Published 10/1/2014
John M. Froelich, MD; Roshan P. Shah, MD, JD

Quiet Before the Storm: What to Watch Out for After the Elections

As summer ends, political rhetoric heats up. Although little is accomplished in Washington, D.C., between the end of the August recess and Election Day, the action is just around the corner. Few truly novel policies may be introduced in the weeks ahead, but orthopaedic surgeons need to keep a watchful eye on legislative activities as Congress moves through the lame duck session and begins a new session in January 2015.

An SGR fix?
The first real opportunity for substantial legislative activity occurs during the lame duck session after the November elections. Although it usually lasts only about a month, the lame duck session can be packed with fireworks or, as the name suggests, be lame. A small undercurrent of optimism suggests that a resolution of the sustainable growth rate (SGR) issue could be addressed during the 2014 lame duck session.

Earlier this year, Congress made a significant push to finally and permanently fix the SGR. However, efforts were hampered by partisan politics, as House Republicans attached an amendment delaying implementation of the individual mandate from the Affordable Care Act to their version, and Senate Democrats provided no “pay-fors,” or ways to offset the cost of a fix so it would be budget-neutral in their version. As a result, neither the House nor the Senate bills had a chance of passage in the other chamber. Instead, another 12-month patch was passed (Protecting Access to Medicare Act of 2014: H.R. 4302).

Oregon’s Sen. Ron Wyden has been a fiscal hawk about the issue and supports eliminating the SGR. He now heads the Senate Finance Committee and may find more support for a true fix during the lame duck session than he did last spring. It will take goodwill from both sides of the aisle as well as in chambers of Congress to pass anything, but this December may be the best opportunity for passage before the price likely goes up and the SGR gets muddled together with the ever-present debt ceiling deadlines.

The debt ceiling and IOAS
The issue of the debt limit and a potential expansion of the debt ceiling will come into play early next year. The most recent Temporary Debt Limit Extension Act (S 540) expires on March 15, 2015.

But why should orthopaedists care about debt ceiling legislation? Recent debt ceiling debates have shown that the legislative fix for the issue will come at the 11th hour. When a deal of this magnitude is passed so close to the deadline, it often includes a few last-minute additions that skate through on the back of a must-pass piece of legislation.

One of those additions might reverse the Stark rule exemption for in-office ancillary services (IOAS) such as physical therapy and advanced imaging. The Congressional Budget Office has most recently scored this as a net savings of $1.8 billion over 10 years. This is not enough money to balance the national budget, but it could be tacked on during a late, heated debt ceiling debate.

Another option might be the SGR. The current legislative patch expires on March 31, 2015, just close enough to the debt ceiling debate to trigger a potential dynamic legislative situation.

One of the most talked about and prepared for policy changes expected this year was the conversion to the International Classification of Diseases, 10th edition (ICD-10) coding set. The implementation of ICD-10 was postponed as part of the SGR patch, delaying the roll-out of ICD-10 for 1 year from the original date of Oct. 1, 2014.

The interesting thing to note is that the SGR and ICD-10 were addressed in the same piece of legislation for the first time this year. It remains to be seen whether this initial binding will tie the two policies together in the future.

These are but a few of the issues that we as orthopaedists are going to be facing in the coming months. No guarantees exist on the direction that each of these issues will take, so continued involvement from the orthopaedic community is needed to secure positive outcomes for our practices and our patients. Regardless of the election outcomes next month, these issues will continue to play a role in how we can provide care for our patients.

John M. Froelich, MD, and Roshan P. Shah, MD, JD, are alumni of the AAOS Washington Health Policy Fellowship (2011–2012). Dr. Froelich is currently an assistant professor of hand surgery at the University of Colorado School of Medicine, Denver; Dr. Shah is an assistant professor of hip and knee reconstruction at Columbia University, New York City.