NOLC provides opportunities to meet legislators, raise issues

G. Jake Jaquet, Madeleine Lovette, and Mary Ann Porucznik

On April 26, 2012, the halls of House and Senate office buildings were filled with more orthopaedic surgeons than legislators, as attendees of the American Association of Orthopaedic Surgeons (AAOS) National Orthopaedic Leadership Conference (NOLC) trooped from office to office and meeting to meeting, educating members of Congress and their legislative aides on issues of importance to orthopaedists.

Each delegation was armed with leave-behind materials explaining the three designated NOLC issues—support for HR1409, the “Quality Health Care Coalition Act,” which would allow equitable negotiations between health providers and health insurance plans; repeal of the Independent Payment Advisory Board (IPAB) provision of the Patient Protection and Affordable Care Act (PPACA); and a permanent solution to the flawed sustainable growth rate (SGR) formula. Many also carried game boards developed as part of the AAOS campaign, A Nation in Motion.

AAOS Now reporters accompanied three of the delegations—Texas, California, and Oregon. Here are their stories.

Pushing for parity
The 18 members of the Texas delegation included members of the Texas Orthopaedic Association (TOA), the Board of Councilors (BOC), and the Board of Specialty Societies (BOS). They scheduled more than 20 Congressional meetings during this year’s NOLC. The delegation placed particular emphasis on HR 1409, legislation that was unfamiliar to many lawmakers.

“Members were thankful that we raised the issue,” said John Gill, MD, chair of the AAOS Advocacy Resource Committee. “Many did not know that physicians’ inability to negotiate fair contracts gives insurers the power to deny their constituents access to care.”

The scarcity of insurance carriers in Texas enables them to dominate the market and press Texas physicians into nonnegotiable contracts. These contracts give insurers the power to deny patients access to optimal care and impose costly administrative burdens on physicians that further limit their ability to provide care.

The delegation also took the opportunity to ask Republican legislators about their party’s alternative to PPACA if the law is repealed. Legislators—including Reps. Michael Burgess, MD; Pete Sessions; and Randy Neugebauer—assured them that if PPACA is repealed, several popular provisions within the bill would be reinstated, including ensuring that patients are not denied insurance because of preexisting conditions and allowing young adults to remain on their parents’ insurance plans.

The Texas delegation also expressed concerns about the recent upticks in Medicare audit activity. The Centers for Medicare & Medicaid Services (CMS) has bolstered its audit programs to achieve the agency’s goal of reducing Medicare payment errors by $50 billion. Medicare Administrative Contractors (MAC), companies that contract with CMS to review claims and recover overpayments from providers in various jurisdictions across the country, are questioning the way that physicians document the medical necessity of specific procedures.

Trailblazer Health Enterprises, LLC, is the MAC for Jurisdiction 4, which includes Texas. It is targeting physician documentation for lower extremity total joint replacement (DRG470) procedures. The delegation expressed concern about the audits because the MAC has not disclosed how its documentation criteria were developed and there is confusion regarding the documentation required. “If we don’t know what we have to document, how will they be able to justify payment denials or clawbacks?” asked Brian S. Parsley, MD. The delegation also noted that audits and subsequent appeals will disrupt the time they spend with their patients.

The delegation petitioned lawmakers to request a ‘stay’ on future audits until appropriate medical necessity criteria can be developed and to authorize CMS to implement an educational program to educate physicians on the audit process and audit criteria. The request was well received by members from both sides of the aisle, including Sen. John Cornyn and Reps. Gene Green, Michael Burgess, and Sheila Jackson-Lee.

Educating and engaging
California has more people—and twice as many practicing orthopaedic surgeons—than any other state. California’s legislators comprise more than 10 percent of Congressional representatives. No wonder that the state’s NOLC delegation was large (27) and its meeting schedule ambitious (31). To avoid overwhelming legislators, the contingent broke into several smaller groups, each meeting with select members of Congress.

In addition to pressing legislators on the three designated NOLC issues, delegates also addressed state-specific concerns. They noted that patient access to care could be affected by the “preferred facilities” program and associated fee threshold for hip and knee procedures implemented by the massive California Public Employees’ Retirement System (CalPERS). CalPERS manages pension and health benefits for more than 1.6 million California public employees, retirees, and their families and is the third-largest purchaser of health care in the nation.

California Orthopaedic Association Executive Director Diane Przepiorski, noted that legislators were most interested in learning about how the healthcare reforms were being implemented in their respective districts. “They seem to be looking to physicians to be innovative as to how they form integrated healthcare systems to improve care,” she said.

“Rep. Loretta Sanchez was our most engaged congresswoman,” remarked BOS Chair-Elect Steven D.K. Ross, MD. “She and her legislative healthcare aide met with BOC representative Christopher A. Wills, MD and me for an extended time and were very interested in our opinions. Rep. Sanchez was especially excited about the A Nation in Motion game; she kept two copies and asked for more. She understood each of our issues, although she did not offer any specifics.”

Kevin J. Bozic, MD, MBA, chair of the AAOS Council on Research and Quality, was among those who met with Rep. Fortney ‘Pete’ Stark. “He was highly engaged and interested, as he usually is during our visits,” said Dr. Bozic. “He is very knowledgeable about healthcare issues, having authored the original ‘Stark’ laws, and actively sought our input on potential revisions to them. We had a lengthy, productive dialogue and look forward to providing clinically relevant input into healthcare legislation.”

“The IPAB was the most universally understood issue among the members we saw,” said Dr. Ross. “Some Republicans were ready to repeal, but most of the Democrats were less supportive and were concerned about the ever-expanding appetite of Americans for healthcare services. Health Legislative Assistant Nora Connors in Sen. Dianne Feinstein’s office made a point of saying that the senator thought it would be very difficult for a congressional committee to offer any suggestions that might be considered rationing.”

Chair of the AAOS Council on Advocacy, Peter J. Mandell, MD, pointed out one element of commonality. “Members of Congress recognize that the SGR needs to be fixed,” he said. “And with the A Nation in Motion board game, I think we moved some into new territory, raising their awareness of the massive burden of musculoskeletal disease in this country and what orthopaedists are doing about it.”

In the vanguard of reform
Just north of California lies Oregon, a state that aims to be in the vanguard of healthcare reform. It recently received a $2 million grant from the federal government to implement a new plan to reduce Medicaid spending through the establishment of coordinated care organizations.

The 6-member delegation included the state’s BOC representatives Clyde A. Farris, MD, and Susan L. Williams, MD; members of the Oregon Association of Orthopaedists (OAO)—Robert M. Orfaly, MD, president; Timothy L. Keenen, MD, vice president; and Nan Heim, executive director—and David Schlactus, MBA, CMPE, president of the American Association of Orthopaedic Executives. Their day started and ended with visits on the Senate side—with Sens. Jeff Merkley and Ron Wyden; in between, they met with the state’s five representatives (four Democrats and one Republican).

For these orthopaedic surgeons who primarily serve in smaller practices and rural areas, passage of HR 1409 is key to establishing a level playing field with insurers and to being able to continue their practices. It was an issue they raised with all their Congressional representatives—and one that struck a chord with Democratic Rep. Kurt Schrader. “As we try to get more coordinated care,” he noted, “this whole antitrust situation is an issue.”

The development of coordinated care options, such as accountable care organizations, was also a topic of discussion with the legislators. The Oregon delegation made the point that having a place at the table for physicians, in general, and specialists, in particular, was important.

“I hope that physicians will drive this process in a bigger way than we’ve seen historically,” agreed Rep. Schrader. “The bundled payment has been a hard nut to crack—to decide who gets the money and how it’s divided up.”

When Dr. Keenan described his involvement in a bundled-payment spine initiative, Rep. Schrader leaned forward. “I’d really be interested in how you see that process working as it goes forward. Does it live up to our expectations? That’s critical to making the system work.”

Democratic Rep. Earl Blumenauer was interested in the value message, acknowledging that orthopaedic procedures are expensive, but realizing that “we need to consider the total costs of the consequences. The extent to which you can paint that picture,” he told the delegation, “is very important.”

Mr. Schlactus, who is affiliated with Hope Orthopedics of Oregon, was ready to paint another picture, focused on the impact of the current SGR situation and what might happen if the IPAB recommends further cuts to provider reimbursement. “We’ve measured the revenue and costs associated with treating Medicare patients,” he told the legislators. “After we cover our overhead, the doctors get just $8 per hour.”

Although every legislator agreed that Congress would not permit further cuts to provider reimbursements, none had a plan to “fix” the SGR formula and all encouraged the AAOS members to stay in touch and share any suggestions.

Debriefing
Although many NOLC delegates did not see much difference in the responses from legislators, several opined that legislators were more aware of healthcare issues than in previous years, perhaps in response to the passage of PPACA.

“The Democratic members and their staffs are busy with plans to implement the law, and the Republican members and their staffs are busy planning replacement legislation in the event the Supreme Court finds the individual mandate in PPACA unconstitutional. Overall, having our legislators more knowledgeable and engaged in healthcare issues is a positive development for the AAOS and our patients,” Dr. Bozic concluded.

G. Jake Jaquet is executive editor of AAOS Now; Madeleine Lovette is the communications specialist in the AAOS office of government relations; Mary Ann Porucznik is managing editor of AAOS Now.