OREF-funded research used to improve reimbursement for orthopaedic procedures
Every day, public policy decisions handed down by health-care policy makers affect the treatment choices that orthopaedic surgeons make. But do these decision makers ever consult actual clinicians?

Since 2003, Kevin J. Bozic, MD, MBA, winner of the 2006 Orthopaedic Research and Education Foundation (OREF) Career Development Award, has been leading an investigation of the relationship between economics, health policy, and the practice of orthopaedic surgery. “I want to create a dialogue between orthopaedic surgeons and government payers, like Medicare, regarding the costs associated with total joint replacement procedures,” said Dr. Bozic. “Discrepancies between resource use and reimbursement discourage some hospitals and surgeons from doing these procedures. That affects both the quality of care delivered and patient access to care.”

An analysis of patient-level clinical and financial data from three high-volume institutions led to a better understanding of the actual costs associated with joint replacement procedures, the first step in opening lines of communication between orthopaedic surgeons and government payers. “This was data that Medicare and other large payers didn’t have,” Dr. Bozic said.

The case for change
Building a case was one thing. Getting heard by the Centers for Medicare and Medicaid Services (CMS) was another.

“A lot of people come to CMS with a hidden agenda,” explained Dr. Bozic. “We said, ‘We’re interested in quality and access to care for our patients,’ and they responded, ‘Yeah, we’ve heard that story before from a lot of doctors and it always leads to some discussion about physician reimbursement.’

“Once they understood that we really had good intentions—and once they looked at some of the data—they were very receptive. In fact, CMS is starving for input from clinicians, but few clinicians want to take an active role,” said Dr. Bozic.

In October 2004, Dr. Bozic presented his data to CMS and the National Center for Healthcare Statistics at the ICD-9 Care and Coordination meeting. It supported a recommendation for more descriptive ICD-9-CM diagnosis and CPT procedure codes.

A few months later, Dr. Bozic and his research team shared the data with the Medicare Diagnosis-related Group (DRG) Advisory Committee. Dr. Bozic recommended splitting DRG code 209 into two separate codes—one for primary joint replacement procedures and a second for the more resource-intensive revision joint replacement procedures.

Both recommended changes were accepted and implemented by CMS. But much remains to be done. With support from the OREF 2006 Career Development Award, funded by the Dr. Dane and Mrs. Mary Louise Miller Endowment Fund, Dr. Bozic is pressing on.

Next steps
“We are now looking at administrative claims code data to evaluate the resource-intensity and overall cost-effectiveness of orthopaedic technologies and procedures,” he said. “Our goal is to give surgeons, patients, hospitals, and policy-makers more objective data on which to base their decisions about the use of new technologies in clinical practice.”

This type of research, and the funding to make it possible, is essential, according to Dr. Bozic.

“Healthcare delivery in the United States is really in a crisis. We now have far better interventions and better technology than we can afford,” he said. “For the future of our profession, we must understand which technologies we should be investing in, and how specific procedures influence patients’ quality of life from a clinical perspective.

“We need research that brings relevant clinical knowledge, objective data, and hard science to inform policy-makers. It’s very important for the orthopaedic community, our patients, and the future of healthcare delivery,” he concluded.

Since 1955, OREF has provided more than $59 million in funding for more than 2,500 grants on research subjects ranging from investigations of the process of fracture healing to studies that ultimately resulted in the development of Bone Morphogenetic Protein. To make a contribution to OREF’s 2007 Annual Campaign, or for more information about OREF, please log on to www.oref.org

Applications for 2008 OREF funding will be available soon. Most applications will be due by October 2007; check www.oref.org for up-dated information. Address questions to Jean McGuire at mcguire@oref.org or (847) 384-4348.