care

• Optimize non‐opioid pain management: acetaminophen and ibuprofen

• Address depression and anxiety as key contributors to chronic pain in HS (e.g., duloxetine, other SSRIs)

Case Example

38


Options which may be less‐preferred:• Hydrocodone (Vicodin):

– Only available with acetaminophen or ibuprofen, so difficult to use in combination with those agents (same with Percocet)

– Want to encourage use of NSAIDs, Tylenol• Codeine:

– Tend to avoid due to wide variability in metabolism to morphine, risk both of adverse events as well as unreliable pain relief

• Fentanyl and other highly‐potent formulations:– Beyond the scope of the dermatology practitioner

• Long‐acting formulations:– Avoid long‐acting opioids for acute pain and for the opioid naïve– Less easily titrated and greater risk of overdose– Best left to the pain specialist

58yo woman with ESRD on dialysis, also alcoholic cirrhosis, presenting with multifocal retiform purpura

Extremely painful, widespread

Calciphylaxis: 50% mortality at 1 year, 80% at 2 yearshigher in a patient like this

Case Example


• Medically complicated patient with pain control needs expected to be significant and ongoing

• This is a patient for pain management or palliative care(with derm providing perspective)– Fentanyl, hydromorphone,

methadone

• Fentanyl PCA in the hospital and transitioned to hospice

Case Example

41


Ultimately, we want to choose a strategy which is:• Commensurate with the patient’s pain level • Safe for the patient’s medical and psychiatric comorbidities• Multimodal and opioid‐sparing (including Tylenol, NSAIDs,

and nonpharmacologic therapies)• Sufficient but short and frequently reassessed

Be Systematic

43

Documentation

It is generally good practice to document the level of pain from visit‐to‐visit using a simple numerical rating scale

Make sure to document all conversations, thought process, and medication orders related to pain management

44

Set Expectations Up Front

1) We are treating pain due to condition X, which is expected, and which we want to help manage

2) Expectation is not for zero pain; use of opioids should be reserved for when they are really needed

3) We expect pain needs to diminish over time as we treat the underlying medical condition

4) One prescriber will be in charge of prescribing pain medication

5) Pain scripts are provided with zero refills, so there will be constant reassessment of ongoing pain needs

6) Refill requests should be received at least a few days before the medicine is expected to run out

45


A good way to reinforce these guidelines is through a pain contract

This documents the discussion and limits the risk of miscommunication

46


47

State reporting

The CDC and various states have issued guidelines for pain management

All states (with few exceptions) have prescription drug monitoring programs and either require or strongly encourage checking the database prior to prescribing opioids

48

State reporting

49

State reporting

50

State reporting

These guidelines and rules are meant to protect the provider and the patient and remove the room for ambiguity

While it might add another step, there is no reason not to participate; really, you fail to do so at your own risk

Dermatologists may be unlikely to stand out among providers from other specialties in terms of prescribing habits, but you never want to be an outlier among your peers without very good reason

Know Your Limits

52

Recognizing Limits and When to Refer

Understand your comfort zone and don’t stray outside it; stay within your scope of practice• A dermatologist’s comfort zone shouldn’t be Fentanyl• Prescribe only medicines which you understand

• Patients who have need of higher potency pain medication, frequent refills, or large quantities of pain medication…

• Patients who do not follow expected course of recovery with decreasing pain following improved medical condition…

• Patients who exhibit “red flag” behaviors…Should be referred to pain management or other qualified provider

50yo woman with pyoderma gangrenosum x 3 years• Also high‐titer ANA and

antiphospholipid antibody positivity

Has asked for pain medicine in the past at various points; previously some behavioral issues with the clinic staff

Doing very well from a PG perspective……Then develops new retiform purpura

Case Example

Before we talk about pain, what is happening here medically?• Biopsy; shows clot / vasculopathy• Is this antiphospholipid antibody

syndrome?• Another hypercoaguable state?

I always suggest urine drug screen as part of the retiform purpura work‐up

Hers was positive for cocaine

Case Example

Cocaine / levamisole‐associated vasculopathy in a predisposed patient

What should be done for pain?Well, it’s complicated

1) Know your patient:• Opioid‐experienced with Hx of drug abuse• Some prior concerning behavior

2) Assess the need:• Acutely painful condition, though should

be self‐limited• Resulting wounds may continue to be

painful

Case Example


• With evidence of drug abuse or diversion, this is a patient who should see pain management, have a formal pain contract, get regular urine drug screens, etc.

Case Example


• Just because a patient is difficult doesn’t mean he / she is abusing narcotics

• Just because a patient has psychosocial issues doesn’t mean he / she doesn’t have real pain

• However, failure to follow rules or documented drug abuse are obvious red flags

• With a patient like this, need to stick to clearly outlined expectations and know your limits

Case Example

58

Recognizing Limits and When to Refer

In this respect, being a dermatologist has its advantages:• Pain management is not our expertise, so it is reasonable to

defer to a pain specialist when patients exhibit significant pain needs or, certainly, drug‐seeking behavior

• Can treat pain as part of the condition we are managing but have a natural transition point should we become uncomfortable or feel prescribing is inappropriate

59

Summary and Conclusions

I have found most patients to whom I prescribe opioid pain medications:1. Truly need them and have a medical condition which is

active and has every right to be painful2. Are understanding and reasonable and adhere to

expectations for timing and quantity of prescribing3. Need less and less pain medicine over time as we work to

improve the underlying medical condition

As a result, I have not had the need to prescribe narcotic pain medicine chronically, and if such a need arose, I would refer to pain management to help address any other issues going on

60

Summary and Conclusions

Keys to successful care of a patient with painful skin disease:• Acknowledge and validate the presence of pain when present• Support the patient in caring for this aspect of their disease alongside

medical therapies• Consider patient characteristics and accurately assess pain needs• Address other contributing factors• Choose a conservative regimen which utilizes non‐opioids and avoids

over‐reliance on narcotics—we often prescribe more than is needed• Set clear expectations and do not stray outside your comfort zone;

know when to refer

The Dermatology Foundation

has supported & advanced my career.

Thank you

[email protected] Vasculitis Clinic, Penn Vasculitis CenterUniversity of Pennsylvania

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Vice PresidentSandra A. JohnsonEVP Emeritus, Nebraska Medical Association

TreasurerLouis J. Goodman, PhD, CAEEVP/CEO, Texas Medical Association

SecretaryDonald H. Alexander CEO Emeritus, Tennessee Medical Association

PAI EVP/CEOKelly C. Kenney, JD

Dustin Corcoran, MBACEO, California Medical Association

Matthew KatzEVP/CEO, Connecticut State Medical Society

Donald J. Palmisano, Jr., JDExecutive Director, Medical Association of Georgia

Philip A. Schuh, CPAEVP, Medical Society of the State of New York

Todd Atwater, JDCEO, Financial Services Inc. and Members’ Insurance TrustSouth Carolina Medical Association

Charles B. Shane, MDLexington, Kentucky

ABOUT HEALTHSPERIEN

Healthsperien, LLC is a Washington, D.C.-based policy and health care consulting firm focused on strategic issues operating at the intersection of public policy, business strategies, operations, and government affairs. We bring a “system” perspective to our work and specialize in payment and delivery models, regulatory issues facing Medicare, Medicaid and commercial payers, and emerging trends in value-based payment. We believe in the importance of innovation and partnerships in shaping a future health care system that addresses the goals of improved access, lower costs and high-quality care.

Healthsperien derives from health, inspiration, and experience, and reflects the firm’s commitment to help clients find an innovative way forward in a complex and changing health care environment.

Information about Healthsperien can be found at http://healthsperien.com/.

PAI MACRA QPP RESOURCE CENTER

Overall Purpose – Comprehensive set of resources that provide context, an overview of core concepts and requirements, and an in-depth discussion of important topics

MIPS Pathway – Resources on the reporting requirements and scoring for each of the four MIPS categories: quality, improvement activities, promoting interoperability, and cost

Advance APM Pathway – Resources on the building blocks of Advanced APMs, overviews of current Advanced APMs, and MIPS APM participation and scoring overview

Navigating the QPP – This resource is helpful for those who may be new to the program and provides information on navigating the basics of MIPS and Advanced APM pathways under the QPP framework

MACRA’S QUALITY PAYMENT PROGRAM

FROM SGR TO MACRA

MACRA – Medicare Access and CHIP Reauthorization

What did MACRA do?

Replaced the annual updated under the Sustainable Growth Rate (SGR) formula with the Quality Payment Program (QPP)

New opportunities for positive/negative adjustments to Medicare Part Be payments

Sunsets and combines 3 previous quality programs (PQRS, Value-Based Payment Modifier, & Meaningful Use) into a single program under the QPP

Went into effect January 1, 2017

2019 is first year of positive/negative payment adjustments based on 2017 performance

MACRA QPP GOALS

1. Create a new Medicare payment system for physicians (and certain other eligible clinicians) across all specialties that is meaningful and flexible

2. Improve patient outcomes and engage patients

3. Encourage physicians to improve performance with “carrots and sticks”

4. Increase the availability of and participation in risk-based models of care

5. Support broad physician participation, including small/solo practices

6. Simplify complex and multiple reporting and performance systems

Source: CMS MIPS and APM final rule

2 PATHWAYS OFFERED

• Annual FFS updates• 4 performance categories: Cost, Quality,

Improvement Activities, Promoting Interoperability

Merit-Based Incentive Payment

System (MIPS)

• Enhanced annual FFS updates• Exempt from MIPS• Potential to earn a 5% bonus payment each for

participating in risk-based payment models

Advanced Alternative Payment

Models (APMs)

ANNUAL FFS UPDATES AND PAYMENT ADJUSTMENTS DEPEND ON THE PATHWAY SELECTED

*Annual physician fee schedule updates may be downwardly adjusted by other budgetary requirements**Due to CMS transition relief policies in 2017, available funds may be insufficient to grant a full 4% incentive payment in 2019; additionally, there is the potential to receive an additional positive payment adjustment for exceptional performance for payment years 2019-2024

There’s a 2-year gap between the performance year and payment adjustment year. 2019 adjustments are based on 2017 performance, and this year’s--2019’s--performance will be used to determine the 2021 payment adjustment.

PATHWAY 1: MERIT-BASED INCENTIVE PAYMENT SYSTEM (MIPS)

QUALITY, COST, PROMOTING INTEROPERABILITY, AND IMPROVEMENT ACTIVITIES

WHO IS SUBJECT TO MIPS PARTICIPATION?

Clinicians who bill for Medicare Part B services

Physicians Physician Assistants

Nurse Practitioners

Clinical Nurse Specialists

Certified Registered Nurse

Anesthetists

Physical & Occupaitonal

Therapists

Qualified Speech-Language

Pathologists

Qualified Audiologists

Clinical Psychologists

Registered Dietitians or

Nutrition Professionals

SOME ELIGIBLE CLINICIANS ARE EXEMPT FROM MIPS

Beginning with 2019, if you exceed one or more of the low-volume threshold criteria, you have the opportunity opt-in to MIPS and report MIPS data to be eligible to receive a positive payment adjustment. You must make the election to opt-in through the QPP portal.

MIPS PARTICIPATION OPTIONS

• Individual clinicians would report under an national provider identification (NPI) number and the tax identification number (TIN) of the practice to which they reassign their benefits

• Would receive score and corresponding payment adjustment based on his/her individual performance

Participate individually

• 2 or more eligible clinicians (ECs) (2 or more NPIs) who are part of the same practice with the same TIN

• Specific reporting requirements and certain reporting options are available for groups of 25 or more physicians and other ECs

• All ECs in the group would receive the same aggregated scoring and corresponding payment adjustment across the practice-level group

Participate as a group

• A combination of 2 or more TINs made up of solo practitioners or groups of 10 or fewer ECs who come together "virtually" (regardless of specialty or location)

• All ECs part of the Virtual Group would receive the same aggregated scoring and corresponding payment adjustment across the Virtual Group

Participate as a Virtual Group

4 MIPS CATEGORIES

Quality

Builds off PQRS

Assesses performance in process and outcome

quality measures

45% of final MIPS score

Promoting Interoperability

Builds off Meaningful Use

Encourages use of certified electronic health record

technology (CEHRT)

25% of MIPS final score

Improvement Activities

New category

Rewards engagement in clinical practice

improvement activities


Cost

Builds off Value-Based Payment Modifier

Assesses performance in episode-based measures, Medicare Spending per

Beneficiary and Total per Capita Cost measures


QUALITY CATEGORY – DERMATOLOGY SPECIALTY MEASURE SET

Measure Name Type Description

Basal Cell Carcinoma (BCC)/Squamous Cell Carcinoma (SCC): Biopsy Reporting Time -Pathologist to Clinician

Process Percentage of biopsies with a diagnosis of cutaneous Basal Cell Carcinoma (BCC) and Squamous Cell Carcinoma (SCC) (including in situ disease) in which the pathologist communicates results to the clinician within 7 days from the time when the tissue specimen was received by the pathologist

Biopsy Follow-UpProcess Percentage of new patients whose biopsy results have been reviewed and communicated to the

primary care/referring physician and patient

Closing the Referral Loop: Receipt of Specialist Report

Process Percentage of patients with referrals, regardless of age, for which the referring provider receives a report from the provider to whom the patient was referred

Documentation of Current Medications in the Medical Record

Process Percentage of visits for patients aged 18 years and older for which the eligible professional or eligible clinician attests to documenting a list of current medications using all immediate resources available on the date of the encounter. This list must include ALL known prescriptions, over-the-counters, herbals, and vitamin/mineral/dietary (nutritional) supplements AND must contain the medications' name, dosage, frequency and route of administration

Melanoma: Continuity of Care - Recall System

Structure Percentage of patients, regardless of age, with a current diagnosis of melanoma or a history of melanoma whose information was entered, at least once within a 12 month period, into a recall system that includes:- A target date for the next complete physical skin exam, AND- A process to follow up with patients who either did not make an appointment within the specified timeframe or who missed a scheduled appointment

QUALITY CATEGORY – DERMATOLOGY SPECIALTY MEASURE SET CONT’D

Measure Name Type Description

Melanoma: Coordination of Care Process Percentage of patient visits, regardless of age, with a new occurrence of melanoma that have a treatment plan documented in the chart that was communicated to the physician(s) providing continuing care within one month of diagnosis

Preventive Care and Screening: Screening for High Blood Pressure and Follow-Up Documented

Process Percentage of patients aged 18 years and older seen during the reporting period who were screened for high blood pressure AND a recommended follow-up plan is documented based on the current blood pressure (BP) reading as indicated

Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention

Process Percentage of patients aged 18 years and older who were screened for tobacco use one or more times within 24 months AND who received tobacco cessation intervention if identified as a tobacco user

Psoriasis: Clinical Response to Systemic Medications

Outcome Percentage of psoriasis vulgaris patients receiving systemic therapy who meet minimal physician-or patient- reported disease activity levels. It is implied that establishment and maintenance of an established minimum level of disease control as measured by physician-and/or patient-reported outcomes will increase patient satisfaction with and adherence to treatment

Psoriasis: Tuberculosis (TB) Prevention for Patients with Psoriasis, Psoriatic Arthritis and Rheumatoid Arthritis on a Biological Immune Response Modifier

Process Percentage of patients, regardless of age, with psoriasis, psoriatic arthritis and rheumatoid arthritis on a biological immune response modifier whose providers are ensuring active tuberculosis prevention either through yearly negative standard tuberculosis screening tests or are reviewing the patient's history to determine if they have had appropriate management for a recent or prior positive test

Tobacco Use and Help with Quitting Among Adolescents

Process The percentage of adolescents 12 to 20 years of age with a primary care visit during the measurement year for whom tobacco use status was documented and received help with quitting if identified as a tobacco user

IMPROVEMENT ACTIVITIES – EXAMPLE ACTIVITIES

Implementation of improvements that contribute to more timely communication of test results

Improved Practices that Disseminate Appropriate Self-Management Materials

Provide 24/7 Access to MIPS Eligible Clinicians or Groups Who Have Real-Time Access to Patient's Medical Record

Provide Education Opportunities for New Clinicians

Use of tools to assist patient self-management

PROMOTING INTEROPERABILITY CATEGORY REQUIREMENTS

PI Objectives and Measures

Objective Measure Required for PI Score?

Max Points

Reporting Requirement

Exclusion

Protect Patient Health

Information Security Risk Analysis Required 0

Yes/No Statement N/A

Electronic Prescribing

E‐Prescribing Required 10 Numerator/ Denominator

Write fewer than 100 permissible prescriptions

Query of Prescription Drug Monitoring Program (PDMP) Bonus 5 Numerator/

Denominator N/A

Verify Opioid Treatment Agreement Bonus 5 Numerator/ Denominator

N/A

Health Information Exchange

Support Electronic Referral Loops by Sending Health Information Required 20

Numerator/ Denominator Transfer or refer patients fewer than 100 times

Support Electronic Referral Loops by Receiving and Incorporating Health

Information Required 20

Numerator/ Denominator

EC who is unable to implement measure for 2019 Receive fewer than 100 transitions of care or referrals, or

has fewer than 100 encounters with patients never before encountered during performance year

Provider to Patient Exchange

Provide Patients Electronic Access to Their Health Information

Required 40 Numerator/ Denominator

N/A

Public Health and Clinical Data Exchange

Report to two different public health agencies or clinical data registries for any of the following: Immunization Registry Reporting Electronic Case Reporting Public Health Registry Reporting Clinical Data Registry Reporting Syndromic Surveillance Reporting

Required 10 Yes/No

Statement

Each of these measures has their own exclusion, but general exclusion criteria include:

Don’t diagnose/treat any disease/condition associated with applicable registry/agency in their jurisdiction

Operate in a jurisdiction in which no agency/registry can accept electronic registry transactions in CEHRT‐specified standards

Operate in a jurisdiction where no agency/registry has declared readiness to receive electronic registry transactions as of 6 months prior to start of performance period

COST CATEGORY MEASURES

Measure Category

Attribution and Case Minimum Measure

Procedural Episodes

Attribution to each MIPS EC who renders a trigger services as identified by HCPCS/CPT code. The case minimum would be 10 episodes for these measures.

Elective outpatient percutaneous coronary intervention Knee arthroplasty

Revascularization for lower extremity chronic critical limb ischemia

Routine cataract removal with intraocular lens (IOL) implantation

Screening/surveillance colonoscopy Acute

inpatient medical condition episodes

Attribution to each MIPS EC who bills inpatient E/M claim lines during trigger inpatient hospitalization (i.e., a MS‐DRG identifying the episode group) under a TIN that renders at least 30% of inpatient E/M claim lines in that hospitalization. The case minimum would be 20 episodes for these measures.

Intracranial hemorrhage or cerebral infarction

Simple pneumonia with hospitalization ST‐elevation myocardial infarction

(STEMI) with PCI

Costs for services and items related to an episode may include, but are not limited to: diagnostic services, treatment services, and ancillary items and services directly related to treatment (e.g., anesthesia for a surgical procedure), services following the initial treatment period that may be

rendered as follow‐up care, etc. Additionally, CMS may include services furnished as a consequence of care, for example, complications, readmissions, unplanned care, and emergency

department visits.

HOW DO YOU REPORT

REPORTING OPTIONS BY CATEGORY

Category Reporting Options

Quality

Individual (themselves or working with a

Qualified Registry, QCDR, or CEHRT)

Medicare Part B Claims; Direct; Log‐In and Upload

Group or Virtual Group (themselves or working with a Qualified Registry,

QCDR, or CEHRT)

Medicare Part B Claims (only for those with small practice designation); Direct; Log‐In and

Upload; CMS Web Interface (for 25 or more ECs);

CAHPS for MIPS Survey; Administrative Claims

Improvement Activities

Individual, Groups, Virtual Groups, and Third‐Party Intermediaries (e.g., Qualified Registry, QCDR, CEHRT, CMS‐approved survey vendor)

Direct; Log‐In and Upload; Log‐In and Attest (via qpp.cms.gov)

Promoting Interoperability

Individual, Groups, Virtual Groups, and Third‐Party Intermediaries (e.g., Qualified Registry, QCDR, CEHRT,)

Log‐In and Upload; Log‐In and Attest (via qpp.cms.gov)

Third‐party Intermediaries Direct

Cost Individual No submission required. CMS will use

administrative claims data. Group or Virtual Group

FINAL MIPS SCORE DETERMINES YOUR PAYMENT ADJUSTMENT

If the final score is above the performance threshold, you will receive a positive adjustment of your Medicare Part B payments.

If the final score is below the performance threshold, you will receivea negative adjustment of your Medicare

Part B payments.

If the final score is equal to the performance threshold, you will receive no adjustment of your Medicare Part B payments.

2019 Performance Threshold =

30 Points

CONSIDERATIONS FOR MIPS PARTICIPATION

Determine whether you are exempt from participation

Determine whether to participate as an individual or as part of a group or virtual group

Determine which measures and activities apply to your practice that you can exceed at

Consider whether the Advanced APM option is feasible before making a final decision

PATHWAY 2: ADVANCED ALTERNATIVE PAYMENT MODELS (APMS)MEDICARE AND OTHER PAYER APMS

WHAT ARE APMS?

An APM is a payment and delivery approach where participants have financial incentives to provide efficient, high-quality care

Include elements that diver from FFS (e.g., bundled payments or gain-sharing); but may have FFS elements

Include performance measures and payments linked to quality and outcomes

Participants may be at risk for some/all cost of care for a patient population or service, but there are variations in the specific characteristics

May apply to services for specific conditions, episodes of care, or patient populations

There are Medicare, Medicaid, Medicare Advantage, commercial, and multi-payer APMs

APMS SUPPORT INNOVATIVE CARE DELIVERY MODELS

APMs are value-based payment arrangements that provide an infrastructure for supporting the underlying care model

The core task of participating in an Advanced APM is to help better manage a patient’s care in ways that improve quality (or at least allow strong performance on specified quality measures) and reduce total costs

Improvements to the underlying care model could be made by optimizing clinical workflows, the technology infrastructure and streamlining operations, or adapting policies and processes that help with better population health management

ADVANCED APMS UNDER THE QPP

Subset of broader category of APMs

Physicians participating in Advanced APMs must meet the quality and reporting requirements that are subject to participation in the APM (this is separate and distinct form the Advanced APM criteria)

Characteristics and criteria for participation defined in MACRA – intention was to set a high bar for model where participants are accountable for cost and quality

Participating physicians may earn a 5% incentive payment – and are exempt from MIPS

The 5% incentive under QPP would be separate and distinct from the payments for services they receive through the APM

Physicians and/or their organizations (called an APM entity) decide whether to participate in the Advanced APM

29

Medicare Advanced

APMs

• Primary focus of QPP in short-term

• CMS has identified several for 2019

Non-Medicare Other Payer Advanced

APMs

• 2019 is the first year these are offered

• Include APMs under state Medicaid arrangements and Medicare Advantage arrangements

WHAT TYPES OF ADVANCED APMS ARE AVAILABLE UNDER THE QPP?

PARTICIPATION THRESHOLDS

Medicare Payment Count Method Medicare Patient Count MethodQP 50% of Medicare Part B payments are

received through a Medicare Advanced APM

35% of Medicare Part B patients are seen through a Medicare Advanced APM

PQ 40% of Medicare Part B payments are received through a Medicare Advanced APM

25% of Medicare Part B patients are seen through a Medicare Advanced APM

All Payer Payment Count Method All Payer Patient Count MethodQP Step 1: Receive 25% of Medicare Part B payments are received

through a Medicare Advanced APMStep 2: 50% of all payments are received through a Medicare Advanced APM and Other Payer Advanced APM

Step 1: 20% of Medicare Part B patients are seen through a Medicare Advanced APM

Step 2: 35% of all patients are seen through a Medicare Advanced APM and Other Payer Advanced APM

PQ Step 1: Receive 20% of Medicare Part B payments are received through a Medicare Advanced APM

Step 2: 40% of all payments are received through a Medicare Advanced APM and Other Payer Advanced APM

Step 1: 10% of Medicare Part B patients are seen through a Medicare Advanced APM

Step 2: 25% of all patients are seen through a Medicare Advanced APM and Other Payer Advanced APM

EXAMPLES OF 2019 ADVANCED APMS

Comprehensive Primary Care Plus

(CPC+)

Medicare Shared Savings Program

Next Generation ACO Model

Comprehensive ESRD Care Model

Oncology Care Model

Comprehensive Care for Joint Replacement

Model

BPCI Advanced

CONSIDERATIONS FOR APM PARTICIPATION

Understanding how performance is measured under a specific APM in relation to what you can control and impact

Evaluating your care model and ability to access and analyze data

Understanding your patient population

What it means to take on financial risk and your ability to bear risk

CMMI 2019 PRIMARY CARES INITIATIVEPRIMARY CARE FIRST AND THE DIRECT CONTRACTING MODELS

Source: CMMI Webinars and Fact Sheets on PCF and DC Models

PRIMARY CARE FIRST (PCF) MODEL

Builds upon the Comprehensive Primary Care Plus (CPC+) Model

Offered in 26 regions in 2020

Two payment tracks within PCF

Practices can participate exclusively in one track, OR participate in both tracs

General/Advanced PCF

High-Needs/Serious

Illness Population (SIP) PCF


PCF MODEL ELEMENTS

General PCF Track SIP PCF Track

Patient Eligibility and Attribution Focus on complex chronic or seriously ill patients.

Have at least 125 aligned beneficiaries, will use voluntary and claims-based attribution.

High HCC score OR 2+ non-elective hospital admissions in previous year OR multiple claims for certain DME (i.e., hospital beds) in previous year, AND they’d have less than 50% of the E/M visits from the same provider (so high-need AND no PCP or lack of care coordination)

Payment - Professional Population-based Payment (PBP) based on practice’s patient risk group

- Flat Visit: $50 - Performance-based Adjustment: up

to 50% of PBP + Flat Visit Fee

- First 12 months: $325 PBPM for first visit, then $275 PBPM

- Flat Visit Fee: $50- Quality Payment: up to $50 PBPM

Measures - Y1: Acute Hospital Utilization- Y2: CPC+ Patient Experience of

Care Survey, Diabetes: Hemoglobin A1c Poor Control, Controlling High Blood Pressure, Care Plan, Colorectal Cancer Screening

- TBD, could include 24/7 patient access and days at home


DIRECT CONTRACTING (DC) MODEL

Builds upon the Next Generation ACO model

No geographic limitations on who may apply at this time

3 voluntary risk-sharing payment model approaches offered


DC MODEL PAYMENT ELEMENTS

Professional Global Geographic

Payment

1) Primary Care Capitation – monthly

cap for enhanced primary care services

1) Primary Care Capitation

2) Total Care Capitation - monthly cap for all

Parts A/B services

1) Total Care Capitation2) Full financial risk

Risk-Sharing 50% Shared Savings/Losses 100% Shared Savings/Losses

BenchmarkingBlend of historical spending and adjusted MA regional

expenditures, and then adjusted to reflect other factors (e.g., population risk)

1-year historical per capita Parts A/B FFS spend in target region trended forward w/ negotiated

discounts

Quality Core set of measures TBD


THANK YOU

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