Published 4/1/2017

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)

Medical liability legislation
Medscape reports that a bill approved by the House Judiciary committee and now under consideration in the U.S. House of Representatives would, if enacted, cap noneconomic damages in medical liability suits at $250,000, but only if the plaintiffs received health care through a federal program, subsidy, or tax benefit, such as Medicare, Medicaid, subsidized plans under the ACA, and employer-sponsored health plans. The bill would also:

  • Limit contingency fees of plaintiffs' attorneys
  • Require damages of $50,000 or more to be paid in installments
  • Exempt clinicians who order a drug or medical device for a patient from product liability or class action suits
  • Require recoverable damages among multiple defendants to be based on their percentage of responsibility
  • Reduce the statute of limitations for medical liability suits to 3 years after date of injury, or 1 year after discovery of injury, whichever comes first

Supporters of the bill say that the caps will reduce the practice of defensive medicine and ensure efficient spending of federal funds.

Merit-based Incentive Payment System
An article in Healthcare IT News reports on comments made by representatives of the U.S. Centers for Medicare & Medicaid Services (CMS) regarding the Merit-based Incentive Payment System (MIPS). A spokesperson for the CMS Quality Measurement & Value-Based Incentive Group says that the agency will allow clinicians to pick the pace of their participation in the program. Medicare clinicians who participate in MIPS will be reimbursed based on a score of zero to 100, with their scores weighted according to the following four components in 2017: quality (60 percent), cost (zero percent), advancing care information (25 percent), and clinical practice improvement activities (15 percent). During 2017, which serves as a transition year, clinicians may report performance periods ranging from 90 days to the full year, but data must be submitted to CMS by the end of Q1 2018 to avoid a penalty.

Overlapping surgery
Findings from a survey published in the Journal of the American College of Surgeons (online) suggest that a small minority of the general public is aware of the practice of overlapping surgery, and most would prefer that the practice be disclosed during the informed consent process. The researchers surveyed 1,454 people and found that only 56 (3.9 percent) had prior knowledge of the practice of overlapping surgery. Overall, 31 percent of respondents supported or strongly supported the practice. However, 94.7 percent said that the attending surgeon should inform them of the practice in advance.

Prior authorization
An article in MedPage Today looks at the issue of prior authorization as discussed at the annual meeting of the Healthcare Information and Management Systems Society. A survey recently conducted by the American Medical Association found that responding medical practices submitted an average of 37 prior authorization requests each week, with an average of 16 hours of physician and staff time required to complete the requests. Overall, 75 percent of respondents found prior authorization to be burdensome, and more than one-third reported having staff who work exclusively on prior authorization. At least one healthcare plan has developed an online authorization portal that allows providers to enter their own authorization information, with instant approval notification, and other organizations are working to develop ways to streamline the authorization process.

The California Medical Association reports that bills have been introduced in both houses of the U.S. Congress to eliminate the Medicare Independent Payment Advisory Board (IPAB). IPAB is a 15-member federal agency called for under the Affordable Care Act, which would be created if Medicare spending growth exceeds certain levels. Cuts proposed by IPAB could be overridden by a three-fifths majority vote of both houses of Congress.

Insurer status
Findings in the Journal of Shoulder and Elbow Surgery (online) suggest that insurance payer status may be associated with perioperative complication risk for patients who undergo shoulder arthroplasty. The authors reviewed data on 103,290 shoulder arthroplasty patients (68,578 Medicare, 27,159 private insurance, 3,544 Medicaid/uninsured, 4,009 other) from the Nationwide Inpatient Sample database. They found that the overall complication rate was 17.2 percent (n = 17,810) and the mortality rate was 0.20 percent (n = 208). Overall, Medicare and Medicaid/uninsured patients had a significantly increased risk of medical, surgical, and overall complications compared with private insurance using controlled match data. Multivariate regression analysis suggested that private insurance was associated with fewer overall medical complications.

Opioid guideline app
The U.S. Centers for Disease Control and Prevention (CDC) has released an opioid guideline app designed to help providers apply the recommendations of the agency's Guideline for Prescribing Opioids for Chronic Pain into clinical practice. The application includes a Morphine Milligram Equivalent calculator, summaries of key recommendations and a link to the full guideline, and an interactive motivational interviewing feature to help providers practice effective communication skills. The app is available for free for both Android and iOS platforms.

FDA device reporting
A U.S. Government Accountability Office report on the use of power morcellators finds potential issues in the U.S. Food and Drug Administration (FDA) reporting system. Following reports of several high-profile device safety issues occurring in hospitals, the agency initiated inspections at 17 hospitals linked to reports of adverse events related to the use of power morcellators and duodenoscopes. The director of the FDA Center for Devices and Radiological Health noted that, although such events appeared to fall under the agency's medical device reporting requirements, the agency did not see corresponding adverse event reports submitted to the FDA adverse event report database. From the inspections, the agency learned several things:

  • Some hospitals did not submit required reports for deaths or serious injuries related to devices used at their facilities; and in some cases, they did not have adequate procedures in place for reporting device-related deaths or serious injuries to FDA or to the manufacturers. Although such reporting is mandatory, the agency believes that these hospitals are not unique, as there is limited to no reporting to FDA or manufacturers at some hospitals.
  • Hospital staff were often not aware of nor trained to comply with all of FDA's medical reporting requirements.

ACO implementation
Two studies published online in the journal JAMA Internal Medicine look at various approaches to accountable care organization (ACO) models. In the first, researchers who reviewed fee-for-service Medicare claims found that, for ACOs that entered in 2012, participation in the Medicare Shared Savings Program (MSSP) was associated with a 9 percent differential reduction in postacute spending by 2014. The shift appeared to be driven by reductions in discharges to facilities, length of facility stays, and acute inpatient care. The researchers noted that MSSP participation was not associated with significant changes in 30-day readmissions, use of highly rated skilled nursing facilities, or mortality.

The second study compares Medicaid ACO models in Oregon and Colorado. The researchers note that the Oregon model was characterized by a large federal investment and movement to global budgets, while the Colorado model was more limited in scope and implemented without substantial federal investment. They also found that standardized expenditures for selected services declined in both states over a 4-year period, but the decreases were not significantly different between the two states. However, the researchers note that the Oregon model was associated with reductions in emergency department and primary care visits, as well as improvements in acute preventable hospital admissions, three of four measures of access, and one of four measures of appropriateness of care.

Bundled payments
A study in the Journal of Orthopaedic Trauma (March) examines the use of a bundled payment model for fracture care. The authors reviewed information on 23,643 operatively treated patients with fracture and 544,067 patients who underwent total joint arthroplasty (TJA) from the New York State Statewide Planning and Research Cooperative System database. Among TJA patients, they found that the difference in hospital charge between patients with minor or severe severity of illness (SOI) ranged from 153 percent to 211 percent. Among patients surgically treated for fracture, the difference in hospital charge between patients with minor or severe SOI ranged between 314 percent and 489 percent. In addition, the authors observed similar differences in mean hospital length of stay and homebound discharge disposition, with patients with fracture demonstrating greater sensitivity to increasing SOI. "Although bundled payments may be a viable option for patients undergoing elective TJA," the authors write, "this payment model requires particular attention when applied to fracture care."
Resident shift limits
The Accreditation Council for Graduate Medical Education (ACGME) will vote on a proposal that among other things would allow first-year residents to work 28-hour shifts—an increase from the current 16-hour limit. The revised standards do not change the number of clinical and educational hours from the current maximum of 80 hours per week, averaged over 4 weeks. The proposed revisions also include:

  • An expanded section on patient safety and quality improvement
  • A new section on physician well-being
  • Strengthened expectations around team-based care
  • Consistent, nationwide resident clinical and educational work hours

Unsolicited patient observations
A study in the journal JAMA Surgery (online) suggests that patients whose surgeons have large numbers of unsolicited patient observations in the 24 months prior to a surgical procedure may be at increased risk of complications. The researchers conducted a retrospective cohort study of 32,125 adult patients who underwent inpatient or outpatient operations at one of seven academic medical centers. They found that 3,501 (10.9 percent) experienced a complication, including 1,754 (5.5 percent) surgical and 2,422 (7.5 percent) medical complications. The researchers noted that prior unsolicited patient observations for a surgeon in the preceding 24 months were significantly associated with the risk of a patient having any complication, any surgical complication, any medical complication, and readmission. Compared with patients whose surgeon was in the lowest quartile of unsolicited patient observations, the adjusted rate of complications was 13.9 percent higher for patients whose surgeon was in the highest quartile.

Benefits vs. harms
Findings in JAMA Internal Medicine (online) suggest that some medical professionals may carry inaccurate expectations of benefits and harms of treatments, tests, and screening tests. The research team conducted a systematic review of 48 studies covering 13,011 clinicians. Overall, 20 studies focused on treatment, 20 on medical imaging, and 8 on screening. The research team found that most participants correctly estimated 13 percent of 69 harm expectation outcomes and 11 percent of 28 benefit expectations. A majority of participants overestimated benefit for 32 percent of outcomes but underestimated benefit for 9 percent of outcomes. In addition, they underestimated harm for 34 percent of outcomes, but overestimated harm for 5 percent of outcomes. The research team argues that inaccurate perceptions regarding benefits and harms of interventions may result in suboptimal clinical management choices.

Implant costs
A research letter published in The Journal of the American Medical Association (Feb. 28) finds that some hospitals may charge private insurers double the typical cost for knee and hip implants. The research team reviewed claims data from a single insurer on 40,372 patients who underwent primary total knee arthroplasty and 23,570 patients who underwent primary total hip arthroplasty. They found that the average selling price (ASP) to hospitals for knee implants was $5023.01, while the mean insurance payment was $10,604.52. Similarly, the ASP for hip implants was $5619.75 and the mean insurance payment was $11,751.25.

Low back pain
The American College of Physicians (ACP) has released a new guideline regarding clinical recommendations on noninvasive treatment of low back pain. The recommendations are based on a systematic review of randomized, controlled trials and systematic reviews published through April 2015 on noninvasive pharmacologic and nonpharmacologic treatments for acute, subacute, or chronic low back pain. The guideline offers the following strong recommendations:

  • Given that most patients with acute or subacute low back pain improve over time regardless of treatment, clinicians and patients should select nonpharmacologic treatment with superficial heat (moderate-quality evidence), massage, acupuncture, or spinal manipulation (low-quality evidence). If pharmacologic treatment is desired, clinicians and patients should select nonsteroidal anti-inflammatory drugs or skeletal muscle relaxants (moderate-quality evidence).
  • For patients with chronic low back pain, clinicians and patients should initially select nonpharmacologic treatment with exercise, multidisciplinary rehabilitation, acupuncture, mindfulness-based stress reduction (moderate-quality evidence), tai chi, yoga, motor control exercise, progressive relaxation, electromyography biofeedback, low-level laser therapy, operant therapy, cognitive behavioral therapy, or spinal manipulation (low-quality evidence).

Opioids and children
A study in Pediatrics (online) suggests that opioid pain relievers are often stored unsafely in households with children. The research team surveyed a nationally representative sample of 681 adults who reported prescription opioid use and children at home. They found that safe storage was reported by 32.6 percent of those with only young children (age <7 years), 11.7 percent among those with only older children (age 7–17 years), and 29.0 percent among those with children in both age groups.>

Adverse event reports
Data published in Production and Operations Management (online) suggest slow response by medical device manufacturers in response to certain adverse event reports. The researchers used a combination of econometric and predictive analytic methods to analyze user-generated reports on adverse events linked to medical devices. They found that a high "signal to noise ratio" (defined as more adverse event reports) correlated with underreaction, or delays in the responses of manufacturers. Conversely, user feedback related to adverse events characterized by high severity was associated with an increased likelihood of overreaction.

Clinician hiring trends
The Medicus Firm has released a report based on the hiring activity of more than 250 healthcare employers from 2012 through 2016. Among other things, the report notes that 90 percent of physicians hired during that period received signing bonuses. The report also notes that:

  • Physician employment as a practice model continues to dominate physician recruiting activity nationwide, with 91 percent of physicians placed being hired on as employees.
  • The placement rate of advanced practice clinicians such as physician assistants and nurse practitioners increased significantly for the fourth consecutive year.
  • International physicians accounted for 31.77 percent of placements made in 2016.

California provider directories
California Healthfax notes that a report from the California Department of Managed Health Care finds a large degree of inaccuracy in provider directories and compliance reports supplied by insurers. The report states that 36 of 40 Timely Access Compliance Reports submitted by insurers for 2015 contained "significant data inaccuracies" to the degree that they were not usable. Across insurers, 22 percent to 56 percent of physicians listed in their compliance reports were not listed in the plan's provider rosters.