Published 12/1/2018

Second Look—Advocacy

Medicaid access in states without expanded eligibility

According to a report from the Government Accountability Office, low-income adults in states that have not expanded Medicaid are more likely to forgo medical care than those who live where coverage has been expanded. In nonexpansion states, 40 percent of low-income adults said they had unmet medical needs compared to 26 percent of low-income residents in expansion states. Twenty percent of low-income adults living in nonexpansion states reported financial barriers to necessary medical care compared to 9 percent of low-income adults residing in expansion states. Low-income individuals in expansion states were more likely than those in nonexpansion states to report having a usual place of care when they are sick or in need of medical advice (82 percent versus 68 percent, respectively).


The Centers for Medicare & Medicaid Services (CMS) issued its final Medicare Physician Fee Schedule (MPFS) for 2019. Changes include modifications to Part B drug payments and telehealth services. Clinicians will now be paid for making use of “communication technology-based services.” By lowering the wholesale acquisition cost from 6 percent to 3 percent, Part B drug prices will reduce seniors’ out-of-pocket spending. CMS also finalized evaluation and management (E/M) documentation burden reduction proposals but did not finalize any coding proposals, including a single collapsed E/M rate and add-on G-codes.

Sports Medicine Licensure
Clarity Act signed into law

President Donald Trump signed into law the Sports Medicine Licensure Clarity Act, which protects traveling physicians and allows traveling athletes to be treated by healthcare professionals who are familiar with their medical histories. AAOS has supported this legislation since 2015. AAOS President David A. Halsey, MD, said the bill’s passage “represents years of hard work trying to get it across the finish line, and it is a significant win—not only for practicing sports medicine professionals, but also for the large percentage of orthopaedists involved in the treatment and care of sports-related injuries.”

Orthopaedic PAC contributes to midterm elections

According to the Center for Responsive Politics, the healthcare industry collectively gave $46.7 million to candidates for the midterm elections, which took place on Nov. 6. Individual employee contributions bring the total to nearly $200 million, the highest amount for any other midterm election going back to 1990. The Orthopaedic Political Action Committee (PAC) made the largest contribution, giving $1.37 million to candidates of both parties. Its largest single contribution of $250,000 was made to the Congressional Leadership Fund, a GOP super PAC. John T. Gill, MD, chair of the Orthopaedic PAC, said in a statement, “Like many other healthcare groups, we’re having to contribute more this cycle while health care remains a central issue and competitive races are occurring across the country.”

New Medicare payment model

The Trump administration unveiled an Advance Notice of Proposed Rulemaking, which requests information on a model that may lower drug prices, making them comparable to those of other advanced countries. Physicians also would be paid a flat fee for administering Medicare Part B prescriptions, rather than a percentage of the drug’s price. The plan could save Medicare beneficiaries and the government an estimated $17.2 billion over five years. AAOS is reviewing the proposals and will comment.

CMS gives governors authority on insurance reform
CMS released new guidance that provides state governors with more flexibility in meeting standards pertaining to section 1332 of the Affordable Care Act (ACA). Governors no longer will require state legislature approval for waiver plans. State residents can choose short-term insurance coverage as an alternative to ACA plans as long as a similar number of people in the state still have coverage. CMS hopes the change will strengthen the insurance market and expand coverage options. Opponents of the guidance say that even if the same number of people have coverage, access may be worse if beneficiaries choose skimpier plans.

Older patients depend on physician advocacy
A study published in Clinical Interventions in Aging (online) found that older patients may prefer to be less involved in healthcare decisions, instead relying on their physicians to serve as the decision makers. Researchers interviewed 802 adults (mean age, 77.82 years). Patients’ age and functional limitations were negatively correlated with their satisfaction with their physicians. When the researchers controlled for confounding factors, increased emotional support and willingness to act as an advocate were both associated with more positive physician-patient relationships. Among the total participants, 87 percent said their physicians serve as advocates on their behalf.

Knee replacement setting affected by audits
According to a Modern Healthcare report, hospital administrators may be placing patients who require joint replacement into the outpatient setting for fear of audits by Medicare contractors. Although CMS has forbidden contractors from reviewing total knee arthroplasty surgeries, the agency has reportedly allowed Medicare auditors to ignore the ban. Surgeons are concerned that the shift to the outpatient setting will put frail patients who need joint replacement surgery at risk.