AAOS provides comments to CMS on payment policy changes
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The American Association of Orthopaedic Surgeons issued formal comments to the CMS on proposed payment policy changes for calendar year 2022, with focuses on the inpatient only list and ongoing cuts to physician reimbursement.
In addressing the Medicare Hospital Outpatient Prospective Payment System and Ambulatory Surgical Center Payment System proposed rule, the AAOS focused on the key change of reversing the elimination of 298 procedures, including 266 musculoskeletal procedures, from the inpatient only list. According to Douglas W. Lundy, MD, chair of the AAOS Advocacy Council, the AAOS believes that decisions made regarding where a patient should undergo surgery should be made on an individual basis between the physician and patient.
Inpatient only list
According to a press release from the AAOS, Daniel K. Guy, MD, president of the AAOS, encouraged CMS to consult with stakeholders on important regulatory changes.
“When musculoskeletal procedures were identified as the first group to be eliminated from the [inpatient only] IPO list, CMS would have benefited from a consultative effort with orthopedic surgeons to determine the suitability of specific procedures, the impact on Medicare beneficiaries and on the delivery of health care services,” Guy said in the release. “With further review, CMS has taken a step back as unintended consequences have become apparent. The AAOS is ready to be an important resource to assist CMS in making the best decisions for patients and their care.”
Lundy added AAOS is encouraging CMS to use peer-reviewed evidence to be more specific about which procedures should be on the inpatient only list.
“Some of the additional factors that should be considered are does the patient live alone? How much pain are they having? Have they been prior hospitalized? Are they depressed? What is their functional status? Do they have high-risk medications? Knowing this information helps their health literacy,” Lundy said.
Lundy also noted the 2-midnight rule has been another issue that the AAOS is working with CMS to identify a better solution.
“I understand the overall basis behind why they did [the 2-midnight rule] was to try to get away from these unnecessary overnight stays, but there are certain procedures, especially as technology advances, that it is not always necessary or appropriate for that to happen,” Lundy said.
Cuts to reimbursement
The AAOS also focused on the ongoing cuts to reimbursement in the Medicare Physician Fee Schedule, for which CMS proposed to reduce the conversion factor by 3.75% without incorporating the office/outpatient evaluation and management code updates into the global surgical codes, according to the AAOS press release.
“AAOS strongly urges CMS to maintain the current funding levels. This is critical to preserving access to patient care during the COVID-19 public health emergency,” Guy said in the release.
Although CMS increased the reimbursement for ambulatory codes, allowing physicians to receive higher reimbursement for ambulatory visits and interventions, Richard Iorio, MD, president of the American Association of Hip and Knee Surgeons, noted orthopedic surgeons want to get paid for the work they do. According to Iorio, current surgical reimbursement does not take into account surgeon or staff time for preoperative education and optimization of patient comorbidities as well as postoperative in person, telehealth and/or digital platform visits which are not recognized in the calculation for work Relative Value Units attributed to total joint replacement. He added the decrease in volume in joint replacement due to the COVID-19 pandemic, the movement toward more outpatient arthroplasty as well as the changes to the Inpatient Only Rule, which have decreased hospital and surgeon reimbursement for TJR, has negatively impacted hospital revenues and physician income.
“We echo all of the AAOS’ reluctance to accept those changes. The decreases in reimbursement associated with the new cuts from the [Relative Value Scale Update Committee] RUC and the cuts in the physician payment schedule end up to be another 10% cut on what we already had,” Iorio, chief of adult reconstruction and total joint arthroplasty service and vice chair of clinical effectiveness at Brigham and Women’s Hospital, said.
Improving telehealth
Another area of concern is the use of telehealth in orthopedics, according to Lundy. Although the AAOS is urging CMS to permanently maintain the flexibilities for telehealth services offered during the public health emergency, Lundy noted the AAOS is also working with CMS to find ways to broaden the reach of telehealth services to patients of all socioeconomic backgrounds. He added that telehealth codes should be valued appropriately on par with evaluation and management codes.
“Telehealth was beneficial because physicians can look at people and pick up a lot of non-verbal cues and look at wounds and range of motion,” Lundy said. “We realized it is a different type of an interaction and it is not any less valued, but it requires a tremendous amount of resources.”
The AAOS is also working with CMS to develop Merit-based Incentive Payment System (MIPS) Value Pathways, according to Lundy. He noted CMS introduced a MIPS Value Pathway for total joint replacement in the most recent Medicare Physician Fee Schedule Proposed Rule. The rotator cuff surgery MIPS Value Pathway that AAOS submitted in early 2021 was not included, but AAOS will continue to monitor the program and collaborate with CMS if the opportunity arises.
“We are continuing to work with CMS on other [MIPS Value Pathways] MVPs,” Lundy said. “We are working with neurosurgeons on spine MVPs, and we worked with anesthesia on the total joint MVP. We like to work across the House of Medicine to improve the value of what we are doing.”
Reference:
AAOS comments on proposed Medicare payment policy changes for 2022. https://www.aaos.org/aaos-home/newsroom/press-releases/aaos-comments-on-proposed-medicare-payment-policy-changes-for-2022/. Published Sept. 23, 2021. Accessed Oct. 18, 2021.
Perspective
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The AAOS does some of its best work when it is advocating for patients. That is certainly the case in the comments from Daniel K. Guy, MD, president of the AAOS, on the proposed changes to CMS policy for 2022. There is a significant and important site of service migration of procedures traditionally performed in the hospital setting to the ASC. This trend has been beneficial for patients, surgeons and payers. The patients who are appropriate for treatment in the outpatient setting, however, are a selected population that is well documented in all literature on the subject. CMS took this trend and rushed many procedures not suitable for the outpatient setting to the outpatient only list. The CMS list also fails to recognize that all patients are not appropriate candidates for the outpatient setting for procedures despite the fact that a majority of patients may be safely treated in that setting. The AAOS nicely reminds the government that it might seek the advice of the true experts in musculoskeletal care when making sweeping recommendations about orthopedic patient care and safety.
The never-ending downward spiral of government payment for health care services is also a big part of the AAOS response. Guy makes a strong case that now is not the time to further stress medical practices by reducing their income. This argument is unfortunately a losing battle; like Sisyphus rolling his rock uphill for eternity. Whether through cutting the conversion rate, bundling previously reportable services or attacking CPT code reimbursement, our constant advocacy against these policies is not working. It won’t work going forward. Our best efforts have resulted in a 30% to 40% inflation adjusted loss of value for orthopedic procedures in the last 30 years. It is time to move away from CPT reimbursement or continue to suffer payment decline until surgery and office visits are reimbursed at the same level.
Perspective
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This news brief highlights some of the 2022 regulatory changes being considered by CMS, along with the AAOS’s efforts to make certain those changes are sensible and preserve patients’ access to care. I had mixed feelings in reading the update. Regarding determination of which procedures should be on or off the inpatient only list, it appears that CMS is in fact listening to the concerns of our academy and has altered their position based on our input. This is an encouraging sign that the efforts of our AAOS leadership to enhance their advocacy infrastructure and develop relationships on the Hill has produced results. Thank you to our AAOS Political Action Committee team. Every AAOS member should make sure to send your annual donation to support these efforts.
On a more discouraging note, it appears that our pleas to combat reimbursement decay often falls on deaf ears. While our leader’s presence in these negotiations likely reduces the severity of the payment cuts, these annual reductions push orthopedic practices toward a tipping point. When you combine a reduction in the CMS conversion factor of 3.75%, an inflation rate of greater than 5%, staff shortages and rising salaries, and continued cancellation of elective surgery due to the pandemic, the margins for practices will be tighter than ever.
Perspective
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One of the two issues that the AAOS commented on, at least, was the change in the inpatient only operative list. There are some procedures that were allowed to be done in the hospital only, not paid in the ASC, and then CMS expanded the list and then they contracted the list. I agree with the AAOS: Why wouldn’t CMS ask the AAOS which procedures are safe and effective when performed in an outpatient setting? The AAOS provides information frequently on all types of coding issues. This clearly should have been discussed with stakeholders. It makes it more difficult to provide state-of-the-art patient care when CMS doesn’t allow us to provide useful information. Despite the proposed rule and final rule format, this should have been a cohesive project with the AAOS.
The other issue is the decrease in the conversion factor. We physicians have expenses that continue to go up, some of these automatically. For example, physician leases for our offices routinely have an automatic escalator. CMS, because of budget neutrality, will require physicians to work for 3.75% less this year than last year, a direct physician income reduction. Are they trying to push more and more private physicians our of private practice? That is ultimately what happens. Physicians can no longer absorb the higher expenses. The expense-to-income ratio continues to go up, so physicians cannot afford to be in private practice. That is exactly what has happened in the past 10 years – more physicians leaving private practice.
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