How many times have you tried to read a healthcare policy article (maybe one of ours) and said to yourself, "I don't understand this because of all of these acronyms and abbreviations!" (Strictly defined, acronyms are abbreviations that form pronounceable words—such as "JAMA"—and abbreviations are sets of letters pronounced as letters—such as "CMS"; for the purpose of this four-part series, we will use "acronyms" to refer to both.)
We are all guilty of using a tremendous variety of acronyms in our daily practice of orthopaedic surgery. The peril comes from the potentially confusing acronyms that directly affect us, such as governmental and payer-related ciphers, arising from outside our specialty. We often don't really know what these acronyms mean, yet others communicate with us using them and expecting us to fully understand.
PPACA is changing healthcare delivery. Medicare has released CJR to improve quality and reduce cost. NQF is defining quality using PROMs, while HEs are reducing payments to physicians. Medical education is reduced to a debate about IME and DME expenses, while MDs are befuddled by all the acronyms and having to adhere to MU requirements.
If the preceding paragraph was clear as mud, please read on. In this four-part series, we will seek to decipher many of the acronyms commonly used in healthcare policy discussions and in articles in AAOS Now. We will address them in the following categories: federal government, federal laws, quality, and practice
In this first installment, we cover commonly used acronyms relating to the federal government.
- DHHS or HHS: Department of Health and Human Services
HHS is a huge agency in the federal government that is headed by the Secretary of Health and Human Services, Sylvia Burwell. Hers is an extremely powerful position; the appointee is a member of the president's cabinet. In 2016, the budget for HHS is more than $1 trillion, which is about a quarter of the entire federal budget. The Secretary controls a significant amount of funding related to health care in the United States, and 12 subordinate governmental agencies that affect the delivery of healthcare report to her. Some of these are as follows:
- CMS: Centers for Medicare & Medicaid Services
CMS is the largest agency under HHS and is the controlling body for Medicare and Medicaid. The current (interim) administrator of the CMS is Andy Slavitt. The administrator is appointed by the president and confirmed by the Senate. In 2015, the budget for CMS exceeded $906 billion. CMS controls the payment for all Medicare and Medicaid services and decides how these funds are distributed. Because many private insurance programs follow the lead of CMS, this agency has a tremendous amount of influence on healthcare policy in the United States. CMS administrates programs such as Meaningful Use (MU) and the Physician Quality Reporting System (PQRS).
- FDA: Food and Drug Administration
The FDA is also under HHS, and this agency is responsible for ensuring that pharmaceuticals and medical devices are safe and effective, along with many other duties. When devices are used "off label," they are used in a manner that was not approved by the FDA.
- NIH: National Institutes of Health
The NIH, another governmental agency under HHS, is responsible for biomedical research. The NIH does research through its own programs, and it also funds a significant amount of high-quality research throughout the country.
- CDC: Centers for Disease Control and Prevention
Based in Atlanta, the CDC is responsible for more than just stemming the spread of contagious diseases. Its mission is to improve the nation's public health through the control and prevention of disease, injury, and disability. Most people do not know that the CDC even focuses on issues such as occupational health, injury prevention, and reducing obesity. It issues the Morbidity and Mortality Weekly Report.
- AHRQ: Agency for Healthcare Research and Quality
The AHRQ is important to orthopaedic surgery, as it is the agency that is leading some of the initiatives well known to us clinicians. For example, the AHRQ is driving many of the clinical practice guidelines and quality measures, and it also manages the National Guideline Clearinghouse. The AHRQ is leading efforts to decrease medical errors and improve quality, and it oversees the TeamSTEPPS program.
- OIG: Office of Inspector General (HHS)
The OIG enforces many of the rules and laws of HHS, and it is an often-misunderstood agency within the federal government. In fact, there are many different OIGs throughout the administration. The OIG under HHS is responsible for enforcing compliance with the rules and laws around Medicare and the other governmental healthcare programs. The main purpose of the OIG is to find and eliminate fraud, waste, and abuse. The OIG is active within the domain of CMS, but it also monitors for abuse in the FDA, the NIH, and the CDC. OIG agents carry guns and handcuffs, and they are definitely folks you don't want to see at your doorstep.
There are many other agencies that work under HHS. The ones listed above are among the most commonly cited organizations in current healthcare policy discussions. What follows are acronyms that specifically address components of CMS and Medicare.
- CMMI: Center for Medicare and Medicaid Innovation
The CMMI is a branch of CMS, and was developed as a result of the Patient Protection and Affordable Care Act of 2010 (PPACA). The whole purpose of the CMMI is to improve quality and slow spending by testing innovative payment and delivery system models. The CMMI is the administrator of several programs that directly affect the practice of orthopaedic surgery including Accountable Care Organizations (ACOs), Bundled Payments for Care Improvement Initiative (BPCI), and Comprehensive Care for Joint Replacement Model (CJR). These programs will be described in a subsequent Acronyms 101 article!
- MedPAC: Medicare Payment Advisory Commission
MedPAC was formed in 1997 as an independent federal agency that is responsible for advising Congress on matters concerning Medicare and Medicaid. MedPAC specifically provides Congress with analysis and advice concerning Medicare and the interaction of the private payers with Medicare. Not surprisingly, MedPAC supported the introduction of the controversial CJR program.
- CBO: Congressional Budget Office
The CBO was formed in 1974 as an agency under the legislative branch whose primary responsibility was to advise Congress on the fiscal impact of the legislation it was considering. The CBO has an enormous task in that it must "score" proposed and existing legislation to determine the overall financial impact that these laws would have on the federal budget. The director of the CBO has significant influence on Congress through these analyses.
- RAC: Recovery Audit Contractor
The RAC program was started as a demonstration project by HHS in 2003, and it became a permanent program in 2006. The purpose of the RAC is to find overpayments and inappropriate reimbursements to physicians under the Medicare fee-for-service program. The government divided the nation into four regions, and different private corporations are assigned the recovery efforts in each region. The RAC auditors are paid on a contingency fee basis; therefore, they make more money if they collect more "overpayments" from physicians.
- MAC: Medicare Administrative Contractor
A MAC is completely different from a RAC. A MAC is a private insurance company that serves as the intermediary between the healthcare providers and Medicare for certain geographic areas. MACs administer Medicare Part A, B, and DME (durable medical equipment). Under the Medicare Access and CHIP Reauthorization Act (MACRA), the terms for MACs were extended from 5 to 10 years.
- NQF: National Quality Forum is an organization that helps validate quality metrics in health care. The endorsement of a quality metric by NQF is important for acceptance of the metric by Medicare.
These are some of the most common acronyms describing federal offices and agencies that affect the practice of orthopaedic surgery. This listing is not comprehensive. Subsequent articles will define and describe other acronyms that make up the confusing fabric of healthcare policy.
Douglas W. Lundy, MD, MBA, is a member of the AAOS Council on Advocacy and of the editorial board of AAOS Now. He is co-president of Resurgens Orthopaedics in Atlanta. Thomas C. Barber, MD, is the chair of the Council on Advocacy and is a total joint surgeon in Oakland, Calif.