Published 1/1/2013
Madeleine Lovette

AAOS Taking Lead in Defining Quality in Orthopaedics

Orthopaedic Quality Institute seeks to identify path forward

With last summer’s Supreme Court decision and the re-election of President Obama, healthcare reform is here to stay. The Patient Protection and Affordable Care Act (PPACA) is putting pressure on providers to improve outcomes and lower the cost of care. In addition, market forces being exerted by both consumers and businesses are compounding the demand for better healthcare at lower costs.

Recognizing this demand and the power of collaboration, the American Association of Orthopaedic Surgeons (AAOS) initiated an annual Orthopaedic Quality Institute (OQI) in 2011. The OQI brings payers, purchasers, and representatives of other providers together with orthopaedic surgeons to identify and improve musculoskeletal care delivery and affordability.

The 2012 OQI, held Nov. 8–9, in Washington, D.C., built upon the inaugural meeting by addressing the AAOS role in defining quality musculoskeletal care and specific recommendations. AAOS President John R. Tongue, MD, and other participants noted that the meeting had a more energetic tone than the inaugural session. The presentations examined PPACA initiatives and parallel private sector reforms and highlighted concrete accomplishments and deliverables contributing to the quality movement.

A sense of urgency marked the conference, which was cochaired by Kevin J. Bozic, MD, MBA, chair of the AAOS Council on Research and Quality, and Craig A. Butler, MD, MBA, chair of the AAOS Health Care Systems Committee. Speakers and participants highlighted the need for evidence-based outcome measures and multistakeholder partnerships to meet the goals and milestones established by PPACA.

Data demand
In his opening remarks, Dr. Bozic acknowledged that orthopaedic conditions are some of the most expensive to treat and that the costs and outcomes of those treatments vary. He noted that both payers and purchasers want to know that their orthopaedic care is a good value.

“Healthcare costs are continuing to soar, and consumers are paying much of the tab,” said Dr. Bozic. “We have a real duty to our patients to measure quality and cost in orthopaedics, with the ultimate goal of improving the value of the care we deliver.”

This sentiment was echoed by consumer representative Cheryl DeMars, MSW, president and CEO of The Alliance, a nonprofit, employer-owned cooperative that seeks to help its members manage their healthcare dollars and have a positive impact on employee health.

Ms. DeMars said that the cost pressures on Alliance members are more acute than ever and that a movement to explicitly fund evidenced-based, appropriate, cost-effective care is growing.

“For our employers, health care is a significant and rising cost,” said Ms. DeMars. “Employers are beginning to ask for transparent information on quality and cost.” According to Alliance members, orthopaedics is associated with higher utilization rates than cardiology, neurology, and other specialties. Between 2000 and 2009, for example, the number of total knee replacement surgeries increased four-fold; readmissions after total joint replacements cost Alliance members $35 million and 7,687 hospital days.

“The path for the future will be to pair cost with quality information,” said Ms. DeMars. “Our members want to make this information available to their employees and encourage them to choose providers who will offer the most value.”

Meeting the demand
In response to the demand for evidence-based medicine and performance data, both private and public healthcare sectors are looking for better ways to capture outcomes and report them to providers and consumers.

According to Carolyn Clancy, MD, director of the Agency of Healthcare Research and Quality, and Thomas B. Valuck, MD, JD, senior vice president of strategic partnerships at the National Quality Forum, quality measures are becoming increasingly valuable to payers and purchasers. A quality outcome measure typically originates from the patient’s medical record, while a quality process measure usually quantifies an operational process by using rates, percentages or time durations that delineate the appropriateness of care being delivered to patients.

They noted that the healthcare quality movement is shifting to an integrated electronic platform derived from registries, electronic medical records (EMR), and data-based sources. The information is used to calculate performance measures, provide real-time information to clinicians, and ultimately influence the determination of payment.

Both speakers emphasized the importance of AAOS member participation in reporting programs and registries such as the American Joint Replacement Registry. Such participation can help improve the evidence base used to develop clinical practice guidelines, appropriate use criteria, and other quality measures.

“Measurement data are useful for payers and purchasers to determine who the high-quality providers are,” said Dr. Valuk. “They are also useful to providers for identifying areas that need improvement.”

Kate Goodrich, a representative from the Center for Medicare and Medicaid Services (CMS), also encouraged AAOS members to participate in reporting programs like the CMS Physician Quality Reporting System (PQRS) and registries to accelerate the acquisition of robust measures.

“Registries are the fastest growing method for submitting clinical quality measures,” Ms. Goodrich said. “Participation by physicians and other clinicians in these and other initiatives is essential to the success of quality measurement and improvement efforts.”

A sense of urgency
According to Dr. Bozic, patients expect that physicians are the most qualified to measure quality and value in their respective specialties. However, if providers do not meet this demand on a timely basis, consumers and payers are not going to wait. This urgency might explain why public and private payers have begun to develop their own rating and payment systems to measure provider cost and quality.

PPACA, for example, requires Medicare to phase in a value-based payment modifier beginning in 2015 to assess provider payments based on both the quality and cost of that care. In addition, commercial rating organizations such as Consumer Reports have also begun to report provider value to patients.

According to John Santa, MD, MPH, director of the health ratings center at Consumer Reports, his organization and others are looking to medical professional societies like the AAOS for data. He noted, however, that his company reports on any public data that “it can make sense of and thinks is credible.

“Physician comparison and cost performance measures are in demand. We believe that physicians have access to valuable data, and when it is collected and analyzed by those in the specialty, it will be more informative,” said Dr. Santa. “We stand ready to work with the provider community, but consumer advocates are going to continue their activities regardless of the degree of collaboration.”

Future quality objectives
OQI speakers and participants acknowledged the progress that the AAOS has made in the past year. For example, the AAOS is developing broader evidence-based clinical practice guidelines (CPGs) by shifting the emphasis from the treatment of a specific condition to the comprehensive care of the patient. In addition, the AAOS is identifying CPGs and appropriate use criteria (AUC) topics with more substantial evidence bases, including patients and payers/purchasers in CPG and AUC development, and modifying the language of CPGs to make them more user-friendly for a multitude of healthcare stakeholders. But much more can be done to ensure that communities across the country receive affordable, high-quality musculoskeletal care.

In the end, attendees agreed that the AAOS should take the following steps in moving forward on quality initiatives:

  • Continue to collaborate with healthcare stakeholders, including patients, to identify the evidence gaps and quality challenges in orthopaedics.
  • Acknowledge the importance of quality measurement and physician performance reporting in addressing the cost and quality variance of high-volume orthopaedic procedures.
  • Place a stronger emphasis on patient outcomes and patient satisfaction.

Madeleine Lovette is the communications specialist in the AAOS office of government relations; she can be reached at lovette@aaos.org