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Guest Post: Will Rep-Less ORs Improve Surgical Consistency?

OrthoBuzz occasionally receives posts from guest bloggers. The following commentary comes from David Kovacevic, MD in response to a November 14, 2016 article in The Washington Post.

Sandra G. Boodman’s recent column in The Washington Post, ”Why is that salesman in the operating room?… sheds light on the potential for conflicts of interest and other possible pitfalls of having device reps in the OR.  Currently, device reps are required to abide by the ethical standards set forth by AdvaMed, a medical device trade association. In addition, the American Academy of Orthopaedic Surgeons has adopted standards of professionalism regarding orthopaedist-industry conflicts of interest.

Both device rep and surgeon should have one common goal—to do what is in the best interest of the patient. Ultimately, though, the surgeon is responsible for patient welfare and safety.  This includes thorough pre-surgical planning; expertise in surgical anatomy, approach, and technique; complete knowledge about surgical instrumentation and implantable devices; and total transparency in the doctor-patient relationship.  The competent surgeon also manages the surgical team, collaborates with the anesthesia team, and recognizes the device rep’s adjunct role.

The presence of device reps in the operating room should be limited to answering implant-specific questions for the surgical team.  Patient-care problems can arise when the surgical team leader (i.e., the attending surgeon) and surgical team rely too heavily on device reps for technical expertise and assistance.  This can lead to questions as to who really is in charge and accountable.

Several solutions exist for sidestepping such ambiguity.  The consent-for-surgery form should state explicitly that a device rep may be present in the procedure room, and the device rep should wear scrubs or a disposable head cover that is a different color from the OR attire worn by surgical and anesthesia teams. The most effective solution, though, lies in building, developing, and sustaining surgical teams focused on improving operating room efficiency and consistency.  That’s a large undertaking, and the culture change needed for it requires buy-in from multiple stakeholders, such as the medical director of perioperative services, departments in the supply chain, and leaders in anesthesia, surgery, and nursing.

One rationale for a rep-less model is to reduce the cost of implants by working directly with and purchasing from the implant manufacturer and bypassing the group purchasing organization, sales reps, and distributors.  As Boodman’s article explains, for Loma Linda University Medical Center this meant obtaining device inventory directly from the implant manufacturer and training one of its surgical technicians as a de facto rep. The result was at least a 54% reduction in total case costs for primary total hip and total knee replacement procedures and empowering surgical technicians with additional knowledge about implants. It is too early to tell whether this model enhances consistency in the operating room, decreases operative time, or reduces length of stay and 30-day hospital readmission rates.

We should expect ongoing scrutiny of the device rep’s role in the operating room. With help from surgeons, hospitals and health systems should consider developing more effective surgical teams, including surgical techs specially trained about implants, to improve patient outcomes and consistency.

David Kovacevic, MD is associate fellowship director of shoulder and elbow surgery and assistant professor in the Department of Orthopaedics & Rehabilitation at Yale University School of Medicine. He can be reached at david.kovacevic@yale.edu or @KovacevicMD.

 

Guest Post: Cautious Early Optimism about Medicare’s Bundled Payment Programs

jointOrthoBuzz occasionally receives posts from guest bloggers. This guest post comes from Richard Yoon, MD.

In a recent issue of JAMA, Dummit et al. analyzed cost and quality results from the Centers for Medicare & Medicaid Services (CMS) Bundled Payment for Care Improvement (BPCI) initiative. The authors compared joint-replacement results between hospitals that voluntarily participate in the BPCI program versus matched comparison hospitals that do not participate. Nearly 60,000 lower extremity joint replacement procedures from each hospital type were included in the analysis.

Medicare payments declined over time in both groups of hospitals, but the authors noted a greater decline in costs among the BPCI hospitals, primarily due to reduced utilization of post-institutional acute care. There were no statistical differences in quality between the BPCI hospitals and comparison hospitals, as measured by unplanned admissions, emergency department visits, and mortality at both 30 and 90 days. These results echo those reported by other pilots in the United States and suggest that similar programs could reduce cost per episode of care without compromising quality.

However, even proponents of the new programs are cautious. For example, in his JAMA editorial, Elliot Fisher, MD warns readers that because BPCI is a voluntary program, the results may not reflect the true impact of a more widespread bundled-payment model.  The incentives, he argues, could end up contributing to volume increases or shifts toward healthier—and “more profitable”—patients. As Fisher concludes, “Bundled payments leave the overarching incentive to increase volume solidly in place.”

In a separate JAMA Viewpoint article, Ibrahim et al. warn that another CMS program, the Comprehensive Care for Joint Replacement (CJR) model, could unintentionally amplify already existing racial disparities in elective joint replacement. CJR is a mandatory initiative in 67 randomly selected US metropolitan areas. The authors say that CJR might improve postoperative quality of care for minority patients after joint replacement, but that the program could also end up favoring healthier, well-insured patients.

Overall, at this early stage, these two CMS models offer promising, comprehensive approaches to joint replacement that may prove cost-saving without comprising quality of care. Results like the ones published by Dummit et al. are hopeful, but longer-term, outcomes-based, and cost-focused studies that include epidemiologic and racial impact must be performed as we move forward carefully.

Click here to read a previous OrthoBuzz post about BPCI.

Click here to read a previous OrthoBuzz post about CJR.

Richard Yoon, MD is a fellow in orthopaedic traumatology and complex adult reconstruction at Orlando Regional Medical Center.

Orthopaedists Again Atop Physician-Compensation List

For its 2016 survey of physician compensation, Medscape received information from more than 19,000 physicians across 26 specialties. Orthopaedists again topped the list this year at $443,000 (see graph below), followed by cardiologists ($410,000), and dermatologists ($381,000). Orthopaedists and cardiologists were the top two earners last year also (see related OrthoBuzz post).

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Although orthopaedists were the highest-paid group overall, only 44% of them felt they were fairly compensated (see graph below). Orthopaedists who felt fairly paid made $156,000 more than those who believed their compensation was not fair.

Screen Shot 2016-04-04 at 9.16.31 AMOn a more positive note, nearly half (46%) of orthopedists believe that relationships with patients are a major source of satisfaction (see below). In the comments section included with this question in the Medscape survey, orthopaedists frequently mentioned helping patients and teaching as rewards of practice.

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In  Medscape’s calculations, compensation for employed physicians included salary, bonus, and profit-sharing contributions. For partners, compensation included earnings after business taxes and deductions, but before income taxes.

Guest Post: Get Ready for Medicare’s CJR Model

OrthoBuzz occasionally receives posts from guest bloggers. This “guest post” comes from Richard S. Yoon, MD and Alexander McLawhorn, MD, MBA.

Starting on April 1, 2016, Medicare will implement its Comprehensive Care for Joint Replacement (CJR) model in about 800 hospitals in 67 metropolitan areas around the United States. Finalized in November 2015, the CJR initiative is intended to enhance value for patients undergoing lower extremity joint replacement (LEJR) by motivating institutions to achieve quality improvement via cost control. (For a complete discussion of “value” in orthopaedics, see “Measuring Value in Orthopaedic Surgery” in JBJS Reviews.)

Medicare hopes CJR will promote standardized, coordinated care that takes each LEJR patient seamlessly through an “episode of care” that maximizes outcomes at a reduced cost.  Episodes are triggered by hospital admission and are limited to admissions resulting in a discharge paid under MS-DRG 469 or 470. For CJR purposes, episodes last for 90 days following discharge.

Initially, episode target prices will be based on historical hospital-specific reimbursements, but over time, the target prices will increasingly reflect regional averages. If a hospital’s average LEJR episode cost is below the target price, it can receive a “bonus” from CMS. If its average cost is above the target price, it will owe CMS the difference. CMS has designed a gradual rollout plan to mitigate downside risk in the first year and provide current and future participants adequate time to implement evidence-based, cost-effective care and other quality programs in their institutions.

Richard Iorio, MD, chief of adult reconstruction at NYU-Langone Medical Center’s Department of Orthopaedic Surgery, says, “There will be definite winners and losers in CJR. Once geographic pricing becomes the dominant metric for target prices, there will be intense price competition in geographic areas and potential access problems for high risk patients.” At the moment, CJR stratifies risk based only on MS-DRG code and whether a patient has a hip fracture. Unless a more robust risk stratification method is implemented, “cherry-picking” patients may become a significant issue. (See related OrthoBuzz post “Tool for Pre-TJA Risk Stratification.”)

If you are an orthopaedic surgeon who performs LEJR, ask your department head or health system about CJR, because strategies that minimize cost and maximize quality may vary from hospital to hospital. Alignment of hospitals and surgeons is probably the most critical success factor  with CJR. To that end, gainsharing— a key component of well-functioning hospital-surgeon partnerships within any bundled-payment environment —for individual orthopaedic surgeons is specifically allowed within the CJR final rule.

Click here for more information, including FAQs and a list of participating areas.

Richard S Yoon, MD is executive chief resident at the NYU Hospital for Joint Diseases.

Alexander McLawhorn, MD, MBA is an arthroplasty fellow at the Hospital for Special Surgery.

 

Whither Meaningful Use?

Meaningful use (MU) Stage 2 and 3 requirements have been a bane of existence for many physician practices, so a collective sigh of relief was heard when acting CMS administrator Andy Slavitt hinted recently that a more streamlined approach to regulating health care IT is coming.

Suggesting that MU as we know it may end altogether sometime in 2016, Slavitt offered few specifics in a speech at the recent JP Morgan Healthcare Conference, saying only that details of the new plan will come out “over the next few months.”

Beth Israel Deaconess Medical Center CIO John Halamka, MD, a frequent blogger on the subject of meaningful use, has said more than once that Stages 2 and 3 tried to do too much too fast, while lauding the functional foundation established by Stage 1. Halamka noted that when MU requirements are heaped on other rules and regulations such as HIPAA, the ACA, ICD-10, and Medicare value-based payment systems, the entire game becomes too complicated and confusing for everyone, including government auditors.

On January 14, 2016, 31 healthcare organizations (including notables such as Geisinger, Intermountain, and Partners) sent a letter to HHS secretary Sylvia Burwell, urging her to “restructure the MU program to fit future care needs and focus on improving interoperability and usability” of EHRs.

Stay tuned…OrthoBuzz will keep you posted.

CMS Delays Start of Joint-Replacement Bundled Payments til April 1, 2016

The final rule from the Centers for Medicare & Medicaid Services (CMS) regulating “episode-of-care” Medicare payments to hospitals for hip and knee replacements includes a postponed start date of April 1, 2016. The originally proposed implementation date was January 1, 2016.

Approximately 800 hospitals nationwide are subject to the new payment model, which makes hospitals eligible for bonuses or penalties, depending on their quality and cost performance from the day of patient admission to 90 days post-discharge. Based on comments about the initial rule by 400 key stakeholders, CMS also agreed to eliminate penalty payments during the first year of implementation.

Because the CMS model—dubbed Comprehensive Care for Joint Replacement, or CJR—permits gainsharing, individual orthopaedic surgeons could benefit financially if hospitals they are affiliated with receive bonuses. The AAOS commended CMS for revising the methodology for calculating the composite quality score and said that the delayed implementation “adds some flexibility,” but the group is still calling for CMS to “postpose the mandatory implementation feature of the program until at least 85 percent of providers have attained meaningful use [of EHRs] or another metric of infrastructure readiness.”

AAOS Issues Statement on Opioids in Orthopaedics

The current prescription-opioid/heroin epidemic in the US has been much publicized of late. According to a recent AAOS information statement, the nearly 100-percent increase in the number of narcotic pain-medication prescriptions between 2008 and 2011 corresponds to an increase in opioid diversion to nonmedical users as well as a resurgence in heroin use.

Among the strategies the AAOS statement calls for to stem the tide of opioid abuse and manage patient pain more safely and effectively are the following:

  • Opioid-prescription policies at the practice level that
    • set ranges for acceptable amounts and durations of opioids for various musculoskeletal conditions,
    • limit opioid prescription sizes to only the amount of medication expected to be used,
    • strictly limit prescriptions for extended-release opioids, and
    • restrict opioid prescriptions for nonsurgical patients with chronic degenerative conditions.
  • Tools (such as the opioid risk tool at MDCalc) that identify patients at risk for greater opioid use.
  • Empathic communication with patients, who “use fewer opiates when they know their doctor cares about them as individuals,” according to the statement.
  • An interstate tracking system that would allow surgeons and pharmacists to see all prescriptions filled in all states by a single patient.
  • CME standards that require periodic physician CME on opioid safety and optimal pain management strategies.

Noting that stress, depression, and ineffective coping strategies tend to intensify a person’s experience of pain, the statement concludes that “peace of mind is the strongest pain reliever.”

CMS Offers ICD-10 “Cheat Sheets”

In less than a week from this posting, on October 1, 2015, ICD-10 diagnosis codes will debut. OrthoBuzz already reported on the 12-month leniency policy announced by the Centers for Medicare and Medicaid Services (CMS).  In addition, during the home-stretch to the ICD-10 launch, CMS has published an online series of “cheat sheets” to help providers select at least the first few correct digits for the new codes. The guidance is primarily for family practitioners, but there are sections for back and neck pain and joint and limb pain that orthopaedists might find useful.

Keep in mind that private insurers are not obliged to follow CMS’s leniency lead in this area, although according to a Medscape.com article, Aetna, Humana, and Anthem have announced that they will. UnitedHealthcare is reportedly still mulling the issue, and Medicaid policies regarding how precise ICD-10 codes need to be will vary from state to state.

After October 1, please share your early ICD-10 experiences with OrthoBuzz by clicking on the “leave a comment” button in the box next to the title of this post. And good luck!

Decent Work/Life Balance Found in Ortho Residencies

Doximity’s 2015-2016 Residency Navigator is designed to help medical students make informed choices about residency programs by analyzing more than 94,000 ratings and hand-written reviews from Doximity members who are currently in or recently graduated from US residency programs. From that data, Doximity’s VP of Product Management Shari Buck turned up two interesting findings about orthopaedists in training:

–Among the specialties with the highest ratings for work hours (tolerability of shift and call schedules) and schedule flexibility (real-life accommodations for events such as weddings and pregnancy), orthopaedic surgery came in fourth, behind physiatry, dermatology, and radiation oncology—and just ahead of emergency medicine.

–On the other hand, female residents in general appear to be less satisfied than their male counterparts, and the gender gap is especially pronounced in historically male-dominated specialties like orthopaedic surgery (83.7 percent satisfaction among women versus 95.9 percent for men; p<0.05).

Calculating Individual Complication Rates Is Complicated

Rating hospitals on the basis of complications is one thing, but when you publish complication-rate scorecards for individual surgeons, as ProPublica did recently with nearly 17,000 surgeons nationwide, things can get personal.

ProPublica, an independent investigative-journalism group, examined five years of Medicare records for eight common elective procedures, three of which—knee and hip replacements and spinal fusions—orthopaedists perform. For each of the eight procedures, a panel of at least five physicians, including relevant specialists, reviewed 30-day readmission data to determine whether the readmission represented a complication; if a majority agreement was not achieved, the case was excluded from analysis. The analysis also excluded trauma and other high-risk cases, along with cases that originated in emergency departments.

Overall, complication rates were 2% to 4%. About 11% of the doctors accounted for about 25% of the complications.

In a ProPublica article about the scorecard, Dr. Charles Mick, former president of the North American Spine Society, is quoted as saying, “Hopefully, [the scorecard] will be a step toward a culture where transparency and open discussion of mistakes, complications, and errors will be the norm and not something that’s hidden.”  For its part, the AAOS responded with a press release that welcomed transparency but cautioned that “the surgical complication issue is much more complex, and cannot be effectively addressed without considering all of the variables that impact surgery, care, and outcomes.”

Pre-emptively, ProPublica clarified its methods in a separate article. Any 30-day readmission that the panel determined to be a complication was assigned to the surgeon who performed the original procedure. After compiling a raw complication rate for each doctor, researchers screened each patient’s health record and assigned a “health score.” That health score was used as part of a mixed-effects statistical model to determine an individual’s adjusted complication rate. No rate is reported if a surgeon performed a procedure fewer than 20 times.

Over the years, physician groups have complained that conclusions derived from Medicare data are inherently flawed, an argument that one orthopaedist made in the ProPublica article, citing the “multitude of inaccurate and confusing information that is provided to state and federal organizations.” Interestingly, two renowned patient-outcome experts cited in the ProPublica article came to separate conclusions. Dr. Thomas Lee, chief medical officer at healthcare-metrics consultancy Press Ganey, was quoted as saying that “the methodology was rigorous and conservative,” while Dr. Peter Pronovost, director of the Armstrong Institute for Patient Safety and Quality at Johns Hopkins, told ProPublica in an email just prior to the scorecard release that “it would be highly irresponsible to present this to the public in its current form, or to make an example of any surgeon based on faulty data analysis.”

In another take on ProPublica’s ratings, radiologist Saurabh Jha spins a yarn on KevinMD  of two fictional orthopaedists, Dr. Cherry Picker and Dr. Morbidity Hunter. The moral of this tale, Dr. Jha says, is that ProPublica’s scorecard is “a reservoir of Sampson’s paradox…when the data says ‘bad surgeon,’ the surgeon might in fact be a Top Gun—a technically gifted Morbidity Hunter—the last hope of the poor and sick.”

Obviously the ProPublica scorecard has touched many a nerve among hip/knee-reconstruction and spine surgeons. Have you looked at your numbers? What do you think? Please join the discussion by clicking on the “Leave a comment” button in the box above, next to the article title.