Orthopaedic Surgeons Discuss War Injuries, Updates on TKA, Opioid Hearings, and More

The 13th annual EWI symposium is the latest installment in the annual symposium series, which has served to define current knowledge and identify areas for future research regarding the management of extremity trauma for NIH, Congress, the Department of Defense, orthopaedic surgeons, researchers, industry, and other relevant government agencies since 2006. For the 2018 event, general sessions highlighted government funded research output, prolonged field care, amputee care and management, disaster preparedness and intentional violence, precision orthopaedics and rehabilitation, and pain and opioid dependence. The symposium also featured updates from the Army, Air Force, and Navy consultants and how the National Academies of Sciences, Engineering, and Medicine (NASEM) is maintaining readiness on the Homefront by calling for a National Trauma System.
EWI XIII Planning Team (L-R): Andrew Schmidt, MD (EWI XIII Oversight Chair), MAJ Jonathan Dickens, MD (EWI XIII Scientific Director), MAJ Daniel Stinner, MD (EWI XIII Military Co-Chair), and Robert O’Toole, MD (EWI XIII Civilian Co-Chair)

Until recently, total knee arthroplasty (TKA) was included on the Medicare inpatient-only (IPO) list. In light of the removal of TKA from the IPO, AAOS is providing answers to some frequently asked questions. It will be updated continually, as questions arise. Please find the most up to date information on the AAOS website, here. For additional questions, please contact Dena McDonough, Manager of Payment Policy at mcdonough@aaos.org.

Q1: What does removal from the IPO mean?

A1: Medicare classifies a procedure as “inpatient-only” based, in part, on the expectation that a stay of at least two midnights would be medically necessary. CMS uses established criteria to review the IPO list on an annual basis for determining whether any procedures should be removed from the list. Medicare explicitly states that removal of a procedure from the IPO list does not require the procedure to be performed only on an outpatient basis. It simply allows for the possibility in appropriate instances. The removal from the IPO allows for both hospital outpatient and inpatient care. The procedure is still not approved for ambulatory surgery centers (ASC). Addition to the ASC-approved list is a separate decision that Medicare may revisit in the future.

On January 24, 2018, AAOS sent a letter to the Department of Health and Human Services’ (HHS) regarding their “Promoting Healthcare Choice and Competition Across the United States” Request for Information. In the letter, AAOS notes that it shares the Administration’s desire to see meaningful burden reduction while preserving valuable competition and patient choice and fulfilling statutory obligations. AAOS urged the Department to consider a number of recommendations, which address the needs of our members and the mutual goal of delivering high quality care at affordable prices to patients.

To start, AAOS expressed support for efforts to reduce payment differentials by site for the same services. AAOS has been supportive of making payments for services furnished in the physician office or the ASC equal to payments in the outpatient setting, but also noted that it has consistently recommended seeking this equilibrium not by bluntly reducing the outpatient payments to equal ASC or office payments but by also increasing payments in those settings toward a more middle ground.

On January 17, the House Ways and Means Committee held a hearing titled “The Opioid Crisis: The Current Landscape and CMS Actions to Prevent Opioid Misuse.” The hearing focused on efforts by the Centers for Medicare and Medicaid Services (CMS) to utilize data to identify individuals in the Medicare Part D program who are at risk to abuse opioids. It also examined the agency’s tools to support those efforts and any areas in need of improvement.

“The opioid crisis in this country is devastating entire communities,” stated House Ways and Means Chairman Kevin Brady (R-TX). “While many Medicare patients need certain opioid medication as part of their treatment, there are a growing number of reports of opioid abuse within the Medicare program. As one of the biggest payers of prescription drugs, CMS has a responsibility to ensure that prescription drugs are not abused, particularly those that are highly addictive such as opioids. During this hearing, Members will learn from experts about Medicare and opioids and whether CMS facilitates opioid use that may not be medically necessary and could be harming the very community Medicare is intended to help.”

Modifier-25 is used to denote significant, separately identifiable evaluation and management (E&M) services by the same physician on the same day of the procedure or other service. In August 2017, Anthem released a policy that would cut, by 50 percent, evaluation and management (E&M) services billed with modifier-25 when reported with a minor surgical procedure code or a preventive/wellness exam. Since then, many state orthopaedic societies have contacted Anthem to request they reconsider. In December 2017, the California Orthopaedic Association (COA) and the American Medical Association (AMA) received word that Anthem will delay the cut until March 2018 and amend the new policy to a 25-percent reduction when modifier-25 is used.¹

On January 9, the Centers for Medicare and Medicaid Services (CMS) announced a new voluntary bundled payment model that will qualify as an Advanced Alternative Payment Model (Advanced APM) under the Quality Payment Program. This new model, called “Bundled Payments for Care Improvement Advanced” (BPCI Advanced), requires participants to bear financial risk, have payments under the model tied to quality performance, and use Certified Electronic Health Record Technology. By meeting these requirements, participants can earn the Advanced APM incentive payment.

On Feb. 3, 2018, the Pediatric Orthopaedic Society of North America (POSNA) sent a note to its membership thanking members for involvement related to the reauthorization of the Children’s Healthcare Insurance Program (CHIP) funding. Read the note below and find more specialty-specific (BOS) advocacy news online here.

The Children’s Healthcare Insurance Program (CHIP) is a program created in 1997 to fund healthcare for children whose families are not eligible for Medicaid and lack access to affordable private insurance. Nearly 9 million children across the country are enrolled in CHIP. In September 2015, an extension of the program was authorized until September 30, 2017 by a bipartisan vote. But, in this past fall, Congress did not take action to extend funding in time, and the authorization expired. At that time, the AAOS and POSNA combined forces. A letter drafted by the POSNA Advocacy Committee, and signed by leadership of POSNA, AAOS, AAP and SRS was delivered to the congressional leadership (Senators Mitch McConnell and Chuck Schumer, Congresspersons Paul Ryan and Nancy Pelosi), advocating for reauthorization of the program. Also, with considerable logistical support from the AAOS, POSNA launched a grassroot campaign, where members could sign onto a website, automatically contacting their senators and representatives with a letter in support of CHIP.

The government is back open, and we expect a flurry of activity in the coming weeks. Importantly, Congress will need to pass an omnibus appropriations bill to fund the government very soon, and this will be the best opportunity to obtain relief for physician-owned hospitals. H.R. 1156 would repeal the moratorium on expansion and new construction, but we need your help to move this legislation – contact Republican leadership TODAY to urge the inclusion of H.R. 1156 in the omnibus appropriations bill. Click here to act!

House GOP Warming to Obamacare Fix, The Hill, 2/1/18

CMS Proposes Opioid Prescribing Limits for Medicare Enrollees, Medpage Today, 2/1/18

U.S. Government Proposes 1.84 Percent Hike in 2019 Payments to Medicare Insurers, Reuters, 2/1/18

Republicans Give Up On Obamacare Repeal, Politico, 2/1/18

Why the CDC Director Had to Resign, Politico, 1/31/18

Anthem’s New CEO Looks to Medicare, Technology Investments for Growth, Forbes, 1/31/18

Long-Dreaded Amazon Threat to Drug Middlemen Draws Closer, Bloomberg, 1/31/18

Trump Declares Cutting Drug Prices is a Top Priority, CNBC, 1/30/18

Fewer Doctors Are Opting Out of Medicare, Modern Healthcare, 1/30/18

Senators Urge New Rule to Combat Opioid Crisis in Rural Areas, The Hill, 1/30/18

Senate Confirms Trump Health Secretary, The Hill, 1/24/18

Short-term Spending Agreement Provides Longer-term Relief for CHIP, The Washington Post, 1/22/18

The Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) ended the Sustainable Growth Rate formula, and the Centers for Medicare & Medicaid Services (CMS) then replaced it with the Quality Payment Program. Remember – the Quality Payment Program has two tracks you can choose: Advanced Alternative Payment Models (APMs) OR the Merit-based Incentive Payment System (MIPS). AAOS has shared the details of QPP and MIPS, which can be found on our website, here: www.aaos.org/MACRA-DeliveryReform/.

Click here, to view the interactive version of the map below, which features each state’s PAC support for 2017.

To learn more about the Advisor’s Circle, email Stacie Monroe at monroe@aaos.org.