AAOS Bulletin - June, 2006

Orthopaedic leaders tackle major issues

NOLC examines pay-for-performance, coding and dispute resolution

By Susan Nowicki, APR

More than 200 orthopaedic surgeons spent four days in Washington, D.C., debating the major issues affecting orthopaedic practice during the 2006 National Orthopaedic Leadership Conference (NOLC).

They also visited Capitol Hill to convey the viewpoints of the orthopaedic community on a number of legislative issues, including Medicare reimbursement and medical liability reform.

During NOLC, the Florida delegation convinced Sen. Mel Martinez (R-Fla.) to sign the DMLR pledge. (From left to right, seated) BOC members Patrick M.J. Hutton, MD; Alan S. Routman, MD (holding the signed pledge); Jose Montanez-Huertas, MD; Adam S. Bright, MD; (standing) Marge Hutton; BOC member Mark E. Fahey, MD; Sen. Martinez; BOC member Brian S. Ziegler, MD; Cynthia Halcin, MD; and Fraser Cobbe, executive director of the Florida Orthopaedic Society.

Participants came from state orthopaedic societies, orthopaedic specialty societies, the AAOS Board of Directors, the Board of Specialty Societies (BOS) (COMSS), the Board of Councilors (BOC), the Orthopaedic Political Action Committee (PAC) Executive Committee, the Leadership Fellows Program, the Washington Health Policy Fellows Program and the AAOS Councils on Education, Advocacy and Research, Quality Assessment & Technology and the Communications Cabinet.

Panel discussions were held on a range of timely topics such as gainsharing, alternative dispute resolution mechanisms and scope of hand surgery.

During a special ceremony, AAOS President Richard F. Kyle, MD, presented the first Media Orthopaedic Reporting Excellence (MORE) Awards. Created at the request of the BOC, the MORE Awards recognize journalists who help advance the Academy’s mission of enhancing public awareness of orthopaedic-related issues and medical advancements that restore patients’ quality of life. A detailed report on the awards can be found here.

Dr. Kyle also gave an update on unity efforts and spoke about the Board of Directors Spring Workshop on Communications (see “Across the President’s Desk” for more information). AAOS First Vice President James Beaty, MD, discussed the Academy’s efforts on new technology evaluation and trauma call. Second Vice President E. Anthony Rankin, MD, outlined plans for a unified advocacy agenda and setting priorities for the issues to which the Academy will commit resources.

Capitol Hill visits

On the first evening, orthopaedic surgeon and Georgia’s 6th congressional district Rep. Tom Price, MD (R) spoke with attendees about preparing for Capitol Hill visits. He explained that physicians must frame liability reform as a patient care issue rather than a financial one. He expressed his belief that the federal government shouldn’t be involved in the debate over diagnostic imaging at all. Rep. Price also said that surgeons should not let members of Congress tell them that reimbursement issues will eventually be fixed. He noted that physician pay is a small percentage of total health care costs and represents the most efficient use of health care dollars.

Eric Gordon, staff member for Rep. Frank Pallone Jr. (D-N.J.), explained how Capitol Hill works, noting that the environment is confusing, hectic and fast-paced. And, fierce partisanship and the high deficit are making it harder to operate.

The next day, NOLC participants urged senators and representatives to fix the flawed Medicare payment formula, to preserve office-based imaging services and to reverse the cut in payment for imaging services scheduled for Jan. 1, 2007. Members can view the background material provided to members of Congress on the AAOS Web site (password protected).

During these visits on Capitol Hill, debate began on S. 22, the Medical Care Access Protection Act of 2006. Orthopaedic surgeons urged senators to sign the Doctors for Medical Liability Reform (DMLR) pledge to support comprehensive medical liability reform and to vote for S. 22. For further information on the DMLR campaign, chaired by Stuart L. Weinstein, MD, immediate past president of the AAOS, go to: www.ProtectPatientsNow.org.

On May 8, just a few days after the NOLC concluded, the Senate considered S. 22 and another medical liability reform bill, as part of “health week.” Under the procedural rule known as cloture, 60 votes were needed to close debate and vote on the bills. Neither measure achieved the required votes. According to David Lovett, director of the AAOS Washington Office, “It is not clear if there will be further action on this issue in the Senate during the 109th Congress. However, the AAOS will continue to work on expanding grassroots support in favor of medical liability reform.”

Update on gainsharing

David A. Halsey, MD, chair of the AAOS Gainsharing Team, led an interactive presentation on the topic. Changes in Medicare Part A vs. Part B and the advent of value-based purchasing related to pay for performance have generated increased interest in gainsharing. In addition, the Deficit Reduction Act of 2005 requires funding of up to six gainsharing demonstration projects.

Of paramount concern to NOLC participants was the impact of gainsharing arrangements on the patient-physician relationship. Dr. Halsey asked, for example, “If an orthopaedic surgeon believes that XYZ implant is the only or best implant for a patient and that implant is not part of the gainsharing arrangement, what should the orthopaedic surgeon do?Should the patient be informed of the gainsharing arrangement and, if so, must the patient approve of the agreement?

Frank B. Kelly, MD, chair of the AAOS Communications Cabinet, makes a point during the discussions, while Joseph C. McCarthy, MD, awaits his turn at the mike.

“Further, does gainsharing improve the health and well-being of the patient and/or the community? If not, should an orthopaedic surgeon support legislation or regulations that would prohibit gainsharing?”

To help AAOS develop a response on gainsharing, Dr. Halsey used the audience response system and asked NOLC participants for their opinions.

• Approximately 72 percent of participants disagreed with the statement: Gainsharing is an ethical arrangement between hospitals and physicians.

• Nearly 84 percent of participants disagreed with the statement:
The best gainsharing arrangement permits the hospital and physicians to enter into exclusive contracts with vendors to limit the types of supplies and devices.

• More than 96 percent of participants disagreed with the statement:
AAOS should actively support gainsharing arrangements in which physicians receive a direct payment from supply-device contracting and arrangements.

There was no clear consensus, however, on whether AAOS should develop a position statement on gainsharing or what that position might be.

Alternative dispute resolution

The BOC Work Group on Alternatives in Professional Liability presented alternatives that already exist for physicians and patients to adjudicate malpractice claims. Thomas Barber, MD, described the Kaiser Permanente Alternative Dispute Resolution system, which includes binding arbitration for its member physicians and a medical center ombudsman program for patients. Robert Quinn, MD, Physician Risk Manager with COPIC Insurance Company, discussed his company’s 3Rs program, which stands for Recognize, Respond to and Resolve Patient Injury.

Dr. Barber said that all Kaiser physicians are required to sign an arbitration agreement. Their experience has been that it helps to reduce large claims payouts and to reduce spurious suits. “It means physicians spend less time away from their practices,” explained Dr. Barber. “It is less intimidating than a court proceeding, and awards tend to follow the nature of the error rather than the nature of the injury.

“We have found that patients do not object to signing the agreement, and while the overall number of suits hasn’t declined, the awards tend to be less and we tend to prevail more often than under the traditional tort system. In general, it has been a positive experience—we would not go back,” he said.

Dr. Barber also explained that the Kaiser ombudsman program has been very successful. “Every adverse outcome or patient who threatens a suit, is reported to the ombudsman by the physicians involved. The reduction in the number of lawsuits has been dramatic and the program is very cost-effective. (Kaiser is self-insured for professional liability.) It is also our experience that patient safety can be improved.”

Dr. Quinn noted that COPIC’s claim philosophy is to compensate negligently injured patients, minimize waste of resources in the tort system and defend defensible medicine, regardless of cost.

“It is a no-fault program designed to prevent medical injuries from entering the ineffective, inefficient and adversarial legal system,” he explained. “The program is based on early intervention and emphasizes communication and disclosure. Our goals are to maintain the physician/patient relationship; encourage open/honest communication, including disclosure of the unanticipated event; encourage expressions of concern including an apology when appropriate; meet patients’ needs at a crucial time; and reduce litigation expenses.”

BOC actions

The BOC considered and approved two Advisory Opinions for submission to the AAOS Board of Directors at its June meeting. They include “Advisory Opinion #1: Develop Guidelines on Percutaneous Therapeutic Disc Procedures” and “Advisory Opinion #2: Physician Performance Indicators.”

The BOC Professionalism Committee also held an open hearing on potential new standards of professionalism (SOPs). One dealt with advertising by orthopaedic surgeons and the other focused on orthopaedist-industry conflicts of interest. Feedback on both proposed SOPs will be provided to the Academy’s Committee on Professionalism.

Key contact program

Member participation in AAOS legislative outreach efforts is key to their success. John T. Gill, MD, BOC secretary and chair of the Key Contact Work Group, provided an overview of the Orthopaedic Key Contact Program and urged NOLC participants to consider participating. The key contact program has been successful at the state level and the goal now is to “create a list of orthopaedic surgeons across the nation who can assist the efforts of the Washington office.”

Key contacts will already have meaningful relationships with members of Congress or are willing to develop them. The ultimate goal, said Dr. Gill, is to match at least one orthopaedic surgeon with every member of Congress (435 representatives and 100 senators). What are the expectations of a key contact? He or she should:

• Develop and maintain a meaningful relationship with his or her member of Congress

• Have readily established lines of communications with the member

• Be willing to contact that member expeditiously when issues of importance arise and the network is alerted

• Call on the member in the district or in Washington

• Get to know key staff members

• Serve as a resource on medical issues

• Attend town hall meetings, events and fundraisers

Dr. Gill suggested that members interested in joining the program contact their state Councilor or their state orthopaedic society.

Coding and RUC initiatives

Bradford M. Henley, MD, chair of the AAOS Coding, Coverage and Reimbursement Committee, briefed participants on current coding and AMA/Specialty Society/RVS Update Committee (RUC) activities. He explained the CPT Editorial Panel and RUC processes, including the current five-year review, and emphasized the need for orthopaedists to become knowledgeable about how to develop coding proposals and complete RUC surveys. AAOS makes its recommendations to the RUC based on survey data collected from members, so surgeon input is crucial.

At RUC meetings, explained Dr. Henley, the AAOS must convince committee members that the proposed payment recommendation is reasonable. If the AAOS is successful, the recommendation is forwarded to Medicare for approval. The RUC process is important because Medicare almost always adopts the RUC’s recommendations and uses them to set payment rates for all Medicare procedures.

Scope of hand surgery issue

Andrew N. Pollak, MD, BOS chair, led a panel discussion on the scope of hand surgery. Panelists included the presidents of five orthopaedic specialty societies, including David M. Lichtman, MD (American Society for Surgery of the Hand); Ronald E. Palmer, MD (American Association for Hand Surgery); Michael J. Bosse, MD (Orthopaedic Trauma Association); William A. Grana, MD, MPH (American Orthopaedic Society for Sports Medicine); and Joseph P> Iannotti, MD (American Shoulder and Elbow Surgeons).

Panelists discussed extending the scope for hand surgeons up to the shoulder, but there has been resistance to this change. Dr. Lichtman noted that this is not so much an expansion of scope, but of definition, because many hand surgeons are already doing arm procedures. He felt that hand surgeons need to be responsible for the whole limb, and there have been increasing financial difficulties for surgeons who are strictly limited to the hand. He outlined steps needed to allow hand specialists to practice on the entire arm and stressed the need to work with other subspecialties.

Dr. Iannotti reframed the discussion as a scope of training issue, especially fellowship training. “Specialized fellowship training is key to patient care,” he said. “I am concerned with the lack of required shoulder training within hand fellowships.” He also noted concerns that the extended scope could allow general and plastic surgeons to operate on the shoulder, something he felt orthopaedic surgeons should be doing.

Dr. Bosse pointed out obstacles to patient access to hand care and related professional problems within the field. He stressed the need to focus on patient access to hand care and finding ways to increase the number of practitioners in the field.

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