Published 8/1/2013
Mary Ann Porucznik

Value Measures and Discrimination

Will value measures create access-to-care issues for patients who are obese?

The decision by the American Medical Association to recognize obesity as a disease that requires a range of medical interventions to advance treatment and prevention is a step in the right direction, according to some advocates. But much more needs to be done, especially with regard to access-to-care issues, according to presenters during the AAOS Now–sponsored forum on “Obesity, Orthopaedics, and Outcomes.”

“Many orthopaedic surgeons who perform total joint replacement tend to avoid treating patients who are obese,” noted Adolph J. Yates Jr, MD, associate professor of orthopaedic surgery at the University of Pittsburgh. “These surgeries are harder to perform and take longer, resulting in lost opportunity costs. Patients who are obese have more complications and more frequent off-hour returns to the operating room and the emergency department.”

Dr. Yates pointed to a “burgeoning literature” that supports the increased risk of total joint surgery for obese patients. Among patients with a body mass index (BMI) of 50 or higher, for example, the infection rate after total joint surgery is nearly five times that of patients with a normal body weight. The in-hospital risk of complications is nearly eight times higher.

“Despite these high complication rates, total joint replacement in obese patients is a beneficial surgery that relieves pain and improves function. In fact, several studies show that, based on patient-reported outcomes, patients who are overweight and those who are normal weight have similar improvements and satisfaction,” said Dr. Yates.

Whether patient weight has an impact on the longevity and survival of the prosthetic joints has yet to be determined, noted Dr. Yates; studies have shown varying results. “But without a doubt, patients will be helped and their lives improved,” he said.

The risk/benefit matrix
Is there a threshold at which the higher risk of complications outweighs the probability of a successful surgery? According to Dr. Yates, patients with a BMI of 50 or higher are at a much higher risk of incurring complications after total joint surgery. And surgeons can make a unilateral decision on whether to perform surgery. “You don’t have to say ‘yes’ just because you have a discussion with the patient,” he said.

Recent legislative and regulatory efforts—as well as concerns about costs, quality, and value—may also have an impact. Both government and private payers are concentrating “not just on cost efficiency, but on value—cost efficacy—which is a different topic,” said Dr. Yates.

Macroeconomic concerns—such as the disease, procedure, cost, and demographics—are sparking cost-utility analyses to measure benefits to society in terms of quality-added life years (QALY). In these analyses, QALY thresholds are set, and must be met to support the provision of a specific service at a specific cost.

But it is the microeconomic concerns—the patient, the surgeon, the hospital, and the cost—that are driving multiple measurements that “in my mind,” said Dr. Yates, “are going to affect how readily the people we work with want to help the obese and may cause them a lot of lost healthcare opportunities.”

For example, private, state, and federal health programs are tightening the indications for many types of surgery, requiring additional copayments from patients, and mandating documentation that previous nonsurgical treatments have failed. Dr. Yates is concerned that, at some point, a patient’s BMI may become an issue.

The reporting impact
As public reporting of costs and outcomes for various procedures increases, Dr. Yates fears that the complications and poorer outcomes due to obesity may prompt some providers to avoid treating obese patients. Tying outcomes to payments—under systems such as global bundled payments, accountable care organizations, and the Physician Quality Reporting Service (PQRS)—may also have an impact on care for obese patients.

“Most academic medical centers are working at a 4 percent margin,” noted Dr. Yates. “When penalties for higher readmission and complication rates kick in and when care for patients who have complications is no longer compensated, these centers will be at risk for closing.”

Quality and Resource Use Reports (QRUR) are another tool being implemented by the Centers for Medicare & Medicaid Services (CMS) that could affect a patient’s access to care. Already being used on a trial basis in parts of the United States, QRUR will be extended to cover all physicians over the next 4 years.

A confidential feedback report to physicians, QRUR compare the quality and cost of care for that physician’s Medicare patients with those of other physicians in the same specialty and with all physicians in a specified area.

“Surgeons will be able to see how the cost of their care compares to that of other surgeons. Surgeons may be paid more or less, depending on how well they are seen as cost-efficient to CMS,” said Dr. Yates.

Accuracy, risk adjustment, and “medical necessity” are among the issues that could have an impact on outcomes reporting. “When you look at CMS administrative databases, they’re frequently not correct when compared to registry databases,” noted Dr. Yates. “The risk adjustments aren’t refined; there’s no gradation. They go from obese (BMI > 30) to morbidly obese (BMI > 40), but they don’t consider the super obese (BMI > 50); it’s not a continuous variable.”

Demands by CMS and insurers that patients meet certain indications for surgery to prove medical necessity are also problematic for surgeons who treat obese patients. “Some of these patients just can’t go to physical therapy,” said Dr. Yates, “and that could result in a ‘claw-back’ of payments when the claim is audited.”

Global payment systems—such as bundled payments for specific types of surgery—may increase pressure on providers to avoid “risky” patients, despite the high probability of gain for the patient. “CMS will take its savings off the top,” said Dr. Yates, “and it’s up to the surgeon, the hospital, and other providers to provide care with a large enough margin that they all can stay in business. The focus will be on avoiding complications that increase the cost of care and unreimbursed readmissions after surgery.”

Is there an answer?
According to Dr. Yates, some hospitals have already begun to restrict access or demand that patients lose weight prior to scheduling surgery. He noted that better risk adjustment tools are needed, as are more appropriate reporting codes and databases.

“What I think ought to happen,” he said, “is that certain classes of patients should be excluded from the analysis of value/benefit determinations and bundled payments. We ought to be comparing apples to apples. For example, a comparison of various hospitals where total joint replacement surgeries are performed ought to be based on a population of 60- to 70-year old women who have a BMI of less than 30 and one risk factor—hypertension. If you compare just those patients from one hospital to another, you actually have a measure of quality that can be risk-adjusted appropriately, as opposed to comparing centers that care for big folks with those that don’t.

“I would love to see exclusionary criteria for many of these measures,” concluded Dr. Yates, “or, as orthopaedic surgeons, we will be pressured by our hospitals, partners, and groups not to take patients who are high-risk, regardless of our moral or ethical concerns for that patient relationship.”

The AAOS Now forum on “Obesity, Orthopaedics, and Outcomes” was held on March 18, 2013. For a copy of the agenda book, including selected study abstracts, email aaoscomm@aaos.org

Mary Ann Porucznik is managing editor of AAOS Now. She can be reached at porucznik@aaos.org

Links to a variety of other organizations and programs on obesity

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