The rack, popularized by Torquemada the Grand Inquisitor, was a device of orthopaedic torture. In it, the victim’s ankles were fastened at one end and his wrists at the other. The inquisitor could then twist a ratchet, pulling the ankles distally and the wrist proximally, thereby dismembering the victim.

The modern orthopaedic torture device—less gruesome but pain-inflicting nonetheless—is the RAC: Recovery Audit Contractor. As noted in AAOS Now last year, “The Recovery Audit Contractor (RAC) program was created through the Medicare Modernization Act of 2003. Designed to extract waste from the Medicare system by identifying and recovering improper payments paid to healthcare providers, the RAC program has been successful in reclaiming money through retrospective reviews of fee-for-service claims, a process known as ‘claw back.’” Sounds innocent, but this is a torture machine, no doubt about it.

The RAC program was not created with orthopaedic surgery in mind, but given the nature of our practices and the types of conditions we treat, I suspect that orthopaedists (and our patients) will be disproportionately tortured by RACs. Specifically, we as orthopaedic surgeons are apt to be tagged for providing care that RACs say fail the test of medical necessity.

Let’s follow the dots. Total knee replacements are up. … Medicare gets the bill, increasing costs to the system. … The Centers for Medicare & Medicaid Services (CMS), in its effort to reduce costs, tries to find fault with the provider. … The claw back money comes from a health system, which, in the United States, is faith-based most of the time, operating on margin, and, if it’s lucky, will survive to provide an anchor and safety net for local communities.

The problem is that the dots don’t line up! A review of the National Institutes of Health Consensus Statement on Total Knee Replacements (December 2003) finds that experts agree that this treatment provides “substantial improvement in the patient’s pain, functional status, and overall health-related quality of life in about 90 percent of patients.”

Since the issuance of this document, there has been no consensus on the indications for a knee replacement other than “pain unresponsive to drug therapy.” The only one who knows whether this actually occurred is the patient.

Although some guidelines have been released regarding the metrics to be used, these metrics have not been verified and are significantly different from the dialogue that takes place among patients, their families, and their physicians in deciding that a knee replacement is necessary. This simple fact has not prevented the RAC auditors from announcing impending claw backs of improper payments.

Why so many surgeries?
The reason that knee replacement surgeries are increasing has little to do with physicians performing needless or improper surgery.

Knee replacements are a mature treatment, with demonstrated long-term benefits and safety. Gone are the horror stories of years past. Instead of an abundance of caution and trepidation, patients now have a commonplace familiarity with the surgery. Widespread advertising by the medical/industrial complex featuring slim, fit individuals enjoying a life of leisure and sports only reinforces this optimistic perception.

The well-publicized recall of Vioxx® (rofecoxib) has enhanced the public perception that some pain killers cause heart attacks. The pharmacy printouts are becoming longer, the print smaller, and, when reinforced by the pharmacist’s verbal cautions regarding their use in the presence of hypertension, the public has decided that this is not an avenue to be pursued.

Insurance company denials for medications such as Celebrex® (celecoxib), Vimovo® (naproxen and esomeprazole magnesium), and Duexis® (ibuprofen and famotidine) have effectively removed these modalities as treatment options. The healthcare consumer, faced with exorbitant health insurance premiums, does not want to consider additional out-of-pocket expenses for proprietary medications, effectively removing these medications as treatments. Indirectly, these denials are provoking earlier consideration of knee replacement surgery than would happen if these medications were reasonable options.

There is now a generation of surgeons who can perform the procedure safely, expeditiously, effectively, and reproducibly. With community outreach, social media, web pages, and consumer rating services, it’s easier than ever before to find a surgeon. The decision has gone from one made by the physician for a patient in extremis (orthopaedically) to one made by a savvy healthcare consumer who has shopped around and has seen videos of the surgery. Technology has made the esoteric commonplace, giving it widespread acceptance.

The improvements in materials, such as highly crosslinked polyethylene, in manufacturing and in finishing have improved the durability of implants. This has enabled expansion of indicated age ranges so more people are eligible. The U.S. population is aging, and the “baby boomers” are reaching retirement age. All of this adds up to more total knee replacements being performed, appropriately.

Making the right decision
Any good validated screening tool should correctly identify all the appropriate knee replacement patients and screen out those who are not. If I consider the knee surgeries I would rather not have done, I find that decisions were made based on inadequate information, incomplete facts, and wrong motivation.

A RAC audit may identify situations that, upon review, are simple to remedy. Although, in principle, electronic health records are supposed to make the patient chart transparent, in practice, our system is not there yet. Many of the parameters a RAC requires to be in the hospital record are contained in detail in the physician’s office record. Until electronic office notes automatically transfer to the hospital record, manually transferring the record should resolve this basic issue.

The radiographic findings of cysts, sclerosis, osteophytes, and joint narrowing are often present on the image but not recorded as such by the radiologist. The interpretation may conclude simply moderate or severe degeneration, without identifying the underlying cause. This can be remedied by raising the radiologist’s awareness of the need for documentation.

As far as medication efforts, in large physician practices, sharing electronic health records should show previous attempts to manage pain. I find it problematic that the mandated electronic health record at my hospital is deficient in disseminating the information needed to avoid being flagged for an audit.

The impact of audits
In the short term, a large cadre of auditors will provoke an equally large cadre of compliance specialists—all of whom will drive up healthcare costs and divert resources from new technology and healthcare infrastructure. The automated checklists will never replace the priority of the patient’s health and orthopaedic needs.

As a resident, I was taught by Zachary Bert Freidenberg, MD that the following were indications for treatment:

• Adequate findings
• The desire to improve
• Adequate health

In my own discussions with patients, I include the following:

• The medication doesn’t work (or the patient will not take it).
• The joint’s abilities do not meet the patient’s needs (duplicative in a sense of the desire to improve).
• The patient has a trick knee that cannot be trusted. That is all.

Menachem M. Meller, MD, practices at Mercy Fitzgerald Hospital/Mercy Philadelphia Hospital.

Additional Resources

1. Anderson A, Martin R: What You Should Know about Medicare Audits. AAOS Now, February 2012 (http://www.aaos.org/news/aaosnow/feb12/advocacy3.asp) Accessed Jan. 4, 2013.
2. National Institutes of Health. NIH Consensus Development Program: NIH Consensus Development Conference on Total Knee Replacement. Statement on total knee replacement. 2003 Dec 8-10;20(1):1-34. http://consensus.nih.gov/2003/2003TotalKneeReplacement117html.htm Accessed Jan. 4, 2013.