Physician Practice Changes After Paying Malpractice Claims
OrthoBuzz occasionally receives posts from guest bloggers. In response to a recent study in The New England Journal of Medicine, the following commentary comes from Matthew Deren, MD.
Malpractice. The word itself causes a visceral reaction for many of us in medicine. Although the vast majority of physicians will not pay a malpractice claim during their careers, there is still concern about the quality of care provided by doctors with multiple claims paid, either through out-of-court settlements or through court verdicts. The National Practitioner Data Bank (NPDB) was created, in part, to help prevent a doctor with a long list of malpractice claims paid from moving to a new geographic area for a “fresh start” without full disclosure of his or her claims history.
In the March 28, 2019 issue of The New England Journal of Medicine, Studdert et al. examined changes in practice characteristics among physicians who had paid malpractice claims from 2003 through 2015. By linking the NPDB to Medicare data, the authors identified a cohort of >480,000 physicians, 89.0% of whom had paid no malpractice claims. Nearly 9% of physicians had one paid claim, while the remaining 2.3% of physicians had two or more paid claims. That 2.3% accounted for 38.9% of all the claims paid during the study period.
A total of 19,098 (4%) of claims paid were in orthopaedic surgery, which made it the seventh most-sued specialty studied. When evaluating the subgroup of all physicians with ≥3 claims paid, the authors noted that they were more likely to be male, 50 years of age or older, and to practice in surgical specialties. In multivariate analysis, physicians with at least one paid claim were more likely to leave the practice of medicine than those with none. Finally, physicians with multiple paid claims were more likely to switch into small or solo practices, but the study found “no clear association between the number of claims and the propensity to relocate, within or between states.”
To be clear, the number of malpractice claims paid by a doctor is not necessarily a reliable indicator of quality of care, though many patients arrive at that conclusion. Just as important, this study doesn’t conclude that solo practitioners—in orthopaedics or any other specialty—are more likely to have paid a higher number of claims. There are many excellent physicians in solo practices across the United States.
Ultimately, this study shows that the majority of physicians have not paid a single malpractice claim and that physicians who have paid multiple claims are not more likely than other doctors to relocate their practice. These findings should help patients trust the various procedures that are in place to prevent the exceedingly small number of physicians with a long list of malpractice payouts from relocating in an attempt to leave their history behind them. From the physician viewpoint, the findings emphasize that the impact of malpractice claims goes beyond the emotional and personal into the realm of prompting changes in practice environment.
Matthew Deren, MD is an orthopaedic surgeon at UMass Memorial Medical Center, an assistant professor at University of Massachusetts Medical School, and a member of the JBJS Social Media Advisory Board.
Addressing the Gender Gap in Orthopaedics
OrthoBuzz occasionally receives posts from guest bloggers. This guest post comes from Megan Conti Mica, MD, in response to the 2018 Medscape Orthopaedist Compensation Report.
In a recently published Medscape survey looking at orthopaedic compensation, orthopods were the second-highest paid specialists overall. Despite that, only 51% of orthopaedist respondents to the Medscape survey felt they were fairly compensated. My question to you is: How fairly compensated would orthopods feel if that second-highest salary was decreased by $150,000 annually without reason?
While the reported overall wage gap between female and male physicians is more than $50,000 annually1, the Medscape survey found that the gender wage difference for orthopaedic surgeons was $143,000 annually—adding injury to insult. That annual gap would amount to $4 million of lost wages for women over a 30-year career as an orthopaedic surgeon.
Why does medicine in general and orthopaedics in particular have a gender gap? Is it because male surgeons have better outcomes than female surgeons? Not according to a 2017 study that found that patients of female surgeons experienced lower death rates, fewer complications, and fewer 30-day readmissions to the hospital, compared with patients of male surgeons.2 While I do not believe that gender alone makes one a better surgeon, I do believe that gender diversity within our field is imperative.
What is more disheartening is it seems no one with the power to make change is doing anything to close the gap. In 2009, only 4% of the AAOS fellows were female. Honestly, I cannot blame women for not trying to join the “boys club.” If someone told you that you would be a distinct minority in your profession, make less, and have to work harder, most rational human beings would find a different career. If we want more women in orthopaedics, we need to understand that the gender wage gap is just the surface of a bigger issue.
I challenge everyone (men and women) to do better. Help your female partners. Be more attentive and mentor female surgeons. Support women when they speak up, and champion for them when they don’t. The attributes that make a great orthopaedic surgeon—love of and dedication to this great specialty—are gender-neutral.
Megan Conti Mica, MD is a hand and upper-extremity surgeon at the University of Chicago Medical Center and a member of the JBJS Social Media Advisory Board.
References
- JAMA Intern Med. 2016;176(9):1294-1304. doi: 10.1001/jamainternmed.2016.3284
- BMJ 2017;359:j4366, Published 10 October 2017. doi: 10.1136/bmj.j4366
The Future of Private Practice Under Value-based Care
OrthoBuzz occasionally receives posts from guest bloggers. This guest post comes from Jason Weisstein, MD, MPH, FACS.
An increasingly frequent concern is that the Merit-based Incentive Payment System (MIPS) and value-based care in general could lead to the demise of private physician practices. With the prevalence of that concern comes pressure for private practices to join Accountable Care Organizations (ACOs), where groups of doctors and/or hospitals synergize to deliver coordinated care to Medicare patients. ACOs certainly have their benefits, but the risks of joining one need to be evaluated as well. An ACO may work for one orthopaedic practice but not for another. From my perspective, private practices, both small and large, will be able to thrive under MIPS. Here’s why:
- First, the final ruling from MACRA has given physicians the ability to report with the ‘pick your pace’ model. The slow, phased introduction for MIPS gives practices a window of time to get on track. 2017 is the transitional year, giving practices time to identify processes and an EHR system that best fit their needs.
- Second, CMS established flexible MIPS measurements based on practice size. (Small practices are typically considered to be those with ≤15 providers, and large practices have >15 providers.)
- Third, if you have the right support from your vendors—especially your EHR system vendor—you will have a built-in MIPS intelligence platform, composite scoring, and support and advisory services to help you along the way.
- Finally, the government has earmarked an extra $500 million for “exceptional performance” for each year of the first five years of MIPS. The right EHR system can direct and support you to achieve this exceptional-performance rating.
Ultimately, the decision to join an ACO or remain a private practice is a multifactorial one. You should consider the options available and how they will impact you, both in the short term and long term. Either way, value-based care is here to stay, and finding an EHR vendor with the best resources for your practice is a crucial component for success.
Jason Weisstein, MD, MPH, FACS is the Medical Director of Orthopedics at Modernizing Medicine.
Maximizing Specialized Health Registries Under MIPS
OrthoBuzz occasionally receives posts from guest bloggers. This guest post comes from Jason Weisstein, MD, MPH, FACS.
I want to expand on my previous posts (Tips to Excel Under MIPS and Why EHR Data & Analytics Matter) and focus on another differentiating factor when it comes to electronic health record (EHR) systems and your success with Medicare’s Merit-based Incentive Payment System (MIPS).
The ability to interact with specialized health registries is another functionality your EHR system should have. Active engagement with a clinical data registry falls under the Advancing Care Information (ACI) component of MIPS. In general, having EHR-enabled access to such specialized health registries can make MIPS compliance easier and help you earn bonus points, which translates into increased practice income.
Some examples of orthopaedic-specific registries could include the following:
- Medial Meniscus Tear, Acute Registry
- Plantar Fasciitis Registry
- Low Back Pain
- Herniated Disc, Cervical Registry
In addition to having the ability to interact with orthopaedic-specific registries in order to participate in ACI and improve your MIPS score, registry engagement through your EHR system will help to improve population health by collecting and reporting on data about musculoskeletal treatment effectiveness and disease trends. Public health reporting can be very complicated and time-consuming, but having an EHR system that automatically and seamlessly collects and transmits the data to the registry, without manual intervention, is a robust advantage.
Finally, access to registry data will help your practice with the Improvement Activities component of MIPS, which, during the so-called transition year of 2017, is weighted at 15% of the total MIPS score.
Jason Weisstein, MD, MPH, FACS is the Medical Director of Orthopedics at Modernizing Medicine.
Why EHR Data & Analytics Matter to Orthopaedic Practices
OrthoBuzz occasionally receives posts from guest bloggers. This guest post comes from Jason Weisstein, MD, MPH, FACS.
Selecting and/or changing your electronic health record (EHR) system is an investment of time, money, and training. There should be a thorough vetting process in place so you can select the right technology for your practice. One of the many questions you should ask when evaluating an EHR for your practice is the system’s ability to capture and display data. Data capture and analysis are critical for many reasons, one of which is reporting for the Merit-Based Incentive Payment System (MIPS).
The Value of Structured/Discrete Data
You want an EHR system that can capture structured, actionable data and automate patient and regulatory compliance documentation in near real-time. It is crucial to focus specifically on what is known as “discrete” or “structured” data. The opposite of narrative data, discrete/structured data captures specifics from each patient encounter.
Structured data matters so much because it is mineable—that is, it can be uniquely identified retrospectively. Structured data is crucial for group analytics, research, and the imminent obligations, such as MIPS, that the government and payers are placing on orthopaedic groups.
To maximize financial success, your EHR system should automatically capture all the data you need at the point of care to build and report your composite MIPS score. Once you have this data, you need tools that can help you visualize and analyze it.
The Importance of Visible Analytics
Analytics tools in your EHR system should:
1) Comparatively benchmark your near real-time quality and cost data to those of your peers
2) Visibly illustrate financial information to improve your bottom line and operations.
It is essential for everyone at a practice to have access to this real-time comparative benchmarking of both quality and cost data to succeed under MIPS. The analytics tools should not only show individual clinician performance and practice performance, but also where you stand when compared to other orthopedic surgeons and practices.
Making your financials visible can aid in improving your bottom line and operations far beyond a MIPS score. Having peer-to-peer comparisons in real-time will give you the chance to make operational changes, if necessary, to improve your practice.
From patient check-in to discharge, your analytics tool should enable you to identify and track key clinical, financial and operational processes to uncover insights to help optimize your practice. For example, orthopaedists would undoubtedly benefit from analytics on the prescribing of high-risk medications such as narcotics, blood thinners, and NSAIDs. Ultimately, robust analytics capabilities can help you measure and enhance your performance by making high-quality medical decisions for your patients and keeping costs down.
Jason Weisstein, MD, MPH, FACS is the Medical Director of Orthopedics at Modernizing Medicine.
JBJS/AOA Webinar–Implementing Medicare’s Quality-Incentive Programs
Are you confused and frustrated by Medicare’s Quality-Incentive Programs, such as the Merit Based Incentive Payment System (MIPS), Comprehensive Care for Joint Replacement (CJR) program, and the Surgical Hip and Femur Fracture Treatment (SHFFT) model? If so, this webinar is for you.
On Tuesday, August 15, 2017 at 8:00 PM EDT, The Journal of Bone & Joint Surgery (JBJS) and the American Orthopaedic Association (AOA) will host a complimentary LIVE webinar featuring the following speakers and topics:
- Brian McCardel, MD will discuss choosing MIPS-related quality measures, improving performance on those measures, and qualifying for bonuses.
- Thomas Barber, MD, FAOA will focus on managing clinical care including how to deliver low-cost high-quality care for high-risk orthopaedic patients.
- Alexandra Page, MD will discuss partnering with hospitals and post-acute organizations to improve patient care and reap financial rewards.
Moderated by Douglas Lundy, MD, FAOA, the webinar will include a live Q&A session between the audience and panelists.
Can Only 4 Questions Yield Meaningful Patient Outcome Measures?
In today’s data-driven, evidence-based world of orthopaedics, capturing accurate information about a patient’s physical function can require patients to answer dozens of separate questions. In the June 7, 2017 edition of JBJS, Hancock et al. investigate whether the computer-based tool called PROMIS (Patient-Reported Outcomes Measurement Information System) PF CAT is more efficient than and just as reliable as the more burdensome function-evaluation instruments.
In short, the answer is yes. Among a group of otherwise healthy patients scheduled to undergo meniscal surgery, the PROMIS PF CAT scores were generally highly correlated with traditional patient-reported physical-function measures, such as the SF-36 Physical Function instrument and the KOOS Sport and Quality-of-Life scores.
In contrast to the more traditional fixed-length questionnaires, the PROMIS PF CAT presents an initial item to the patient, and uses the response to that to select the most informative next item. That process continues only until a predefined level of precision is reached, at which point the test ends. The vast majority (89%) of the patients in this study completed the PROMIS PF CAT after answering only four items.
Considering its strong correlation with other widely accepted measurement tools and its efficiency, the authors conclude that PROMIS PF CAT “may be a good alternative for evaluating physical function in meniscal injury populations,” and that it could help “reduce burnout and maintain high response rates” in a time-constrained health care environment.
9 Tips to Excel with MIPS
OrthoBuzz occasionally receives posts from guest bloggers. This guest post comes from Jason Weisstein, MD, MPH, FACS.
MIPS—the Merit-based Incentive Payment System—is still a mystery to many orthopaedic surgeons. But it can have a big positive or negative impact on your practice.
MIPS is a federal improvement-incentive program consisting of Quality, Resource Use, Clinical Practice Improvement, and Advancing Care components. To demonstrate excellent performance (and reap the associated rewards), physicians can choose the activities and measures that are most meaningful for their practice. Weights are assigned to each category based on a 1 to 100 point scale. In 2017, the transition year, weights are as follows: Quality-60 percent, Cost-0 percent, Improvement Activities-15 percent and Advancing Care Information-25 percent.
I often hear a lot of grumbling from colleagues about their electronic health record (EHR) systems as one of the major causes of physician burnout. However, implementing the right technology will help you excel under this new reimbursement model.
Here are 9 MIPS tips related to EHRs:
- Choose the Quality benchmarks that best fit your practice. You need at least 20 eligible cases per Quality measure. Go to the CMS website and select benchmarks that have established measures.
- Report Quality for an entire year or over 90 days.
- Make sure your EHR has built-in dashboards that enable you to keep an eye on your composite score in near real-time, from day to day.
- Be sure that the EHR you select captures data being entered at the point of care and can enable this data to be used for multiple purposes.
- Get a head start on the Advancing Care component. Selecting an EHR vendor with successful Meaningful Use (MU) attestations is critical.
- Earn bonus points via specialty registries and Clinical Improvement Activities.
- Make sure your EHR allows you to compare your performance with that of your peers using analytical tools.
- When engaging in Clinical Improvement Activities, follow guidelines based on your specific practice size.
- Submit only the required number of Clinical Improvement Activities for the given measurement year, because the following year, you may need to pick a different activity.
With the shift to MIPS and value-based care, orthopaedic surgeons and their teams can thrive by adapting and utilizing technology that fits within their workflows and that helps them understand how they are performing in real time, both within their own practices and compared with their peers nationwide.
Jason Weisstein, MD, MPH, FACS is the Medical Director of Orthopedics at Modernizing Medicine.
Guest Post: Cautious Early Optimism about Medicare’s Bundled Payment Programs
OrthoBuzz 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.
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