Healthcare reform, as it is being implemented under the Affordable Care Act, raises questions about who defines quality outcomes and who sets performance measures for orthopaedics. New payment models call for incorporating quality and value measures, but what and how meaningful these measures might be are unknowns.

During the Fall Meeting of the AAOS Board of Councilors and Board of Specialty Societies (BOS), panelists focused on patient-centric performance measurements as an essential part of quality reporting and reimbursement for physicians and health systems, and on the importance of AAOS involvement in the development of these measures.

Moderator David A. Halsey, MD, BOS secretary, pointed out that orthopaedic surgeons are the best source for knowledge and experience on meaningful measurements for musculoskeletal care. He encouraged specialty societies to become engaged in initiatives to develop quality performance measures and stressed the importance of sharing information.

Performance measure initiative
According to Kevin J. Bozic, MD, MBA, chair of the Council on Research and Quality, value is defined as the benefits derived over the cost of receiving those benefits. Within health care, benefits include quality of care as well as the service associated with that quality.

Dr. Bozic pointed out that several organizations—ranging from the National Quality Forum to the internet rating service Yelp.com and from insurers to consumer organizations—are already defining quality in musculoskeletal care and orthopaedics. He noted that patients trust professional societies to define quality in orthopaedics over independent organizations, health plans, and others, and that professional societies must begin to work with these organizations to develop appropriate quality metrics.

The Centers for Medicare and Medicaid Services (CMS) is also looking to implement a unified set of clinical quality measures and e-reporting requirements to align its quality programs and reduce the provider’s reporting burden under programs such as the Physician Quality Reporting System, the Physician Value Modifier, and the Electronic Health Records Meaningful Use programs, as well as the programs that would repeal and replace the Medicare sustainable growth rate (SGR) formula with payments based on the value and quality of services.

Dr. Bozic outlined the differences between clinical practice guidelines, appropriate use criteria (AUC), and performance measures (Fig. 1). He explained that process measures are structural in nature, which are relatively easy to define and difficult to manipulate. They are actionable and can result in feedback on a participant’s compliance. However, they are not always clinically relevant and may not correlate with outcomes. Outcome measures, such as complications, readmissions, and reoperations are, he said, the best measures of quality, but require risk adjustment and result in limited feedback.

“Specialty societies and the AAOS can improve quality by looking at evidence and identifying gaps in care,” said Dr. Bozic. He noted that the AAOS and the American Association of Hip and Knee Surgeons (AAHKS), in collaboration with the Physician Consortium for Performance Improvement, have established six performance measures for total knee replacement.

Finally, Dr. Bozic introduced a new initiative recently approved by the AAOS Board of Directors to develop performance measures. The goals of the program include developing orthopaedic performance measures, facilitating validation testing and implementation, establishing criteria for endorsement of measures developed by others, working with specialty societies on specialty-specific performance measures, and identifying priority topic areas, in conjunction with patients and policymakers.

Quality and advocacy
“I think we are closer to repealing the SGR than we have been in years,” said Thomas C. Barber, MD, chair of the Council on Advocacy. A bipartisan bill (HR 2810), which would eliminate the SGR, has been approved by the House Energy and Commerce Committee. The legislation has a value-based paradigm that requires a quality metric index, and payments from Medicare would be linked to quality starting in 2019. Further, it has a 5-year transition period, threshold-based measures, and quality metrics, which would be determined by medical specialty societies.

Dr. Barber also covered efforts to preserve the in-office ancillary services (IOAS) exemption. Recently, discussions on the IOAS have introduced the concept of mandatory AUC for all imaging studies, which he thinks would be very difficult to implement.

Regulatory advocacy, explained Dr. Barber, focuses on what happens after a measure becomes law. Efforts then focus on how the legislation is implemented. Using meaningful use of electronic medical records (EMR) as an example,
Dr. Barber pointed out that although 55 percent of AAOS members have EMR, only 27 percent have qualified for meaningful use payment, in part because the quality metrics “are not orthopaedic-friendly”; in fact, only one orthopaedic-related metric currently exists. He also noted that beginning in 2014, practices that do not qualify for meaningful use could be penalized.

Recently, the AAOS entered into a joint venture with CMS and The Brookings Institute, a major think-tank, on establishing CPGs for hip fracture care and developing a payment system that would encourage appropriate care. He also discussed the importance of partnerships with registries, including the American Joint Replacement Registry.

What’s the evidence?
“Evidence-based medicine (EBM) is not going to fit everyone perfectly; that’s not the goal,” said David Jevsevar, MD, MBA, who chairs the Committee on Evidence-Based Quality and Value. “It’s not a rule; it’s not a protocol.”

According to Dr. Jevsevar, EBM is the integration of best research evidence with clinical expertise and patient values. He explained that CPGs are reference sources, AUC promote implementation, and performance measures score implementation.

Dr. Jevsevar pointed out that orthopaedics has several observational studies, but still needs more prospective trials to measure efficacy and effectiveness. Comparative effectiveness studies—measuring two treatments against each other in terms of effectiveness and cost—are rare.

Michael Suk, MD, JD, MBA, chair of the BOS Health Policy Committee, wrapped up the session by discussing what creates value, which he explained has a contemporary definition of outcomes over cost plus patient experience. He pointed out the new emphasis on patient engagement and patient-driven care. “Better care does not always mean higher cost,” he noted. “Providers will face steadily increasing pressure to take cost out of the system while maintaining or increasing the quality of care.”

Although specialty societies must play a role in the development of physician performance measures, a 2013 quality metrics survey found that only 14 percent of orthopaedic specialty societies have a committee dedicated to quality, and just 9 percent undertake advocacy on quality. Dr. Suk outlined several potential participation opportunities, including having a volunteer member committee focused on quality, participating in the Choosing Wisely® campaign, joining an existing outcomes registry, or creating an outcomes registry.

“State societies and specialty societies have several opportunities to be engaged,” concluded Dr. Halsey. “Now is the time to participate in these movements.”

Elizabeth Fassbender is the communications specialist in the AAOS office of government relations. She can be reached at fassbender@aaos.org