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Published 5/1/2017

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)

Medicaid reimbursement eligibility
An analysis by Modern Healthcare finds that more than 65,000 providers in 15 states may be ineligible for reimbursement under Medicaid under an Affordable Care Act provision that requires certain providers to revalidate their eligibility. Under the initiative, providers that enrolled in Medicaid prior to March 25, 2011, were required to submit revalidation notices to the U.S. Centers for Medicare & Medicaid Services (CMS) by Sept. 25, 2016, or risk being dropped. There is no national database of Medicaid providers, but the publication reviewed data from 15 state Medicaid agencies and notes that Texas alone cut more than 28,000 of its 298,000 Medicaid providers. The provision is designed to curb fraud and abuse in Medicaid programs.

Medical liability factors
A study published in Clinical Orthopaedics and Related Research (online) examines trends in medical liability claims related to anesthesia in nonspine orthopaedic surgery. The researchers reviewed data on 475 claims related to nonspine orthopaedic surgery and 1,592 claims related to other procedures. They found that nonspine orthopaedic anesthesia liability claims more frequently cited nerve injury and events arising from the use of regional anesthesia than other surgical anesthesia liability claims. The researchers suggest that the trend "may reflect the frequency of regional anesthesia in orthopaedic cases rather than increased risk of injury associated with regional techniques." They suggest that, when neuraxial procedures and anticoagulation regimens are used concurrently, "care pathways should emphasize clear lines of responsibility for coordination of care and early investigation of any unusual neurologic findings that might indicate neuraxial hematoma." In addition, the researchers write "postoperative use of multiple opioids by different concurrent modes of administration warrant special precautions with consideration given to the provision of care in settings with enhanced respiratory monitoring."

Medical liability trends
According to findings published in JAMA Internal Medicine (online), the rate of medical liability claims paid on behalf of physicians declined over a 23-year period, although mean compensation amounts and percentage of paid claims exceeding $1 million increased overall. The researchers reviewed data from the National Practitioner Data Bank from Jan. 1, 1992, to Dec. 31, 2014. They found that from 1992-1996 to 2009-2014, the rate of paid claims decreased from 20.1 to 8.9 per 1,000 physician-years, but the mean payment increased from $286,751 to $353,473 during that same period. Of paid claims, 7.6 percent exceeded $1 million in 1992-1996, compared to 8.0 percent in 2009-2014. The researchers noted that diagnostic error was the most common type of allegation, present in 31.8 percent of paid claims.

PRO reporting incentives
A study published in The Journal of Arthroplasty (April) suggests that the costs of collecting and reporting patient-reported outcomes (PRO) data on total hip arthroplasty (THA) and total knee arthroplasty (TKA) procedures may exceed payment penalties called for by CMS. CMS has proposed a move to payment based on PROs, with failure to report on PROs resulting in a 2 percent payment penalty during 2016. The research team reviewed data from the 2013 Medical Group Management Association Compensation and Financial survey on physician cost to report PROs, based on an annual volume of 125 TKAs and 75 THAs, with 1,000 new patient visits and 2,000 established patient visits. They found that the cost to collect PROs ranged from $47,973 to $56,288, which far outweighed the 2016 penalty of $2,954 for failing to report the measures.

Medicare billing appeals deadline
An article in Modern Healthcare states that the U.S. Department of Health and Human Services (HHS) reports that it will be unable to clear its pending Medicare billing appeals backlog by a court-mandated 2021 deadline. The court had previously ordered the agency to reduce its backlog by 30 percent at the end of 2017, 60 percent by the end of 2018, and 90 percent by the end of 2019. HHS states that there are currently 667,326 pending appeals, and projects the number of pending appeals to rise 3 percent by the end of 2017 and 46 percent by the end of 2021. HHS states that it has more pending appeals than previously anticipated, and it lacks resources to fully address the backlog.

SHFFT implementation date
Modern Healthcare reports that CMS has issued an interim final rule that delays implementation of the Surgical Hip and Femur Fracture Treatment (SHFFT) model from July 1 to Oct. 1, 2017. The rule was published in the Federal Register on March 21.

Resident work hour limits
Reuters reports that the Accreditation Council for Graduate Medical Education (ACGME) has voted to increase shift hour limits for first-year residents from 16 to 24 hours, with a limit of 80 hours worked per week. Supporters of shorter limits have argued that patient care could be impacted by residents who are overworked. However, recent research has yielded evidence supporting the view that reduced work hour limits have had little positive impact on patient safety, but may adversely affect resident training.

Match Day
The National Resident Matching Program (NRMP) has released the results for Match Day 2017. Among other things, 1,013 applicants applied for 727 positions in orthopaedics, across 165 programs. NRMP states that specialties with more than 30 positions that achieved the highest percentages of positions filled by U.S. allopathic seniors—considered to be a measure of competitiveness—were integrated plastic surgery (93.1 percent), orthopaedic surgery (91.9 percent), and otolaryngology (91.5 percent).

Opioid prescribing
According to a study in the Annals of Surgery (online), dissemination of operation-specific guidelines for opioid prescribing to surgeons may be linked to a reduction in the number of opioids prescribed. The research team analyzed opioid prescription and use for five common outpatient procedures at a single center and developed guidelines for opioid prescribing to reduce the number of pills prescribed and satisfy 80 percent of patients' opioid requirements. They found that use of the guideline was linked with a 53 percent reduction in total number of pills prescribed. Overall, only one patient of 246 (0.4 percent) required a refill opioid prescription, while 85 percent of patients used either an NSAID or acetaminophen.

On-site inspections
Data from a study in the journal JAMA Internal Medicine (March 20) suggest that patients admitted to hospitals under survey by The Joint Commission may be at reduced risk of mortality compared to those admitted during nonsurvey periods. The researchers reviewed information on 244,787 admissions during a survey week and 1,462,339 admissions during a nonsurvey week. They noted a significant, reversible decrease in 30-day mortality for admissions during survey weeks compared to nonsurvey weeks. They write that the observed decrease was larger than 99.5 percent of mortality changes among 1,000 random permutations of hospital survey date combinations, suggesting that observed mortality changes were not attributable to chance alone. The researchers also found that mortality reductions were largest in major teaching hospitals. They observed no significant differences in admission volume, length of stay, or secondary outcomes.

MedPAC payment report
The Medicare Payment Advisory Commission (MedPAC) has issued its March 2017 Report to the Congress: Medicare Payment Policy. The report includes the agency's analyses of payment adequacy in fee-for-service Medicare and provides a review of Medicare Advantage and Part D. Among other things, MedPAC recommends that payments to physicians and hospitals be increased by the amount specified in current law during 2018. However, the agency recommends no payment increase for 2018 for ambulatory surgical centers (ASCs) or long-term care hospitals, and a 5 percent reduction in payments for home health agencies and inpatient rehabilitation facilities. The agency writes that the recommendations "are expected to reduce spending in the Medicare program without harming beneficiaries' access to care."

Computerized support systems
According to a study in JAMA Surgery (online), use of a computerized clinical decision support system (CCDSS) may be associated with improved use of venous thromboembolism (VTE) prophylaxis and a reduction in VTE events. The authors conducted a meta-analysis of nine prospective cohort trials and two retrospective cohort trials comprising 156,366 participants. They found that CCDSS use was linked with a significant increase in the rate of appropriate ordering of prophylaxis for VTE and a significant decrease in the risk of VTE events.

CMS Open Payments website
Findings published online in the Journal of General Internal Medicine (online) suggest that few patients may make use of publicly available information on industry payments to physicians via the CMS Open Payments website. The researchers surveyed a nationally representative pool of 3,542 adults, and found that, of 1,987 respondents who could be matched to a specific physician, 65 percent saw a physician who had received an industry payment during the previous 12 months. They state that only 12 percent of survey respondents knew that physician payment information was publicly available, and only 5 percent knew whether their own physician had received payments.