The March 16, 2016 JBJS includes a careful incidence, treatment, and outcome analysis by Pearson et al. of CMS data regarding C2 cervical-spine fractures that occurred in the Medicare population from 2000 to 2011. The study’s methodological quality comes as no surprise, as the group hails from Dartmouth, the home of the renowned Dartmouth Atlas of Health Care, which has posed many vexing clinical and cost questions for the orthopaedic community.
Pearson et al. found that while the incidence of C2 fractures in the elderly increased 135% from 2000 to 2011, the rate of surgical treatment for this injury remained essentially unchanged. I find that static rate of surgical treatment troubling, because, after controlling for potential confounders, the authors found that surgical treatment was associated with a nearly 50% decrease in 30-day mortality and a 37% decrease in one-year mortality, relative to nonoperative approaches.
I believe that our apparent reluctance to perform surgery in these cases is due to the underlying belief that upper C-spine fixation/fusion in the elderly presents a prohibitively high risk. I question that general proposition because we think quite the opposite nowadays when managing hip fractures and many other metaphyseal fractures with high complication profiles in older people. Certainly, the major risks with upper C-spine surgery are potentially fatal neurologic and vascular injuries, but this well-done analysis demonstrates that the mortality outcomes are markedly better with surgery. In addition, JBJS recently published a paper by Joestl et al. on the outcomes of C2 fusions in geriatric patients with a dens fracture nonunion, which confirmed good outcomes and a favorable risk profile (see related OrthoBuzz post).
I think it is time for the orthopaedic, neurological-spine, and rehabilitation communities to seriously reconsider our approach to elders with C2 fractures. As Pearson et al. conclude, until an RCT is performed on this question (if ever), “surgeons and patients should use the available data in a shared decision-making model to choose the treatment consistent with an individual patient’s values.”
Marc Swiontkowski, MD
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.
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.”
Improvements in surgical procedures continue to evolve at a brisk pace. It seems that, every year, incisions become smaller and operations, more streamlined. Certain operations that in the past would only have been performed as inpatient procedures are now being considered for outpatient surgery with same-day discharge.
In the May 2015 issue of JBJS Reviews, Kurd et al. review the ability to perform spine surgery in an ambulatory setting. The authors note that anterior surgical discectomy and fusion is now commonly performed in an ambulatory surgery center and, if patients are carefully selected, lumbar microdiscectomies and laminectomies can be performed in an ambulatory surgery center as well. The authors stress the importance of an established transfer plan to a hospital when needed and the ability to treat neurologic complications if they occur. Most importantly, the ability to treat potentially serious complications in a timely manner is critical.
The rationale for performing spine surgery in an ambulatory surgery center is primarily for the convenience of the patient. The authors note that friendly staff, minimal wait times, efficiency, and perhaps ease of parking allow for ambulatory surgery centers to have overall patient satisfaction rates of up to 92%. In addition, by moving procedures out of a hospital and into ambulatory surgery centers, the cost savings to Medicare alone have been substantial.
Practice guidelines for some of the important decisions regarding patients undergoing anesthesia have been established by the Society for Ambulatory Anesthesia (SAMBA), whose goal is to provide guidance on the use of anesthesia in an ambulatory setting. Recommendations such as avoiding general anesthesia when possible, using propofol for induction and maintenance, avoiding nitrous oxide and other volatile anesthetics, minimizing the use of opioids, and maintaining adequate hydration are among the most important. In addition, SAMBA recommends that all diabetic patients undergoing surgery at an ambulatory surgery center should have a hemoglobin A1C of <7%.
While several reports have established the safety of performing cervical surgical spine surgery in an ambulatory surgery center, concerns still exist regarding the treatment of life-threatening events such as an epidural hematoma. Other rare complications such as vertebral artery injury or esophageal injury require intraoperative consultation with another surgery subspecialty such as vascular surgery or otolaryngology, and such consultations may not be available in an ambulatory surgery center.
The spinal procedure that is most commonly performed on an outpatient basis is a single-level lumbar decompression. Microdiscectomy is also frequently performed. This article reviews the largest prospective series of outpatient lumbar discectomies to date and indicates that the role of proper patient selection is paramount and that comorbidities such as obesity, chronic obstructive pulmonary disease, and a history of stroke increase the risk of needing hospitalization. As the use of the ambulatory setting for spinal surgery continues to evolve, further delineation of the ideal conditions and requirements will become evident. In the meantime, elderly patients and patients with multiple comorbidities may be better managed at a hospital as they are at an increased risk of requiring hospitalization.
Thomas A. Einhorn, MD
Editor, JBJS Reviews
During a well-attended symposium on bundled payment initiatives for joint replacement at the 2015 AAOS Annual Meeting, speakers shared enlightening pearls and pitfalls related to Medicare’s Bundled Payments for Care Improvement initiative. But no one mentioned the fact that by 2018, Medicare will shift the 90-day global period for joint replacement—and all other covered surgeries—to a 0-day global period.
This fact is discussed in an eye-opening Perspective by Mulcahey et al. in the April 9 New England Journal of Medicine. Noting that bundled payments in general are designed to improve care and reduce cost, the authors call this decision, which would essentially unbundle postoperative visits, “striking.” The shift to a 0-day global period for surgery is based on an HHS Inspector General audit that found that the number of postoperative encounters between surgeons and patients are actually well below the number paid for in the 90-day bundle. Total knee arthroplasty, for example, includes three inpatient, one hospital-discharge, and three outpatient surgeon visits in its 90-day package.
Mulcahey et al. contend that “removing some or all postoperative visits from global packages will reduce procedure payment rates” for surgeons, but it remains to be seen how surgeons, orthopaedic and otherwise, will respond to the policy change. OrthoBuzz will keep you posted.
On April 14, 2015 the Senate voted 92-to-8 to approve legislation previously passed by the House that puts an end to the SGR-based physician payment formula for Medicare services. At posting time, President Obama said he would sign the bill. The Senate-passed measure is identical to the bill approved by the House; all amendments introduced in the Senate were defeated.
After the vote, many medical societies, including the AMA and AAOS, heaped praise on Congress. In a rare moment of brevity from Capitol Hill, Michigan Rep. Fred Upton told Kaiser Health News (KHN), “Stick a fork in it. It’s finally done.”
But according to KHN, “while the law lays out a structure on how to move to new [Medicare] payment models, much of their development will be left to future administrations and federal regulators.” And an even colder rain on the parade came in a report from Paul Spitalnic, the head actuary at the Centers for Medicare and Medicaid Services (CMS). Spitalnic’s report soberly observes that the legislation about to be signed into law “raises important long-range concerns that would almost certainly need to be addressed by future legislation.” While the bill specifies physician payment-update amounts for all future years, the CMS report says that “the specified rate updates would be inadequate in years when levels of inflation are higher or when the cumulative effect of price updates not keeping up with physician costs becomes too large.”
So while orthopaedists in the twilight of their active-practice careers may be able to “stick a fork in it,” younger surgeons may be distracted by debates about physician Medicare payments that are apt to crop up again.
Despite an overwhelming 392-to-37 vote in the House to scrap the SGR formula for physician Medicare payments, the Senate adjourned for a two-week recess without voting on the measure. Senators were distracted from taking action on the House SGR-repeal bill by a pre-recess “vote-o-rama” on other legislation, mostly budget amendments. Many in Washington expect that the Centers for Medicare and Medicaid Services will postpone Medicare payments during the first two weeks of April, essentially preventing the 21% slash in physician reimbursement set to kick in on April 1. That will buy time for the Senate to reconvene and vote on the SGR bill.
Jennifer Haberkorn of Politico Pro told Kaiser Health News that any amendments to the House-passed SGR measure that the Senate debates—such as a full “pay-for” or four years of expanded funding for the Children’s Health Insurance Program rather than two—“are unlikely to be approved, but [Senators] want to be able to make a point.” Conventional wisdom posits that the delay will not hurt the chances of an SGR repeal finally passing both chambers and being signed by President Obama.
With 12 days to spare before a 21% reduction in physician Medicare payments takes effect, a bipartisan coalition of House and Senate lawmakers introduced identical bills that would scrap the SGR-based formula for physician reimbursement. Medscape.com reported that the SGR Repeal and Medicare Provider Payment Modernization Act of 2015 would boost physician pay by 0.5% during the second half of 2015 and in subsequent years from 2016 through 2019. The legislation redesigns the Medicare payment model from fee-for-service to pay-for-performance, and it also merges Medicare’s EHR and quality-reporting programs for easier administration by providers. Later this week or early next week, the House is expected to amend the legislation to extend the Children’s Health Insurance Program (CHIP) for two more years.
For the first time in recent memory, GOP leaders in both houses are indicating they won’t insist on specifying “pay-fors” for the entire cost of the bill. While Tea Party Republicans in the House are still calling for a complete cost offset, House Speaker John Boehner could get the bill passed amid Tea Party objections if he musters enough Democratic support.
In an online statement responding to the legislative filing, AAOS President Frederick Azar, MD, said, “The AAOS commends congressional leadership for introducing legislation to permanently repeal and replace the SGR formula.”
According to the latest Congressional Budget Office (CBO) figures, replacing the SGR-based Medicare physician-reimbursement formula over the next 10 years, as proposed in legislation introduced last year, would cost $174.5 billion. But a closer look at the CBO numbers reveals that the accrued physician-payment costs over the same 10 years would be an estimated $137.4 billion if current reimbursement rates were frozen through 2025. That’s a difference of (only) $37.1 billion.
Under current law, fees that physicians receive for Medicare services will be cut by about 21% beginning on April 1, 2015. Two pending pieces of federal legislation—HR 4015 and S 2000—would repeal the SGR formula, but the bills do not include suggestions for covering the cost of an SGR replacement.
The American Hospital Association has gone on record against the “rob-hospitals-to-pay-doctors” approach that some people have advocated, saying in January that it “cannot support any proposal to fix the physician payment problem at the expense of funding for services provided by other caregivers.”
If a permanent repeal of the SGR formula isn’t politically feasible until after the 2016 presidential election, Congress will probably approve another short-term “patch” this year. That would be the 18th time in 12 years that legislators have kicked this expensive can down the road.
For most physicians, HR 4302, federal legislation signed into law on April 1, 2014, was important because it delayed until March 1, 2015 drastic SGR-imposed cuts to Medicare physician payments. While many people are wondering what the next chapter of that saga will bring as the deadline approaches, tucked away in Section 218 of HR 4302 is another provision that could have far-reaching effects on daily orthopaedic practice: a Medicare requirement tying payment for advanced diagnostic imaging to appropriate use criteria (AUC).
That section of the legislation requires providers who order advanced diagnostic imaging for Medicare patients—such as CT and MRI—to consult physician-developed AUC, and document such consultation, beginning on January 1, 2017. Beginning on January 1, 2020, 5% of the ordering clinicians deemed to be “outliers” will be subject to a prior-authorization requirement.
In the meantime, the bill requires the Centers for Medicare and Medicaid Services (CMS) to issue rules for imaging AUC, “developed or endorsed by national professional medical specialty societies or other provider-led entities,” no later than November 2015. It also directs the Health and Human Services Secretary to identify, by April 1, 2016, clinical decision-support tools to help physicians navigate the appropriateness criteria.
The goal of appropriateness criteria is to encourage clinicians to practice evidence-based medicine for improved patient outcomes and to use limited healthcare resources more efficiently. But, like any “administrative” task appended to already-complex medical practices, AUC for diagnostic imaging are controversial.
To find out more about the development of imaging AUC and what this pending requirement might mean for orthopaedists, OrthoBuzz recently spoke with three experts:
David Jevsevar, MD, MBA, chair of the American Academy of Orthopaedic Surgeons’ (AAOS) Committee on Evidence-Based Quality and Value and vice-chair of orthopaedics at Dartmouth-Hitchcock Medical Center
Alexandra Page, MD, chair of the AAOS Health Care Systems Committee and an orthopaedic surgeon at Kaiser Permanente
From these interviews, three themes emerged:
- The need for collaboration among radiologists and orthopaedists in developing imaging AUC
- The potential benefits of imaging AUC
- The need for imaging AUC to be as user-friendly as possible
Development through Collaboration
The AAOS has a comprehensive process for developing AUC, but collaboration with other specialty societies is essential. Ideally, AUC are developed from a peer-reviewed evidence base, but such evidence is not always available.
Dr. Jevsevar: As much as we want AUC to be “evidence based,” there’s not a whole lot of imaging-related evidence out there. Ordering a plain radiograph of a patient who presents with symptoms of knee osteoarthritis seems self-evident and is diagnostically useful, but there’s no published evidence to support the practice. Consequently, most of the AUC already in use are based on a consensus methodology.
Dr. McGinty: The ACR’s AUC are evidence-based when there is evidence and consensus-based when there’s not. We also constantly revisit AUC in light of new evidence. When necessary, our AUC committees deploy “rapid response teams” to make sure guidelines are updated quickly and accurately.
Over the last 20 years the ACR has developed AUC for many clinical scenarios, and the process has always involved collaboration with other relevant specialties. The 24 musculoskeletal AUC that we already have established were developed in collaboration with physicians from the AAOS. Collaboration is essential because the evidence from which AUC are developed has to be representative of the specialty that’s going to use them.
Dr. Page: Cross-specialty collaboration among physicians allows us to be stronger negotiators with CMS and other large entities. My interactions with the ACR have always been with people more interested in how we can work together than in the “territorial” issues.
At Kaiser, we also collaborate with primary care doctors to establish AUC for musculoskeletal and other imaging. For example, we agree that advanced imaging is not appropriate in a primary care setting for an initial presentation of routine low back or knee pain. Collaboration helped make this an educational experience rather than an adversarial one.
Dr. Jevsevar: With imaging, interdisciplinary input is necessary for developing AUC because we all see patients through our own lenses. AAOS representation on the ACR working groups to develop AUC ensures that both perspectives are represented. The AAOS has also successfully collaborated with primary care specialties to develop AUC for diagnosis and initial treatment of distal radius fractures, osteochondritis dissecans, and knee osteoarthritis.
The putative benefits of imaging AUC fall into two main areas: improved patient outcomes and lower health-system costs.
Dr. McGinty: Institutions and health systems that have already implemented imaging AUC have shown that they reduce costs to the system, including costs related to unnecessary imaging. We also expect that patient outcomes will improve due to decreased complications from inappropriate surgery.
Dr. Jevsevar: Imaging AUC will also help physicians measure themselves transparently. It will help identify outliers who order more imaging studies than necessary. But instead of a punitive response to that, we’re aiming for an educational response: Why is someone an outlier, and what education can we provide so that person can change behaviors?
Dr. Page: The collaborative process of developing AUC in and of itself makes us better clinicians and more empowered to provide better patient care.
All three experts whom we interviewed insisted that imaging AUC will have to be seamlessly integrated into usual clinical workflows. Extra steps that are not “automatic” will be received unhappily.
Dr. McGinty: The user-friendliness of the platform is key. Ideally, AUC filters would be embedded into the EHR system so they are seamless to the clinician. Even better would be systems that automatically track clinician adherence to AUC for reporting purposes. But for all that to happen, there will have to be ongoing collaboration with EHR vendors.
Dr. Jevsevar: Any process that’s onerous will not be good for anybody. If a procedural step is pushed to doctors, they’ll be more likely to perform it than if they have to go out and get it. I like the AAOS AUC app, but even consulting that requires an additional step. I envision an EHR-based AUC tool that will initially block a doctor from ordering an imaging study that’s not “appropriate.” Or an embedded pop-up message will remind a doctor who’s about to order an MRI or CT in a specific clinical scenario what the evidence base says.
Having said that, even if AUC are seamlessly integrated into the EHR, I don’t think they should be unreasonably rigid. Almost all practice guidelines assume a “routine patient.” But we often see patients who are not routine, so AUC need to allow for flexibility. We’re all trying to find the right balance between providing the best care at the population and system levels and at the same time delivering the best patient-centered care to each individual.