In January, smelling change in the air, I attempted to make some predictions for evolving hot topics for AAOS Now in 2016. This focus on change continues with this, our March issue.
For starters, the AAOS office of government relations in Washington, D.C., provides an excellent overview of the evolution of the Meaningful Use program. (See "Meaningful Use Update.") The article explains that the Centers for Medicare & Medicaid Services (CMS) did not release their updated rules for compliance with the meaningful use program until too little time remained for physicians to comply for the mandated 90 days. As a result, a blanket (and easier to request) hardship exemption was offered. However, in Craig R. Mahoney, MD; Stephen W. Shick, MD; and Alexandra E. Page, MD's detailed introduction to the Merit-based Incentive Payment Systems (MIPS) and Alternative Payment Models (APMs) arising out of the Medicare Access and Chip Reauthorization Act of 2015, we learn that MIPS will replace meaningful use. (See "Understanding APMs and MIPS."). Before you read that article, though, you may want to read Drs. Lundy and Barber's story list of federal acronyms. This is the first in a series that will undoubtedly serve as an excellent reference when parsing these CMS announcements in the months and years to come.
What does all this meaningful use mean for orthopaedic surgeons? Most of us are aware that failure to participate will be met with increasing penalties (up to 7 percent of Medicare revenue). To comply, doctors and hospitals have already made substantial investments. When the rules change, electronic medical record systems need to be upgraded or scrapped. Those cost money, but, even worse, they can have recurrent, marked impacts on productivity.
As we move from Meaningful Use to MIPS, our reimbursements will also be adjusted based on the quality of care provided. These merit payments and penalties are budget neutral to current reimbursement. Although I am sure AAOS Now readers will be awarded for their above-average care, the net impact on physicians as a whole will be negative as we spend more money to earn a bonus or at least avoid a penalty.
How much will MIPS improve care? MIPS is new, but commenters have noted that it is built on the older P4P (pay for performance) incentives. Up until a 2014 RAND report, data supporting the effectiveness of these programs to improve care remained sparse.
APMs, such as care bundles, are more intriguing because, in theory, they allow the physician to lead a team reengineering the care pathway to improve outcomes while saving money. Most data suggest that the first pass or two does offer considerable savings. Continuing to ratchet up savings after that will be difficult, but if quality continues to improve, we all win.
A key part of most APMs is to shift financial risk to the providers. So far, in the total joint bundle project, that risk is borne by the hospitals. Will control of the bundle also go to the stakeholder taking the risk? If hospital administrators wrest control from physicians, what impact will that have on cooperation between these parties and the relative balance of quality of care and cost?
Knowing how to manage this risk requires a deep understanding of our patient populations and their surgical outcomes. These bundles also require transparency around the true costs of care. Collecting and acting on these data will, no doubt, improve value and outcomes. Right now, however, building the infrastructure to capture this information remains, for many providers, daunting and expensive. How much will these systems add to the already staggering administrative overhead physician practices face?
Fee for service is much maligned, but it has one advantage, it's simple. You do X, you get paid Y (theoretically at least).
CMS has announced that by 2018, in 2 short years, 90 percent of all Medicare payment will be tied to quality of care. Are we ready to measure and benchmark? There is no doubt that quality data can be used to identify problem areas in healthcare delivery. However, are we really ready to incentivize or discourage care pathways for a larger percentage of our patient population based on the data we are currently able to capture? Although we are working hard to do better, in many healthcare systems, surgeons and even hospital administrators share a healthy skepticism for the "quality metrics" we are offered. In many areas, there is no agreement on the optimal measures. When reasonable measures do exist, they often do not stratify for risk based on patient comorbidities, technical complexity, or other factors. Key thought leaders will address this issue in the annual AAOS Now Forum on Sunday, March 6, in Orlando, Fla. Articles from the Forum will be published in AAOS Now over the coming months.
In my own practice, we have been trying to prepare ourselves for value-based reimbursement. We are making progress, but a number of substantial hurdles remain. Although Meaningful Use is predicated upon interoperable electronic health records, direct communication between these records remains more fantasy than reality. My hospital electronic medical record (EMR) faxes my office EMR (the rehab center has a third system). Culling data that covers a patient's care from a longitudinal perspective, therefore, continues to be done by hand and with great drudgery and expense. Of course, we cannot share risk in a fiscally sound manner without a clear, actuarial approach to these data.
We want to understand how much our care costs and how that compares with charges. Outside of CMS programs, reimbursements remain shrouded by confidentiality and antitrust rules.
The best accounting for costs of care may come through time-driven activity-based costing processes. Several recent studies have shown the power of these techniques to identify system inefficiencies and improve value. Yet, these processes are expensive and time-consuming themselves. Some centers have internal capacity to provide these data, but most will outsource these efforts to consulting firms. How many centers will realize enough shared savings through alternative payment models to cover these investments?
In Austin, our new University of Texas Dell School of Medicine is focusing on healthcare delivery systems and will likely provide us tools not available to most orthopaedic surgeons. I am told that, given the superheated job market for healthcare analytics personnel, building these capacities will become increasingly expensive.
As these programs evolve, we hope to keep you informed with a "what you need to know now" approach. That said, the acronyms and bureaucratic language of CMS pronouncements can make even the health delivery systems enthusiast's eyeballs bleed.
Hopefully, many of you are headed to the AAOS Annual Meeting in Orlando, Fla. While there, seek out symposia on these subjects. Talk to content experts in this area. Whether or not you are able to attend the meeting, make a donation to the AAOS Political Action Committee (Orthopaedic PAC) that is consistent with our need to influence the huge changes facing orthopaedics and the impact those changes will have on our patients' access to care.
After a painful adolescence, these changes could well improve the quality of orthopaedic care. By containing costs, these programs may maintain or improve access to that care. However, it seems clear that these changes are much more likely to be positive if they are firmly guided by physicians.
Last but not least
Finally, from the home office—I would like to congratulate Mary Ann Porucznik, the long-time managing editor of AAOS Now, on her retirement. Mary Ann had been a 15-year employee of the AAOS and, along with S. Terry Canale, MD, worked to transform the old AAOS Bulletin into the fine, industry-segment-leading publication you have before you now. Dr. Canale was able to extract from Mary Ann a promise not to retire before he did, but I was not that lucky.
Even under crushing deadlines, Mary Ann always maintained a calm demeanor. She was equally calm when pointing out errors or flaws in reasoning from highly opinionated orthopaedic surgeons. Mary Ann commands a wonderful memory and a great grasp on important matters in the world of orthopaedics from advocacy to clinical issues. Having had enough of deadlines, she has retired and I would like to wish her well. I am told she plans to stay in the Chicagoland area for now, but may choose a warmer climate in the future (Austin is warmer, Mary Ann). She is involved in a number of community activities and will, no doubt, stay busy. I know we will all miss her. That said, we are hoping to be able to call on her well of experience from time to time. I thank her for her help, guidance, and patience as I joined AAOS Now.
Eeric Truumees, MD, is the Editor-in-Chief of AAOS Now.
A one-woman show
Over the past 8 years, the AAOS has, in my somewhat biased opinion, put together the best monthly news magazine in medicine. At first I, and now Dr. Truumees, got most of the credit, but in both cases, the credit was ill-deserved. The workhorse in AAOS Now was Mary Ann Poruzcnik. Mary Ann was a "one-woman show." She has a photographic memory; most facts she had on the tip of her tongue, and those she didn't have, she got. She had an uncanny ability to write lots of copy on a moment's notice. Perhaps her greatest quality was to treat all staff and Academy contributors equally. As long as I knew her, I never saw her express any malice or contempt for anyone, but if she had a dissenting opinion she would let you know it—softly—and usually she was right. I have no doubt that AAOS Now will thrive, but it and the AAOS membership are going to miss one of the finest managing editors in the publications business. There just ain't many around anymore like Mary Ann.
S. Terry Canale, MD