AAOS Bulletin - October, 2006

When the wheels came off…

Richard F. Kyle, MD

A CMS decision and a rollerblading accident made this a summer to remember

Over this summer, I had two experiences that I will long remember. Both side tracked well-laid plans, and both reinforced my beliefs in the value of orthopaedic unity and the capabilities of orthopaedic surgeons.

In late June, while I was attending the American Orthopaedic Association annual meeting in San Antonio, Texas, “the wheels came off” the Medicare reimbursement schedule when the Centers for Medicare and Medicaid Services (CMS) announced its response to the recommendations of the American Medical Association’s (AMA) Relative Value Scale Update Committee (RUC).

Although CMS accepted some of the RUC’s recommendations—particularly in orthopaedic trauma, wrist, hand, and finger services—it proposed decreasing the values of total hip arthroplasty (THA) (code 27130), total knee arthroplasty (TKA) (code 27447) and open treatment of femoral neck fractures (code 27236), rejecting the RUC’s recommendation to maintain current values for those three services.

CMS recommended cuts of 10 percent to 11 percent for THA, 4 percent to 5 percent for TKA, and 6 percent to 7 percent for open treatment of femoral neck fractures. As the most frequently reimbursed codes by Medicare and Medicaid, reductions in payment levels would have a serious impact on reimbursements to orthopaedic surgeons. If the cuts were implemented, total reimbursements to orthopaedic surgeons would be reduced by $47 million to $58 million over the course of one year.

How did the payments get off-track? Why didn’t CMS accept the RUC’s recommendation to retain current reimbursement levels? The answers were not clear. The AAOS, experts in the areas of coding and classification, and members of the American Association of Hip and Knee Surgeons (AAHKS) had developed surveys and studies that supported maintaining the current values for these procedures. Now we needed to respond to the CMS decision and, if possible, effect a change.

Working together WORKS!
Almost immediately, an alliance between the AAOS and AAHKS was formed to respond to the unsettling news. An e-mail alert notifying AAOS members of the decision was distributed. A team of AAOS leadership and staff, along with AAHKS leadership, came together to address the issue. The team included AAHKS President William J. Hozack, MD; coding specialists R. Dale Blasier, MD, Carlos J. Lavernia, MD, Brian S. Parsley, MD, and Bernard A. (Bernie) Pfeifer, MD; Council on Advocacy Chair David A. Halsey, MD, and myself, as well as AAOS staff members Robert C. Fine, JD, CAE; Robert H. Haralson III, MD, MBA; Robert Jasak, JD; David Lovett, JD; Kathryn Pontzer, JD; and Daniel Sung, JD.

We formulated a plan of action during a series of conference calls. Although CMS rarely reverses its decisions, we knew that we had to make the case for maintaining the values of these codes. As part of the multilayered strategy that was developed, the AAOS and AAHKS prepared a written response to the proposed rule during the commentary period.

On June 26, just days after the announcement, several leaders in the orthopaedic community and I met with officials at CMS. We hoped to build on a cooperative relationship that had begun to develop earlier in the spring. Then, we had met with CMS to address issues under Medicare Part A, including the formation of meaningful guidelines and measures under a pay-for-performance system. We had also outlined the need to partner with CMS to establish a total joint registry that could help reduce costs and improve the quality of joint replacements.

The meeting was cordial and coordinated, and we felt well-received by CMS. During the meeting, we presented additional information and survey data to support continuing the present level of reimbursement for THA, TKA and femoral neck fracture treatment.

We pointed out that reducing reimbursement for total joint procedures—just as 79 million aging “baby boomers” would be needing these services—could create problems with access to care. Many arthroplasty surgeons, who themselves are part of the “boomer” generation, are already considering early retirement and reducing the number of surgeries they perform. Low reimbursement levels would do little to attract younger surgeons to replace them. Fellowship positions in arthroplasty are already becoming difficult to fill. We also outlined our concerns with comparative codes and methodology.

The AAOS and AAHKS have provided written commentary to CMS. In response, we have heard that the codes will not go on to the refinement process, which is a good sign. But a final decision on whether CMS will reverse its initial decision and accept the RUC’s recommendation to maintain reimbursements for these codes at their current level will not be published until the end of this month.

The joint effort by the AAOS and the AAHKS to effect this change for the mutual benefit of our members demonstrates the cooperation needed in the advocacy arena. When orthopaedics speaks with one voice, we stay on track and we will be heard. As soon as additional information is available, you will be notified by e-mail and given updates in our publications. The collaborations between the Academy and the specialty societies to address issues of reimbursement and access to specialty care will continue and will, I hope, achieve many successful outcomes.

Rollerblading to surgery
The “wheels came off” with a much different outcome later in the summer, while I was rollerblading down a steep hill near my home. When the wheels on my right skate popped out, I immediately crashed. A quick tuck and roll saved my head, but I landed on the tip of my left shoulder. I felt and heard my left acromioclavicular (AC) and coracoclavicular (CC) ligaments rip and tear in sequence. A passing motorist stopped to tell me I should be more careful…and asked if I knew any good orthopaedic surgeons.

AAOS President Richard F. Kyle, MD, presided over the September Board of Directors meeting wearing a sling after tendon allograft surgery to repair torn acromioclavicular and coracoclavicular ligaments.

Knowing both the anatomy and the consequences of such an injury, I realized the motorist was right. But as an orthopaedic surgeon, I also realized that the failure rate of any surgery can be directly correlated to the number of techniques described in the literature, and that the fixation of an AC separation can be fraught with complications.

The next day, I contacted two friends—Richard J. Hawkins, MD, of Spartanburg, S.C., and Louis U. Bigliani, MD, of New York City. While pointing to my age as a countraindication for surgery, both said a tendon allograft was possible. Luckily, two young and very talented orthopaedic surgeons in Minneapolis—Michael Q. Freehill, MD, and Andrew H. Schmidt, MD—agreed to do the surgery. Dr. Freehill had done a shoulder fellowship with Dr. Bigliani and is currently part of the AAOS Leadership Fellows Program; Dr. Schmidt is chair of the program committee for the 2007 Annual Meeting. I knew I was in good hands.

I arrived in the operating room with my own instruments and my own ideas. Thankfully, these talented surgeons made an immediate decision to give me a general anesthetic to ensure my complete cooperation. Although the sleeve of periosteum was completely stripped off the underside of my clavicle, and both the CC and AC ligaments were avulsed from the acromion, they were not shredded. Both were repaired and reinforced with the allograft. My postoperative recovery went well and I’m looking forward to rollerblading again.

The incident did teach me a lesson though. I plan to encourage the Council on Education to expand its efforts to develop simulators for orthopaedic surgery. While a surgical skills simulator may be useful in teaching arthroscopic surgical techniques, a pain simulator—to be applied to any orthopaedic surgeon who thinks his patients complain too much—may be helpful in teaching empathy and reinforcing the concepts of patient-centered care.

As others who have benefited from the talents, skill and caring of orthopaedic surgeons, I now have a new appreciation for the individuals who have chosen this challenging career. I also have a greater appreciation for the research and technological developments that made my surgery possible.

Orthopaedists are uniquely qualified to provide care for patients with musculoskeletal conditions, as the recently approved position statement on emergency care services states. We must apply our unique qualifications to advocate on behalf of our patients and to ensure continued access to specialty care for those who need it.

Richard F. Kyle, MD

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