In his 2014 wrap-up (“Whatever Happened to 2014?”), S. Terry Canale, MD, suggested that many of 2014’s hot-button issues have been deferred to 2015. After reading his excellent review, one question and one thought arose. First, the question: Which of these deferments are susceptible to further delay? Second, I thought that, although many items, such as the sustainable growth rate (SGR) fix and the International Classification of Diseases (ICD)-10 code set, have been deferred or “patched over” a number of times, the past 5 years have ushered in major changes to orthopaedic practice lives.
Although I have yet to meet an orthopaedic surgeon who is eagerly anticipating ICD-10, for example, I also know that many have invested heavily in preparing their practices for this change. So far, these investments have been wasted. Isn’t ICD-11 just around the corner? The year ahead will bring additional challenges to orthopaedic practice management from all sides. Wholesale coding changes, should they arrive, are but a small sliver. These deferments may be popular in the short term, but the mountains of red tape and unpredictability of these federal decrees renders careful practice planning and anticipation nearly impossible.
As most AAOS Now readers are aware, there are other challenges to sound financial planning in the coming years. One of these is the elimination of global service fees. We are told the changes to these codes will be released gradually, but we have little idea of the size of this “hit.” At the very least, administrative costs to bill patients during this period will increase substantially.
These onerous new regulations have contributed to the migration of private practice and new orthopaedic surgeons into hospital employment agreements. Many practices are unable to model their future financial health and are reluctant to invest in young surgeons. Those older orthopaedists sick of administrative hassles have been greeted by hospital administrators eager to lock in their patient flow and contribution margins.
I’ve been in private practice and I am now an employed physician. Employment, by even the most benevolent nonprofit hospital system can be a lesson in bureaucracy, inaction, and frustration. It’s clear that physicians and hospital administrators speak a different language even though some of the words and phrases are the same. “Quality of care,” for example, may have a different meaning in the other dialect. Of course, those hospital systems with dominant market share and a sheaf of noncompete clauses may find the chance to reduce surgeon salaries tempting. Will these doctors stay?
Given the changes we can anticipate, which issues should be first and foremost in our discussions with our patients, partners, practice managers, hospital executives, and elected representatives?
Data collection and reporting
In 2015, data collection and reporting will be front and center. As Dr. Canale noted, the Physician Open Payments (Sunshine Act) database has yet to have much of an impact. In 2015, however, this may change. At some point, this data may be reworked into a user-friendly form. Patients and others may start to actually consider these relationships more closely when selecting a caregiver.
I suspect that the data that will have the greatest impact will center on the costs and quality of the care we deliver. Increasingly, payers will attempt to drive patients to lower-cost providers. And, as patients shoulder an increasing portion of the bill, they will seek out greater price transparency. With a better sense of the costs involved, these patients may well pursue care with the cheaper group across town or they may fly across the country. The smart orthopaedic surgeon will be working with his partners and hospital administrators to identify the true costs of his care to his patients and reduce those costs where possible.
As medical tourism increases, ethical questions about our duty to those patients who come to us with complications from surgeries carried out elsewhere will continue to skyrocket as well. How much of our scarce operating room time do we owe our neighbor with the infected total knee that was performed 800 miles away? How much will the move away from global service periods support this type of medical tourism? Will we create an underclass of “local yokel” orthopaedic surgeons whose practices survive on follow-up care from patients operated upon elsewhere?
Data collection has long been the purview of academic orthopaedics. In 2015 and beyond, this can no longer be true. Meaningful Use Stage 3 criteria are on their way and will require outcomes data collection from all of us. This data collection can be onerous, as I know from personal experience. But, we all need to be part of the framing of the value/quality debate. Each of us should collect reasonable patient-reported outcomes data so that spurious instruments and process measures are not used to judge our effectiveness.
Today, process measures such as readmission rates are used to rate the quality of our care, but little or no risk stratification is included. Websites such as medicare.gov/HospitalCompare and medicare.gov/PhysicianCompare will be useless until a more reflective dataset is used. In the absence of such risk stratification, we are likely to create a horde of medical refugees unable to get needed medical care from surgeons or hospitals loath to risk their ratings from the Centers for Medicare & Medicaid Services or Consumer Reports.
Over the past couple of years, the number of patients using physician rating websites has skyrocketed. The savvy orthopaedic surgeon will work with his practice management team to manage an online presence. I would mention, in passing, that three doctors facing criminal charges—two neurosurgeons and one orthopaedic surgeon—all had excellent ratings on multiple review sites at the time of their indictments. The orthopaedic surgeon had been convicted of healthcare fraud for multiple cases of faked surgery, yet received 4.5 out of 5 stars on the Healthgrades website. On the Vitals website, he not only won the compassionate doctor award but also twice won the patient’s choice award. There has to be a better way to guide patients.
It is incumbent on each of us to work with our partners as well as our local, state, and national medical societies to identify those measures that can be collected without undue burden on our office practices yet also offer a meaningful portrait of the care delivered.
Yes, as Dr. Canale wrote, 2014 was a year of delays and deferments. Yet, the daily practice of orthopaedic surgery has changed a great deal over the past few years. In the office, I am working on my third electronic medical record (EMR) system. It has its advantages, sure. But this one is, by far, the slowest. We’ve been on it for months, but there is simply no way to restore productivity to previous levels. Beyond the time I spend documenting an encounter, the EMR-generated notes I read from a patient’s hospital stay or another doctor’s office assessment are multiple pages long, but the critical data is buried.
It’s too soon to tell if the relabeling of hydrocodone will save lives or, as is all too often the case, some unintended consequence will only compound the problems of addiction and diversion. As physicians are increasingly being graded on patient satisfaction, these problems will not be solved without acknowledging the demand side of the equation as well.
Over the past few years, a number of hospital systems have decided to cut out the middle-man, relabel themselves as health systems, and offer insurance products directly to patients. Steven Brill, in the Jan. 19 issue of Time Magazine, wrote an interesting follow-up to his April 2013 “Bitter Pill: Why Medical Bills Are Killing Us” article. While “Bitter Pill” focuses on the hospital chargemaster, his new article, “What I Learned from My $190,000 Open-Heart Surgery,” focuses on various options to reform health care expenses. He concludes that doctor administered “oligopolies” [large hospital systems with employed physicians and their own insurance products] would cut costs and maintain quality by aligning incentives under one roof. I suspect the Cleveland Clinic’s Toby Cosgrove agrees, but how about the orthopaedic surgeon in private practice? Certainly, adding complexity to our already chaotic “system” might well lead to complete collapse.
Is our situation dire? With change comes opportunity. But, those changes also require us to keep our heads in the game in ways we may not have considered in the past. The academic orthopaedic surgeon must be involved in advocacy, cost-effectiveness research, and practice management to an ever-increasing degree. The private practice surgeon needs to learn the language of the cost and quality literature. He must collect, and act on, his outcomes data.
Some employed physicians may feel comfortable getting a regular salary and want to stay out of the fray. They shouldn’t. That hospital employer will not keep paying that salary if the surgeon’s contribution margin plummets. Each orthopaedic surgeon owes his or her patients ongoing advocacy efforts to maintain access to care, funding for research, and reimbursement for quality orthopaedic care.
In the coming year, AAOS Now will explore these issues and others in detail. It will provide regular updates from Washington and guidance from practice management experts. It will review new portable technology and apps that assist the practicing orthopaedic surgeon. Of course, as orthopaedic surgeons, we cannot lose focus from our true center, the care we provide our patients.
The coming year promises to be full of new findings and controversies. From general questions such as how new modalities in biologics, stem cells, cell culture, and bone morphogenetic proteins apply to our patients to more specific issues such as management options for SLAP (superior labrum anterior to posterior) lesions, AAOS Now will continue to keep our readership updated through articles, roundtable discussions, and debates. You may choose to read some. You will be able to listen to others in the car on the way home. Along the way, please send us your ideas and concerns.
Eeric Truumees, MD, is editor-in-chief designee for AAOS Now. He can be reached at email@example.com