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Published 7/1/2011

Second Look—Advocacy

If you missed these Headline News Now items the first time around, AAOS Now gives you a second chance to review them. Headline News Now—the AAOS thrice-weekly, online update of news of interest to orthopaedic surgeons—brings you the latest on clinical, socioeconomic, and political issues, as well as important announcements from AAOS.

Support for IPAB falters
According to
Politico.com, support for the creation of the Independent Payment Advisory Board (IPAB) is decreasing. The IPAB is a panel created by the Patient Protection and Affordable Care Act (PPACA) and tasked with reining in Medicare costs. Beginning in 2015, if Medicare spending exceeds a specific target, the IPAB will have the authority to recommend cuts that will immediately take effect unless Congress votes to block or change them. Several House Democrats have come together to support a bill repealing the IPAB.

CMS review of existing work RVUs
On May 24, 2011, the U.S. Centers for Medicare and Medicaid Services (CMS) released a proposed rule related to the congressionally mandated 5-year review of existing procedure work relative value units (RVUs). The rule reviews CMS recommendations for approximately 300 procedure codes, including 23 codes for procedures that are commonly performed by orthopaedic surgeons. Many of the CMS recommendations for these 23 codes were for values lower than had been recommended. The American Association for Orthopaedic Surgeons plans to comment on the proposed rule by the July 25, 2011, deadline. CMS will review comments, possibly make adjustments to their proposed values, and release the 2012 Medicare Physician Schedule on or around Nov. 1, 2011.

Streamlining the medical liability process
An article in the New York Times (June 13) profiles a program designed to reduce legal wrangling surrounding medical liability cases. Under the federally backed judge-directed negotiation initiative, judges are brought in early to attempt to actively mediate settlements. Supporters say that the program streamlines the process by potentially reducing years of court battles and legal expenses. According to a spokesperson for the U.S. Agency for Healthcare Research and Quality, some estimates indicate that, if adopted nationally, the program could save more than $1 billion annually.

CBO: Tort reform would save $57 billion
According to an estimate released by the U.S. Congressional Budget Office (CBO), implementation of the so-called Help Efficient, Accessible, Low-cost, Timely Healthcare (HEALTH) Act would directly and indirectly lower healthcare costs by lowering premiums for medical liability insurance and reducing the use of healthcare services prescribed by providers through reduced threat of medical liability lawsuits. The bill caps awards and attorney fees in medical liability suits, modifies the statute of limitations and the “collateral source” rule, and eliminates joint and several liability. CBO estimates that adoption of the act would reduce federal deficits by almost $14 billion from 2011 to 2016 and by about $57 billion from 2012 to 2021.

Medicare geographic adjustment system
The Institute of Medicine (IOM) reports that nearly 40 percent of hospitals have been granted exceptions in calculating their Medicare geographic adjustments. Such adjustments to Medicare payments are intended to cover regional variations in wages, rents, and other costs incurred by hospitals and individual healthcare providers. IOM states that the high number of adjustments suggests that “fundamental changes to the data sources and methods the program uses to calculate the adjustments are needed to increase the accuracy of the payments,” and recommends that Medicare recognize a single set of payment areas for both hospitals and physicians.

Medical liability claims in outpatient settings
A study in the Journal of the American Medical Association (JAMA) (June 15) shows that many medical liability claims come from events that occur in outpatient settings. The retrospective analysis used data from the National Practitioner Data Bank (2005 through 2009) on medical liability claims paid on behalf of physicians in outpatient and inpatient settings. During 2009, 10,739 liability claims were paid on behalf of physicians—4,910 for events in the inpatient setting, 4,448 for events in the outpatient setting, and 966 involving events in both settings. The most common reason for a paid claim in an outpatient setting was diagnostic, while the most common reason in the inpatient setting was surgical. Overall, the mean payment amount for events in the inpatient setting was significantly higher than in the outpatient setting.

AHRQ on hospital readmissions
An analysis of data from 15 states conducted by the U.S. Agency for Healthcare Research and Quality found that in 2008, nearly 12 percent of hospital stays were readmissions within 30 days of a previous stay. In addition, 7 percent of hospital stays were readmissions within 14 days of their previous stay and 4 percent were readmissions within one week. The highest rate of readmission occurred in the 45-to-64 age group. Among patients younger than 65, readmission rates were 50 percent higher for adult Medicaid patients compared to privately insured patients. For Medicare patients age 65 and older, nearly one in five hospital stays were readmissions within 30 days.

CON processes are often political
The certificate-of-need (CON) process has evolved into an arena in which providers often battle for service-line dominance and market share, according to a research brief released by the non-profit Center for Studying Health System Change (HSC). Based on interviews conducted in six states (Connecticut, Georgia, Illinois, Michigan, South Carolina, and Washington), the CON approval process can be highly subjective and tends to be influenced heavily by political relationships, such as a provider’s clout, organizational size, or overall wealth and resources, rather than policy objectives. Michigan, however, has included several elements that contribute to greater objectivity and transparency in the state’s CON process.

Factors in ED closings
The number of hospital emergency departments (EDs) in nonrural areas declined by about 27 percent—from 2,446 to 1,779—between 1990 and 2009, according to a study in JAMA (May 18). Data from annual surveys conducted by the American Hospital Association was used to determine risk factors for ED closure; for-profit hospitals and those with low profit margins were more likely to close than nonprofit hospitals or those with high profit margins. The risk of a hospital closing its ED was also higher among hospitals in more competitive markets, safety-net hospitals, and those serving a higher share of populations in poverty.

Knowing what test costs can reduce orders
A study in the Archives of Surgery (May) suggests that making healthcare providers aware of the costs of some tests can reduce the number of tests ordered, resulting in a cost savings. The prospective observational study of blood work ordered for all nonintensive care unit patients on three general surgical services at a single tertiary care hospital. At baseline, charges for daily phlebotomy were $147.73/patient. After 11 weeks of residents being made aware of the daily charges for phlebotomy, the charges dropped as low as $108.11/patient per day.

Risk for VTE in low-volume hospitals
A study in Arthritis & Rheumatism (online) finds that hospitals with lower surgery volumes are associated with a greater risk of mortality and the development of venous thromboembolism (VTE) in patients who have primary elective total hip arthroplasty (THA) or total knee arthroplasty (TKA). Data from a statewide database showed that patients who underwent elective primary THA at lower-volume hospitals (fewer than 200 annually) were at greater risk of VTE and 1-year mortality. In addition, patients 65 years or older who underwent elective primary TKA at low-volume hospitals had significantly higher odds ratios for 1-year mortality compared to high-volume hospitals.