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Wow! Whatever happened to 2014? I didn’t even see it go by! It seems as if 2014 was the year of the “postponement.” Any actions on issues of importance have been moved to 2015. Another way of saying this is that the advocacy and practice management issues that are most significant for medical practices have been delayed or deferred to 2015.

AAOS Now

Published 1/1/2015
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S. Terry Canale, MD

Whatever Happened to 2014?

Is it over or did it just get postponed?

It seems that both the legislative and executive branches of the federal government (the president and Congress) have decided to adopt a “policy of postponements,” as David J. Rothkopf calls it. So important issues have been postponed until after the midterm elections, or until the lame-duck session, or until the 114th Congress takes office, or maybe even postponed until after the 2016 presidential elections so that someone else in the White House can deal with the issues.

But I’m not going to postpone any more. AAOS Now has chosen 10 “hot topics” from 2014, many of which were postponed by others but covered by AAOS Now.

Needless to say, work by the Academy’s Board of Directors, volunteers, and staff did not get postponed, and moved forward making great progress in education, advocacy, quality, and construction (See No. 10).

1. The SGR and ICD-10
Because Congress couldn’t agree on how to pay for repealing the sustainable growth rate (SGR) formula, we got an “almost” repeal early in 2014, in the form of another delaying patch and tied to the postponement of the ICD-10 implementation date. (I’ll wager ICD-10 doesn’t have a code for that!)

Organized medicine is now caught on the horns of a dilemma. Almost all physicians want to repeal the present SGR formula, but just as many probably do not want to implement ICD-10 coding. Unfortunately, many large practices have already spent huge sums of money gearing up for the start of ICD-10 and now have excess expenses on their books. In 2015, we can hope that the two issues will be separated.

2. Simulation training and education
I have been involved in musculoskeletal surgical simulation education since its beginning with the AAOS in the early 1980s. Howard Mevis, director of the Academy’s department of electronic media, evaluation programs, course operations, and practice management, has worked with Jay Mabrey, MD; W. Dilworth Cannon Jr, MD; and Robert A. Pedowitz, MD, PhD, guiding this process through tortuous, albeit exciting, times and with very little financial backing.

I believe a breakthrough occurred in 2014, due in part to the Accreditation Council of Graduate Medical Education mandates for resident training in simulation and in part to the advances in technology for simulation models. In 2015, I hope simulation programs spread across the country and more affordable equipment becomes available. The data are already showing the benefits of simulation training in surgical education.

3. The Sunshine Act
“I can see clearly now, the rain has gone … ” Hey, not so quick. The purpose of the Sunshine Act was to disclose anything of value transferred to physicians from device or pharmaceutical companies. This was to be very transparent; if it had to be reported, organized medicine wanted complete, full, and transparent disclosure.

But because of delays, electronic reporting glitches, irrelevant and incomplete data, and huge numbers (of those being reported), the whole process seems slow, tired, and hard to navigate, in addition to being confusing. Instead of sunshine, we had fog. Will the sun ever shine through? Not in 2014.

Stay tuned for more government postponement actions; someday, it will be a “bright sunshiny day.”

4. Midterm elections
Well, Republicans gained control of both houses of Congress after winning seven new seats in the Senate. The lame-duck Congress did pass a budget bill that didn’t include either an SGR repeal or an ICD-10 delay. However, it did cut the budget for the Independent Payment Advisory Board (IPAB)—that 15-member appointed board with the authority to make fast-track changes to Medicare payments—while simultaneously maintaining funding for peer-reviewed orthopaedic research and increasing funding for the National Institutes of Health. It also included language supporting the AAOS position on the proposed changes to global payments. (See cover story, “CMS Converting All Global Payments for Procedural Services to Zero Days.”)

In 2015, the Republicans will have to live up to their promise of change. No longer will the news channel “spin commentators” be able to blame the Democrats for all the government’s faults. In 2015, the Republicans will have to produce or be criticized by the news commentators.

5. Practice management
AAOS Now
readers can’t seem to get enough articles on practice management, perhaps because, like advocacy, it keeps changing all the time. New initiatives instituted in 2013 and implemented in 2014 will hopefully show some results in 2015. Much of the data about how orthopaedists like being hospital employees also should be forthcoming in 2015.

In 2014, AAOS Now had news stories on bundled payments, medical tourism in the United States and abroad, concierge medicine, perioperative medical homes, and comanagement agreements.

Wow! Whatever happened to 2014? I didn’t even see it go by! It seems as if 2014 was the year of the “postponement.” Any actions on issues of importance have been moved to 2015. Another way of saying this is that the advocacy and practice management issues that are most significant for medical practices have been delayed or deferred to 2015.
Inaction and delays added to the weight of issues that must be addressed in 2015, crushing the memory of unmet goals in 2014.
Courtesy of Thinkstock

6. Stem cells: Myth or miracle?
First it was bone morphogenetic protein, then platelet-rich plasma, and now stem cells, the magical mesenchymal cure for cartilage defects, soft-tissue injuries, tendonitis, arthritis, and nonunions. I thought 2014 would be the year of the stem cell, but all we got was “take two stem cells and call me in 2015.” So another delay, but maybe more research will make a little more sense and organization out of stem cells.

So did anything happen in 2014? It looks as if it all got postponed to 2015. But several events weren’t delayed and most were clinical and newsworthy.

7. A focus on addiction and drugs
The use of opioids as street drugs and the flagrant abuse of oxycontin forced the U.S. Food and Drug Administration to reclassify hydrocodone combination products as Schedule II drugs in 2014. Now, physicians must write prescriptions for these drugs (a call-in is no longer sufficient) and only a limited number can be prescribed (90-day supply). This will help, but there is still the drug-seeking patient and how to manage the patient’s pain.

Not only that, but our profession is looking hard at itself concerning physician substance abuse. With 15 percent of physicians abusing substances, it is necessary that we police our own before any such abuses affect our patients. In 2014, several good articles appeared in AAOS Now on all the ramifications of addiction involving our patients and our physicians.

8. The upper extremity
Popular news stories continued to focus on reverse total shoulder arthroplasty and controversial reports on the best way to treat rotator cuff pathology. But two smaller items caught the eye of our readers: First, an unexpected bacterium revealed as a possible cause of occult shoulder infections, and second, updates on treatment modalities for Dupuytren contracture of the finger.

In 2014, the organism Propionibacterium acnes (P acnes), which is extremely hard to culture, was reported to be the unknown cause of shoulder infection and/or failed shoulder operations. P acnes has even been compared to Helicobacter pylori, which also is difficult to culture but may be the origin of most gastric ulcers. Further evidence in 2015 and beyond will determine the prevalence of this little-known and seemingly benign bacterium that caused me embarrassing moments as an adolescent with acne.

Some order was finally put into the new treatment of Dupuytren finger contracture in 2014. Several reports compared percutaneous needle aponeurotomy or injection with collagenase and manipulation to older, more formal open surgical release and fascial resection. Collagenase and needle aponeurotomy are both enjoying success in treating initial contractures and recurrences. I’ll bet Professor Dupuytren would turn over in his grave if he knew that the palm contracture named after him was being injected with meat tenderizer!

9. Fat and heads
Two entities that continued to be of interest in 2014 were obesity and concussion. Obesity (and other comorbidities) make it difficult to surgically treat afflicted patients and, more important, make it difficult to treat the surgical complications that seem to occur more often in these patients. However, the concept of denying surgery to patients who are obese because of a possibility of poor results and increased complications is being challenged as unethical. Stay tuned—this has been delayed, but will be brought up again in 2015.

The second entity is concussions in athletes. The National Football League (NFL) settled an almost $900 million lawsuit with players who suffered terminal effects from concussions. Following that, it was reported that effects of concussion can be seen in the form of early dementia and subtle loss of mental acumen secondary to concussions, and another class-action lawsuit has been filed against the NFL by the players.

AAOS Now even spoke with a member of the NFL Concussion Committee about the issue. (See “Unlocking the ‘Black Box’ of Concussion.”)

The real question is whether parents will be willing to sit by and allow their children to participate in collision sports that are known to cause concussions, if concussions cause permanent damage at any age, however small they may be. In 2014, information about which organized sports cause what percentage of concussions was made known. So while the lawsuits are pending, the real effect on organized collision sports is not yet known.

10. A new home for orthopaedics
I really would be remiss if I didn’t mention the Academy’s new “digs,” which unofficially opened in December 2014. I was involved with AAOS when it was located in a small office on Michigan Avenue in downtown Chicago (1978); then it moved out to Park Ridge, Ill. (1985), then to Rosemont, Ill. (1991), where the Orthopaedic Learning Center (OLC) opened (1993), and now to the newest and nicest building in Rosemont, with the most sophisticated learning center anywhere. Equity partners in the building include the American Orthopaedic Society for Sports Medicine, the American Association of Hip and Knee Surgeons, the Arthroscopy Association of North America, and the OLC.

Congratulations to all of our fellows, other specialty societies, industry, and staff whose hard work and contributions made this possible. Staff moved into the new building on Dec. 8, 2014, and the first courses in the OLC will be held later this month.

Did we close 2014? I didn’t see it go by—was it postponed or did I just miss it?

S. Terry Canale, MD, is the editor-in-chief of AAOS Now. He can be reached at aaoscomm@aaos.org