The AAOS Office of Government
Relations’ regulatory efforts ensure that orthopaedic concerns are addressed
even after the conclusion of the legislative process and throughout agency
rulemaking and implementation stages. To this end, the regulatory staff works
closely with Department of Health and Human Services agencies such as the Food
and Drug Administration (FDA), Centers for Medicare & Medicaid Services
(CMS), the Agency for Healthcare Research and Quality (AHRQ), and the Centers
for Disease Control and Prevention (CDC). In addition, expertise in coding,
reimbursement, and payment policy is shared across the Academy and with our
members. The Office of Government Relations also houses the AAOS’ patient
safety, quality, registry and research advocacy efforts. All of these are key
services to our fellowship and members.
CMS
Guidance on TKA out of the Medicare IPO list
On January 8, 2019, in a major win
for AAOS’ advocacy efforts, the Centers for Medicare & Medicaid Services
(CMS) issued an unprecedented guidance to help resolve confusion surrounding
the removal of total knee arthroplasty
(TKA) from the Medicare Inpatient-Only only (IPO) list. The policy change,
which was made in the 2018 Medicare Outpatient Prospective Payment System
(OPPS) Final Rule, allows for payment of
the procedure in either the hospital inpatient or outpatient setting. This
guidance reiterates that the surgeon is the final arbiter of the setting of
care and provides several clinical case studies to guide how CMS’ Quality
Improvement Organizations (QIOs) will review claims based on the two-midnight
rule. The guidance can be found here
Scoliosis
Screening
On January
9, 2018, the United States Patient Safety Task Force (USPSTF) released updated
guidance on screening for adolescent idiopathic scoliosis. The guidance was upgraded
from “D”, discouraging screening, to “I”, indicating the data is inconclusive
on the effectiveness of screening. POSNA and SRS led a letter in June 2017
signed by 13 other BOS societies as well as AAOS and the American Academy of
Pediatrics urging the USPSTF to upgrade their recommendation. Read the
USPSTF’s announcement here
Medicare Access and CHIP
Reauthorization Act (MACRA) and the Quality Payment Program
AAOS submitted comments to CMS on
its proposed rule that would make changes in the third year of the Quality
Payment Program, including participation requirements for 2019. The 2019
Quality Payment Program proposed and final rules took significant steps to
respond to AAOS’ concerns for needed flexibility and simplification, as well as
protection for small, solo, and rural practices.
In the Final Rule, CMS specifically addressed our request that it not eliminate or reduce the Small Practice Bonus as proposed. AAOS requested that if CMS assigned the Bonus to the Quality performance category, it should not reduce its value from 5 points. CMS acknowledged our request and, in fact, raised the Bonus from 5 to 6 points. AAOS is working to introduce an incentive-based third pathway/alternative to the MIPS and Advanced APM tracks that reduce clinician burden while improving payment incentives.
Read
the entire AAOS comment letter here
Evaluation
and Management (E/M) Documentation Changes
In response to AAOS comments
regarding proposed revisions to Evaluation and Management (E/M) Services as
part of the Medicare Physician Fee Schedule
Rule 2019; CMS implemented changes to documentation policies to reduce
clinician burden. CMS will preserve the current coding for complex patients,
delaying collapse of E/M codes 99201-99215 to the year 2021. AAOS continues to
be involved in discussions regarding proposed changes to the to the coding and
payment system through the AMA’s CPT/RUC Workgroup on E/M and is participating
in new code valuation processes.
Site Neutral Payment Policies in Medicare
Outpatient Final Rule 2019
The final rule included expansion of
site-neutral payments that would remove incentives for hospitals to employ
private practices and would level the playing field. It also has proposals for
physician office equivalent payment rate for clinic visits at an off-campus
provider-based department (PBD) which would lower out-of-pocket for patients.
The rule also updates the ASC payment using the hospital market basket and
separates payment for non-opioid pain management in ASCs.
Bundled Payment Models
On January 9, 2018, CMS announced a new voluntary
bundled payment model that will qualify as an Advanced Alternative Payment
Model (APM) under the Quality Payment Program. This new model, called “Bundled
Payments for Care Improvement Advanced” (BPCI Advanced), which launched on
October 1, 2018, requires participants to bear financial risk, have payments
under the model tied to quality performance, and use Certified Electronic
Health Record Technology. The pricing methodology of this new model no longer
relies on the National Trend Factor (NTF), as AAOS has consistently argued that
the NTF is detrimental to the sustainability of BPCI models.
AAOS has some additional concerns including the model’s interaction with CJR, the semi-annual reconciliations, and benchmark price consideration. Recently, however, CMS notified convenors of an anticipated Amendment to the participation agreement which we expect will eliminate the 50 percent cap on physician reimbursement. The anticipated change is a huge win for our legislative and regulatory advocacy as AAOS continues working to ensure that interested orthopaedic surgeons have the tools and resources needed to participate. This includes a well-attended webinar, which aired on February 21, 2018, and several formal communications with CMS.
For the webinar and to read more about
these issues, visit: www.aaos.org/advocacy/medicarepaymentcms/
Surgical Risk Reduction Toolkit
AAOS
continually works to develop ways to help fellows and active members improve
the quality of their practice, decrease complications, and increase the value
of their work to society. The SRR Toolkit is designed to help identify
patient-specific risk factors that can be medically optimized throughout the
care episode and provide resources to help the doctor-patient partnership
manage and optimize specific risks for each patient. The easiest pathway to
improved patient outcomes following complex orthopaedic surgery is avoiding
medical complications that lead to increased length of stay, hospital
readmission, and return to the operating room. The methodology takes advantage
of easily accessible resources to create a team approach to address known
avoidable complications and improve clinical outcomes. The toolkit is housed on
AAOS.org.
Family of Registries
Working
closely with CMS, AAOS was accepted into the Research Data Assistance Center
(ResDAC) program and on April 13, 2013, CMS announced at AAOS would be granted
access to Medicare claims data for registry needs.
The
2019 Physician Fee Schedule/Quality Payment Program (PFS/QPP) proposed rule
recommended requiring a QCDR measure owner “to agree to enter into a license
agreement with CMS, permitting any approved QCDR to submit data on the QCDR
measure”. This had significant negative implications for AAOS registries. The
proposal would have infringed on a QCDRs intellectual property rights, impacted
the ability to recoup costs related to the significant capital, resources,
staff, and time that is needed to approve performance measures, and stifle
innovation by rewarding those who aren’t creating measures and penalizing those
who are. AAOS wrote detailed comments opposing this provision and singed onto a
letter by the Physician Clinical Registry Coalition (PCRC) that also expressed
this sentiment. A phone call was held with CMS to discuss this issue, among
others. When CMS released their final rule on November 1, 2018 they stated that
“based on the feedback and concerns raised by stakeholders, in the interim, we
are not finalizing this proposal” – this was a big win for registries.