Published 9/1/2015

Second Look – Advocacy

These items originally appeared in AAOS Headline News Now, a thrice-weekly enewsletter that keeps AAOS members up to date on clinical, socioeconomic, and political issues, with links to more detailed information. Subscribe at www.aaos.org/news/news.asp (member login required)

Surgeons’ complications database
has posted an online database of complication rates for elective procedures performed by nearly 17,000 surgeons in the United States. The organization drew data from 5 years of Medicare records for eight common elective procedures, including spinal fusion and knee and hip arthroplasty. Of all surgeons in the database, 11 percent database accounted for about 25 percent of all complications; 756 surgeons who performed at least 50 operations did not record a single complication, and another 1,423 surgeons recorded only one complication.

Transitioning to ACOs
Data published in Annals of Family Medicine (July/August) suggest that changes in reimbursement for physicians who transition from a fee-for-service to accountable care organization (ACO) model may be negligible. Based on data from a national survey of primary care physician practices, physicians in ACO and non-ACO practices with no substantial risk for costs generally received nearly one-half of their compensation from salary, slightly less from productivity, and about 5 percent from quality and other factors. Physicians not working in ACOs but with substantial risk for primary care costs received two-thirds of their compensation from salary, nearly one-third from productivity, and slightly more than 1 percent from quality and other factors. Participation in ACOs was associated with significantly higher physician compensation for quality, whereas financial risk was associated with much greater compensation from salary.

Healthcare reform impact on care
According to data in the Journal of Orthopaedic Trauma (online), implementation of healthcare reform may have little effect on treatment of femoral neck fracture. Based on data on 23,485 patients treated for femoral neck fracture in Massachusetts before and after institution of statewide healthcare reform, no significant differences were found in the type of surgical intervention performed pre- and post-reform. However, after adjustment for case-mix and surgical intervention, length of stay and likelihood of failure-to-rescue were significantly reduced. In addition, t discharges to skilled nursing facilities significantly increased during the post-reform period. The differences in quality measures could not be necessarily attributed to healthcare reform.

Impact of negotiating drug prices
A report released jointly by Carleton University School of Public Policy and Administration and the consumer group Public Citizen argues that Medicare Part D could save between $15.2 billion and $16 billion each year if it could secure the same prices that Medicaid or the Veterans Benefits Administration (VBA) receives on the same brand-name drugs. The report also found the following:

  • After rebates, brand-name drugs cost Medicare Part D 198 percent of the median costs for the same drugs in the 31 Organization for Economic Cooperation and Development (OECD) countries.
  • Medicare Part D pays, on average, 73 percent more than Medicaid and 80 percent more than the Veterans Benefits Administration (VBA) for brand-name drugs.
  • Although Medicaid and VBA often are used as benchmarks, those organizations also pay higher prices than many OECD countries.

Projected healthcare spending
The U.S. Centers for Medicare & Medicaid Services (CMS) projects total healthcare spending to increase an average of 5.8 percent per year from 2014 through 2024. The rate is less than the 9 percent average seen in the three decades leading up to 2008. Other findings of the report include the following:

  • Approximately 19.1 million additional people are expected to enroll in Medicare during the next 11 years.
  • The overall insured rate is expected to rise from 86.0 percent to 92.4 percent over the next 11 years.
  • Medicaid spending during 2014 is projected to decrease by 0.8 percent because new enrollees are expected to be somewhat healthier than those who were enrolled previously. Overall spending may increase by 12.0 percent in 2014, as a result of a 12.9 percent increase in enrollment related to coverage expansion under the Affordable Care Act.

Specialty certification and recertification
A survey of members of the Tennessee Medical Association finds that many physicians in the state find the cost and effort associated with specialty certification and recertification to be unreasonable, with little return on investment in terms of patient care. Among the survey findings are the following:

  • One in four physicians said they intend to relinquish their board specialty certifications before retiring from medicine, and 74 percent plan to let them lapse after they retire.
  • Approximately 64 percent of respondents have had multiple recertifications after their residency or fellowship, and more than half of those have undergone recertification two or more times.
  • More than one in three physicians begin preparing for recertification at least 1 year in advance.
  • The average cost among respondents to become certified by their specialty boards is approximately $2,250.

Standards for blood clot prevention
A research letter published in the journal JAMA Surgery (online) argues that “best-practice” standards for the prevention of blood clots after surgery may be set too low. The retrospective review of 128 patients who were treated at a single center and had hospital-acquired venous thromboembolism (VTE) found that 36 patients (28 percent) had non-preventable, catheter-related upper extremity clots, leaving 92 patients (72 percent) with potentially preventable clots. Of those patients, 79 (86 percent) were prescribed clot-preventing medications, yet only 43 (47 percent) received “defect-free care.” Of the 49 patients (53 percent) who received suboptimal care, 13 (27 percent) were not prescribed risk-appropriate clot-preventing drugs, and 36 (73 percent) missed at least one dose of appropriately prescribed medication. Although existing VTE care goals set by The Joint Commission and CMS say that one dose of clot-preventing medication is given to patients within the first day of hospitalization, data suggest that may not be enough.

Observation care transparency
Congress has approved and the president is expected to sign legislation to require hospitals to tell Medicare patients when they receive observation care yet have not been admitted to the hospital. Under the so-called NOTICE Act, hospitals would be required to provide written notification to patients 24 hours after receiving observation care, explaining that they have not been admitted to the hospital, the reasons why, and the potential financial implications. While under observation care, Medicare patients are ineligible for more comprehensive Medicare hospitalization coverage, and may also be ineligible for Medicare’s limited nursing home benefit for care after admission to a hospital. Hospitals will be required comply with the act 12 months after it is enacted.

IOM report
A report by the Institute of Medicine (IOM) looks at timeliness in access to health care and outlines the following basic principles to develop systems-based approaches to scheduling and access:

  • Matching supply with projected demand through formal, ongoing evaluation
  • Immediate engagement and exploration of patient’s needs, at the time of inquiry
  • Patient preference on the timing and nature of care, invited at inquiry
  • Need-tailored care with reliable, acceptable alternatives to clinician visits
  • Surge contingencies, or provisions for accommodating patients’ acute issues that cannot be addressed in a timely manner
  • Continuous assessment of changing circumstances in each care setting

Off-label drug promotion
The Associated Press reports that a federal district court has ruled that the U.S. Food and Drug Administration (FDA) may not prohibit a drug manufacturer from truthfully promoting its product for off-label use, because doing so would violate the First Amendment. The ruling only applies to the 2nd U.S. Circuit Court of Appeals, which includes New York, Connecticut, and Vermont. However, observers note that it could set a precedent with far-reaching implications.

Reduction in uninsured numbers
According to survey data released by Gallup, the percentage of people in the United States who lack health insurance has fallen from 17.3 percent in 2013 to 11.7 percent in the first half of 2015. The random sample included178,072 adults in 2013 and 88,667 adults through the first half of 2015. All survey participants were aged 18 years or older, and from all 50 states and the District of Columbia. In addition, states that opted to expand Medicaid and set up their own state exchanges or partnerships in the health insurance marketplace have seen significantly greater declines in uninsured rates since 2013 compared to states that did not take those steps.

Physician dissatisfaction with EHRs
A report released by AmericanEHR and the American Medical Associations suggests that many physicians may be dissatisfied with their electronic health records (EHR) systems. The survey of 940 physicians between May 30, 2014 and July 18, 2014 found the following:

  • 42 percent of respondents thought their EHR system’s ability to improve efficiency was difficult or very difficult
  • 72 percent thought their EHR system’s ability to decrease workload was difficult or very difficult
  • 54 percent found their EHR system increased their total operating costs
  • 43 percent said they had yet to overcome the productivity challenges related to their EHR system

Clinical performance measures
A research letter published in JAMA Internal Medicine (online) suggests that clinical performance measures may not adequately measure overuse of care. The research team identified all outpatient and emergency department process measures from major national measure programs and clearing houses. Of the 521 measures that met inclusion criteria, 477 (91.6 percent) targeted underuse, 34 (6.5 percent) targeted overuse, and 14 (2.7 percent) targeted misuse (4 measures addressed two target issues). Overall, of 16 measure collections, just 3 contained an “appreciable” representation of overuse measures, while 7 contained no overuse measures.

Follow-up data for high-risk devices
Findings from a study published in The Journal of the American Medical Association (Aug. 11) suggest that more timely follow-up studies should be conducted for “high-risk” therapeutic devices approved via the FDA Premarket Approval (PMA) process. The review of data on 28 high-risk therapeutic devices that received initial marketing approval via the PMA pathway during 2010 and 2011 identified 82 premarket and 204 postmarket studies of the devices. Of the postmarket studies, only 26 were reported as completed within 3 to 5 years of FDA approval. In addition, five devices had no postmarket studies and 23 devices had three or fewer postmarket studies. Further, approximately half of the studies did not measure comparative effectiveness of the device against an existing product.