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Published 9/1/2016

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)

CMS Proposed Rule
The U.S. Centers for Medicare & Medicaid Services (CMS) has released a proposed rule for the 2017 Hospital Outpatient Prospective Payment System and the Medicare Ambulatory Surgical Center Payment System. Among other things, CMS proposes the following actions:

  • Implement Section 603 of the Bipartisan Budget Act of 2015, which will affect how Medicare pays for certain items and services furnished by certain off-campus outpatient departments of a provider.
  • Remove the Pain Management dimension of the Hospital Consumer Assessment of Healthcare Providers and Systems survey from Medicare's Hospital Value Based Purchasing Program.
  • Make several changes to the objectives and measures of the Medicare Electronic Health Record (EHR) Incentive Program for eligible hospitals and critical access hospitals attesting under the Medicare EHR Incentive Program.

EHR reporting period
CMS is proposing a 90-day EHR reporting period in 2016 for all eligible professionals (EPs), eligible hospitals, and critical access hospitals (CAHs), to assist healthcare providers and increase flexibility in the program. The EHR reporting period would be any continuous 90-day period between Jan. 1, 2016, and Dec. 31, 2016. The American Hospital Association and the College of Healthcare Information Management Executives both praised CMS for shortening the meaningful use reporting period. CMS is also looking to eliminate the Clinician Decision Support and Computerized Provider Order Entry objectives and measures for eligible hospitals and CAHs, and proposed lowering thresholds for some meaningful use stage 2 measures. EPs, eligible hospitals, and CAHs that have not successfully demonstrated meaningful use in a prior year would be required to attest to Modified Stage 2 (instead of Stage 3) by Oct. 1, 2017.

Hardship exemption: CMS is proposing that certain EPs, who have not successfully demonstrated meaningful use in a prior year but intend to attest to meaningful use for an EHR reporting period in 2017, and intend to transition to the Merit-Based Incentive Payment System (MIPS) and report on measures specified for the advancing care information performance category under the MIPS as proposed in 2017, can apply for a significant hardship exception from the 2018 payment adjustment.

Volume and patient outcomes
A study published in Annals of Surgery (online) suggests that increased trauma center volume may be associated with improved patient outcomes. The authors conducted a retrospective cohort study across 287 centers involving 839,809 patients with injury severity score greater than 15. They found that each 1 percent increase in trauma center volume over time was associated with a 73 percent increased likelihood of improving center-level standardized mortality ratio (SMR). Conversely, each 1 percent decrease in volume over time was associated with a 2-fold increase in odds of worsening SMR. In addition, the authors noted significant improvement in SMR emerged in Level I and Level II trauma centers following 3 or more preceding years of increasing volume. The authors note that the impact of volume should be taken into account when designating new trauma centers.

Antibiotic stewardship
An article in U.S. News & World Report looks at efforts to reduce antibiotic overprescribing. A recent CMS proposal would require hospitals to develop antibiotic stewardship programs to ensure the responsible use of antibiotics and minimize effects of overuse. In addition, a recent report from the Pew Charitable Trusts offers several stewardship strategies to improve antibiotic prescribing, including the following:

  • audit and feedback of provider prescribing rates compared against peers or practice guidelines
  • clinical decision support to provide clinicians with information to help them determine the most appropriate diagnosis and treatment plan for individual patients
  • communication training to help physicians effectively discuss treatment options to overcome patient expectations for antibiotics

In addition, the article states that the U.S. Centers for Disease Control and Prevention plans to increase efforts to get healthcare providers to implement better systems to reduce antibiotic resistance caused by overprescribing.

Female physician salaries
A study published in JAMA Internal Medicine (online) finds significant differences in salary between male and female physicians at public medical schools. The research team compared publicly available salary information for 10,241 academic physicians at 24 public medical schools against data from a physician database with detailed information on sex, age, years of experience, faculty rank, specialty, scientific authorship, National Institutes of Health funding, clinical trial participation, and Medicare reimbursements. After adjustment for age, experience, specialty, faculty rank, and measures of research productivity and clinical revenue, they found that female physicians earned an average of $19,878 less than their male counterparts.

Medicare claims data available
New rules under the Medicare Access and CHIP Reauthorization Act (MACRA) allow qualified entities to confidentially share or sell analyses of Medicare and private sector claims data to providers, employers, and other groups, Healthcare IT News reports. The rationale is that the data would be used to help individuals and organizations make more informed healthcare decisions.

Qualified entities must combine the Medicare data with other claims data, such as private payer data, to produce quality reports that are representative of how providers and suppliers are performing across multiple payers. According to CMS, 15 organizations have already applied and been approved as qualified entities. CMS added that future rulemaking is expected to expand the data available to include standardized extracts of Medicaid data.

Medical device evaluation system
In a letter published in The Journal of the American Medical Association (online), Robert M. Califf, MD, commissioner of the U.S. Food and Drug Administration (FDA) and Jeffrey Shuren, MD, JD, director of the FDA Center for Devices and Radiological Health argue in favor of a more robust national evaluation system for medical devices. The writers note that in 2012, FDA began the process of establishing a National Evaluation System for Health Technology (NEST) to "quickly identify problematic devices, accurately and transparently characterize and disseminate information about device performance in clinical practice, and efficiently generate data to support premarket clearance or approval of new devices and new uses of currently marketed devices." Further, some experts have recommended the development of a federated virtual system for evidence generation through strategic alliances among data sources such as registries, electronic health records, payer claims, and other sources. "A national evaluation system that engages all stakeholders could enable the FDA to focus efforts on facilitating the development and interpretation of more informative data essential for policy making and clinical decisions for individuals and populations," the writers state.

Repeal or revamp Stark Law?
Modern Healthcare reports that, in testimony before the Senate Finance Committee, executives from several large health systems argued for repeal or revamping of the Stark Law, stating that the law's wording makes it difficult for physicians to enter innovative payment arrangements, consistent with new requirements under MACRA. The Stark Law generally prohibits physicians from referring Medicare patients to hospitals, labs, and colleagues with whom they have financial relationships.

MACRA confusion
Findings from a survey of 600 physicians conducted by Deloitte Development LLC suggest that many physicians lack a complete understanding of MACRA. Overall, 50 percent of nonpediatric physicians surveyed had never heard of MACRA, and 32 percent only recognized the name. Additional findings from the survey include the following:

  • Twenty-one percent of self-employed physicians and those in independently owned medical practices displayed some familiarity with MACRA, compared to 9 percent of employed physicians.
  • Although 8 out of 10 physicians surveyed preferred fee-for-service payment models, 71 percent said they would participate in value-based payment models if offered financial incentives to do so.
  • Seventy-four percent of physicians surveyed believe performance reporting to be burdensome and 79 percent do not support linking compensation to quality.

Opioid bill
President Obama has signed into law the Comprehensive Addiction and Recovery Act, which authorizes the federal government to award state grants for opioid-related initiatives around education, prevention, treatment, and recovery efforts. The Act incorporates elements of 18 opioid-related bills passed earlier this year by the U.S. House of Representatives. The bill authorizes $181 million in new spending, but the Associated Press notes that the president had sought an additional $920 million to fund programs to combat opioid misuse and increase the availability of naloxone.

The American Association of Orthopaedic Surgeons (AAOS), along with other medical organizations, has urged Congress to provide funding for the unfunded programs.

Adverse events
A study published in JAMA Surgery (online) looks at the issue of adverse event disclosure. The research team conducted an observational study of 35 surgeons who were surveyed regarding their perceptions of an adverse event, personal effects from disclosure, and baseline attitudes toward disclosure. They found that surgeons who were less likely to have discussed prevention, those who stated the event was very or extremely serious, or reported very or somewhat difficult experiences discussing the event were more likely to have been negatively affected by the event. In addition, surgeons with more negative attitudes about disclosure at baseline reported more anxiety about patients' surgical outcomes or events following disclosure. The research team concludes that "quality improvement efforts focused on recognizing the association between disclosure and surgeons' well-being may help sustain open disclosure policies."

CMS hospital star ratings
Kaiser Health News reports that CMS will soon publish star ratings summing up the quality of 3,662 hospitals, despite concerns of some stakeholders that the ratings system may unfairly penalize hospitals that serve higher numbers of lower-income patients. Under the system, hospitals will be rated between one and five stars, based on 64 individual hospital measures already available on the CMS Hospital Compare website. Based on current data, CMS states that 102 hospitals would receive the best rating of five stars, 934 would get four stars, 1,770 would receive three stars, 723 would be awarded two stars, and 133 would get the lowest rating of one star. An additional 937 hospitals are not rated due to lack of data.