So it shouldn’t surprise us that achieving change on a national scale takes time. Yet everywhere I go, I’m confronted by fellows who are as impatient and frustrated as I am about the perceived lack of forward movement in accomplishing some basic goals, such as fixing the flawed Sustainable Growth Rate (SGR) formula.


Published 6/1/2008
Tony Rankin, MD

Advocacy: A marathon, not a sprint

We’ve all had the experience of having something take longer than we think it should—whether it’s a drive home made interminable because of an unseen accident on the road ahead or a practice governance decision that drags on because one of the partners can’t see another viewpoint.

Tony Rankin, MD

Because much of the work necessary to achieve these objectives goes on behind the scenes, I want to draw open the curtain a bit and let you know what the AAOS is doing.

Health Care Systems Committee
Recently, the Council on Advocacy, under the direction of David A. Halsey, MD, established a new Health Care Systems Committee. This committee will work closely with the government, private payors, and other external entities, providing clinical expertise and input so that these groups can make informed decisions regarding the allocation of resources with respect to diagnosis, treatment, and management of musculoskeletal conditions and disorders.

The need for this committee grew out of the Work Group on AAOS Involvement in Medicare Part A Issues, which I chaired. Serving on the Work Group with me were Kevin J. Bozic, MD, MBA; Charles H. Classen Jr, MD; William L. Healy, MD; S. Glen Neale, MD; and Thomas P. Sculco, MD.

Although Medicare Part A is usually considered the “hospital” portion of the Medicare payment, decisions made on the Part A side—such as whether and how much to reimburse for new technologies—are increasingly having an impact on AAOS members. In addition, health policy experts and government officials have been exploring reimbursement reforms that could pay for “episodes of care,” which would combine Part A and Part B reimbursement mechanisms.

The Work Group also realized that involvement with the Centers for Medicare and Medicaid Services (CMS) to provide guidance on clinical assessments under Part A would create opportunities by establishing the AAOS as a cooperative partner interested in collaborating on more efficient healthcare systems. But the AAOS is, first and foremost, a membership organization of physicians; we do not want our involvement in Part A issues to detract from our strong commitment to advocacy efforts in Medicare Part B.

After more than a year of study, the Work Group recommended that “AAOS should increase its involvement in areas of Medicare Part A where AAOS input would (a) add value to the decision-making process; (b) impact patient access to and quality of care; and (c) affect the direct and indirect resources available to orthopaedic surgeons attempting to deliver care to their patients in an environment of increased costs and declining reimbursements.”

Having an impact
The Work Group identified several areas where AAOS input might have an impact on Medicare Part A decisions. One of the most important areas was in changes to the Medicare Inpatient Prospective Payment System (IPPS). In response to recommendations made by the Medicare Payment Advisory Commission (MedPAC), CMS has been overhauling the IPPS. CMS has now implemented a new series of Medicare Severity Diagnosis-Related Groups (MS-DRGs).

The new MS-DRGs are cost-based and the changes are expected to disproportionately affect the orthopaedic and cardiac sectors, both of which are considered “overvalued” by MedPAC.

In addition, CMS has recently proposed expanding the list of “avoidable complications” that are “reasonably preventable” through proper care and that will no longer be paid at a higher rate if acquired during a hospital stay. Among the nine conditions under consideration for 2009 are surgical site infections following certain elective procedures, deep venous thrombosis/pulmonary embolism (DVT/PE), Staphylococcus aureus septicemia, and Clostridium difficile-associated disease.

Although this rule affects hospital DRG payments only, this initiative could have significant implications for physician documentation of admission and patient care. The new Health Care Systems Committee establishes a mechanism for the AAOS to respond and provide input to CMS on this issue.

Responding to change
The AAOS has already begun to engage CMS in a dialogue on this issue. With regard to hospital-acquired conditions (HAC), for example, we expressed our concern with classifying DVT/PE as “avoidable.” As we all know, trauma and joint replacement surgery patients are at high risk for DVT/PE due to common patient characteristics (such as immobility and obesity), severe vessel trauma, and venous stasis. Our response to CMS emphasized the “even the best prophylactic measures currently available cannot prevent clot formation in every patient.”

The AAOS supports the routine provision of prophylaxis to orthopaedic patients as part of the standard of care. But no evidence exists that all DVT/PE is reasonably avoidable. In our view, “including this in the list of conditions covered by the HAC payment policy would have a negative impact on patient care, deny providers necessary resources to effectively treat these patients, and fall outside the scope of the legislative intent of this policy.”

CMS has shown signs of agreeing with the AAOS position on whether DVT/PE is reasonably avoidable, but continues to consider DVT/PE for inclusion on the HAC nonpayment list, so the AAOS will continue to work with CMS on this issue. We are in the process of preparing a second response to submit by the June 13 deadline.

The AAOS is committed to remaining engaged and active in advocacy. We may not achieve all of our goals, but we will not stop our efforts to ensure that the voices of orthopaedic surgeons are heard. Our patients—as well as our members—are depending on us.

I encourage you to engage as well. Visit the Government Relations section of the AAOS Web site ( You’ll find a wealth of materials, including background papers for many of the issues on which AAOS is active, fact sheets, reference materials on both state and federal issues, and organizing tools.

You can also engage by joining the Orthopaedic Political Action Committee ( Your contribution and support will help ensure that the AAOS can finish the advocacy marathon.