Published 12/1/2016

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)

Medicare episode payments
A study published in JAMA Surgery (online) finds substantial variation across hospitals regarding Medicare episode payments for rescued patients with perioperative complications, noting that higher Medicare payments may not be associated with improved clinical performance. The researchers conducted a retrospective cohort study of Medicare claims data for four procedures, including 307,399 patients who underwent total hip arthroplasty (THA). They found that among patients who experienced complications, those who were rescued had higher price-standardized Medicare payments than those who died. Overall, payments for patients who were rescued at the highest cost-of-rescue hospitals were two to three times higher than at the lowest cost-of-rescue hospitals ($41,354 versus $19,028 for THA). In addition, compared with lowest cost-of-rescue hospitals, highest cost-of-rescue hospitals had higher risk-adjusted rates of serious complication, with similar rates of failure to rescue and overall 30-day mortality.

MACRA payment model evaluator
The American Medical Association (AMA) has unveiled a free online tool designed to help physicians determine how new Medicare payment models under the Medicare Access and CHIP Reauthorization Act (MACRA) of 2015 will impact their practices. According to the AMA, the Payment Model Evaluator, which was developed with the expertise of physicians and input from partners, provides physicians and their staffs with guidance on how to participate in the MACRA payment model best suited for them, and also provides relevant resources. The AMA will continually update the Payment Model Evaluator to respond to regulatory changes and to keep practices up to date about evolving MACRA rules.

HHS EHR guides
The U.S. Department of Health and Human Services (HHS) Office of the National Coordinator for Health Information Technology (ONC) has released two guides designed to help healthcare providers effectively use health information technology. EHR Contracts Untangled: Selecting Wisely, Negotiating Terms, and Understanding the Fine Print, explains important concepts in electronic health records (EHR) contracts, and includes example contract language to help providers and health administrators in planning to acquire an EHR system and negotiating contract terms with vendors. The Health IT Playbook is a web-based tool intended to simplify the process of finding practical information and guidance on specific topics as providers research, buy, use, or switch EHRs.

HIPAA risk assessment tool
HHS has updated its Health Insurance Portability and Accountability Act (HIPAA) Security Risk Assessment tool, which is designed to help small and medium-sized practices assess the information security risks in their organizations under HIPAA. The application also produces a report that can be provided to auditors. The updated tool includes Windows 10 compatibility and improved reporting features. A version of the tool is also available for the iPad.

CMS reports
AMA Wire notes that the U.S. Centers for Medicare & Medicaid Services (CMS) has released its 2015 Physician Quality Reporting System (PQRS) Feedback Reports and 2015 Annual Quality and Resource Use Reports (QRUR). The 2015 PQRS feedback reports reflect data from Medicare Physician Fee Schedule claims received with dates of service from Jan. 1, 2015, to Dec. 31, 2015, that were processed into the National Claims History by Feb. 26, 2016. The feedback reports will include all measures reported by the National Provider Identifier for each submission mechanism used. The 2015 QRURs outline how solo practitioners and groups performed in 2015 on the quality and cost measures used to calculate the 2017 Value Modifier. To obtain copies of the reports, an Enterprise Identity Management account with the appropriate role is required.

Provider mental health
Information published in General Hospital Psychiatry (November-December) suggests that some physicians may be reluctant to seek treatment for mental illness due to stigma surrounding treatment and disclosure. The research team surveyed a convenience sample of 2,106 female physicians regarding mental health history and treatment, perceptions of stigma, opinions about state licensing questions on mental health, and personal experiences with reporting. They found that almost 50 percent of respondents believed that they had met criteria for mental illness, but had not sought treatment. The research team states that key reasons cited for avoiding care included:

  • a belief they could manage independently
  • limited time
  • fear of reporting to a medical licensing board
  • a belief that diagnosis was embarrassing or shameful

In addition, the research team found that only 6 percent of respondents with formal diagnosis or treatment of mental illness had disclosed to their state.

Patient comprehension
Data from a study in The Journal of Bone & Joint Surgery (Oct. 5) suggest that use of a multisensory patient education program could improve patient comprehension and informed consent. The authors conducted a randomized trial of 67 patients considered medically appropriate for a knee corticosteroid injection. Each patient listened to a 10-minute scripted lecture based on content from the AAOS OrthoInfo website, along with either video, model, or no additional components, followed by a validated comprehension test. The authors found that mean comprehension scores were 71 percent for the verbal only group, 74 percent for the verbal plus video group, and 84 percent for the verbal plus model group.

Patient safety concerns
An article in HealthLeaders Media suggests that some medical students may be uncomfortable questioning their superiors regarding patient safety issues, even when they see something they find to be concerning. The writer notes that a survey of medical students published in the American Journal of Medical Quality (online) finds that 62 percent of respondents perceived problems in safety and 44 percent saw what they believed to be lack of evidence-based care. However, only 51 percent of students said they were comfortable reporting incidents to their superiors and just 20 percent noted a change in response after bringing up their concerns. One study author argued that whether the quality issues were real or not, they need to be addressed. "Either [the students] are missing the opportunity to learn about quality and safety, or they are missing the opportunity to learn about clinical medicine," he said.

National Trauma Action Plan
A perspective piece published in The New England Journal of Medicine (Oct. 19) argues for the establishment of a National Trauma Action Plan designed to build on advances achieved by the military health system through experience in Iraq and Afghanistan and, "by doing so, to drive the number of preventable deaths after injury down to zero." The writers note that in 2004, the U.S. armed forces created the Joint Trauma System (JTS), an enterprise modeled on high-performing civilian trauma systems, which included the creation of a trauma registry to compile treatment and outcomes data, including information on the timing and causes of death and disability, the establishment of procedures to improve performance and the quality of care, and the formation and dissemination of clinical practice guidelines. Data from that registry illuminated challenges and identified aspects of care that were either suboptimal or associated with poor outcomes. In addition, the JTS used continuous performance-improvement processes and "focused empiricism" to inform practice and evolve standards of care.

National patient identifier
In a letter to committee leaders in the U.S. House of Representatives, a coalition of 23 healthcare industry stakeholders has advocated for removal of an 18-year-old ban that prevents HHS from developing and implementing a national patient identifier system. "The absence of a national strategy for accurately identifying patients has resulted in significant costs to hospitals, health systems, physician practices, and long-term post-acute care (LTPAC) facilities as well as hindered efforts to facilitate health information exchange," the writers argue. They note that patient identification errors often begin during the registration process, and "can initiate a cascade of errors, including wrong site surgery, delayed or lost diagnoses, and wrong patient orders." The writers suggest that increased data exchange among providers along with incorrect or ineffective patient matching could have an increasingly negative effect on patient safety.

Satisfaction after ED admission
According to a research study published in the Journal of the AAOS (October), admission through the emergency department (ED) may be an independent risk factor for reduced satisfaction with physician performance. The researchers evaluated 6,524 inpatient patient experience surveys from two academic level I trauma centers over a 5-year period. They found that 85.18 percent of patients admitted through the ED were satisfied with their care, compared to 89.44 percent of patients admitted through other pathways.

Rural trauma
A study published in JAMA Surgery (online) compares treatment for trauma patients in urban and rural settings. The research team analyzed prospectively gathered data on 53,487 injured patients transported by emergency medical services agencies to 28 hospitals in 2 rural and 5 urban counties in Oregon and Washington. An institution was considered rural based on 60 minutes or more driving proximity to the nearest level I or II trauma center and/or rural designation in the CMS ambulance fee schedule by zip code. They found that rural versus urban sensitivity of field triage for identifying patients requiring early critical resources was 65.2 percent versus 80.5 percent, with only 29.4 percent of rural patients who needed critical resources initially transported to major trauma centers, compared to 88.7 percent of urban patients. After accounting for transfers, 39.8 percent of rural patients requiring critical resources were cared for in major trauma centers, compared to 88.7 percent of urban patients. The research team noted that mortality did not differ significantly between rural and urban regions; however, 89.6 percent of rural deaths occurred within 24 hours, compared with 64 percent of urban deaths. In addition, rural regions had higher transfer rates and longer transfer distances.

Provider directory errors
Kaiser Health News reports that a CMS review finds a large number of errors in provider directories for private Medicare Advantage plans. The agency states that incorrect information was found for almost half of 5,832 physicians listed in directories across 54 Medicare Advantage plans. Among other things, the review found:

  • wrong phone numbers for 521 physician offices
  • wrong addresses for 633 physician offices
  • five Medicare Advantage plans had error rates that exceeded 60 percent of listed physicians

Patient status reviews
CMS has announced that Beneficiary and Family Centered Care Quality Improvement Organizations (BFCC-QIOs) will resume initial patient status reviews of short stays in acute care inpatient hospitals, long-term care hospitals, and inpatient psychiatric facilities to determine the appropriateness of Part A payment for short stay hospital claims. On May 4, 2016, the agency temporarily paused the reviews in an effort to promote consistent application of medical review policies regarding patient status for short hospital stays and to allow time to improve standardization in the review process. CMS states that it has examined and validated BFCC-QIO peer review activities related to short stay reviews and initiated provider outreach and education regarding the Two-Midnight policy.

Drug prices
A report commissioned by two hospital industry groups found that increases in spending on inpatient drugs have largely been driven by sharp increases in prescription drug prices and not by higher usage of the same drugs or switching to pricier alternatives for treatment of the same condition. Between 2013 and 2015, hospitals' average annual inpatient drug spending increased by some 23 percent, the study reported, with the increase on a per-admission basis even higher—39 percent. At a press briefing, the chief pharmacy officer of the Cleveland Clinic noted that hospitals were seeing large price increases for generic drugs whose prices had long remained stable, Kaiser Health News reports. "It would be one thing if price increases were associated with clear and important clinical improvements, but they're not," said Chip Kahn, chief executive of the Federation of American Hospitals, which sponsored the study along with the American Hospital Association. A spokesperson for a pharmaceutical trade group said the report gave a distorted picture by focusing on isolated examples and drugs and downplayed the effect of hospital markups in driving the drug spending increases.