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Published 11/1/2017

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).

Overtreatment and liability
Findings from a survey in PLOS One (online) suggest that many physicians believe overtreatment to be common and often driven by fear of medical liability. The research team surveyed 2,106 American Medical Association physicians and determined that an interpolated median of 20.6 percent of overall medical care may be unnecessary, including 22.0 percent of prescription medications, 24.9 percent of tests, and 11.1 percent of procedures. Most commonly cited reasons for overtreatment included the following:

  • fear of medical liability (84.7 percent)
  • patient pressure/request (59.0 percent)
  • difficulty accessing medical records (38.2 percent)

In addition, 70.8 percent of respondents stated they believe physicians are more likely to perform unnecessary procedures when they profit from them.

Physician Compare reviews
An article from Bloomberg BNA looks at efforts by the U.S. Centers for Medicare & Medicaid Services (CMS) to add beneficiary reviews of healthcare providers to the Medicare Physician Compare website. The writer states that some physician groups have opposed the proposal, noting that such reviews could unfairly damage the reputations of some medical practices, and arguing that it may be premature to initiate such an effort on a national scale without more testing and explicit information on how the data would be used. In addition, the Medical Group Management Association has noted that such reviews could be used to adjust physician payment under the CMS Merit-based Incentive Payment System. The U.S. Agency for Healthcare Research and Quality is developing a series of narrative questions to assist patients with reviews and plans to conduct field testing. CMS states that it will review results of the field testing before proposing changes to Medicare physician quality rules.

Medical staff independence
A post on the California Medical Association website looks at a lawsuit that could affect the independence of hospital medical staffs. At issue is a case in which the board of directors of a medical center voted to terminate the hospital's medical staff organization, install a slate of appointed officers, and approve new medical staff bylaws and rules drafted without staff input. According to the complaint, the rest of the staff was then terminated and granted provisional status as part of the new medical staff, along with a provision, since amended, that physicians could achieve and maintain active status by proving their economic value to the hospital—an arrangement the plaintiffs have referred to as "an illegal kickback scheme." Closing arguments took place Oct. 2, with a ruling expected in 45 to 60 days.

Humanitarian efforts
According to a research letter in JAMA Surgery (online), 5,786 civilians in Afghanistan underwent a total of 9,428 surgical procedures performed by U.S. military medical personnel between Jan. 1, 2002, and March 21, 2013. Of those, 2,853 patients (49.3 percent) were treated for conditions classified as non–war-related, and 1,446 procedures (29.8 percent) were for musculoskeletal injuries. The researchers base their findings on information from the Patient Administration Systems and Biostatistics Activity database.

Market concentration
According to a study in Health Affairs (September), concentrated insurance markets may have a negative effect on physician reimbursement. Members of the research team reviewed data on hospital admissions and visits across five physician specialties to assess how provider and insurer market concentration correlated with prices. They found that in areas with moderately concentrated insurance markets, based on U.S. Department of Justice and U.S. Federal Trade Commission definitions, insurers had the bargaining power to reduce provider payments in highly concentrated provider markets. The researchers found that hospital admission prices were 5 percent lower compared to less concentrated insurance markets. Within the physician specialties, cardiologist prices were 4 percent lower, radiologist prices were 7 percent lower, and hematologist/oncologist prices were 19 percent lower. However, the research team did not find evidence that high insurer concentration reduced visit prices for orthopaedists or primary care physicians.

EHR overhead
Data published in Annals of Family Medicine (online) suggest that clinicians may spend 5.9 hours a day interacting with electronic healthcare record (EHR) systems. The authors conducted a retrospective cohort study of 142 family practitioners in a single system in Wisconsin and found that they spent an average of 4.5 hours during clinic hours and 1.4 hours after clinic hours working with the EHR each day. They also found that clerical and administrative tasks accounted for 44.2 percent of total EHR time, while inbox management accounted for 23.7 percent.

Opioid prescriber training
The U.S. Food and Drug Administration (FDA) states it has issued letters to 74 manufacturers of immediate release (IR) opioid analgesics intended for use in the outpatient setting. The FDA notified them that such drugs will now be subject to a more stringent set of requirements under a Risk Evaluation and Mitigation Strategy (REMS). Among other things, the agency will require manufacturers to offer training to healthcare providers who prescribe IR opioids, including education on safe prescribing practices and consideration of nonopioid alternatives. With this update, IR opioids are now subject to the same regulatory requirements as extended release/long-acting opioid analgesic formulations. In addition, the FDA Opioid Policy Steering Committee is considering the possibility of requiring mandatory prescribing education for healthcare professionals.

Licensure and mental health
Findings published in Mayo Clinic Proceedings (October) suggest that potential repercussions to medical licensure may discourage some physicians from seeking help for a mental health condition. The authors obtained data on care-seeking attitudes for a mental health problem from a nationally representative sample of 5,829 physicians. Of those, 2,325 (39.9 percent) stated that they would be reluctant to seek formal medical care for treatment of a mental health condition due to medical licensure concerns.

Hip fracture outcomes
Data from a study published in The Journal of Bone & Joint Surgery (Sept. 20) suggest that hip fracture surgical outcomes may not be significantly affected by surgeon or hospital volume. The authors reviewed information on 14,294 patients from a single, large, integrated healthcare system. They found no significant association between surgeon or hospital volume and mortality at 30 days, 90 days, or 1 year, and also no association between surgeon or hospital volume and reoperation, medical complications, or unplanned readmission. The authors state that the data do not suggest that hip fractures be preferentially directed toward high-volume surgeons or hospitals for treatment.

Insurance and opioids
An article from ProPublica and The New York Times suggests that insurer approval policies may play a role in the opioid epidemic. The writers state that a number of health insurance companies have limited patient access to pain medications that may carry a lower risk of addition or dependence, while encouraging the use of cheaper generic opioid medications. The publications analyzed Medicare prescription drug plans covering 35.7 million people in the second quarter of 2017 and found that only one-third of the people covered had access to a painkilling skin patch containing a less risky opioid. Patients were required to obtain prior approval for the nonaddictive but more expensive patches, while almost every plan covered common opioids and very few required any prior approval.

Work-life balance
A survey of medical residents conducted by Medscape finds that 33 percent of respondents consider work-life balance to be the greatest challenge they face, and 66 percent list "manageable work schedule/call hours" as a key to avoiding burnout. Additional findings include the following:

  • 85 percent say they still look forward to working as doctors
  • 76 percent list clinical knowledge and experience as the most rewarding part of their jobs
  • 38 percent cite work schedule/call hours as a key factor they'll look for in their first jobs
  • 10 percent report that making a serious mistake is a concern of theirs always or most of the time
  • 32 percent of men and 29 percent of women turn to exercise to cope with stress and burnout

The researchers surveyed 1,546 medical residents across more than 25 specialty residency programs.

TAA reimbursement
An article in HealthLeaders Media notes that a recently released update to the Inpatient Prospective Payment System by the CMS will in FY 2018 increase the reimbursement bundle for primary total ankle arthroplasty procedures, by moving these procedures from the lower-paying Medicare Severity Diagnostic Related Group (MS-DRG) 470 to MS-DRG 469.

ED use and ACA
Information released by the U.S. Centers for Disease Control and Prevention finds that hospital emergency department (ED) visits increased to a record high of 141.4 million in 2014, the first year of insurance expansion under the Affordable Care Act (ACA). An article in Modern Healthcare notes that the data run counter to some predictions that ACA implementation would be associated with a reduction in ED use. Overall, only 4.3 percent of ED visits were linked to nonurgent presentations. The report also finds that Medicaid and Children's Health Insurance Program beneficiaries accounted for 34.9 percent of ED visits during 2014, followed by privately insured individuals (34.6 percent), Medicare beneficiaries (17.5 percent), and the uninsured (11.8 percent).

NIH funding
Science reports that the U.S. Senate Labor, Health and Human Services, and Education Appropriations Subcommittee has approved a $2 billion increase in funding for the National Institutes of Health (NIH) in 2018. That amount is nearly double the increase proposed by the U.S. House of Representatives. If passed, the proposal would set NIH funding at $36.1 billion for the fiscal year starting Oct. 1, 2017.