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Published 8/1/2017

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).

Ransomware prevention
An article in Modern Healthcare looks at the issue of ransomware attacks on the healthcare system. Ransomware restricts user access to the computer until the user pays a fee to the attackers and can be delivered via email attachments or links within emails. Several healthcare systems in the United States and elsewhere have been the subject of recent attacks. The writer notes that a few malicious emails are likely to penetrate even sophisticated firewalls and argues for implementation of employee training programs to reinforce cybersecurity efforts and complement technologies such as antivirus software. "Training takes a concerted effort that cuts across the entire hospital," she writes. "… everyone needs to understand how vulnerable their organization is to an attack and the dangers of unleashing a virus or malware. Training must teach employees how important it is to be unceasingly careful. … it takes perseverance and the understanding that guarding against all kinds of malware, including ransomware, is more than a one-time class—it's an entire mindset necessary not only for protecting the organization's reputation, but for protecting patients."

Windows security vulnerabilities
The U.S. Department of Health and Human Services (HHS) Office for Civil Rights is warning healthcare providers and others regarding security vulnerabilities in several Microsoft products, including the Windows operating system, and a threat by a malicious cyber group labeled by the U.S. Department of Homeland Security as "Hidden Cobra." The agency states that the group is targeting critical infrastructure sectors in the United States. The notice comes on the heels of a recent series of ransomware attacks on healthcare organizations.

Medical liability cap overturned
The Orlando Sentinel reports that, in a 4-3 decision, the Florida Supreme Court has determined a state law limiting noneconomic damages in medical liability cases to be unconstitutional. In the majority opinion, the court concluded that "caps on noneconomic damages … arbitrarily reduce damage awards for plaintiffs who suffer the most drastic injuries." In addition, the court wrote that "…because there is no evidence of a continuing medical malpractice insurance crisis justifying the arbitrary and invidious discrimination between medical malpractice victims, there is no rational relationship between the personal injury noneconomic damage caps … and alleviating this purported crisis."

PQRS pay cuts
The U.S. Centers for Medicare & Medicaid Services (CMS) states that about 500,000 healthcare providers can expect to see a 2 percent cut in reimbursement this year under the Physician Quality Reporting System (PQRS). According to the report, about 80 percent of penalized providers chose not to participate in PQRS. Although the PQRS program technically ended Dec. 31, 2016, providers are evaluated based on 2-year-old data. The final year providers will face penalties under the program is 2018. PQRS is being phased out as the agency transitions to the Merit-based Incentive Payment System (MIPS).

Physician ownership
AMA Wire reports that, for the first time, less than half of physicians own their own practices. Researchers reviewed information from American Medical Association Physician Practice Benchmark Surveys of physicians who provide at least 20 hours of patient care per week, are not employed by the federal government, and practice in one of the 50 states or the District of Columbia. They found that in 2016, 47.1 percent of respondents were practice owners, 47.1 percent were employed, and 5.9 percent were independent contractors.

Drug monitoring programs
A study published in the International Journal of Emergency Medicine (online) finds that few emergency medicine providers in Florida routinely check the state's prescription drug monitoring program (PDMP) database every time they prescribe opioids. The researchers surveyed 88 prescribers, including 54 attending physicians, 13 residents, and 21 extenders. Overall, 3 percent of respondents reported using the PDMP every time they prescribed opioids, 51 percent used it only when they suspected possible misuse, and 21 percent reported rarely using the database. The researchers note that 70 percent of prescribers reported receiving no formal education on identifying individuals at increased risk of opioid misuse.

Antirheumatic medication guideline
The American Association of Hip and Knee Surgeons (AAHKS) and the American College of Rheumatology (ACR) have jointly published a guideline on the perioperative management of antirheumatic medication for patients with rheumatic diseases who undergo elective total hip arthroplasty (THA) or total knee arthroplasty (TKA). Primary recommendations include the following:

  • Nonbiologic disease-modifying antirheumatic drugs (DMARDs) may be continued throughout the perioperative period in patients with rheumatoid arthritis, spondyloarthritis, juvenile idiopathic arthritis, and lupus undergoing elective THA or TKA.
  • Biologic medications should be withheld as close to one dosing cycle as scheduling permits prior to elective THA or TKA and restarted after evidence of wound healing, typically 14 days, for all patients with rheumatic diseases.

The guideline is based on a multistep systematic literature review conducted by 31 specialists from more than 20 hospitals and professional organizations.

Unprofessional behavior
A study in The BMJ (online) suggests that interns and residents may be unlikely to speak up when presented with unprofessional behavior, even when they perceive a high potential for patient harm. The research team queried 837 medical and surgical interns and residents from six academic medical centers in the United States regarding professional behavior vignettes. They found that 75 percent perceived unprofessional behavior, and of those, 46 percent said they would speak up regarding that behavior. In addition, 49 percent perceived traditional safety threats, and of those, 71 percent said they would speak up in response. Overall, respondents were less likely to speak up to an attending physician in the professionalism vignette than the traditional safety vignette, even when they perceived a high potential for patient harm.

Surgical mortality disparities
Data from a study in Health Affairs (June) suggest a reduction in racial disparities for surgical mortality. The authors reviewed Medicare inpatient claims data from 2005 through 2014 for five high-risk and three low-risk procedures, including hip arthroplasty and knee arthroplasty. Based on 30-day mortality rates, they found that national mortality trends improved by 0.10 percent per year for black patients and by 0.07 percent per year for white patients, which significantly narrowed the black-white difference.

Readmission rate disparities
A study in Health Affairs (online) notes significant disparities in surgical readmission rates between black and white Medicare patients. The authors reviewed 30-day hospital readmission rates from a state of New York database for six major surgical procedures, including hip arthroplasty. They found that overall, black patients on traditional Medicare plans were 33 percent more likely to be readmitted compared to white patients. Further, black patients enrolled in Medicare Advantage plans were 64 percent more likely to be readmitted compared to white patients.

POD reporting
An article in Bloomberg BNA notes that the recently released U.S. Medicare Payment Advisory Commission June 2017 Report to the Congress: Medicare and the Health Care Delivery System argues for increased scrutiny of physician-owned distributorships (PODs). The authors state that most PODs are subject to Open Payments reporting requirements as group purchasing organizations (GPOs). "However, PODs that purchase devices for resale to a single hospital rather than a group of hospitals do not meet CMS' definition of a GPO and are therefore excluded from reporting." The authors further note that the U.S. Senate Finance Committee has determined "that many PODs do not report their physician ownership interests to Open Payments, and some PODs have changed how they compensate physicians to circumvent the reporting requirements." The agency recommends that CMS increase efforts to report physician ownership information and assess penalties on noncompliant PODs.

Exchange participation
An analysis performed by CMS indicates that insurance options on health insurance exchanges are projected to continue to disappear in 2018. The county-level map shows projected health insurance exchange participation based on the known issuer participation public announcements through June 9, 2017. According to the map, there are fewer plan options compared with last year. CMS also notes that in 47 counties nationwide there will be no coverage options on the exchanges. "This is yet another failing report card for the exchanges," states CMS Administrator Seema Verma. "The American people have fewer insurance choices and in some counties no choice at all. CMS is working with state departments of insurance and issuers to find ways to provide relief and help restore access to healthcare plans, but our actions are by no means a long-term solution to the problems we're seeing with the insurance exchanges."