During the past two years, as I’ve traveled and met with orthopaedic surgeons across the country, I’ve heard a lot of questions—especially about the Academy’s quality efforts. “What’s the use of clinical practice guidelines if they don’t say anything?” ask some. “I don’t practice cookie-cutter medicine,” say others, “and isn’t that what these ‘appropriate use criteria’ call for?”


Published 4/1/2013
Joshua J. Jacobs, MD

Turning a Challenge Into an Opportunity

How quality efforts can help achieve advocacy goals

Joshua J. Jacobs, MD

And then there are those who say, “What’s the point? Those policy makers in Washington are just going to start dictating what we can do, and payers are going to start issuing their own guidelines, and no one is listening to us anyway.”

These are valid questions and, as a researcher, I understand the challenge we face. Clinical practice guidelines—CPGs—are based on evidence. And, quite frankly, the evidence for a lot of what we do in orthopaedics isn’t very strong—but is very difficult to obtain.

As for appropriate use criteria—AUCs—they’re anything but cookie-cutter medicine. The AUC process involves hundreds of physicians—your colleagues—coming together to address a variety of clinical scenarios and melding their judgment with evidence to determine whether, in a particular situation, a particular treatment is appropriate. Sometimes, two or three different treatments might be appropriate. Then, it’s the clinician, in conjunction with an informed patient, who makes the decision.

AUC developed by the AAOS, in conjunction with specialty orthopaedic societies, are urgently needed. In fact, other organizations are already producing AUCs in the musculoskeletal area, but without the input of practicing orthopaedic surgeons or an evidence-based foundation.

Is that what we want? It’s certainly not what I want. If AUCs will be developed—and they surely will be—and if orthopaedic surgeons will be held accountable to them—and we surely will be—then I want orthopaedic surgeons—not members of the payer community—to be the developers. In the interests of our patients, clearly, it will be better if we develop AUCs, based on the best available evidence and our expertise in managing musculoskeletal disease.

I’m quite excited to be stepping into the AAOS presidency just as our very first AUC is released. (See “AAOS Board Adopts Distal Radius Fracture AUC,” this issue’s cover story.) This will be an important tool in improving the quality of care delivered to patients. It is something that we, as orthopaedists, can emphasize when we meet with payers and policy makers who are looking at healthcare costs and making determinations on payment and availability of services.

Quality as advocacy
That is the point. We will be most effective if our advocacy message is presented as a potential solution to the current healthcare crisis, not just a demand for fair reimbursement.

For example, to address the claims of overuse, we can point to the development of our CPGs and AUCs, and to the establishment of the American Joint Replacement Registry. To answer the question of the value of our services, we can respond with information developed on the value of musculoskeletal care that supports the cost-effectiveness of the procedures we perform.

Quality as advocacy works; I have personally witnessed its effectiveness. A few months ago, members of the House Ways and Means Committee requested a meeting with the AAOS. They wanted to understand how our quality programs could be helpful in their legislative actions in the healthcare sector, including a fix to the sustainable growth rate formula. The development of high quality and credible CPGs and AUCs is resource intensive, but ultimately will prove to be well worth the effort.

Your Academy is taking great care to ensure that these quality products reflect actual practice and not be divisive. In the past several years, members of the Presidential Line and the Council of Research and Quality have spent a great deal of time working with specialty societies, who are the content experts, on the role that CPGs and AUCs will play in the future.

The Academy will redouble its efforts to collaborate with specialty societies to produce credible, useful guidelines and AUCs that contribute to the quality and efficiency of healthcare delivery in the United States. Recently, the New England Journal of Medicine published a perspective article calling for AUCs for total joint replacement as a way to contain costs. The authors specifically mentioned the Academy as developing the needed criteria—they have taken notice of our quality initiatives!

When it comes to quality efforts, the question is: Who do you want developing the guidelines and criteria that will shape the way we practice? Your Academy or the payer community—including federal and state governments? Your colleagues or nonorthopaedic surgeons? To me, the answer is clear: Our profession—our Academy—needs to take this on.

Last year, some of the Medicare Audit Contractors (MACs) adopted their own “appropriateness” criteria for determining the validity of total joint replacement claims in their audit processes—in a nontransparent and nonevidence-based fashion. When the MACs began not only to deny claims but also to “claw back” payments already made, hundreds of patients and surgeons were affected. Although many of these denials were overturned on appeal, the process consumed hours of time better spent in patient care.

It was due to the advocacy efforts of your Academy that many of these criteria were later revised. We could show the MACs the evidence, make the argument, and win the point.

Can we avert a crisis?
In a recent survey, leading economists were asked: “What will be the three most important economic challenges facing the United States over the next 10 and the next 60 years?” Issues such as the national debt, globalization, and energy were not at the top of the list. Instead, 86 percent of respondents listed either social security and pensions or health care and health insurance as the greatest economic challenges.

We cannot escape this reality, which has the potential to adversely affect our practices and our ability to deliver the orthopaedic care that our patients need. Our profession needs to have the tenacity to identify, based on the best available evidence, what works. We also need to have the courage to identify what does not work and be prepared to change our practices accordingly. I hope you will join me in turning these challenges into opportunities.