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Published 8/1/2016

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 rule on ACO payments
The U.S. Centers for Medicare & Medicaid Services (CMS) has released a final rule designed to improve how Medicare pays accountable care organizations (ACOs) in the Medicare Shared Savings Program (MSSP) by recognizing cost variation at the regional level. Under the rule, CMS will now set ACO performance benchmarks using regional, rather than national, spending growth trends. The efficiency of individual ACOs will be measured against other providers in the same regional market, rather than just against an ACO's own past performance. Among other changes, ACOs that participate under Track 1 of the MSSP will be granted the option of extending their initial agreement for 1 year before taking on financial risk under Track 2 or Track 3. In addition, the final rule defines time frames and other criteria for reopening of a determination of ACO shared savings or shared losses to correct financial reconciliation calculations; for example, ACOs will have 4 years to challenge an initial determination of shared savings or shared losses for good cause.

Medicare FFS appeals
A report released by the U.S. Government Accountability Office (GAO) offers recommendations to the U.S. Department of Health and Human Services (HHS) to improve the appeals process for Medicare fee-for-service (FFS). The GAO finds that CMS and two other components within HHS use data collected in three appeal data systems to monitor the Medicare appeals process, yet the systems fail to collect other data that the agencies could use to monitor appeals trends. The GAO notes variation in how appeals bodies record decisions across the three systems, and that the ability of HHS to monitor emerging trends in appeals is limited and is inconsistent with federal internal control standards that require agencies to run and control agency operations using relevant, reliable, and timely information. The GAO recommends several actions to HHS, including improving the completeness and consistency of the data used by HHS to monitor appeals, and implementing a more efficient method of handling appeals associated with repetitious claims.

Discrimination, antibiotics, and infection control
CMS has released a proposed rule to update the requirements that hospitals and critical access hospitals must meet to participate in the Medicare and Medicaid programs. Among other things, CMS proposes revising the conditions of participation to address the following:

  • discriminatory behavior by healthcare providers that may create real or perceived barriers to care
  • use of the term "Licensed Independent Practitioners" that may inadvertently exacerbate workforce shortage concerns
  • requirements that do not fully conform to current standards for infection control
  • requirements for antibiotic stewardship programs to help reduce inappropriate antibiotic use and antimicrobial resistance
  • the use of quality reporting program data by the hospital Quality Assessment and Performance Improvement program

Comments on the proposed rule must be submitted by Aug. 15, 2016.

Socioeconomic disparities
HealthLeaders Media reports that the U.S. House of Representatives has passed legislation that would, if enacted, ease payment restrictions for some hospital outpatient services and adjust 30-day readmissions penalties to account for socioeconomic disparities. Among other things, the bill would do the following:

  • modify the treatment of ambulatory surgery center patient encounters under the Meaningful Use program
  • require that CMS report Medicare enrollment data by congressional district
  • extend the Rural Community Hospital Demonstration Project for an additional 5 years

The U.S. Senate is considering companion legislation.

Medicare solvency
The Boards of Trustees for Medicare have released their 2016 annual report regarding federal hospital insurance and federal supplementary medical insurance trust funds. The report projects the Medicare trust fund to be insolvent by 2028—2 years earlier than an estimate of 2030 projected in the previous two reports, but later than a 2026 estimate from the U.S. Congressional Budget Office. The report does not include alternative payment models (APMs) currently being tested by the U.S. Center for Medicare & Medicaid Innovation, but does include the Medicare Shared Savings Program for ACOs.

Communication toolkit
The U.S. Agency for Healthcare Research and Quality (AHRQ) has released an online toolkit to help healthcare providers communicate accurately and openly with patients and their families when a medical error has occurred. The toolkit is designed to expand use of the Communication and Optimal Resolution (CANDOR) process, which gives hospitals and health systems the tools to respond immediately when a patient is harmed and to promote candid, empathetic communication and timely resolution for patients and caregivers. The AHRQ notes that CANDOR and similar programs help remove barriers to the reporting of near misses and errors and encourage open communication regarding prevention of future errors. The CANDOR process has been tested and applied in 14 hospitals across three health systems.

Medical students
A survey released by the Association of American Medical Colleges suggests that only 26 percent of medical students retain their initial preferred residency specialty over the course of medical school. Among all specialties, orthopaedics had the highest percentage (53.6 percent) of students who initially indicated they planned to pursue that field and continued to do so. The researchers compared responses for 10,353 graduating medical students who completed the 2015 Graduation Questionnaire as well as the Matriculating Student Questionnaire, which matriculants are invited to complete during the summer prior to their first year of medical school.

Hospitals and ASCs
An article in Modern Healthcare looks at the issue of ambulatory surgery centers (ASCs). The author notes that total joint arthroplasty is one of the largest and most profitable service lines at many hospitals. An increase in outpatient arthroplasty has led to tension between hospitals and ASCs, although some hospitals have begun performing their own outpatient joint replacements, and others have embraced a collaborative model, working with ASC operators. However, the writer states that "institutional inertia" may make it difficult for those involved in cooperative efforts to implement innovative practices to better serve patients.

Surgery fraud
The U.S. Department of Justice states that nine defendants have now pleaded guilty in a case involving nearly $600 million in fraudulent billing for spinal surgeries. Healthcare IT News reports that three defendants have joined six others who have already pleaded guilty and are cooperating in an ongoing investigation that may involve dozens of surgeons, including orthopaedists.

Medical liability—Pennsylvania
The Pittsburgh Post-Gazette reports that medical liability jury verdicts hit a 15-year low in Pennsylvania during 2015. The paper notes that in 2004, juries issued verdicts in 449 medical liability cases, with 78.4 percent of those verdicts in favor of the defendant; in 2015, there were 101 verdicts, with 78.2 percent favoring the defendant. The Physician Insurers Association of America notes that verdict cases represent less than 9 percent of resolutions in medical liability cases, with the majority dropped or dismissed.

Hospital mergers
A report from the nonprofit The MergerWatch Project suggests that many states do not adequately oversee the effect of hospital consolidation on consumer access to healthcare services. The writers analyzed information on state statutes, regulations, and Certificate of Need (CON) laws, and found that "state hospital oversight programs as they exist today are insufficient to address the current market conditions." The report notes that several states have no type of CON mechanism to oversee hospital transactions, and even among those with robust CON oversight, many regulations were designed to prevent expensive duplication of services and are unsuitable to address the impact of hospital downsizing and consolidation.

Career satisfaction
A survey of employed and self-employed physicians conducted by Medscape finds similar levels of career satisfaction in both groups. The researchers surveyed 3,960 employed physicians and 1,027 self-employed physicians across specialties. They found that 72 percent of employed physicians and 73 percent of self-employed physicians described themselves as satisfied with their careers. Other findings include the following:

  • Sixty-five percent of employed physicians say their institutions put patient outcomes before financial interests; 14 percent disagree.
  • Eighty-five percent of physicians overall say that quality of patient care is "good" or "very good" in their setting.
  • Identical levels (81 percent) of employed and self-employed physicians feel a sense of pride and accomplishment in their work.
  • Fifty-four percent of employed physicians say their work-life balance improved after they left private practice, while 19 percent say it became worse.

Hospital readmissions
Findings published online in the journal JAMA Surgery examine factors associated with hospital readmission and suggest that many readmissions may be unavoidable. The authors reviewed information on 173 patients who had unplanned readmissions within 30 days at a Level 1 trauma center. They found that common causes for readmission included 29 patients with injection drug use who were readmitted with soft tissue infections at new sites, 25 with disposition support issues, 23 with infections not detectable during index admission, and 16 with sequelae of their injury or condition. Overall, 16 patients (9.2 percent) were identified as having a likely preventable complication of care, while two (1.2 percent) were readmitted due to deterioration of medical conditions. On univariate and multivariate analyses, they found that female sex, presence of diabetes, sepsis on admission, intensive care unit stay during index admission, discharge to respite care, and payer status were identified as risk factors for readmission.

Bundled payments
A perspective piece published in HealthLeaders Media looks at the issue of bundled payments and 30-day readmissions. According to information from CMS, all-cause 30-day hospital readmissions for Medicare fee-for-service beneficiaries ranged from 19 percent to 19.5 percent from 2007 to 2011, but rates fell to 18.5 percent in 2012 and 17.5 percent in 2013. A spokesperson for one hospital that adopted a bundled payment system for hip and knee procedures states that readmission rates have fallen 60 percent since the introduction of bundled payments.