COVID-19 Presidential Update from Joseph A. Bosco III, MD, FAAOS

August 10, 2020

I hope this letter finds you well, both personally and professionally. These continue to be challenging times. It is clear that the COVID-19 pandemic and its attendant consequences will be with us until an effective vaccine is developed, tested, and widely disseminated. The timing of this is uncertain, but it is unlikely to occur prior to the first quarter of 2021. With this reality in mind, we moved the AAOS 2021 Annual Meeting from March 18, 2021, to August 31, 2021. This move is not without consequences and was done out of concern for both attendees and staff. The Presidential Line and I personally notified each specialty society President of the decision and we convened a project team to determine how to best make the meeting work for our specialty society colleagues. We are also engaged in discussions with our industry partners to ensure that they remain fully committed to the rescheduled meeting. Moving the meeting is a heavy lift for both volunteers and staff, but doing so a year in advance ensures that all stakeholders will work together to make the 2021 San Diego meeting a success.

In Washington, D.C., things have slowed down into a more normal rhythm with lawmakers beginning to think about the long-term impact of their COVID-19 response efforts. They are even planning for 2021, starting with the payment policy proposals you may have seen announced by the Centers for Medicare & Medicaid Services (CMS) last week. I want to address the severe impact that these proposals will have on musculoskeletal care if they are finalized. Hopefully, it will encourage all of you to actively participate in the rule-making process before the comment period ends on October 5, in addition to participating in our ongoing In-District Advocacy Event.

This week, the CMS published its 2021 Hospital Outpatient Prospective Payment System (OPPS) and Ambulatory Surgical Center Payment System proposed rule. Among other policy changes, the agency is proposing to eliminate the Inpatient Only List over three years, but will start by moving nearly 300 musculoskeletal procedures to the hospital outpatient setting in 2021. It is also proposing to move total hip arthroplasty to the ASCs. This is a direct quote from the 781-page proposed rule:

“CMS proposes to expand the number of procedures that Medicare would pay for when performed in an ambulatory surgical center (ASC), which would give patients more choices in where they receive care and ensure CMS does not favor one type of care setting over another. For CY 2021, we propose to add eleven procedures that Medicare would pay for when provided in an ASC, including total hip arthroplasty. Since 2018, CMS has added 28 procedures to the list of surgical services that can be paid under Medicare when performed in ASCs.”

As noted in the statement we published last Friday, the AAOS believes that the setting where patients receive their care is best decided by physicians. While we are cautiously optimistic about CMS’ attempt to offer these flexibilities by promoting site neutrality and lifting restrictions on high-value physician-owned hospitals, we are concerned about the potential for unintended consequences associated with eliminating the Inpatient Only List. By doing so, CMS may exacerbate many of the same unresolved issues that we continue to face as a result of hip and knee arthroplasty being recently removed from the list. For example, payers, including Medicare Advantage and commercial carriers, often misinterpret the policy change to mean that these procedures must be performed exclusively in the outpatient setting. This confusion adds even more delay and paperwork to existing prior authorization requirements and, most importantly, jeopardizes patients’ safe, timely access to care.

We are strongly encouraging CMS to carefully reassess this aspect of the proposal in light of these concerns, and our Office of Government Relations (OGR) is already engaging with the agency regarding these issues.

CMS also recently published its proposed 2021 Medicare Physician Fee Schedule. The schedule includes an 11% reduction of the Medicare conversion factor (from $36.09 to $32.26), and this cut for 2021 is further compounded by the proposal to reduce the work relative value units and direct practice expense inputs for hip and knee arthroplasty by an additional 5.4%. Per CMS estimates, on average these proposed cuts will reduce payments of all orthopaedic surgical services by approximately 5% and hip and knee replacements by 10%. As I expressed in the related statement we put out last week, the AAOS is extremely disappointed in CMS’ decision to disregard our petitioning, many discussions and data presented against these cuts. Devaluing the time and effort that our surgeons spend prioritizing value-based care communicates a larger plan by the agency to gradually reduce the value of these procedures. The OGR is partnering with our orthopaedic specialty societies in urging CMS to refrain from finalizing both punitive cuts, and will also be urging Congress to waive budget neutrality in Medicare Part B, so that positive updates to other specialties do not result in cuts to surgeons. Additionally, we have engaged the Board of Councilors to mount a state-based grassroots campaign to pressure our congressional representatives to oppose these cuts.

Given all of the drastic changes being proposed, we need to act fast. This is an opportunity for AAOS leadership to build and lead coalitions with the orthopaedic specialty societies and the Board of Councilors, as well as with nonorthopaedic organizations, to oppose these disincentives to improving clinical outcomes. The OGR continues to advocate for our position to policymakers, but it is equally important that AAOS members compliment these efforts via the AAOS Advocacy Action Center. I am confident that we will take full advantage of this critical window of time to make a difference. Thank you, in advance, for helping to shape the future of musculoskeletal care.

Thank you and stay well,

Joseph A. Bosco, III, MD, FAAOS
AAOS President