Published 4/1/2018

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).

Physician independence
An article in Modern Healthcare points to a 2017 report from the American Medical Association that found that for the first time, less than half of U.S. physicians are independent, and resources required to comply with quality payment programs have been cited as a major factor for that shift. The writer notes that some independent-practice providers have chosen accountable care organization (ACO) participation as a way to successfully adapt to payment reform while retaining autonomy. In addition, some health systems and hospitals have chosen to form ACO partnerships with independent physicians as a way of working together without direct employment.

Billing overhead
A study in The Journal of the American Medical Association (JAMA; Feb. 20) estimates administrative costs associated with physician billing activities in a large academic healthcare system with a certified electronic health record system. Members of the research team interviewed 27 health system administrators and 34 physicians to construct a process map charting the path of an insurance claim through the revenue cycle management process at a single academic medical center. They estimated processing time and total costs for billing and insurance-related activities to be 13 minutes and $20.49 for a primary care visit, 32 minutes and $61.54 for a discharged emergency department visit, 73 minutes and $124.26 for a general inpatient stay, 75 minutes and $170.40 for an ambulatory surgical procedure, and 100 minutes and $215.10 for an inpatient surgical procedure. Of those, time and costs for activities carried out by physicians were estimated to be 3 minutes or $6.36 for a primary care visit, 3 minutes or $10.97 for an emergency department visit, 5 minutes or $13.29 for a general inpatient stay, 15 minutes or $51.20 for an ambulatory surgical procedure, and 15 minutes or $51.20 for an inpatient surgical procedure.

Medicaid reimbursement
A study in The Journal of Bone & Joint Surgery (JBJS; Feb. 7) examines variability of Medicaid reimbursement for inpatient orthopaedic procedures. Members of the research team reviewed state-level Medicaid reimbursement data for the 10 most common orthopaedic procedures, and found that the range of variability exceeded $1,500 for all 10 procedures. The coefficients of variation ranged from 0.57 for posterior or posterolateral lumbar interbody arthrodesis (higher coefficient indicates greater variability) to 0.32 for hip hemiarthroplasty. In comparison, the variability for Medicare reimbursements was 0.07 for all 10 procedures.

Bundled payment models
Findings published in JBJS (Feb. 21) suggest that bundled payment proposals such as the canceled Medicare Surgical Hip and Femur Fracture Treatment (SHFFT) model should adopt robust risk-adjustment methods to ensure fair provider reimbursement and continued patient access to care. Members of the research team reviewed a 5 percent random sample of Medicare data from 2008 to 2012 and identified 27,898 patients who met SHFFT inclusion criteria. They found that most comorbidities were associated with higher reimbursement, but dementia was associated with an average decrease in payment of $2,354. In addition, diagnosis-related groups (DRGs) showed significant differences in reimbursement (DRG 480 was reimbursed by an average of $10,421 more than DRG 482), and payments varied significantly by state. The researchers write that risk adjustment that incorporated specific comorbidities demonstrated better performance than use of DRG alone.

The American Association of Orthopaedic Surgeons notes that the U.S. Centers for Medicare & Medicaid Services (CMS) withdrew the SHFFT model in 2017.

MIPS cost measures
An article in Modern Healthcare discusses measures under the CMS Merit-based Incentive Payment System (MIPS). The measures track cost data for eight procedures, including knee arthroplasty and lower limb revascularization. As part of a pilot program, the agency created reports for approximately 17,000 medical practices based on claims data from June 1, 2016 to May 31, 2017, and surveyed those practices regarding accuracy of the results. CMS plans to use the measures in 2019 to calibrate payments for 2021. Some observers have voiced concerns that the measures will not properly account for factors such as patient clinical complexity and socio-demographic status.

“Service sharing” arrangements
An opinion piece published in JAMA (Feb. 20) argues that service sharing arrangements may offer a mechanism to help small medical practices meet the broader goals of delivery system reform. The writers note that from 1983 to 2014, the percentage of physicians in practices of 10 or fewer declined from 80 percent to 61 percent, and the percentage of physicians in solo practice fell from 44 percent to 19 percent. “Some small practices are experimenting with ways to pool resources across groups, while maintaining their independence and intimacy,” they write. Contracts with shared service providers to pool and manage resources may take several forms, and “may allow small practices to compete in value-based contracts and a policy atmosphere favoring consolidation.”

A report from Leavitt Partners suggests that many physicians may not believe pay-for-performance programs to be effective solutions for quality improvement and cost control. Members of the research team surveyed 621 physicians and found that 22 percent of respondents believed ACOs would reduce spending, and 21 percent supported bundled payments as a means to drive down costs. Overall, just 29 percent of respondents said that ACOs and episode-based payment would improve patient health outcomes.

Opioid prescribing oversight
The U.S. Centers for Medicare & Medicaid Services (CMS) has issued a proposal to increase oversight of opioid prescribing under Medicare Part D. The proposal includes:

  • enhancing the overutilization monitoring system to identify high-risk beneficiaries who use so-called “potentiator” drugs, such as gabapentin and pregabalin, in combination with prescription opioids
  • technical revisions to the Pharmacy Quality Alliance measures used by CMS to evaluate Part D sponsors’ progress in combatting the opioid crisis, and consideration of a new PQA measure, Concurrent Use of Opioids and Benzodiazepines
  • implementation of hard formulary-level cumulative opioid safety edits at the pharmacy (to be overridden only by the sponsor) at 90 morphine mg equivalent, with a 7 days supply allowance
  • a supply limit for initial fills of prescription opioids for the treatment of acute pain with or without a daily dose maximum

Databases mining
Healthcare IT News reports that the U.S. Department of Health & Human Services (HHS) is considering an initiative to use data from CMS to identify practitioners who write a high number of opioid prescriptions. In addition, HHS is considering requiring states to monitor high-risk billing activity to identify abnormal prescribing and usage patterns that may indicate abuse in the Medicaid system, as well as a proposal to monitor state prescription drug monitoring programs (PDMPs) to identify high prescribers.

PDMP reporting
According to Healthcare IT News, Nebraska has become the first state to require reporting of all dispensed prescription drugs to its PDMP. A spokesperson for the Nebraska Health Information Initiative said the move is intended to save lives, not only for patients taking opioids, but potentially for anyone who is prescribed drugs. A national PDMP initiative took effect Jan. 1, 2018.

“Second victims”
The Joint Commission (TJC) has issued an advisory report urging its accredited healthcare organizations to provide support services to so-called “second victims”—providers who may be emotionally traumatized by adverse events. The organization states that nearly half of healthcare providers may be impacted by such events at least once in their career. According to TJC, second victim effects include difficulty sleeping, reduced job satisfaction, guilt, and anxiety (including fear of litigation or job loss); all of which may affect medical judgment. In the months that follow an adverse event, a provider may experience characteristics of post-traumatic stress disorder. In response, TJC “urges health care organizations to take the following actions to support second victims as soon as possible after an adverse event occurs. By addressing the traumatized health care worker, organizations can help ensure that other patients are protected from the domino effect that adverse events can have on health care worker performance.”

Student E/M documentation
CMS has revised the Medicare Claims Processing Manual to allow teaching physicians to simply verify in the medical record any student documentation of components of evaluation and management (E/M) services, rather than re-documenting the work. However, the agency states that teaching physicians “must verify in the medical record all student documentation or findings, including history, physical exam, and/or medical decision making.” In addition, the teaching physician “must personally perform (or re-perform) the physical exam and medical decision-making activities of the E/M service being billed, but may verify any student documentation of them in the medical record, rather than re-documenting this work.”

HHS budget
President Donald J. Trump has released a 2019 budget proposal that includes a 21 percent reduction in funding for HHS. An article in The Hill breaks down some of the changes, including the following:

  • $11 billion for the U.S. Centers for Disease Control and Prevention, a cut of approximately $900 million
  • $35.5 billion for the National Institutes of Health, an increase of $1.4 billion
  • $5.8 billion for the U.S. Food and Drug Administration, an increase of $673 million
  • an overall $10 billion HHS-wide investment in fighting the opioid crisis

An article in HealthLeaders Media notes that although the U.S. Congress “is unlikely to vote on a singular budget, the various provisions listed in the executive proposal outline the legislative agenda the Trump administration would like to pursue in 2018.”

Health expenditure growth
A report from the CMS Office of the Actuary projects a national health expenditure growth of 5.5 percent on average annually from 2017 through 2026. The agency notes that the growth in national health spending is projected to be faster than projected growth in gross domestic product (GDP) by 1 percent over the same period, with the health share of GDP projected to rise from 17.9 percent in 2016 to 19.7 percent in 2026. CMS states that the growth is expected to be driven primarily by fundamental economic and demographic factors, such as trends in disposable personal income, increases in prices for medical goods and services, and shifts in enrollment from private health insurance to Medicare.