Editor’s note: This article is part of a yearlong series, Advocacy 201, which focuses on the work of the Advocacy Council to improve the practice of orthopaedic surgery. This article and the next installment will specifically address quality of care.
AAOS functions are divided among four councils: Education, Advocacy, Membership, and Research and Quality. Previous AAOS Now articles described the nature of the three subcommittees that deliver much of the work of the AAOS Advocacy Council: the Health Care Systems Committee, the Coding Coverage and Reimbursement Committee, and the Medical Liability Committee (to read more, see the February, March, and April issues).
This article spotlights one of three broad healthcare policy areas on which these committees focus and from which AAOS develops its annual Unified Advocacy Agenda. Those areas are access to quality care, physician burden relief, and payment reform.
Access to quality care
Ensuring access to quality care is an integral part of the work of these committees. Although federal initiatives such as the Affordable Care Act and Healthy People 2020/2030 have historically focused on decreasing the number of uninsured Americans and patients’ out-of-pocket costs as key policy issues, there is a growing body of evidence that access to care is far more complex. In addition to affordability, primary factors include geographic proximity and transportation to a doctor or hospital, an adequate healthcare workforce, and the availability and timeliness of services. These factors are intertwined with cost and must be considered when determining obstacles to patients receiving necessary medical care. Part two of this series will describe several current efforts by policy makers and insurers to advance access to quality care.
According to the National Center for Health Statistics, 17.4 percent of surveyed adults indicated they delayed or did not seek medical care due to cost in 2019. The ongoing COVID-19 pandemic has introduced new challenges to accessing care, such as avoiding care due to fear of coronavirus infection. Orthopaedic surgeons must contend with the downstream consequences of delayed or forgone care, which can exacerbate injuries and chronic conditions. According to a study on health service utilization during the pandemic, approximately 1 in 7 adults (15 percent) reported that household members delayed or were unable to get elective procedures or surgery for important health problems during the pandemic, and more than half (54 percent) reported negative health consequences as a result.
Current efforts to address barriers to accessible care
To date, the Centers for Medicare and Medicaid Services’ (CMS’) efforts to improve access to quality care have broadly focused on developing pay-for-performance reimbursement models, which attempt to reward healthcare professionals and facilities for providing high-quality, high-value care. Orthopaedics often serves as a testing ground for CMS’ value-based care models due to the relatively high volume and cost of many procedures and the ability to easily define episodes of care.
Most advanced payment models have shown mixed results in improving access to quality care. Only recently have models such as the Comprehensive Care for Joint Replacement Program and the Bundled Payments for Care Improvement Advanced Model implemented policies to incentivize patient-centered care. Risk standardization is also gaining recognition for its importance in leveling the playing field for safety-net hospitals and other facilities serving rural and underserved areas. AAOS has a long history of supporting inclusion of risk-adjustment factors in payment models to mitigate the effects of treating more complex patients.
A mechanism to control healthcare utilization commonly used by Medicare Advantage (MA) and commercial insurers is authorization of services before they are rendered. Proponents of prior authorization identify the mechanism as a tool to improve affordability and quality of care. However, prior authorization has also been shown to inhibit access in other ways. Most notably, prior authorization has had a negative impact on timeliness of care due to the administrative burden placed on providers. In a 2021 survey by the American Medical Association, 93 percent of surveyed physicians reported care delays associated with prior authorization requirements, and 82 percent reported that these requirements may sometimes lead to patients abandoning treatment.
Congress has taken note of the burden of prior authorization on physicians and patients. The Improving Seniors’ Timely Access to Care Act of 2021 (H.R. 3173/S. 3018) would protect patients from unnecessary delays in care by streamlining and standardizing prior authorization under the MA program. AAOS sees this legislation as a high priority, and its Office of Government Relations continues to actively collaborate with other medical specialty associations and congressional champions to move it forward.
Flexibilities implemented during the pandemic for telemedicine and physician-owned hospitals (POHs) have improved access to care for many musculoskeletal patients, especially those in rural and underserved communities. Policy changes enacted by Congress and the federal agencies to temporarily lift restrictions on telehealth services during the public health emergency (PHE) have removed geographic barriers to care. Many of these policies are set to expire at the end of the PHE, potentially reversing impressive progress made in modernizing the nation’s healthcare system and thereby limiting healthcare access. AAOS has been an active advocate for legislation seeking to reform and expand telemedicine access and flexibility in the 117th Congress. To date, AAOS has endorsed five telemedicine-focused legislative bills, including the Telehealth Modernization Act (H.R. 1332/S. 368). AAOS has also advocated with CMS to make Medicare and Medicaid telehealth waivers permanent.
Throughout the PHE, CMS has recognized the important role POHs can play in providing high-quality care in certain communities. Recent regulations have made it easier for POHs in areas with high concentrations of Medicaid patients to expand. However, more can be done to reduce the restrictiveness of these regulations and improve patient access beyond the pandemic. AAOS actively supports the Patient Access to Higher Quality Health Care Act of 2021 (H.R. 1330), which would repeal the restrictions on expansion and new construction of POHs set forth in Section 6001 of the Patient Protection and Affordable Care Act.
Existing efforts to improve access to quality care are perhaps best described as a patchwork of short-term initiatives and experiments. It is encouraging that Congress, regulators, and commercial insurers appear to be sharpening their focus on addressing access to quality care, especially as it relates to health equity. The next article in this series will explore what future healthcare access initiatives may look like and how orthopaedic surgeons may be affected.
Brandy Keys, MPH, former director of registry and regulatory advocacy in the AAOS Office of Government Relations, contributed to this article.
Douglas W. Lundy, MD, MBA, FAAOS, is chair of the Department of Orthopaedic Surgery at St. Luke’s University Health Network and chair of the AAOS Advocacy Council.
- Morbidity and Mortality Weekly Report: QuickStats: Percentage of Adults Aged ≥18 Years Who Had an Unmet Mental Health Care Need Because of Cost in the Past 12 Months, by Age Group and Sex—National Health Interview Survey, United States 2019. Available at: https://www.cdc.gov/mmwr/volumes/69/wr/mm6943a8.htm?s_cid=mm6943a8_w. Accessed Feb. 17, 2022.
- Findling MG, Blendon RJ, Benson JM: Delayed Care with Harmful Health Consequences—Reported Experiences from National Surveys During Coronavirus Disease 2019. JAMA Health Forum. 2020;1(12):e201463.
- Medicare Payment Advisory Commission: Report to the Congress: Medicare and the Health Care Delivery System. Available at: https://www.medpac.gov/wp-content/uploads/import_data/scrape_files/docs/default-source/reports/jun21_medpac_report_to_congress_sec.pdf. Accessed Feb. 17, 2022.
- O’Connor MI, Jimenez RL, Parks ML, Nelson C: Alternative Payment Models for Joint Replacement Threaten Safety Net Hospitals and May Diminish Access for Vulnerable Patient Populations. AAOS Now. July 2020.
- American Medical Association: It Is Time to Fix Prior Authorization. Available at: https://www.ama-assn.org/system/files/prior-auth-reforms-issue-brief.pdf. Accessed Feb. 17, 2022.
- AAOS: AAOS Comments on 2021 Medicare Outpatient Prospective Payment System Proposed Rule. Available at: https://www.aaos.org/globalassets/advocacy/issues/aaos-2021-opps-comments.pdf. Accessed Feb. 17, 2022.