Published 5/1/2017
Elizabeth Fassbender

The Future of Orthopaedic Practice in America

During the 2017 Annual Meeting symposium, "American Orthopaedic Practice: Where Are We Headed" introduced by Immediate Past-President Gerald R. Williams Jr, MD, experts examined the evolving state of health care in the United States, including efforts to repeal and replace the Affordable Care Act (ACA), and newer payment models.

According to Thomas C. Barber, MD, the ACA included a number of basic insurance reforms as well as innovation, mandates, subsidies, and taxes. The Trump healthcare agenda, he said, calls for a complete repeal of Obamacare, modifying existing law that inhibits the sale of health insurance across state lines, allowing individuals to use Health Savings Accounts (HSAs), and more.

Kevin J. Bozic, MD, MBA

"However, many conservatives are upset that the bill doesn't go far enough," Dr. Barber said of the ACA repeal legislation known as the American Health Care Act (AHCA). "And a lot of liberals are very concerned because it doesn't cover enough people. So you are really irritating both sides… conservatives are trying to put their foot down. We'll see what happens."

Dr. Barber also emphasized the importance of Independent Payment Advisory Board repeal and medical liability reform. "However, given some Republican perspectives, passing such legislation may be difficult," he said. "Watch your Twitter accounts—things are changing day to day."

Things in Washington are indeed changing rapidly. House Speaker Paul Ryan (R-Wis.) has since pulled the AHCA from consideration, after it was clear Republicans could not secure a basic majority to advance the bill. For the latest updates on efforts to repeal and replace the ACA, visit www.aaos.org/advocacy/affordablecareact/

Healthcare system challenges
"These are the glory days of medicine," said Kevin J. Bozic, MD, MBA. "Never before has there been a time when we can completely rewrite the code on how we care for people and how we deliver and pay for health care. But it's also an incredibly challenging time."

According to Dr. Bozic, the biggest driver of dysfunction in the U.S. healthcare system is the lack of competition among providers, based on value. "Healthcare competition is misdirected to shifting costs and leveraging bargaining power, rather than improving health," he argued. "The most rational approach to transforming the U.S. healthcare system is to focus on value."

Dr. Bozic explained that the Medicare Access and CHIP Reauthorization Act (MACRA) is central to the Centers for Medicare & Medicaid Services' push for value and quality. According to Dr. Bozic, the Centers for Medicare & Medicaid Services hopes to decrease cost and improve quality of care by tying fee-for-service payments to quality and value through outcomes reporting (Merit-based Incentive Payment System [MIPS]) and alternative payment models (APMs).

Most physicians will be subject to payment adjustments under the MIPS pathway, he explained. MIPS is a performance-based payment adjustment that applies to all providers (unless they are new to Medicare, have low Medicare volumes, or participate in an Advanced APM), with a composite performance score based on four categories: Quality, Improvement Activities, Advancing Care Information, and Cost. The Quality category replaces the Physician Quality Reporting System (PQRS). Improvement Activities is a new category that would reward clinical practice improvement. The Advancing Care Information category replaces the Meaningful Use program, and the Cost category replaces the Value-Based Modifier.

"As you can see, a lot of quality measurement and reporting activities that occurred through different programs in the past are being consolidated," said Dr. Bozic. "Furthermore, 2017 is a 'transitional' year for MIPS, which means that as long as you submit something, you'll get a neutral payment adjustment. However, if you do not participate at all in the transition year, the result is a negative 4 percent payment."

Because MACRA received strong bipartisan support when it passed Congress, its implementation is expected to continue as outlined in the law, noted Dr. Bozic.

The Advanced APM track, explained John Cherf, MD, MPH, MBA, incentivizes payment for participating in innovative payment models. The two alternative payment models that have emerged for orthopaedic surgeons are bundled payments and the accountable care organization (ACO). These new payment models incentivize cost reduction while ideally maintaining or improving quality.

"The takeaway from these government programs is that they are growing or expanding," said Dr. Cherf. "They are moving from voluntary to mandatory, the scale is large, the scope is centered on specific diagnosis-related groups, and there is a huge focus on orthopaedics and cardiology," he said. "It will be important to try to participate and capture as much revenue as possible."

Mike West, CEO of Rothman Institute, explained that when looking at the best opportunities for savings, it's important to consider a prospective vs. retrospective approach for bundled payments, care design, technology investment, and consumer incentives.

Additional symposia presenters included Prof. Timothy Briggs; R. Scott Oliver, MD; L. Scott Levin, MD; and Matthew L. Ramsey, MD.

Elizabeth Fassbender is manager, health policy and communication, in the AAOS office of government relations. She can be reached at fassbender@aaos.org