Published 8/1/2010

Redefining healthcare quality

The recently enacted healthcare reform legislation places significant emphasis on “quality.” More than 50 original provisions and amendments deal directly with quality. These range from the establishment of a “national quality strategy” to the development of quality and efficiency measures, the collection of quality data, and the implementation of programs that foster the delivery of quality care.

John J. Callaghan, MD

The following are among the key quality sections of the legislation:

  • Developing a national strategy for quality improvement, through an interagency work group that would develop outcome, efficiency, and other quality measures and make performance information available to qualified entities to evaluate providers
  • Examining the feasibility of alternative care models, such as accountable care organizations, episode of care payments, medical homes, gainsharing demonstration projects and global payment demonstration projects
  • Improving the quality of health care through research on healthcare delivery systems and comparative effectiveness, shared decision-making programs, improvements to emergency and trauma care, and integration of quality and safety into clinical education
  • Linking Medicare payments to quality outcomes through mandatory participation in the Physician Quality Reporting Initiative, additional incentives for participation in maintenance of certification programs, value-based purchasing programs, public reporting of performance information, and payment adjustments

Where’s orthopaedics?
Although some of these programs may be helpful in improving the consistency of care delivered to patients, others may be more problematic, in part due to the various perspectives and definitions of “quality.” And many AAOS members may wonder, “Where is orthopaedics in these measures?”

We all recognize that orthopaedics is a high-profile “target” of healthcare reform. The number of orthopaedic procedures—particularly joint replacement procedures—has increased significantly and is anticipated to continue to grow. Orthopaedic procedures, in addition to being high-volume, are also costly. Even though physician reimbursement for these procedures fell nearly 26 percent from 1997 to 2007, the “average selling price” of a total hip implant increased more than 130 percent during that same period. Finally, significant variations in practice patterns and outcomes exist.

Because healthcare reform aims to hold down costs by reducing the number of procedures performed and eliminating variances in practice patterns, we can anticipate that the focus on orthopaedists is likely to continue. Not only will we have to prove the value of the procedures we perform, we probably will need to show that we are continuously examining and adopting the “best practices” for delivering safe, appropriate, cost-effective care.

What is the AAOS doing?
The AAOS was actively involved throughout the debates that shaped the healthcare reform bill. We continue to be actively involved as Congress, the Department of Health and Human Services, and the Centers for Medicare & Medicaid Services (CMS) begin to implement the various provisions of the Patient Protection and Affordable Care Act.

In all of our efforts, we aim to ensure that the voice of orthopaedic surgeons is heard. For example, the legislation established several committees on quality and regulatory issue. The AAOS office of government relations is working to position AAOS members appropriately for these committees. As part of the Surgical Coalition, we are also working to ensure surgical representation and access to federal agencies, boards, and institutes, including the new Center for Medicare and Medicaid Innovation, the Independent Payment Advisory Board (IPAB), and the Patient-Centered Outcomes Research Institute.

We already have several fellows, including Robert H. Haralson III, MD, MBA; Robert Karpman, MD; Robert Brooks, MD; and Kenneth Moore, MD, who are experienced in working with groups such as the National Quality Forum, the Ambulatory Quality Alliance, the Surgical Quality Alliance, and the Physician Consortium for Performance Improvement (PCPI). We have and will continue to advocate for quality measures suitable for orthopaedics.

The PCPI, for example, is one area where the AAOS can provide input on orthopaedic-related performance measures, particularly in the areas of venous thromboembolism, osteoarthritis, osteoporosis, and management of back pain. The Academy’s evidence-based clinical practice guidelines can provide valid, high-impact measures and identify knowledge gaps that can become the basis for funded clinical research trials. As these guidelines move into broader topics, they might lend themselves to national performance measures.

In addition, the AAOS will bring to the forefront musculoskeletal issues related to health information technology, hospital-acquired conditions, public reporting, payment bundling, and the value-based payment modifier.

For example, we are currently working with CMS on clarifying the vague language of the value-based payment modifier provisions. The healthcare reform bill requires the publication of measures of quality and cost by Jan. 1, 2012. The AAOS will advocate that these measures incorporate appropriate risk adjustment, that comparisons among specialties and primary care physicians are equitable, that valid measures are used for collecting data, that any information posted to the Internet is both accurate and reliable, and that a review and appeal process is in place.

As Peter J. Mandell, MD, chair of our Council on Advocacy, has said, “You can’t have quality musculoskeletal care without access to orthopaedic surgeons.” The AAOS aims to ensure that orthopaedic patients have access to the musculoskeletal care they need and that orthopaedic surgeons are adequately compensated for providing that care.

Your AAOS will continue to monitor and participate in the quality initiatives that have been mandated by the healthcare reform bill to ensure appropriate implementation of quality measures to provide the best possible outcomes for our patients.

Quality tip
According to a prospective cohort
controlled study reported in the August 2010 Journal of Bone and Joint Surgery, attending and resident orthopaedic surgeons had a higher rate of methicillin-sensitive Staphylococcus aureus (MSSA) colonization and a similar rate of methicillin-resistant S aureus (MRSA) colonization than a high-risk patient group. Although transfer of MRSA from healthcare workers to patients is rare, MRSA surgical site infection is an increasing health problem.

Because most individuals are intermittent carriers of S aureus and because patient care activities may result in colonization, the Centers for Disease Control and Prevention recommends that decolonization of healthcare workers should be done only when they are implicated in a MRSA outbreak. In my mind, this is the practical sort of recommendation that can be implemented to better serve our patients.

Hand hygiene is of pivotal importance in preventing the transmission of both MSSA and MRSA. Alcohol rubs work better than plain soap and water. Disposable gloves may reduce microorganisms on skin surfaces by up to 80 percent, but hand-washing is necessary to finish the job. MRSA survives rather well in the environment, so personal equipment such as personal digital assistants (PDAs) can become an inadvertent source for transmission. In our daily practices, we should be aware of this transmission risk and consider taking precautions.