Federal Legislative Accomplishments

The American Association of Orthopaedic Surgeons (AAOS) Office of Government Relations monitors a wide variety of issues related to advancing the highest quality musculoskeletal health. Each year, the Council on Advocacy reviews and updates its Unified Advocacy and Regulatory Agendas, which guide the Office of Government Relations’ work in the legislative and regulatory arenas. With the primary objectives of enhancing access to and quality of orthopaedic care for our patients, major legislative and regulatory initiatives include Medicare reimbursement reform, addressing health information technology, increasing research funding, protecting in-office ancillary services, and increasing congressional awareness of the large and growing prevalence of musculoskeletal diseases.

2016 was a year of important wins for health care policy. In the wake of the repeal of the sustainable growth rate (SGR) formula, the AAOS Office of Government Relations worked hard to continue to ensure physicians would still be able to prioritize patient needs over government regulation. Below is a list of some accomplishments achieved during 2016 and 2017.

Medicare Access and CHIP Reauthorization Act (MACRA) of 2015 

On October 14, 2016, the Department of Health and Human Services issued its final rule with comment period for the Medicare Quality Payment Program, which implements the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA). MACRA replaced the SGR formula, which exposed clinicians participating in Medicare to potential payment decreases for 13 years. AAOS in June submitted comments to the Centers for Medicare & Medicaid Services (CMS) that outlined a number of areas of concern with the original proposal, including the implementation timeline, restrictive requirements for Advanced Alternative Payment Models (APMs), and the impact on smaller or solo practices (see “Medicare Access and CHIP Reauthorization Act (MACRA) of 2015” under Federal Regulatory Accomplishments, below).

In addition to working on these issue with CMS, AAOS approached members of Congress with concerns about MACRA implementation. AAOS explained that it would be “burdensome, if not impossible, for physicians to get ready for the first performance year of 2017” and that “physicians who find this time frame too difficult to comply with may not participate in the MIPS program at all.” As a result of this pressure, CMS in 2016 announced additional implementation flexibility. For clinicians participating in the Merit-based Incentive Payment System (MIPS), 2017 (the first performance year) is a transition year. Provided clinicians choose to report one measure in the quality performance category, one activity in the improvement activities performance category, or report the required measures of the advancing care information performance category, they can avoid a negative MIPS payment adjustment for the 2017 performance year and the 2019 payment year. This enables small- and medium-sized physician practices to gradually build up to the reporting requirements. Read more online here.

Find more information on MACRA online here.

Meaningful Use Exemption

Significant strides were made on Capitol Hill to help lawmakers and their staff understand the challenges that health care providers face when interfacing with their electronic health care records (EHRs). Several pieces of legislation were passed to help ease burdens and reduce EHR system-related penalties. For example, a bipartisan group of senators and representatives introduced legislation to limit meaningful use (MU) reporting periods to 90 days for hospitals, physicians, and other eligible professionals in 2016, giving providers and hospitals time to prepare for the changes in the MU program that begin in 2017. CMS recognized the importance and interest of the proposed legislation and changed regulations to allow such a reporting period. 

In the rule, CMS also finalized 90-day MU reporting to increase flexibility for eligible professionals who participate in the Medicare and Medicaid EHR Incentive Programs. In addition, CMS is finalizing policies to implement section 603 of the Bipartisan Budget Act of 2015, which requires that certain items and services furnished by certain off-campus hospital outpatient departments will no longer be paid under the outpatient prospective payment system (OPPS) beginning Jan.1, 2017. Currently, CMS explained, Medicare pays for the same services at a higher rate if those services are provided in a hospital outpatient department rather than in a physician's office and “this payment differential has provided an incentive for hospitals to acquire physician offices in order to receive the higher rates.” AAOS supported the MU and site- of-service changes.

Comprehensive Care for Joint Replacement (CJR) Program

Orthopaedic surgeons—especially hip and knee surgeons—are particularly concerned about the Comprehensive Care for Joint Replacement (CJR) program, which was conceived by CMS in 2015 as a mandatory bundled payment program. AAOS created significant awareness of the potential pitfalls of the program through letters to Congress and meetings with legislators, which resulted in several positive changes.

See “Comprehensive Care for Joint Replacement (CJR) Program” under Federal Regulatory Accomplishments online here.

Find more information on CJR online here.

Medical Liability Reform

In the fall of 2016, the House of Representatives overwhelming passed a bipartisan bill that would provide licensure clarity for sports medicine professionals. H.R. 921, the Sports Medicine Licensure Clarity Act – introduced by Reps. Brett Guthrie (R-KY) and Cedric Richmond (D-LA) – will clarify medical liability rules to ensure team providers are properly covered by their professional liability insurance while traveling with athletic teams in another state. From high school to college to professional levels, it is important that the men and women who are trained to protect and care for athletes and who best know the players’ medical histories are able to engage in the treatment of injured athletes. Sens. Thune and Klobuchar introduced similar legislation in the Senate. AAOS worked closely with members of Congress on introduction and through passage of the legislation, participating in markups and congressional hearings. AAOS also worked closely with other groups including the American Orthopaedic Society for Sports Medicine (AOSSM), the American Medical Society for Sports Medicine (AMSSM), and the National Athletic Trainers’ Association (NATA).

The House of Representatives again passed the legislation on January 9, 2017. Read more online here.

Additionally, AAOS continued to build a list of co-sponsors for the Good Samaritan Health Professionals Act, the Provider Shield Act, the Quality Health Care Coalition Act, and more. Already in 2017, Rep. Steve King (R-IA) has introduced the Protecting Access to Care Act, a comprehensive medical liability reform bill that ensures full and unlimited recovery of economic damages in cases of medical negligence, allowing for payment of past and future medical expenses, lost wages, rehabilitation costs, and other out-of-pocket expenses. The legislation also permits the additional recovery of up to $250,000 for non-economic damages, such as damages awarded for pain and suffering.

Find more information on medical liability reform online here.

In-Office Ancillary Services

AAOS prevented the in-office ancillary services (IOAS) exception from being used as a pay-for in any legislation, despite legislative and the President’s Budget. AAOS also established an IOAS Working Group to pursue an aggressive legislative strategy, which resulted in a Congressional Doctors Caucus letter, meetings with targeted Hill staff, and a physician fly-in. Further, the AAOS successfully rolled-out an IOAS study, which has armed AAOS with positive data for efforts to preserve the IOAS exception. The AAOS also worked with the Government Accountability Office (GAO) on its physical therapy self-referral report, recruiting physicians to review the document prior to publication and offer comments.

Find more information on ancillary services online here.

21st Century Cures Act

On Dec. 13, 2016, President Obama signed the 21st Century Cures Act (H.R. 34) into law. The legislation is focused on increasing research dollars for the National Institutes of Health (NIH) and streamlining aspects of regulation at the U.S. Food and Drug Administration (FDA). Before arriving at the president’s desk, the bill passed the U.S. House of Representatives by a vote of 392-26 and the Senate by a vote of 94-5. In addition to the funding, authors of the 21st Century Cures Act hope the legislation will be an “innovation game-changer” by reducing the administrative burden for researchers, increasing data sharing, improving opportunities for new researchers, and modernizing clinical trials (by, for example, requiring the NIH to better incorporate minority groups and update guidelines for the inclusion of women in clinical research studies).

AAOS congratulated members of Congress for passing this bipartisan legislation to accelerate innovation, boost research, and modernize physician practices, all of which will advance patient care exponentially. The Office of Government Relations aggressively supported the legislation, writing numerous letter of support – including to Speaker of the House Paul Ryan (R-WI) and conducted meetings throughout the year on the issue. 

Independent Payment Advisory Board (IPAB)

As a result of AAOS and coalition groups’ pressure, two bills to eliminate IPAB have already been introduced in the U.S. Senate in 2017, one by Senator John Cornyn (R-TX) and another by Senator Ron Wyden (D-OR).  An IPAB repeal resolution has also been introduced in the U.S. House by Congressmen Phil Roe (R-TN) and Raul Ruiz (D-CA), with a full repeal bill expected imminently. AAOS has conducted outreach to all House members to encourage them to join Congressmen Roe’s (R-TN) and Ruiz’s (D-CA) bipartisan bill.

Extremity War Injuries (EWI) and Appropriations

AAOS successfully advocated for $30 million in funding for the Peer Reviewed Orthopaedic Research Program through the Department of Defense Congressionally Directed Medical Research Program. Once the FY2017 defense appropriations money is allocated, this program will have received more than $300 million in funding since its inception in 2009. Additionally, AAOS hosted the twelfth annual EWI symposium, Homeland Defense as a Translation of War Lessons Learned, focused on disaster preparedness as well as an ongoing research agenda that highlighted state-of-the-art research and identified gaps in the treatment of extremity trauma. Read more about the symposium online here.

Trauma Care

AAOS has worked with Representative Burgess (R-TX) and Representative Green (D-TX) to introduce two trauma care bills to ensure that Americans have access to necessary medical services. The bills passed the House of Representatives unanimously. AAOS is now working with appropriators to fund the programs. The Orthopaedic Trauma Association (OTA) is supportive of the bills. 

Emergency Medical Services 

H.R. 4365, the Protecting Patient Access to Emergency Medications Act, was introduced by Reps. Richard Hudson (R-NC) and G.K. Butterfield (D-NC) and referred to the Energy and Commerce Committee. The AAOS-supported legislation would provide a statutory framework to allow emergency medical services (EMS) agencies, professionals, and medical directors to fulfill their mission to save lives and alleviate pain, while also enabling the Drug Enforcement Administration (DEA) to continue with appropriate oversight to prevent drug diversion. Specifically, the bill would permit medical directors to issue standing orders to allow EMS professionals to administer and deliver controlled substances. It would also clarify and codify who is authorized to provide verbal orders for controlled substances. In addition, it would provide the option for a single EMS agency registration as well as guidance and clarification regarding receipt, movement, and storage of controlled substances for the EMS agency. The bill would also provide the EMS community with a clear set of rules and the DEA with auditable records and the necessary authority to prevent drug diversion. Most importantly, H.R. 4365 would enable physicians to continue serving our vulnerable emergency medical patients and providing the best possible care to those who need immediate life-saving and pain medications.  

VA Provider Equity Act

The House introduced legislation that would have included language elevating podiatrists to the same status as physicians under the Veterans Health Administration (VA). AAOS worked diligently with the American Orthopaedic Foot & Ankle Society to ensure that no such language was included in the Senate companion bill.

NIH Research Funding

AAOS works with the National Institute of Arthritis and Musculoskeletal and Skin Diseases (NIAMS) coalition to secure additional research funding for musculoskeletal health. The Ruth Jackson Society and the Gladden Society have also been involved.

Physician-Owned Hospitals

The AAOS supports legislation to repeal the provisions in the ACA relating to physician-owned hospitals. Section 6001 specifically prohibits the construction or expansion of hospitals owned in part or in full by physicians. Repeal would provide patients greater access to quality health care, more provider options and lower costs. AAOS has helped with a number of physician fly-ins on this issue (read more online here), and as a result, Reps. Sam Johnson (R-TX) and Sheila Jackson-Lee (D-TX) introduced the Patient Access to Higher Quality Health Care Act of 2017, which would repeal Section 6001 of the Affordable Care Act (ACA) and lift a ban on creation and expansion of physician-owned hospitals. A Senate version is expected imminently. 

“Hospitals owned by physicians are currently restricted under law from expanding their capacity to treat more patients,” stated Gerald R. Williams, Jr., MD. “These physician-led, patient centric hospitals consistently rank higher under current quality measures than other hospitals and include seven out of the top ten hospitals in the country. They also save Medicare money - $3.2 billion over ten years – and inject funds into local economic activity. The inability of physician-owned hospitals to address growing demand for health care services is bad for our entire health care system and penalizes patients who deserve the right to receive care at the hospital of their choice. We thank Reps. Johnson and Jackson-Lee for their leadership on this issue and implore Congress to lift the restrictions on physician-owned hospitals so more patients can benefit from them.”

Chronic Care and Site Neutral Payments

In addition, AAOS provided comments to the (1) US Senate Committee on Finance Chronic Care Workgroup on policy options for delivering and paying for chronic condition management and the (2) House Energy & Commerce Committee on the Medicare site-neutral payments issue.

Orthopaedic PAC

Today, the Orthopaedic PAC remains one of the largest health care association PACs in the nation. Last election cycle AAOS raised over $3.5 million dollars and enjoyed support from well over 5,200 of our colleagues. $2.5 million was disbursed in that time period, with 60 percent going to Republicans while 40 percent went to Democrats. In the 2016 election, the Orthopaedic PAC participated in 32 U.S. Senate races and 231 U.S. House races, winning an unprecedented 94 percent of those races. Between 2015 and 2016, AAOS attended over 880 events, including 113 local events with AAOS fellows. This expansive political footprint helps us frame the debate on a number of critical health care issues. AAOS also supported the Republican and Democratic Governors Associations, which further amplified our voices in the state political arena. Finally, in 2016, AAOS launched a sophisticated advocacy program, called the Advisor’s Circle, which takes group practices from apolitical to political elite.