A “Yea” on “the Hill” can induce a “Yay!” from patients. The opposite, of course, is also true. Such is the very real trickle-down effect of health policy. And who influences the “Yea” or “Naysers?” Ideally, it’s the doctors and patients. The reality is, however, that there are many other parties vying for a place at the table.
Dr. Brian Parsley, Associate Professor in the Barnhart Department of Orthopedic Surgery at Baylor College of Medicine, is also Chair of the Health Policy Committee for the American Association of Hip and Knee Surgeons (AAHKS). Of emerging health policy, he says, “It is becoming more apparent that in order to care for patients, preserve access to care, and protect the freedom to seek out specialized treatment, we physicians must influence health policy decisions. The AAHKS attempts to sustain our members’ freedom to practice medicine in a way that allows them to properly care for patients. We also support surgeons as they struggle to practice medicine without all the restrictions that are being placed on them.”
“Increasingly, ” adds Dr. Parsley, “health-related decisions are being made by people who are not doctors and who don’t fully understand the impact of their decisions. This is why it is imperative that surgeons become politically active. If we sit back and let others make the decisions, they will…and we may not like what they come up with.”
There are those in the know, out of the know and those who make the know. While an orthopedist would naturally rather be doing an –otomy or an –ectomy, it is essential to the future of your practice and patients that you get involved in the details of health policy. This is better than attending a staff meeting and hearing, for example, that the hospital board voted yesterday and that the reimbursement methodology has now been altered in a way that will negatively affect you.
Dr. Parsley explains: “Whatever societies you have joined, be sure to devote some time to health policy. By doing so you are in a unique position to have a widespread effect on the daily lives of your fellow surgeons, as well as their patients. The AAHKS has representation on the American Medical Association (AMA) committee responsible for developing new codes for surgical treatments and assigning values to the codes. The latter involves determining, among other things, how much work is involved and how much reimbursement is reasonable for the size of the practice. Why should orthopedists get involved in such minutiae? Because each doctor’s office is a business and as small business owners we need to ensure that the business remains viable.”
“Um, the hospital is closed today.” More likely, it’s just closed to Mrs. Jones, a hip patient with a high risk of complications. Giving a bit of background, Dr. Parsley notes, “The AAKHS is also represented on a national quality forum that establishes guidelines for treatment. This is particularly important as we are seeing an increase in the level of case complexity, including more comorbidities. On October 1, 2008, CMS [Centers for Medicare & Medicaid Services] was mandated by Congress to develop guidelines for ‘never events, ’ things that happen in the hospital that should not occur. This is, for example, if someone operates on the wrong leg.”
“While this is something that clearly makes sense, CMS recently made a rather frightening decision. Their guidelines now state that if a ‘never event’ occurs, they will pay for the initial surgery, but will not pay the hospital for the treatment of any subsequent complications. This reflects poorly on the physician and the hospital, and can seriously affect patient care. If an individual with a complex problem has a higher risk of complications, then a hospital may choose to refuse to perform the procedure or the doctor may elect not to treat that patient. In a little over a year they will extend this nonpayment to the surgeons. If something is truly a ‘never event, ’ for example, wrong site surgery, then we are strongly in support of the CMS position.”
Patients are even more removed from the backstage policy struggles than physicians. And with so many puppet masters struggling for control, who is left to focus on the patients? Dr. Parsley says, “Looking at the big picture, healthcare is becoming more and more impersonal. At this point, the one active participant in all this who still protects the patients’ interests is the doctor. The hospital is comprised of business people, implant companies have business people, insurance companies are focused on shareholders, and the federal government is not going to do it. It is orthopedists who are resolute in their decision to care for patients who are the engine behind good health policy.”
Dr. Parsley, a large joint specialist, speaks about the dangers of labeling some conditions as never events: “In hip and knee replacement alone your chance of developing deep vein thrombosis is 40-60% across the board. Even though I do my best to protect you there is still a 10-30% chance of developing a blood clot. It is never going to be 0%, so to have that condition listed as a ‘never event’ is just wrong. Take another example: the fastest growing diagnosis in medicine today is obesity. Blood clots increase tremendously by instance of age and obesity and other complicating factors like hip and knee replacement and delays in treatment. There is no way to make this a ‘never event.’ And if I excluded obese individuals, that would mean turning away half of my patients. Fortunately, we were able to eliminate infection after total knees being listed as a ‘never event.’ Even if you are doing everything right there are still some instances of a ‘never event.’ The fact is that any time you perform an operation it is no longer a 0% chance of nothing happening. If my colleagues and I had not been involved in the policy debate, infection after total knees would have been listed as a ‘never event.’”
Another example of how these non-clinical aspects of medicine affect surgeons involves the AMA relative value utilization committee (RUC), the physician body that works with CMS to evaluate all codes utilized for services. Dr. Parsley explains, “The questions on work value as related to a particular code emanate from CMS and go to the RUC, which then formulates recommendations. CMS accepts about 97-98% of the committee’s suggestions. The issue may be, for example, ‘How much effort and resources does it take for me to put on a cast on the lower leg?’ You have a code for the cast, about 47% of which is based on the doctor’s actual work. Another 45-47% of that code is based on office/overhead expenses, while 4-5% is for malpractice premiums. Each component is factored in and then a certain number is derived, which is then multiplied by a ‘conversion factor.’ (The conversion factor is used to adjust for the budget allowances.) Then that number is multiplied by the RVUs, which is multiplied by a cash value determined by Congress, and ultimately, CMS. And that’s how we get paid. The lesson is: don’t stand on the sidelines and you stand a better chance of being appropriately compensated.”
And the wheels of change are coming to a practice near you. Dr. Parsley: “CMS is requiring that the AMA RUC do a multispecialty practice expense survey in order to review all the practice expenses across medicine. This will mean a complete readjustment of 47% of the reimbursement formula. In 1992 when the Resource Based Relative Value Utilization (RBRVS) Program came into existence, doctors were paid based on a formula that calculated three areas: 1) the direct contact or time that a physician spent caring for a patient, as well as the physician’s skill; 2) practice expenses; and 3) liability insurance. Approximately 95% of the decline in physician reimbursement over the last 18 years has been due to the adjustments made on the practice expense side of the formula. The potential impact on physician reimbursement as a result of this new survey is enormous. We are fortunate that AAOS has a representative who sits on the AMA RUC board.”
If there is a health policy meeting, chances are that the AAHKS has a representative at the table. “We are actively involved in other organizations that affect health policy, ” states Dr. Parsley. “We have representation on the National Quality Forum on Medicine, the AMA Physician Quality Review Initiative, as well as on a new AAOS Health Care Systems Committee looking into the hospital Part A side of Medicare reimbursement. This last effort is aimed at ensuring access to care as orthopedists often have problems getting patients into hospitals. To increase the focus on such activities, AAHKS has recently developed a health policy fellowship. At present we have two fellows in the program. The first is a woman in Boston doing an adult reconstruction fellowship and the second is a gentleman who is completing his Chief Residency year and will be entering his fellowship in August 2009. For two years they will be exposed to a variety of health policy activities which will give them a breadth and depth of understanding that will help carry the field forward. They will be involved in a variety of AAHKS conference calls and meetings, sit in on the AMA CPT coding committee, will attend at least one AMA RUC meeting, attend AAHKS board meetings, go to the AAOS leadership conference, and do a bit of lobbying. Also providing leadership in this arena is AAOS, which has a health policy program with two fellows a year involved in a similar type of program to provide a broad base of Health Policy exposure.”
Once a novice in this subject area, Dr. Parsley says, “Policy may seem daunting, but anyone interested enough can learn. Six years ago I didn’t understand what health policy was or why it was important…now I realize how fundamental it is to our daily practice. It is, however, challenging to find people who are sufficiently interested and qualified to sit on these committees.”
He concludes, “By working on health policy activities, you are developing and maintaining relationships that will at some point have an effect on your fellow surgeons. For example, AAHKS works with AAOS and the AMA to build a base of understanding so that when issues arise that affect hip and knee, we know whom to call. Relationships with consultants can also help you keep an ear to the political ground. It was actually our consulting group that told us about the ‘never event’ issue.”
Also in-the-know on the health policy front is Dr. Mitchel Harris, Chief of Orthopaedic Trauma at Brigham and Women’s Hospital and Associate Professor of Orthopaedic Surgery at Harvard Medical School. Dr. Harris, Chair of the Health Policy Committee for the Orthopaedic Trauma Association (OTA), states, “The OTA is dedicated to expending resources on health policy because such issues affect all members of our local communities as well as the orthopedic trauma surgeons, especially regarding the treatment of uninsured patients. The members of the OTA have always been involved in taking care of the injured patient regardless of his/her insurance status. We strive to ensure that there is no stratification in the quality or access to the healthcare system.”
With the call crisis in full swing, the question to be addressed is, “Whose call is it anyway?” Dr. Harris: “Another major initiative for our organization is local access to ER care. Many orthopedists have limited their practices to elective procedures only, meaning that they don’t feel the responsibility to participate in ER call. The OTA is supporting a policy subscribing to the concept that while each individual orthopedist shouldn’t have to take ER call, each orthopedic community should recognize its collective responsibility to provide care for its citizens. For example, let’s say a successful spine surgeon doesn’t want to cover ER call because it’s a lot of broken ankles and hips. He/she would appropriately uphold their responsibility to contribute to ER call by being available to treat the spine related emergencies.”
Dr. Harris continues, “When a hip fracture or ankle injury comes in, the on-call orthopedist (regardless of subspecialty) should assess the severity of the injury, provide initial care (reduction, splinting) and determine whether or not it could be adequately addressed within his community. This might mean having one of his/her colleagues perform the definitive procedure at a later time. However, by participating locally and accepting the responsibility, it would avoid transferring the injured patient further away from home due to non-medical reasons (insurance status, subspecialty call coverage). It is similar to non trauma problems. If you are a joint replacement surgeon you may not have reason or interest in covering trauma call but you should be able to treat infections and hip dislocations because those are things you participate in all the time. It is essentially spreading the orthopedic community’s collective skill set over all the necessary tasks. We recognize, however, that no one wants to feel like they are being forced to do something that they feel poorly trained to do.”
In an effort to ensure that anyone coming into the ER receives the necessary care, the OTA is collaborating with other medical and surgical societies to advance a healthy agenda. Dr. Harris: “We are charged with improving policy activity as it relates to the management of trauma and emergencies. To this end we actively cooperate with the American College of Surgeons and the Coalition of Trauma Care to conduct letter writing campaigns to local governments. For example, we are actively involved in discussions with the new administration about the importance of regionalized trauma care. This initiative has common benefit to all trauma victims as well as multiple subspecialties of surgery and critical care. Our letter writing campaign has also helped accomplish increased funding for trauma care and research.”
The OTA also works on federal funding issues to make sure that patients and doctors can make efficient use of existing resources. Dr. Harris notes, “The OTA Health Policy Committee has worked closely with the American College of Surgeons to maintain the federal funding for initiatives surrounding trauma care throughout the country. By using information readily available through the National Trauma Data Bank, necessary resources can be identified both on a national and local level. It is often the case that those who are making the decisions that impact trauma care lack a deep appreciation of the issues. We have to help educate our government representatives on the real issues, for example, the fact that the majority of trauma patients are young, meaning that they lose more working days and financial productivity than older individuals.”
Sometimes it’s not clear what’s at stake until, voluntarily or otherwise, we see the problem close up. Dr. Harris: “Not only does an OTA representative who is a member of the Academy attend the AAOS National Orthopaedic Leadership Conference, but patients are invited to speak and explain what effect having the appropriate treatment at the appropriate center has had on their lives. The other way that these issues are ‘brought home’ is if a political person has a loved one who is injured.”
Due to the types of injuries involved, there is a natural fit between the work of the OTA and the military. Dr. Harris explains, “There has been a recent boom in such work because of the emphasis on disaster preparedness. Additionally, the Department of Defense is initiating a program for regionalized trauma and emergency care. The OTA will facilitate this in that we can see how many centers are necessary and how they can be funded. The fundamental question in such work is, ‘If you have people in a facility who are not making themselves available to the community, how do you organize your resources?’”
He adds, “Health policy advocacy has a far more wide-ranging effect than individual patient care. However, in order to be an effective advocate, one must experience first-hand some of the obstacles to the improved delivery of health care. The OTA has encouraged mid-career trauma surgeons to actively participate in the Health Policy Committee. Additionally, our partnering with the military has helped improve our understanding of the needs of the war heroes as they return from modern conflicts. Local access to optimal orthopedic health care is increasingly necessary for all of our communities.”
Looking out over the changing political and healthcare landscape, Dr. Harris sees a possible torrent of patients. “If universal healthcare becomes a reality it will change the flavor of trauma because the currently uninsured individuals will soon have health insurance. This should improve their access to care. However, we still need to function as a medical community to provide the necessary services at a local level. Hopefully, we will have enough orthopedists to treat them.”
With no end to patient need in sight, we need smart healthcare policy now more than ever. That means more doctors like Dr. Parsley and Dr. Harris need—and deserve—to find their seats at the health policy table.
