Published 1/1/2016
Mary Ann Porucznik

AAOS Expands Quality Activities, Updates Position Statements

At their December 2015 meeting, the Board of Directors of the American Association of Orthopaedic Surgeons (AAOS) took several actions that reinforce the AAOS commitment to patient safety, quality care, and advocacy.

The Board approved a new clinical practice guideline (CPG) on Surgical Management of Osteoarthritis of the Knee (see "Evidence Bolsters Recommendations in New CPG.") as well as the following new appropriate use criteria (AUC) (See "New AUC Cover Hip Fracture in the Elderly and Osteochondritis Dissecans."):

  • Hip Fractures for Elderly Patients: Acute Treatment
  • Hip Fractures for Elderly Patients: Postoperative/Rehabilitation
  • Osteochondritis Dissecans of the Femoral Condyle

Both of the AUC on hip fractures include checklists. The complete CPG and AUC can be accessed at www.orthoguidelines.org

In addition, the Board approved the addition of cost/value analyses to AAOS evidence-based medicine initiatives. This would add a cost statement to each AAOS CPG recommendation based on the available economic research.

"The addition of a separate, economic statement to the evidence presented in AAOS CPGs provides the physician with the tools necessary to create his or her own value judgment," explained Kevin J. Bozic, MD, MBA, chair of the Council on Research and Quality. "This addition increases the utility and relevance of AAOS CPGs, without affecting the evidence-based nature of a recommendation."

The Board also voted to endorse the American Society of Anesthesiologists-American College of Surgeons Joint Statement on "Physician-Led Team-Based Surgical Care." The statement outlines the principles of team-based surgical care, coordinated care, and communication, as follows:

  • Patient involvement with shared decision making, patient education and engagement, and alignment of expectations, including risk-based informed consent
  • Risk stratification, risk reductions, and optimization of patients prior to surgery, including medication reconciliation
  • Standardized adherence to high-reliability and safety standards
  • Evidence-based care to reduce variability and perioperative complications
  • Effective coordination of care among all healthcare providers involved in the perioperative care of the patient

Taking positions
The Board voted to adopt the Swaddling and Developmental Dysplasia Position Statement developed by the Pediatric Orthopaedic Society of North America (POSNA). The statement promotes a "hip-healthy swaddling" technique that allows ample room for hip and knee movement in the first few months of life to allow for optimal development of the infant hip.

In addition, the Board voted to approve a number of revised position statements, including the following:

Scoliosis Research Society (SRS)/American Academy of Pediatrics(AAP)/POSNA/AAOS Position Statement: Screening for the Early Detection of Idiopathic Scoliosis in Adolescents (1122)—The AAOS, SRS, AAP, and POSNA believe that screening examinations for spine deformity should be part of the medical home preventive services visit for females at age 10 and 12 years, and males once at age 13 or 14 years. The AAOS, SRS, AAP, and POSNA believe that recent high quality studies demonstrate that nonoperative interventions such as bracing and scoliosis-specific exercises can decrease the likelihood of curve progression to the point of requiring surgical treatment.

Prevention of Hip Fractures Due to Osteoporosis (1116)—The AAOS believes that the growing epidemic of hip fractures requires a comprehensive national response, stressing education, prevention, and research. The AAOS supports the efforts of the National Bone Health Alliance (nbha.org), of which the Academy is a member; the American Orthopaedic Association's (AOA) "Own the Bone" program (ownthebone.org); and the U.S. Centers for Disease Control and Prevention efforts to stimulate a greater understanding of hip fractures. In addition, AAOS urges further governmental and private support for research and education targeted at reducing the burden posed by hip fractures, the costliest of all musculoskeletal injuries. This investment will help reduce the significant financial burden of health care for all Americans.

Delineation of Clinical Privileges in Orthopaedic Surgery (1106)—Given the breadth and complexity of contemporary medical and surgical care, decisions regarding the granting of clinical privileges should be based upon a thorough consideration of each individual's qualifications rather than his or her identification with a specific profession. Each hospital medical staff should develop criteria for the delineation of clinical privileges which apply to all individuals who are permitted by law to provide patient care services independently. These criteria should serve as an objective framework from which to evaluate a practitioner's competence and should be clearly specified in the hospital's medical staff bylaws. At a minimum, these criteria should address licensure, training in the specialty, experience, current competence, and health (physical and mental) status.

Reimbursement of the First Assistant at Surgery in Orthopaedics (1120)—The members of the AAOS are concerned with quality orthopaedic care, and also concerned about how rising costs of insurance may affect the delivery of care. The purpose of this position statement is to assist orthopaedists in working with third-party payers to reduce expenditures for physician first assistants while protecting the health and safety of the patient.

The patient characteristics portion of this position statement was revised to reflect the obese patient, surgical complexity, and increased comorbidities.

Alignment of Physician and Facility Payment and Incentives (1171)—The AAOS supports efforts of all stakeholders to develop and evaluate payment methodologies that will incentivize coordination of care among providers (including physicians and hospitals) and help reduce healthcare inflation. As the demand for musculoskeletal care increases with a more active society and an aging population, it is incumbent on orthopaedic surgeons to take a lead role in the development and deployment of such programs.

To prevent limiting patient access to care, the AAOS believes risk adjustment is an indispensable component of any successful episode of care or bundled payment initiative or policy. Risk adjustment is important because unpredictable and unavoidable outcomes can occur even in the presence of evidence-based practice. Episodes of care must be risk-adjusted for patient demographics, socioeconomic status, comorbidities, and severity of illness and procedure-specific characteristics that account for the differences that contribute to outcomes and costs of treatment.

The AAOS embraces change that improves quality and lowers cost, but the patient must be the primary focus of all initiatives. Orthopaedic surgeons should continuously work to provide high-value musculoskeletal care reflecting the needs and desires of their patients. Orthopaedic surgeons should be empowered to provide appropriate, evidence-based care to patients while recognizing how their medical decisions affect costs. A facility's attempt to control costs and maintain clinical programs should not interfere with the surgeon's goal of providing the highest quality care and serving the patient's best interest. As part of a collaborative effort, orthopaedic surgeons should collaborate with hospitals and healthcare systems in the development of cost-containment strategies that protect patient safety and choice, do not compromise quality of care, and have proper safeguards in place.

The AAOS believes safeguards must be in place to protect the practice of medicine and the financial interests of all parties. The AAOS believes patient access to quality care requires trust, collaboration, and alignment of all involved providers and systems. The incentives and influence should facilitate an environment in which all stakeholders can efficiently improve quality.

Reimbursement for Approved Category I CPT Codes (1173)—The AAOS believes unequivocally that if a service or procedure has a Category I CPT code, it is not experimental or investigational. Therefore, payers should not deny reimbursement for these services and procedures when they are medically necessary. When payers do otherwise, they threaten the health of the public and unjustifiably interfere with the physician/patient relationship.

Therefore, when a physician provides such a service or procedure and has documented his or her work properly and according to payer guidelines, the payer should not deny reimbursement for that service or procedure by claiming it is experimental or investigational.

Medicaid and SCHIP (formerly Existing Government Programs) (1174)—The AAOS) believes that in any consideration of changes to the healthcare financing and delivery system in the United States, the well-being of the patient singularly must be the highest priority.

The AAOS strongly supports providing individuals consistent access to patient-centered, timely, unencumbered, affordable, and appropriate health care and universal coverage while maintaining that physicians are an integral component to providing the highest quality treatment.
The AAOS supports prioritizing the coverage of children under the State Children's Health Insurance Program (SCHIP).

The AAOS supports equity in Medicaid and SCHIP payments with Medicare payment rates; this should be structured as a payment floor under which states could not reimburse providers at levels lower than payment under Medicare. Medicare payment to physicians must be structured so that it remains economically viable for physicians to participate.

In addition, the AAOS believes that patients must be guaranteed their choice of physicians in Medicaid and SCHIP managed care plans.

The AAOS believes that physicians, hospitals, patients, and the federal and state governments have a shared responsibility to ensure stability of Medicaid and CHIP. By participating in these programs, physicians can help to secure access to needed healthcare services for the most vulnerable populations.
The AAOS believes that rules governing Medicaid and SCHIP provide a "defined benefit" rather than a "defined contribution."

The AAOS believes that all Medicaid and SCHIPs should be required to provide "continuous coverage" defined as coverage for one year from the date of eligibility.

The AAOS believes that the primary cost containment focus in the Medicaid program should focus on the increased spending associated with long-term care services and not on reducing coverage or eligibility associated with Medicaid acute care benefits.

The AAOS believes that the rationale for a higher state/federal matching rate for CHIP no longer exists, and the inequity between Medicaid and CHIP matching rates should be eliminated.

The AAOS believes that SCHIP beneficiaries should be allowed to purchase private insurance with their SCHIP dollars if there are minimum benefit guarantees and that a SCHIP option should be available for those that do not chose private programs.

The AAOS supports Medicaid and CHIP provisions that make it clear that physicians should not be required to act as immigration agents by restricting care only to citizens and that they should be appropriately reimbursed for all medically necessary care that they deliver to all individuals.

The AAOS believes that educational standards are important and that patients are best served when their care is overseen by physicians. We support a requirement that Medicaid and CHIPs and care be directed by physicians.

The AAOS supports the creation of Medicaid and SCHIP initiatives that:

  • Establish state reporting requirements on access information indicators;
  • Create a national database that would collect utilization information;
  • Include access measures as an indicator of quality;
  • Align Medicaid and SCHIP quality initiatives with Medicare quality initiatives; and
  • Create an advisory council similar to the Medicare Payment Advisory Commission (MedPAC) that would focus on SCHIP and Medicaid quality and access issues.

Principles of Healthcare Reform and Specialty Care (1176)—The AAOS believes that all changes to the healthcare financing and delivery system in the United States must continue to prioritize the well-being of the patient. The AAOS strongly supports the reform measures and principles set forth in this statement as providing individuals consistent access to patient- centered, timely, unencumbered, affordable, and appropriate health care while maintaining physicians as an integral component to providing the highest quality treatment.

The AAOS believes that as policymakers consider healthcare reforms they should:

  • Make certain that patients are empowered to control and decide how their own healthcare dollars are spent
  • Ensure unencumbered access to specialty care
  • Make healthcare coverage more affordable, including co-pays and deductibles that patients understand and can afford
  • Continue to focus on high quality of care
  • Ensure that healthcare coverage permits healthcare access by reimbursements that cover the cost of providing care
  • Provide parity between Medicaid and Medicare rates. Offering below-market reimbursement of necessary orthopaedic treatment will seriously hamper access to this group of patients.

The AAOS supports efforts to ensure that physicians are adequately compensated for providing medical care to the uninsured. In the absence of universal coverage and adequate reimbursement, the AAOS supports providing physicians with tax initiatives to defray the cost of uncompensated care. The AAOS believes it should be a priority for the federal and state governments to provide adequate long-term sustainable funding for existing government healthcare programs to ensure that these programs are sustainable and enrollees retain access to medical care. The AAOS opposes the use of any tax on healthcare professionals to finance changes to the healthcare delivery system. The AAOS also believes that administrative expenses in private healthcare plans should more closely mirror those of public programs, ensuring that a more significant portion of spending is dedicated to medical care.

The AAOS supports a number of tax initiatives as components of healthcare reform that will level the playing field and help make healthcare coverage more affordable. The healthcare marketplace, which has suffered from the lack of competition, should be strengthened by adoption of policies that restore equity and enhance market competition. Among the reforms that policy makers should consider are:

  • Tax credits, vouchers, and tax deductions for individuals and families for the purchase of healthcare coverage, including refundable tax credits and vouchers to assist lower-income Americans in purchasing health insurance
  • Additional subsidies for those with higher-than-average healthcare costs to help keep overall premium costs lower
  • Extension of tax-favorable health savings accounts
  • State and federal exchanges should permit individuals and families to purchase health insurance across state lines.

The AAOS strongly believes that patient empowerment and individual responsibility are necessary components of healthcare reform. Healthy choices should be recognized and preventive care should be promoted.

The AAOS supports timely, unencumbered, affordable access to appropriate specialty care as it is paramount to achieving quality health care for all patients. Understanding treatment options for a disease or injury may require a shared decision-making process with a specialty physician. Patients must have access to the right treatment, by the right healthcare professional, at the right time to make the right personal treatment decision. For some conditions, the most efficient and effective entry point into the healthcare system is through appropriate specialty access. More specifically, the AAOS believes that access to essential musculoskeletal services must not be impeded—including access to preventive care, pediatric musculoskeletal care, trauma treatment, emergency room care, and disaster preparedness.

Integral to patient care, continuity of care, patient convenience, patient choice, and patient safety is the provision of in-office ancillary services as well as ensuring that patients continue to have the choice of receiving care in a specialty hospital setting. It is in this patient-centered context that physician-owned services must be examined and permitted. The AAOS believes that the well-being of the informed patient is paramount in any healthcare policy.

The AAOS believes that all stakeholders must work together to address emergency department coverage issues. A solution to this problem must include solutions to the unfunded mandate of the Emergency Medical Treatment and Active Labor Act (EMTALA) in order to ensure the success of any healthcare reform proposal. Participation by a patient in a particular healthcare plan should not restrict access or reimbursement to any and all emergency rooms and necessary providers. (Please see the AAOS Position Statement 1172 on Emergency Orthopaedic Care for more information.)

The AAOS believes that the antitrust laws should be changed to allow physicians to collectively negotiate with health plans and insurers without the necessity of joining a labor union. The McCarran-Ferguson Act needs to be amended to change the anticompetitive practices of insurance companies and establish equity among health plans, insurers, and physicians. (Please see Position Statement 1180 on Principles for Physician Payment Reform for more information.)

The AAOS strongly maintains that meaningful medical liability reform at the federal level and/or constitutionally sustainable state medical liability reforms are a necessary component of any viable healthcare reform proposal. Absent liability reforms, billions of dollars will continue to be wasted on defensive medicine, driving up the cost of health insurance. (See the AAOS Position Statement 1118 on Medical Liability Reform for more information.)

The AAOS believes that the burden of administrative cost of private healthcare plans should mirror the costs in the public sector and that the great preponderance of all healthcare expenditures should be spent on actual delivery of health care.

The AAOS believes that health information technology (HIT) has the potential to enhance the quality of care for musculoskeletal patients. Adequate funding for interoperable HIT must be allocated by the federal government, subsidized by cooperation-based state grants, or supported by other private insurer financing mechanisms. The cost of implementing HIT must not be borne by the physician community. AAOS also believes that HIT must accord with preset standards as long as the highest quality patient care is delivered. (See the AAOS Position Statement 1179 on Electronic Health Records [EHRs] for more information.)

The AAOS believes that all payers should contribute equitably to graduate medical education funding. A mechanism should be developed to ensure that the number of residency positions funded through Medicare and other payers actually reflects the nation's healthcare needs. More specifically, policymakers must ensure that additional resources and residency slots are provided for orthopaedic surgeons and other specialists involved in providing trauma care. In addition, loan repayment programs should be expanded and loan deferment programs should be extended to the full length of residency. (See the AAOS Position Statement 1109 on The Financing of Graduate Medical Education for more information.)

The AAOS believes that physicians should be compensated for care offered in good faith to uncompensated individuals. The societal burden of uncompensated care should not be borne by individual practitioners but by the society that allows these disparities.

As healthcare reform continues to evolve in America, the AAOS believes preservation of the autonomy of the physician-patient relationship to be of the highest priority. Though challenges and opportunities are many, each part of the solution must ensure patient-directed physician empowerment to deliver individual value, overall quality, and systemic efficiency. All Americans are or will become patients. Ongoing development of a public-private partnership healthcare system reflecting the principles addressed will serve this and future generations with meaningful healthcare coverage and true access to care.

Electronic Health Records (1179)—The AAOS believes:

  • Health Information Technology (HIT) should strive to improve quality care, and not detract time and attention from the care of patients.
  • An electronic medical record in a physician's office offers great potential to be beneficial for patient care, patient safety, quality care, and measurement of outcomes.

The AAOS encourages all members to adopt EHRs that are affordable, well designed, and widely available. The AAOS strongly supports the development of interoperability standards for all EHRs. The AAOS also supports the development of appropriate standards for meaningful use of electronic health records by Government agencies and private carriers which balance the needs of patients and their families, physicians and their staffs, and regulators. Finally, the AAOS believes these standards should be collaboratively developed by physicians through their professional organizations in cooperation with government agencies. The process should emphasize the requirements for the highest level of quality patient care while recognizing the limits and clinical specialty focus of physicians who use the systems.

The AAOS believes vendors should consider the specific practice workflows and needs of orthopaedic surgeons in developing, implementing, and maintaining EHR systems.

The AAOS believes the following standards are essential for the successful development of meaningful use standards and EHR systems certification:

  • Establish EHR standards by the collective wisdom of physicians actively caring for patients.
  • Establish phased implementation with sufficient incentives over several years, rather than a single, hard deadline with nonadoption penalties.
  • Establish a comprehensive set of certification standards, including data and interoperability standards for all EHR systems.
  • Establish implementation thresholds rather than requiring implementation of all meaningful use criteria as an all-or-nothing requirement that will serve to discourage, not encourage, adoption of EHR.
  • Recognize the different needs and uses of EHR by disparate medical specialties, especially the differences between surgical specialties and primary care specialties.
  • Create meaningful use criteria that are HIPAA compliant, protect patients' privacy, and provide safe harbors so as not to expose physicians and other healthcare professionals to penalties for unintended HIPAA violations.
  • Recognize that many aspects of EHRs such as interaction with government, private payers, labs, patients, pharmacies, and physicians are still in development and therefore, criteria requiring interoperability for the sharing of data may not be attainable for reasons beyond the control of physicians.
  • Recognize the cost burden of adoption of EHR, particularly for small private practitioners, and for practitioners in rural areas.

The AAOS believes the potential benefits of EHR adoption are vast, and we believe widespread usage of well-designed EHRs will benefit our patients and the practice of medicine. We recognize, however, the cost of implementation may appear prohibitive to many practices. We encourage physicians to weigh the benefits versus the risks and costs and also take into account the fact that, in the near future, payers will likely make EHRs a requirement in order to participate in their networks. The AAOS recommends the adoption of well-designed EHRs; however, physicians should take the time to find the system most appropriate in terms of functionality and cost for their own practice. The AAOS also recommends that payers and government agencies recognize variations in system capabilities in setting standards, incentives, and penalties.

Use of Global Service Data (1181)—The AAOS believes the Complete Global Service Data for Orthopaedic Surgery and all authorized orthopaedic subspecialty publications should be considered to be the definitive coding source(s) for the bundling of orthopaedic surgical procedures because the information contained in the Complete Global Service Data for Orthopaedic Surgery and authorized orthopaedic subspecialty publications is compiled and edited exclusively by orthopaedic surgeons.

The AAOS Unified Advocacy and Unified Regulatory Agendas were updated to reflect increased concern about alternative payment models, including the merit-based incentive payment system and the comprehensive care for joint replacement bundled payment model, the need for risk adjustment, and funding for graduate medical education. The Unified Orthopaedic Research Agenda was also updated.

Additional Information: