Published 5/1/2018

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).

Medical liability claims
A report from medical liability insurer Coverys finds diagnosis-related events to be the single largest root cause of medical liability claims. The researchers analyzed 10,618 closed medical professional liability claims from the period 2013 to 2017 and among other things, found the following:

  • 3,466 closed claims with diagnosis-related claims accounted for 33 percent of all claims and 47 percent of indemnity payments
  • 54 percent of diagnosis-related claims were high-severity cases, and 36 percent resulted in death
  • 35 percent of diagnostic errors occurred in nonemergency department, outpatient settings
  • 33 percent of diagnosis-related claims alleged a decision-making breakdown linked to a failure during patient evaluation
  • 53 percent of diagnosis-related claims included risk management issues involving poor clinical decision making

Medicare reimbursement trends
A study in Orthopedics (online) examines trends in Medicare reimbursement for orthopaedic procedures. The researchers reviewed the Medicare Physician Fee Schedule for Current Procedural Terminology code values for common orthopaedic and nonorthopaedic procedures from 2000 to 2016, and adjusted all prices to 2016-dollar values. They found that over the course of the study period, annual reimbursements decreased for all orthopaedic procedures examined except orthopaedic implant removal. Orthopaedic procedures with the greatest mean annual decreases in reimbursement were shoulder arthroscopy/decompression, total knee arthroplasty, and total hip arthroplasty. Orthopaedic procedures with the least annual reimbursement decreases were carpal tunnel release and ankle fracture repair. In addition, the researchers found that the rate of change in Medicare procedure reimbursement varied between orthopaedic specialties, with trauma seeing the smallest decrease in annual change compared with spine, sports, and hand. Finally, they note that annual reimbursement decreased at a significantly greater rate for adult reconstruction than for any other orthopaedic specialty.

ACO withdrawals from CMS program
Changes made by the U.S. Centers for Medicare & Medicaid Services (CMS) to the Next Generation ACO Model program are linked to the withdrawal of seven accountable care organizations (ACOs), and at least one is considering legal action, according to an article in Modern Healthcare. CMS lowered the average risk score for 2017 by 4.82 percent, making it more difficult for participating organizations to earn a bonus and avoid a penalty. The agency says that the changes were made to "account for a significant increase in coding intensity that otherwise threatens the financial sustainability of the Next Generation ACO Model." The publication states that CMS may have been referencing the impact on coding practices of implementing electronic health records and ICD-10 in 2015.

Cost concerns
According to a national survey conducted by the West Health Institute and NORC at the University of Chicago, 40 percent of respondents say they have skipped a recommended medical test or treatment in the last 12 months due to cost, and 32 percent were unable to fill a prescription or took less of a medication because of the cost. The researchers drew data from 1,302 people through a survey designed to be representative of the U.S. household population. Among other things, they found that more than half of respondents said they have received a medical bill for a cost they thought was covered by their health insurance in the past 12 months, and a similar proportion reported receiving a medical bill stating that the amount they owed was higher than expected. More than a quarter said they have had a medical bill turned over to a collection agency.

Access to care
A survey of physicians conducted by the American Medical Association suggests that prior authorization programs may negatively impact patient clinical outcomes. The researchers surveyed 1,000 practicing physicians, of whom 40 percent were primary care physicians and 60 percent were specialists. They found that 92 percent of respondents said that prior authorization programs have a negative impact on patient clinical outcomes, 64 percent reported waiting at least one business day for prior authorization decisions from insurers, and 30 percent said they wait three business days or longer. In addition, 78 percent said that prior authorization sometimes, often, or always leads to patients abandoning a recommended course of treatment. Finally, the survey finds that every week a medical practice completes an average of 29.1 prior authorization requirements per physician, which takes an average of 14.6 hours to process.

Societal impact of FAI treatment
Data published in The American Journal of Sports Medicine (online) suggest that hip arthroscopy may reduce the economic burden of femoroacetabular impingement (FAI) on society. The researchers reviewed data from a private insurance database on 32,143 individuals aged 16 years to 79 years and identified a statistically significant increase of mean aggregate productivity of $8,968 after surgical treatment for FAI. A cost-effectiveness analysis showed a mean cumulative total 10-year societal savings of $67,418 per patient from hip arthroscopy compared to nonsurgical treatment, along with a gain of 2.03 quality-adjusted life years. The researchers estimated the mean cost for hip arthroscopy to be $23,120 ± $10,279, while the mean cost of nonsurgical treatment was estimated to be $91,602 ± $14,675.

Confidential data
A survey conducted by consulting firm Accenture PLC suggests that many healthcare employees would be willing to sell confidential data. The company surveyed 912 qualified employees of health providers (n = 601) and payer organizations (n = 311) from the United States and Canada. All respondents had access to digital health data, including personally identifiable information, payment card information, and protected health data. They found that 18 percent of respondents would be willing to sell confidential data to unauthorized parties, many for as little as between $500 and $1,000. The researchers state that respondents from provider organizations were significantly more likely than those in payer organizations to say they would sell confidential data, including login credentials, installing tracking software, and downloading data to a portable drive, among other actions. Further, 24 percent of respondents said they know of someone in their organization who has sold their credentials or access to an unauthorized outsider.

Reimbursement survey
A survey conducted by Doximity tracks physician reimbursement information and, among other things, identifies an average 4 percent wage increase across the United States from 2016 to 2017. In this survey, orthopaedic surgeons ranked third among all specialties, with an average $537,568 in reimbursement. The survey also notes that male physicians earn more than female physicians across all specialties, with a 28 percent salary disparity in 2017—an increase from a 26.5 percent disparity in 2016. On average, female orthopaedic surgeons earn 19 percent less than their male counterparts or $101,291 less per year.

Medicare opioid restrictions
An article in The New York Times profiles concerns among some providers that restrictions on opioid prescribing may negatively affect some patients. A Medicare rule that is likely to be approved next month will restrict the prescribing of long-term, high-dose opioids. Supporters say the regulation will provide a barrier to opioid addiction. Critics argue that the rule interferes with the physician-patient relationship, and could force patients who lose access to the drugs into withdrawal or encourage them to seek illegal replacements.