Regulations, data are driving a spectrum of developments


Published 1/1/2016
Eeric Truumees, MD

Change Accelerating in 2016

After a year (2015) during which long-awaited changes suddenly came to fruition, it seems that these changes, for good and for bad, will accelerate in the coming year.

In 2015, Congress finally stopped the insane, annual "doc fix" due to the SGR (sustainable growth rate) formula by passing MACRA—the Medicare Access and CHIP (Children's Health Insurance Program) Reauthorization Act. Now even legislative acronyms include acronyms. If you haven't felt inundated by the government's alphabet soup in the past, I suspect 2016 will be your chance to really swim in it.

For orthopaedic surgeons, key provisions of MACRA focus on MIPS (Medicare Incentive Payment System), APMs (alternative payment models, such as ACOs [accountable care organizations] and bundles), and PFPMs (physician-focused payment models). Despite the complicated nomenclature, the message is simple: be prepared for an increasingly heavy emphasis on payment per episode of care and, theoretically at least, quality. Even practices billing solely on a fee-for-service model will see the beginning implementation of the MIPS in their reimbursement as part of the 2016 Medicare physician fee schedule.

Physician groups were initially happy about the MACRA legislation. Not only did it eliminate the SGR, but it also held out the promise of 0.5 percent pay increases for each year from 2016 through 2019. However, because healthcare costs have increased, the final 2016 Medicare fee schedule actually has a 0.3 percent pay cut. The increased costs have prompted payers and the decreased reimbursements have encouraged practices to move toward APMs. In the past year, the numbers of providers participating in care bundles increased sharply and now includes providers working in large practices, smaller hospital systems, and large health care systems.

Some changes, like the transition to the ICD-10 coding system, had been on the horizon for years. Other major changes, while predictable in intent, were missing key technical details until just before the relevant reporting or billing period. Take, for example, the update to stage 2 of meaningful use, which was published in October 2015. That left orthopaedic surgeons with 90 days in the calendar year to meet new program requirements—which entailed meeting the requirements for 90 consecutive days. No wonder the California Medical Association recommended that all physicians apply for a hardship exemption.

The Centers for Medicare & Medicaid Services (CMS) recently delayed implementation of the total joint bundle program until April (see cover story, "CMS Finalizes Mandatory Bundled Payment Model"), and clearly intends to move the bulk of healthcare payments from volume to value over the next couple of years. All of these changes place an increasing emphasis on analytics, outcomes and complications reporting, and navigation of an increasingly complex reimbursement landscape.

These changes will require individual orthopaedic surgeons to learn how to collect these data at their own practices and to interpret these data as part of large registry studies.

Patient changes
Patients' needs and demands will continue to change as well. The increased availability of wearable technologies may enable better assessment of patient compliance and, in some cases, may even offer a better understanding of the impact of disease states and treatments on patient mobility and function. As patients pay a larger portion of their healthcare costs, they are likely to become savvier customers. They will expect convenience, such as the urgent care centers in popular local grocery stores that my hospital system is opening.

The impact of changes such as narrow networks is harder to predict, but may result in an increase in domestic medical tourism. Strong ethical standards for the management of an established patient who had surgery elsewhere, but wants local follow-up for a complication, will be needed.

Consumer-focused health care will require greater price transparency, but 2016 will likely see an increase in other forms of transparency. The numbers of cases of patients using their phones to record their conversations with physicians will grow. The debate about mandatory or patient-request video recordings in the operating room will increase.

Consumer groups are increasingly demanding better and more comprehensive data on physician quality. From the expansion of PhysicianCompare.Gov and the publication of data under the Sunshine Act to the "Surgeon Report Card" offered by ProPublica, the individual surgeon's practices are increasingly "exposed." Recently, the Health Care Incentives Improvement Institute released a report card grading transparency efforts by state medical boards. Most states scored an "F," but notable exceptions included California, where the state's office of the patient advocate increased the number of physicians receiving a report card. Although the amount of information available to patients about individual surgeons, their practices, and various orthopaedic conditions continues to increase, the quality of that information tends to be poor.

Issues of risk stratification should be of great interest to all orthopaedic surgeons and undoubtedly will affect whom we choose to treat, our reimbursement for that management, and our online reputations. In fact, risk stratification will be the topic of the 2016 AAOS Now Forum at the Annual Meeting in Orlando.

Another "hot topic" for 2016 is regenerative medicine. This evolving area uses rejuvenation, replacement, or regeneration techniques to "fully heal damaged tissues and organs." Early examples included solid organ and bone marrow transplants. More recently, stems cells have been injected into virtually every anatomic area, especially the musculoskeletal system. Advances in cell biology, nanotechnology delivery systems, and tissue frameworks have spawned spectacular stories. However, the widespread marketing of this concept seems to far exceed the supportive data.

Patient safety and meaningful use
With wide publication of complication rates for hospitals and individual orthopaedic surgeons, patient safety programs will grow in 2016. Recently, the National Patient Safety Foundation (NPSF) released a report updating the Institute of Medicine's groundbreaking To Err Is Human: Building a Safer Health System. The report concluded that the overall healthcare system is not safer now than 15 years ago, although "significant progress" has been made on individual safety problems. Although fewer patients were harmed from infections, adverse drug events, and other conditions—saving both lives and costs—several problems persist, including patient falls, ventilator-associated pneumonia, and diagnostic mistakes.

The report cited eight problematic areas including inaccurate metrics, poor coordination of care, technology hazards, and a failure to prioritize safety. It suggested a single, national regulatory agency fostering "total system improvement" and offered seven other recommendations, including increased funding for research in patient safety and implementation science, better engagement with patients and their families, and support for the healthcare workforce.

True advances in high quality information exchange and "meaningful use" of electronic medical records (EMRs) will require interoperability of those systems, an area in which we might see some progress in 2016. Recently, several technology companies involved in EMRs wrote to Congress about interoperability, noting that "The Meaningful Use program was designed to help support an interoperable, connected IT system that improves the quality of care delivered while lowering costs for everyone." However, they concluded, "To date, Meaningful Use has failed to achieve these goals."

Patients today have no guarantee that their physicians can access their health information. Software improvements to EMR systems are stymied because vendors must react to many, often conflicting, government regulations. Although the Office of the National Coordinator for Health Information Technology has confirmed that "information blocking" occurs, it has yet to take any enforcement action. Indeed, several major players in the EMR market have themselves been charged with information blocking.

As an employed physician, I see this problem daily. I have one EMR for the hospital and another for the office—by different vendors—which do not communicate directly with each other. Reports are faxed, and lost or misdirected records remain a problem. The need to get patient information from two different systems also reduces time for a face-to-face encounter with the patient.

Are we ready?
These changes are just a few that will accompany the shift from eminence-based to evidence-based medicine. Unfortunately, many of these changes diminish the patient engagement that made us want to become doctors. In a recent study on depression among residents, lead author Douglas Mata, MD, said residents spend "40 to 50 percent of their time on the computer doing secretarial work. Very little time is spent by the bedside. It's not rewarding." I suspect many attending orthopaedic surgeons are starting to feel this way, too.

That study, a systemic review of depression among residents, found the prevalence of depression or depressive symptoms among resident physicians was 28.8 percent and increased with calendar year. This is far higher than the population at large and is especially interesting because incoming medical students score "healthier" than the general population on psychometric testing.

In an accompanying editorial, Thomas Schwenk, MD, writes that depression is closely related to physician burnout, which is also increasing according to a recent study. The same study found that orthopaedic surgeons were more burned out than many other specialties and were also highly dissatisfied with work-life balance.

This spike in burnout rates should be troubling on many levels. Burnout is "associated with higher self-reported rates of cheating on examinations, lying about clinical data, medical errors, and ethical lapses, as well as less altruistic and compassionate care," according to the report.

The pace of change in health care may be a contributing factor, but one aspect is especially troubling—the double bind. For example, physicians are told to be cost-conscious, but most of us feel, and at least one recent study has shown, that physicians spending more money on testing are less likely to be sued. Moreover, talking patients out of tests they demand may be harder than it appears. One study has found that even when physicians received specific training on patient-centeredness and skills in handling patient requests for low-value diagnostic tests (such as spine MRIs for low back pain), rates of ordering these tests did not decrease. Similarly, awareness of the epidemic of prescription opioid abuse does not make it any easier to say "no," given the impact on patient satisfaction scores.

These double binds do not justify suboptimal professionalism, but they do increase stress and decrease the satisfaction of daily practice.

But, my predictions are not all bleak. Eventually, better data will guide our decision making and new technologies will expand our treatment arsenal. I suspect we will eventually emerge with greater power than ever to help our patients alleviate pain and improve function.

New investments in healthcare information technology might make our jobs easier. As the economy improves, the percentage of potential patients with jobs, insurance, and higher incomes increases. These changes will relieve pressure on a practice's bottom line. Expansion and the accompanying economies of scale may be realizable.

The only area of concern may be participation in advocacy. We must hope that the burdens of rapid change do not cause physicians to back away from organized medicine's efforts to represent their fields and patients. Although involvement requires time, we must continue to support our profession through excellent, ethical patient care, advocacy for our patients and ourselves, and a strong commitment to collegiality and participation in our academy and subspecialty organizations.

Eeric Truumees, MD, is the editor-in-Chief for AAOS Now.

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