Published 4/1/2016

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).

CMS overpayment rule
The U.S. Centers for Medicare & Medicaid Services (CMS) has issued a final rule regarding overpayments. Under terms of the rule, physicians are responsible for a 6-year lookback period—a reduction from the 10-year period originally proposed. The final rule requires providers and suppliers that receive funds under the Medicare program to report and return overpayments by the later of the date that is 60 days after the date on which the overpayment was identified; or the date any corresponding cost report is due, if applicable.

RAC appeals
Modern Healthcare reports that a three-judge panel of the U.S. Court of Appeals for the District of Columbia Circuit has reversed the decision of a lower court, which had ruled that a delay in processing Recover Audit Contractor (RAC) appeals did not require court oversight. The U.S. Department of Health and Human Services (HHS) currently has a backlog of approximately 800,000 appeals, or about 10 times as many as it can adjudicate each year at current funding levels. The American Hospital Association and others argued in a lawsuit that the appeals process for improper claims as identified by RACs is too slow and can leave some Medicare payments unresolved for years. The appeals court decision returns the case to the lower court for reconsideration.

CMS VBP program
According to The Portland Press Herald, in a letter to the secretary of HHS, 26 senators have questioned the inclusion of pain control as a quality factor under the CMS Hospital Value-Based Purchasing  program. The writers agree that pain control is a critical component of inpatient care, but argue that in light of an increase in deaths related to opioid abuse, discharge surveys that query patients about pain control may inadvertently compel physicians to prescribe opioid pain relievers in order to improve hospital performance on quality measures. "…[W]e are concerned that the current evaluation system may inappropriately penalize hospitals and pressure physicians who, in the exercise of medical judgment, opt to limit opioid pain relievers to certain patients and instead reward those who prescribe opioids more frequently," they write. "We understand that HHS has begun an examination of whether there is a connection between these measurements and potentially inappropriate prescribing patterns, and whether the survey should be modified to address this concern. We hope this is a robust examination of this issue and includes more input from hospitals and providers, many of whom have expressed concern to us about the survey's impact on opioid prescribing practices."

Supreme Court
An article in Modern Healthcare looks at possible effects the death of U.S. Supreme Court Justice Antonin Scalia could have on pending cases. Justice Scalia was a noted conservative voice on the court, and joined a dissenting opinion in the 2012 case that upheld the individual mandate of the Affordable Care Act (ACA). He also wrote the dissenting opinion in last year's King v. Burwell decision, which allowed Americans in all states to receive insurance premium subsidies. The publication notes that the court is currently considering a case that addresses data sharing, and another with the potential to affect the number of False Claims Act suits brought against healthcare providers and other companies. President Obama has announced his intention to name a successor to fill the vacancy on the court, but opposition in the U.S. Senate is expected to complicate that process.

New quality measures
CMS and America's Health Insurance Plans have released seven sets of clinical quality measures, covering areas such as orthopaedics, accountable care organizations, and patient-centered medical homes. The move is part of the Core Quality Measures Collaborative of healthcare system participants, including the American Association of Orthopaedic Surgeons (AAOS). Included among the core measures are the following:

  • hospital-level risk-standardized complication rate following elective primary total hip arthroplasty (THA) and/or total knee arthroplasty (TKA)
  • hospital-level 30-day, all-cause risk-standardized readmission rate following elective primary THA and/or TKA
  • patient experience with surgical care based on the Consumer Assessment of Healthcare Providers and Systems® Surgical Care Survey
  • use of imaging studies for low-back pain

CMS states that the measures "support multi-payer alignment, for the first time, on core measures primarily for physician quality programs. This work is informing the agency's implementation of the Medicare Access and Children's Health Insurance Program (CHIP)  Reauthorization Act of 2015 (MACRA) through its measure development plan and required rulemaking, and is part of CMS' commitment to ensuring programs work for providers while keeping the focus on improved quality of care for patients."

ACA reimbursement
The Pittsburgh Tribune-Review reports that private health insurer Highmark Inc., plans to reduce payments to physicians who treat patients covered by plans sold on the ACA marketplace. Highmark, which cited an estimated $500 million loss last year on plans sold under the ACA, will reduce physician payments by 4.5 percent starting April 1. Opponents argue that physicians should not be held accountable for Highmark setting plan costs too low to adequately cover patients' care. Highmark contends that lowering physician payments will enable it to continue to participate in the federal marketplace, thereby bolstering marketplace sustainability, according to Alexis Miller, Highmark's special vice president of individual and small group markets. Highmark made this announcement as other nationwide insurers report losses on the federal marketplace for 2015.

Medicare Advantage reimbursement
CMS has released proposed changes for the Medicare Advantage and Part D Prescription Drug Programs in 2017 that will, if finalized, result in an average payment increase of 1.35 percent on Medicare Advantage plans, although the agency notes that individual plans will vary. In addition, CMS proposes to:

  • improve the precision of payments to Medicare Advantage plans that serve vulnerable populations
  • adjust Star Ratings to reflect the socioeconomic and disability status of a plan's enrollees
  • revise the methodology used to risk-adjust payments to plans to more accurately reflect cost of care for dually eligible beneficiaries

Under the CMS Meaningful Use program, participating healthcare professionals must publicly report on their use of electronic health records (EHRs). One way to do so is to submit data to a specialized registry, such as the American Joint Replacement Registry (AJRR). Participation in the AJRR hip and knee arthroplasty registry can help orthopaedic surgeons meet 2016 Meaningful Use requirements.

Affiliation disclosure
CMS has released a proposed rule to implement sections of the ACA that require Medicare, Medicaid, and CHIP providers and suppliers to disclose affiliations with individuals who may be barred from billing those programs or who may owe money to the government. In addition, the proposed rule would provide CMS with additional authority to deny or revoke a provider's or supplier's Medicare enrollment. Finally, the proposed rule would require that to order, certify, refer, or prescribe any Part A or B service, item, or drug, a physician or eligible professional must be enrolled in Medicare in an approved status or have validly opted out of the Medicare program.

ACA penalty program
Findings published in The New England Journal of Medicine (Feb. 24) suggest that some hospital readmissions may have been reduced under an ACA program designed to apply financial penalties to hospitals with higher readmission rates for targeted conditions. The researchers compared monthly, hospital-level rates of readmission and observation-service for Medicare elderly beneficiaries across 3,387 hospitals from October 2007 through May 2015. They found that, from 2007 to 2015, readmission rates for targeted and nontargeted conditions dropped overall. However, shortly after passage of the ACA, readmission rates declined quickly—especially for targeted conditions—and then continued to fall at a slower rate after October 2012 for both targeted and nontargeted conditions. From 2007 to 2015, stays in observation units for targeted conditions increased from 2.6 percent to 4.7 percent, while rates for nontargeted conditions increased from 2.5 percent to 4.2 percent. The researchers write that the evidence does not suggest that changes in observation-unit stays accounted for the decrease in readmissions.

HAI update
A report from the U.S. Centers for Disease Control and Prevention (CDC) finds a reduction in the incidence of healthcare-associated infections (HAIs), but the agency states that further progress is still needed. In the CDC Vital Signs report, the agency examined six antibiotic-resistant species and noted a 17 percent decrease in surgical site infections (SSIs) between 2008 and 2014 related to 10 procedures tracked in previous HAI progress reports. Of those, one in seven remaining SSIs are caused by urgent or serious antibiotic-resistant bacteria. The CDC states that, in acute care hospitals, one in seven catheter- and surgery-related HAIs can be caused by any of the six bacteria studied—a number that increases to one in four infections in long-term acute care hospitals.

Bundled care program
According to findings presented at the AAOS Annual Meeting, initiation of a bundled payment program may be associated with reduced costs and improved quality for patients who undergo total joint arthroplasty. The research team compared data from year one and year three after implementation of the Medicare Bundled Payment for Care Improvement program at a large, tertiary, urban, academic medical center. They note that several programs were implemented after the first year to improve quality metrics: preoperative risk factor optimization within a perioperative orthopaedic surgical home, enhanced care coordination and home services, a change in venous thromboembolic disease prophylaxis to a risk-stratified protocol, infection prevention measures, an emphasis on discharge home rather than inpatient facilities, and a quality-dependent gain sharing program among surgeons. Compared to year one, they noted cost-savings and an improvement in quality of care metrics, along with continued cost savings during year three.

TKA costs
Findings presented at the AAOS Annual Meeting suggest that high-volume hospitals may be associated with increased value per healthcare dollar spent for primary, elective, unilateral TKA compared to lower volume hospitals. The authors used Markov state transition modeling to compare cost-effectiveness for 185,595 TKA procedures performed at high-, medium-, and low-volume hospitals in New York state. They found that lifetime cost of TKA was $36,615 at high-volume hospitals, $39,248 at medium-volume hospitals, and $39,312 at low-volume hospitals.

Nursing staff levels
Data published in the International Journal for Quality in Health Care (online) suggest that nurse staffing levels may correlate to readmission levels after certain orthopaedic procedures. The researchers conducted a cross-sectional analysis of secondary data for 112,017 patients admitted to an acute care hospital for elective or TKA. They found that nearly 6 percent of patients were readmitted within 30 days. After adjustment for patient and hospital characteristics, the researchers found that, for each additional patient per nurse, patients had an 8 percent increased risk of 30-day readmission and 12 percent increased risk of 10-day readmission.

Nurse prescribing
The U.S. Federal Trade Commission (FTC) has submitted written comments regarding a bill under consideration in the West Virginia Senate. If enacted, the legislation would modify the supervision requirements imposed on Advanced Practice Registered Nurses (APRNs) in the state, and permit some APRNs—under limited conditions—to write prescriptions without a formal agreement with a particular supervising physician. In addition, the bill would place the regulation of certain APRNs under the authority of the state Board of Medicine or Board of Osteopathy. The FTC states that the proposal "could benefit patients, as it would permit a route to independent prescribing, at least for some APRNs under certain conditions," but also "raises significant competitive concerns nonetheless, first because of the many conditions and exclusions it would impose on independent APRN prescribing, and second because of the regulatory conflicts of interest that appear to be inherent in the Bill's requirements of physician permission for and oversight of APRN prescribing." The agency also notes that, "because the Bill would assign regulatory authority over APRN prescribing to the Boards of Medicine and Osteopathy, it raises concerns about potential biases and conflicts of interest." The FTC urges the legislature to consider whether the proposed requirements are necessary to assure patient safety, and notes that removing unnecessary requirements may benefit consumers by "increasing competition among healthcare providers."

Health IT proposed rule
HHS and the Office of the National Coordinator for Health Information Technology (ONC) have announced a new proposed rule to enhance the safety, reliability, transparency, and accountability of certified EHR systems. Among other things, ONC would have the authority to review certified health information technology (HIT) products and take action to address potential risks to public health and safety, increase ONC oversight of health IT testing bodies, and increase transparency regarding the overall performance of certified health IT. The proposed rule would also make more information available about how an individual certified health IT product performs in the field.

Health IT legislation
The U.S. Senate Health, Education, Labor and Pensions Committee has unanimously approved bipartisan legislation designed to help improve the use of HIT. Provisions in the Improving Health Information Technology Act include:

  • gathering input from stakeholders to minimize the documentation burden on providers while maintaining quality
  • encouraging certification of HIT for specialty providers and sites of service
  • HHS oversight to investigate and establish deterrents to information blocking practices
  • requirements that HHS give deference to standards developed in the private sector