P4P, reimbursement are hot topics

By: Peter Pollack

By Peter Pollack

Members raise concerns during Town Hall meeting
The annual Town Hall meeting gives members a chance to speak directly to leaders of the AAOS. Robert H. Haralson III, MD, MBA, moderated the meeting, with members of the presidential line, the AAOS Board of Directors, and other staff on hand to answer questions.

On Thursday morning, many of the members’ questions and comments addressed the subject of practice management, and covered topics such as Medicare, pay-for-performance (P4P), the Physician Quality Reporting Initiative (PQRI), and the definition of a medical error.

Kevin J. Bozic, MD, MBA, commented on the issue of medical errors during this year’s Town Hall meeting.

Pay-for-performance concerns
Thomas C. Wilder Jr., MD
, of Seattle, opened the session with a question about the status and future of P4P.

“The Academy is working on performance measures though our Guidelines Oversight Committees with excellent input from the specialty societies,” said E. Anthony Rankin, MD. “We believe that performance measures should be clinically relevant, appropriately developed by the specialty societies, and add value to the treatment. AAOS also believes that there should be additional moneys for improved performance measures; reimbursement should not be punitive.”

“The 2008 PQRI program requires that participants report on 80 percent of patients who are eligible for reporting,” said Dr. Haralson. “You still have time to complete that if you wanted to start now. It would be tough, but you could still do it.

“In addition to the 1.5 percent of your Medicare billing that you might be rewarded with, keep in mind that the quality initiative is here to stay,” he continued. “Physicians will be measuring and reporting on quality from now on, so the other advantage of participating in the Centers for Medicare and Medicaid Services (CMS) program is that you’ll be learning how to do it without being penalized if you make a mistake.”

Danny L. Reveal, MD, of Dayton, Ohio, wanted to know how to get involved with the PQRI program.

Robert H. Haralson III, MD, MBA, moderated the 2008 Town Hall meeting.

“You report quality on the CMS 1500 form when you submit your bill,” Dr. Haralson said. “Orthopaedics has 17 possible performance measures. Four of those measures—choosing a first- or second-generation cephalosporin, starting it within a hour of surgery, stopping it within 24 hours of surgery, and ordering thromboembolic prophylaxis—are almost always done for total joints and most open procedures on a routine basis. If I were in practice and participating, I would tell my coding clerk to add these four codes to the operative code every time I did one of these operations.”

“You get credit for reporting whether or not you did it, so this is a slam dunk for orthopaedic surgeons. You may get a little bit of money, but more importantly, you’ll learn how to deal with quality reporting,” responded Dr. Haralson, who urged everyone to get involved.

Who defines medical errors?
Given the increasing prevalence of community-acquired methicillin-resistant Staphylococcus aureus (MRSA), Julio Gonzalez, MD, of Venice, Fla., asked if MRSA might be reclassified as an inherent risk of being in a medical facility instead of a medical error, for which physicians and institutions might be penalized.

“The Medicare program is having problems trying to identify conditions that are present on admission,” said Bob Jasak, of the AAOS Government Relations Office. “Anywhere that we can make the argument that it’s too difficult to tell what was actually acquired in the hospital, we will make that argument.”

“This is an area that we want to engage officials with,” added Kevin J. Bozic, MD, MBA. “We met with officials in September, and one group had proposed deep vein thrombosis (DVT) as an avoidable hospital complication that wouldn’t be paid for. We educated them that DVT is not necessarily an avoidable hospital complication, and provided all of the supporting documentation and references. We’re actively monitoring conditions that are related to orthopaedic procedures, and we’ll continue to have a voice in the process.”

Temporary versus permanent Medicare fixes
Adam S. Bright, MD
, of Sarasota, Fla., and Dr. Gonzalez both wanted to know what might happen in July, when a planned 10.6 percent Medicare cut is scheduled to go into effect.

“We’ve had discussions with CMS,” said Dr. Haralson. “But until they see an access problem, they will probably continue to whittle away at our reimbursement.”

“We’re likely to see an 18-month fix that would freeze payments. That could be enacted before the July 1 deadline. It’s likely to be in a budget reconciliation bill that will lump several spending proposals together. If President Bush vetoes that bill, however, we’ll see a crunch attempt to fix it between the Fourth of July holiday and the party conventions in August.”

Peter Pollack is a staff writer for AAOS Now. He can be reached at