COVID-19

AAOS’s Information

CMS’s Toolkit

Texas EMS Alliance – How Are EMS Agencies Preparing?

Texas Hospital Association – How Are Texas Hospitals Responding?

Texas Medical Association – Toolkit

Click here to view AAOS’s guidelines for elective surgery (04.09.20).


TOA Asks Entities to Help Practices and Patients
Click here to view TOA’s request for commercial health plans and other entities.


Financial Relief Packages
Click here for a complete summary from McDermott+Consulting (5.06.20).

Sequestration, Medicare’s 2% payment reduction, has been suspended from May 1 to December 31, 2020.


Centers for Medicare and Medicaid Services
CMS Announces Quality Reporting Relief

Provider Enrollment Relief

Click here to view CMS’s regulatory relief for physician-owned hospitals and ASCs (03.30.20).

Click here to view CMS’s guidance for infection control and prevention in outpatient settings.

Click here to learn more about CMS’s accelerated payment program. Click here to view more from McDermott+Consulting (04.07.20).

Click here to view AAHKS’s requests related to CJR and BPCI-A.

Click here for the announcement related to the Stark laws (04.03.02).

Click here to learn more about the fee for service payments and mandatory attestation. Click here to view a summary from ASCA. Click here for the attestation portal (04.17.20).

Accelerated payments vs. CARES Act Grants: What’s the difference? Click here.

CMS halts the accelerated payments (04.27.20). Click here.


Texas Medical Board
Click here to view the TMB’s guidance.

Click here to learn more about the TMB’s rules related to PA/APRN prescriptive authority.

Click here to view updated telemedicine and chronic pain guidance from the TMB.


Surgeries in Texas
Click here to view the Texas Medical Board’s new rule and FAQ (04.21.20).

Click here to read the new executive order (effective on 04.22.20).

Click here to read CMS’s latest guidance (04.19.20).

Click here to view Texas HHSCs guidance for facilities (04.22.20):
HHSC – qa-20-0002


U.S. Drug Enforcement Agency 
Click here to read the DEA’s telemedicine guidance & other COVID-19 information.

Click here to read the DEA’s decision tree (04.05.20):
(DEA-DC-023)(DEA075)Decision_Tree_(Final)_33120_2007


CDC’s Symptom Self-Checker
Click here to view it.


FDA’s Daily Update
Click here to view it.


Surgery Summaries
McDermott+Consulting created a summary of public policy measures and recommendations related to elective surgeries. Click here to view it.

Click here to view Governor Abbott’s executive order related to elective surgeries in Texas.

Click here to view the American College of Surgeons’ elective case triage for orthopaedics.

Click here to view the Texas Medical Boards guidance.


Ambulatory Surgery Centers
Click here to view the state’s updated regulations.

Click here to view more about the federal regulations from ASCA.

Click here to learn more about the state of Texas’ regulations.

Click here to view ASCA’s webinar.

Click here to view CMS’s 04.03.20 guidance for ASCs that are temporarily classifying as hospitals.

ASCA sent a letter to the U.S. Department of Treasury and Small Business Administration on April 1, 2020, to ensure that ASCs with equity investors business partners are eligible for Payment Protection Program loans.


Texas Worker’s Compensation
Click here to view TDI-DWC’s resource page.

Click here to view TDI-DWC’s telemedicine statement (04.02.20).


Telemedicine
Click here to learn more from McDermott+Consulting.

Click here to learn more about Modernizing Medicine’s April 3 webinar.

Click here to view BCBS of Texas’ telemedicine policy for commercial health plans.

Click here to view the Force Therapeutics example.

 

The Musculoskeletal System


Are You Ready for the Trump Administration’s New Price Transparency Rules?

Mel Gunawardena speaking at TOA’s 2018 Annual Conference in Fort Worth

Author: Mel Gunawardena, Managing Partner, SYNERGEN Health

In November 2019, two new rules that require pricing information to be made public were finalized by executive order and announced by the Trump administration. The rules – Calendar Year 2020 Outpatient Prospective Payment System & Ambulatory Surgical Center Price Transparency Requirements for Hospitals to Make Standard Charges Public Final Rule and the Transparency in Coverage Proposed Rule – reinforce historic steps to increase price transparency to empower patients. Additionally, the administration hopes this recent move will increase competition among all hospitals, group health plans, and health insurance issuers in individual and group markets.

While the Trump administration anticipates that the executive order will reduce costs, hospitals fear this could have the opposite effect and drive prices even higher. This has led to the American Hospital Association, Association of American Medical Colleges, Children’s Hospital Association and Federation of American Hospitals recently announcing their intent to sue the federal government alleging the rule exceeds the CMS’ authority by forcing them to disclose negotiated prices.

The goal in which the executive order hopes to achieve is to enhance the ability of enrollees and patients to make more informed decisions about their care by knowing the costs and quality of health care plans available. With the predominant role that third-party payers and the U.S. government play within the health care system compared to other major and minor purchases made every day, patients have very little insight into prices and cost sharing information. For example, when going out to dinner, prices can easily be seen on menus or signs. Also, many restaurants are required by their state’s health department’s to publicly post A, B or C letter grades to indicate their level of food safety & quality compliance. With this line of thinking, this kind of transparency reduces payment disputes when the bill arrives and allows people to ensure they’re getting quality food.

Although no prices are shown for office visits today, they are often available upon request. As a way to address the practice of surprise billing, the executive order hopes to provide complete transparency to patients in regard to the pricing and quality of every person and institution that is part of a given care plan. This includes surgeons, surgical assistants, labs, hospitals, anesthesiologists, rehab and hospital care personnel, surgical centers, etc.

As seen across industries, the legal challenges of this executive order have left many health care organization’s leaders wondering what’s next and if/when they should prepare for implementation of the regulation. If this becomes law, physicians such as orthopedic groups must carefully consider how this could impact their practice sooner rather than later.

Key questions to weigh are:

While the final rule on hospital pricing won’t go into effect until Jan. 1, 2021 (if no legal proceeding delay it), taking the time to review and develop necessary processes can assist providers with managing potential risks and aftereffects. Additionally, taking this time to eliminate any procedures/activities that obstruct price transparency can increase mutual engagement between the patient and provider and can improve the current patient financial experience.

AAOS Announces Study of Stem Cells & Biologics

Click here or on graphic to learn more!

 

A Look at Medicare’s Competitive Bidding Program for DME

TOA recently sat down with Ross DeRogatis of Matrix Orthopedics to look at Medicare’s Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) Competitive Bidding program, which will affect back and knee braces.

Ross is the President/Owner of Matrix Orthopedics, an exclusive Donjoy distributor.  He has been in the DME space for over 10 years and currently has a team of 24 servicing accounts throughout the state of Texas (with the exception of the Houston and El Paso markets).

TOA: What is the current status of Medicare’s DMEPOS competitive bidding program?

Ross DeRogatis:  The Centers for Medicare & Medicaid Services (CMS) contracted with Palmetto GBA to operate as the competitive bidding implementation contractor (CBIC) to administer the Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) Competitive Bidding Program. Palmetto GBA is responsible for conducting certain functions including performing bid evaluations, selecting qualified suppliers, setting payments for all competitive bidding areas, and supporting CMS education efforts. Palmetto GBA also assists CMS and its contractors in monitoring the program’s effectiveness, access and quality.

In 2003, Congress originally authorized CMS to implement a competitive bidding program (CBP) for DMEPOS. Multiple rounds of bidding have been conducted for many different DMEPOS categories over the past decade.

On November 3, 2018, CMS requested feedback on a proposal to include certain off-the-shelf (OTS) knee and back orthotics/braces in the next round of competitive bidding (known as Round 2021, since contracts will become effective on January 1, 2021).

In early 2019, CMS announced that OTS knee and back braces would be included in the 2021 round.

OTS orthotics are defined as products that require minimal self-adjustment, and do not require expertise in trimming, bending, molding, assembling, or customizing to fit to the individual.

TOA: What are the next steps for the industry when it comes to the competitive bidding program?

Ross DeRogatis: DMEPOS suppliers will compete to become Medicare contract suppliers by submitting one bid for the “lead” item within a product category (e.g., knee orthotics/braces) for each competitive bidding area (CBA). There are 130 CBAs included in the 2021 round. Winning bidders must be able to provide the lead item in a product category, as well as all other products included in that category. This can be accomplished through various approaches.

CMS will evaluate bids based on the supplier’s eligibility to provide the identified products within a CBA, its financial stability, and the bid price offered. Contracts will be awarded to suppliers who offer the best price and meet applicable quality and financial standards.

DJO also has been working closely with industry associations and thought leaders to protect access to high quality products needed by our patients and advocated for the exclusion of certain codes of the identified products/HCPCS codes from the CMS competitive bidding process and changes to the correct coding guidance with respect to custom fitted codes.

DMACs issued a revised Correct Coding Guidance in March 2019:
https://cgsmedicare.com/jb/pubs/news/2019/03/cope11845.html
https://cgsmedicare.com/jc/pubs/news/2019/07/cope13077.html

More information is available at these links:

Official CMS website
Industry educational sites like DME CBP Education
Timeline

The Medical Expert Witness Industry: Q&A with J. Clark Race, MD

Clark Race, MD is board certified in Orthopedic Surgery by the American Board of Orthopaedic Surgery and has been in private practice in the Austin area since 1983.

Dr. Race recently created Expert Witness Doctors to provide medicolegal services, which include depositions, trial testimony, medical record reviews, IMEs, peer reviews, disability evaluations, designated doctor exams, rehabilitation planning, and maximum medical improvement/impairment ratings.

TOA recently sat down with Dr. Race to discuss the latest developments in the medical expert witness industry.

TOA: How did you decide to create a medical expert witness company? 

Clark Race: I have been practicing orthopedics in Texas for approximately 40 years. During that time, I have treated many patients in the Texas Workers’ Compensation system. In the process of doing that type of work, I would receive inquiries from third parties to review medical records and render an opinion regarding the appropriateness of orthopedic care, causation, and future medical expenses. As time went on, I began to receive requests directly from law firms to review cases and render opinions. In many of these cases, the law firms requested that I become a designated medical expert witness.

Over time, I found it increasingly difficult to work through third party companies who hired me on behalf of a law firm or an insurance carrier. Many of these third-party companies had opaque fee schedules and poor communications, which would result in many cases in confusion and/or missing of deadlines. As a result, I decided to form a PLLC which was solely engaged in medical/legal work. That business has grown over time, and I have received requests for services from other types of specialists. For that reason, the company that began solely to represent me and my work has begun to include other specialists for review of medical/legal cases.

Another reason for forming this company was to circumvent the middleman in this process. The customers for this type of work are law firms and insurance carriers. I found over time that having a third-party middleman became more confusing than it was helpful, and I have found that it is much easier to conduct this business in a situation where communications and deadlines are controlled and managed more efficiently.

Under its current structure, this company is engaged in providing services for Independent Medical Examinations, record reviews, Peer Reviews, disability examinations, and medical/legal expert witness work. The company is structured so that any potential clients can directly speak with my administrative assistant, who responds promptly and accurately to the requests and communicates any necessary information to the doctors who are involved. This has greatly improved the efficiency and decreased the stress level associated with trying to do this type of work through one’s medical office. The type of work is often confusing to medical practice office staff, and I found that calls and requests were frequently mishandled or delayed. Under the current structure, there is one individual who is responsible for coordinating the collection of records, communicating with clients and with the participating physicians, and making sure that no deadlines are missed. Medical records are stored in a HIPAA secure website where participating physicians may review these records at their convenience to perform their work. This has also eliminated the need for handling large volumes of paper files, which become extremely burdensome after a period of time.

TOA: TOA hears from a lot of medical expert witness companies. What is it that you have done differently?

Clark Race: The difference between this company and other medical expert witness companies is that this company is physician owned and managed. We have a transparent fee schedule so that all participating physicians have access to our fee schedule and their expected reimbursement rates. This company is structured as a “group practice.” We help with report writing, deposition preparation, and offer other educational and useful information on our website regarding performing medical expert witness work. Again, the primary difference in this company and other companies is that we can communicate efficiently and directly with our participating physicians with minimal disruption of their daily workflow. This alleviates stress and utilizes less of the physicians’ time trying to keep up with deadlines, report requirements, contact information, etcetera.

TOA: What types of orthopaedic services are needed the most?

Clark Race: As I am an orthopedic surgeon, most of the requests that I receive are for the evaluation of orthopedic cases. We also receive frequent requests for neurological and neurosurgical consultants. To a lesser extent are requests for emergency room physician services, OB/GYN physicians, and general surgery consultants.

Most of the orthopedic cases involve injuries sustained in motor vehicle accidents in which the plaintiff is alleging multiple injuries that may or may not be compatible with the accident in question. The plaintiff’s bar normally works with medical providers who will often overtreat the patients and recommend surgeries that are not indicated. There is frequent over-treatment of these clients, which generates large medical charges that form the basis of the damages, which are the basis of the litigation. Common issues that need to be opined upon include mechanism of injury, causation of alleged injuries, the relationship of alleged injuries to the accident in question, future medical treatment, and ability to return to work.

Practicing physicians who have experience dealing with traumatic injuries are uniquely qualified to opine on these issues.

In my opinion, the most common injuries which are involved in litigation involve alleged spine injuries. These are often the result of motor vehicle accidents or other traumatic injuries. Other common injuries include shoulder injuries, hip and knee injuries, and alleged neurological injuries as a result of trauma.

TOA: What types of reactions have you seen orthopaedic surgeons had towards orthopaedic surgeons who acted as expert medical witnesses against them?

Clark Race: In my experience, there have been no negative reactions from other orthopedic surgeons or treating physicians regarding testimonies and expert witness. The crucial factor in rendering these opinions is to base them on evidence-based medicine and to provide fair and accurate reports without bias toward the plaintiff or the defendant. If these principles are followed, it is my experience that there is minimal risk to the medical expert providing opinions.

As long as the testifying medical experts are qualified to opine on the alleged injuries in dispute and they use scientifically based information to form their opinions, there is minimal risk of being disqualified as an expert or being involved in any litigation over one’s opinions.

The American Academy of Orthopedic Surgeons has been supportive of physicians participating in the medical/legal system. These legal matters require expert medical opinions to resolve the issues in question. The Academy has rules of conduct that require participants to give fair and accurate opinions and to base their opinions on scientific evidence.

Being a medical expert witness has a sidebar to my orthopedic practice for several years. I find the work interesting and, in large part, the involved attorneys are intelligent and courteous. They are glad to have expert medical witnesses who are able to present the facts of the case and render cogent opinions regarding the questions at hand. The work has the additional benefit of being able to be done when an individual has extra time. The deadlines for production are usually far into the future, allowing ample time to review records, create reports, etcetera. The reimbursement is quite satisfactory and is an additional method to counteract declining reimbursements for the actual practice of medicine. If a physician is interested in engaging in this type of work, it is helpful to begin by performing Peer Reviews or medical record reviews. Working in the Workers’ Compensation system is also quite useful as that system has many similarities to the civil litigation system. If one becomes adept at this type of work, it has been my experience that interested parties will begin to request an individual’s service to review legal cases and possibly testify as a medical expert witness.

 

There are multiple educational resources to gain further knowledge and experience in this area. The American Academy of Orthopedic Surgeons’ annual occupational medical meeting is an excellent starting place. There are multiple other companies that are national in scope, which provide ongoing in-person training for performing IMEs, doing record reviews, and participating in expert witness work. These would be highly recommended to anyone considering engaging in this type of work who has not had previous experience.

Learn more about the company at: www.expertwitnessdoctors.com.

A Look at the Evolution of Football Injuries

TOA recently sat down with Field Scovell, MD of the Carrell Clinic in Frisco and Shane Miller, MD of Texas Scottish Rite Hospital for Children in Frisco to take a look at the evolution of football injuries and their treatment.

The following is TOA’s conversation.

TOA: Have you and your colleagues changed the way that you manage concussions over the past few years? 

Field Scovell: The threshold has been lowered, and rightly so. And our sensitivity is up.  We are looking for it: Not just the hit or contact, but a player’s reaction to it.  Our overall approach, especially at lower levels, has improved. The state requirements for education for coaches and trainers is good.  And most everyone in the stands is aware of the issue.  It can be tricky because there is some inconsistency in return to play among schools at all levels.  But no question the approach is better, and treatment/plan for recovery is better as well.

Shane Miller: There has been a shift toward more active recovery and rehabilitation following concussion over the past few years. Both the AAP and CDC issued guidelines last year emphasizing the potential negative impacts of prolonged rest on recovery, including increased symptom burdens and longer recovery times. Early light aerobic activity has been shown to speed recovery and decrease the risk of persistent post-concussive symptoms. Patients should be counseled to return to non-sports activities (including school and light physical activity) as their symptoms allow after no more than 2-3 days of rest following the injury.

https://pediatrics.aappublications.org/content/142/6/e20183074

TOA: Have you seen an evolution in injuries on the football field?  And how are the parents of your patients responding to football injuries?

Field Scovell: I do not believe there is an increase in the severity of injuries.  Kids are often in better condition from a physical standpoint because that aspect of sports has become such a big part of the game.  It is an entire industry now.  What has changed is that often before an injured kid gets off the field the parents are waiting for them on the sideline.  I don’t know if it’s an evolution of the helicopter parent.  But it’s a real problem.  It interferes with the ability of the medical team to evaluate a kid on the sideline.  Also, I’ve dealt with parents, often they have some connection to the medical profession (nurse, PA, doctor) treating their own kids before a game or even during a game. It’s crazy.  I don’t know if it’s a lack of trust, a product of the internet world we live in, or this idea that every kid is going to the NFL.  Often I have instructed kids and parents that there is no need to go to an ER and just to follow up at a Saturday morning injury clinic or first thing the next week.  And they end up going to an ER for an injury that’s not an emergency.

Shane Miller: As a collision sport, inherent injury risks exist. Injury rates increase with age, as players grow bigger, faster and stronger. The rates of serious injury in youth football are relatively low compared to that of high school and college, and game injury rates remain higher than practice. Implementation of safety training, rules and equipment have the potential to reduce injury risk. For example, football fatalities dropped markedly after the introduction of the spearing rule in 1976 (see below)

https://nccsir.unc.edu/files/2019/02/Annual-Football-2018-Fatalities-FINAL.pdf

TOA: What is your reaction to Andrew Luck’s retirement from the NFL?

Field Scovell: My reaction is that this is consistent with the general trend in youth football.  Participation is down.  Parents are asking why I would allow my kid to be at risk for injury, namely concussion.  I say good for him.  It takes a very mature person to make that kind of decision to walk away from a sport or an activity that you are really good at and can make wages that none of us will ever see.  My son plays football.  I wonder what’s at risk?  Concussion is one thing.  An ACL tear means your knee is different for the rest of your life.  It’s a tough deal.  There are so many benefits to playing sports and especially football.  But at what cost?  It’s worth asking.

Shane Miller: Every athlete is entitled to the right to determine when it is time to hang up the cleats and walk away from the game, for any reason. Andrew Luck has been a warrior who has struggled to stay healthy and remain on the playing field. So many of us treat patients with injuries and chronic pain, and witness firsthand the impact that pain has on all aspects of life, not to mention one’s desire to play a sport that continues to wreak havoc on his body. Luck is a very bright individual with a future that is likely to be even more significant off the field. Similar to Tony Romo and others who have traveled the same road before, sometimes it takes more courage and wisdom to know when to walk away than it does to remain.

TOA: How are the parents of your athletes responding to injuries? Have you witnessed a shift in their response to football?

Shane Miller: Increased awareness, media attention, and legislation have prompted even the most avid sports enthusiasts to evaluate the safety of participation in youth tackle football. Concerns regarding the potential long-term cumulative neurocognitive risks of repeated concussive and subconcussive impacts and potential development of chronic traumatic encephalopathy (CTE) which has been diagnosed in a small subset of former collegiate and NFL players have experts on both sides of the ball defending their positions. The 2018 AAP guidelines state, “The long-term effects of a single concussion or multiple concussions has still not been conclusively determined.”

The AAP issued a policy statement in 2015 on Tackling in Youth Football addressing many of the points of controversy. One recommendation has been to ban tackle football until a certain age. A recent study by Chrisman, et al. found that 61% of parents surveyed would support age restrictions for tackling, and an additional 24% “maybe” would support restrictions. Interestingly, parents surveyed overestimated the risk of concussion in high school tackle football (83% perceived the rate to be >10 out of 100/year, when actual reported incidence rates range from 4-7 out of 100/year).

Another recommendation along these same lines was the expansion of non-tackling (ie, flag football leagues). Peterson, et al. followed youth flag and tackle football leagues and concluded that injury is more likely to occur in youth flag football than in youth tackle football, and severe injuries and concussions were not significantly different between leagues. The expansion of 7-on-7 football recently in Texas has also seen significant injuries, now mandating the use of soft-shell helmets in response to high profile injuries and efforts toward injury risk reduction.

https://pediatrics.aappublications.org/content/136/5/e14

Texas Medical Board Offers Guidance Related to the State’s New Opioid Law

The Texas Medical Board (TMB) issued preliminary guidance related to Texas’ new limit on opioid prescriptions that will go into effect on September 1, 2019. The 10-day limit on opioid prescriptions was created by HB 2174 in the 2019 Texas Legislature.

Click here to view the initial guidance:
HB 2174 Initial Guidance – TMB

TOA Encourages the Texas Medical Board to Seek Legislative Intent on Opioid CME Bills

The Texas Orthopaedic Association (TOA) supported legislative efforts in the 2019 Texas Legislature to require continuing medical education (CME) for prescribing opioids. TOA was pleased that lawmakers worked with TOA on the issue.

Instead of passing an omnibus bill related to opioids, the 2019 Texas Legislature took a “shotgun approach” to opioids by passing a number of different bills. As a result, three bills mandating CME for opioids were signed into law. While each bill appears to address the same concept, each bill contains different verbiage. As a result, regulators could interpret the different verbiage found in each bill to result in three different CME requirements. Three different CME mandates could result in redundancy that would take away from other valuable continuing education activities.

TOA submitted a letter to the Texas Medical Board (TMB) on August 26 that asks the TMB to seek legislative intent from lawmakers so that CME guidance can be created by the TMB this fall. Physicians are in the process of planning their 2020 continuing education activities, and it is critical that they are provided the opioid guidance as soon as possible.

Click here to read TOA’s response to the TMB.

A Look at Youth Baseball Injuries with Henry Ellis, MD & Christian Balldin, MD


TOA recently sat down with Henry Ellis, MD of Texas Scottish Rite Hospital for Children in Frisco and Christian Balldin, MD of The San Antonio Orthopaedic Group to take a look at youth baseball injuries.

TOA: Why do you think that have witnessed an epidemic of arm injuries in baseball recently?  On one end, people say that it’s due to increased specialization by kids playing baseball all year. On the other end of the argument, a book like the MVP Machine: How Baseball’s New Nonconformists Are Using Data to Build Better Players argues that kids in Latin American countries have always played baseball all year. Instead, they believe that the recent epidemic is due to bad mechanics and physics. 

Henry Ellis: The real answer is that it is both. Kids in Latin American countries may be playing year around, but they don’t have nearly the intensity that we have with multiple tournaments, pitching coaches, several teams in the same season, and parental influences.

Our culture pushes kids to a level of competition that we typically reserve for high school or college. As early as 1st grade in some communities, kids are trying out for all-star teams and practicing daily. It is not just a recreational sport that kids play to have fun with their buddies.

The second part is mechanics particularly during adolescent then they pitch from a pre-pubescent to a teenager.  Throwing techniques used in Little League can be harmful as you grow, build muscle, and increase your throwing velocity. This has clearly been shown in several large studies.

Christian Balldin: It is a combination of reasons for this. Mostly it is over use by simply not allowing for enough rest. The torque on the shoulder and elbow when throwing is quite extreme and is simply too much if the arm is continuously fatigued. Not only is it over use, but kids and athletes today are getting bigger and stronger at an earlier age than ever before with our sports specific training and specialization along with better nutrition to optimize that. There is probably some degree of better recognition of injuries now than in years past as well, which will increase the number of documented injuries.

The Latin American kids do play year round, but perhaps not with the same intensity as we are seeing here with practices, batting practice, personal training sessions, agility, speed and strength sessions on top of the games, which are plenty.

TOA: What can baseball players do to avoid arm injuries?

Henry Ellis: A national safety committee thru POSNA came up with 10 articles that parents should know about in the last five years.  Two of these articles were related to baseball injuries.  We created an educational video with a hyperlink.  Will send those hyperlinks this week, but the just is:

Christian Balldin: Ensure that their bodies are getting enough rest, proper nutrition, throwing mechanics and having good people around them. It is vital that the coaches, and especially the parents, understand the need for good communication and not just push their kids through an achy elbow and shoulder. Education from the orthopedists, athletic trainers, coaches, and parents to the kids and athletes is very important.

TOA: The injuries have mostly been limited to pitchers. But we’re now seeing position players with the same elbow injuries.  Any thoughts there? 

Henry Ellis: Yes – Due to the success of pitch coach awareness, I see more catchers than pitchers in my practice with elbow overuse injuries.  They often times throw more frequent, and on some team, the catchers also act as relief pitchers.  We still need a better understanding on this topic.

Christian Balldin: Again, overuse and some of the same issues I touched on earlier.  The position players sometimes rotate as a pitcher on certain teams, which has an effect, but it is mostly just overuse/overtraining.

Henry Ellis, MD (left) and Christian Balldin, MD speaking at TOA’s 2018 Annual Conference in Fort Worth.

Medicare’s CY 2020 OPPS/ASC Payment Proposal

The Centers for Medicare and Medicaid Services (CMS) released its proposed payment policy for the Medicare hospital outpatient prospective payment system (OPPS) and ambulatory surgical center (ASC) payment system for calendar year (CY) 2020 on July 29, 2019.

Keep in mind that the American Association of Orthopaedic Surgeons (AAOS) is currently digging through the proposed rule, and AAOS will provide an extensive analysis and comment letter in the near future.

TOA members have been provided an extensive analysis of this proposal. TOA members can either check their e-mail or log into TOA’s website to view the full proposal.

Stakeholder comments are due on September 27, 2019, and you may want to consider making comments on some of these proposals.

Click here to reference the full rule.

Key Concepts
TOA encourages you to read through TOA’s entire summary. In addition, watch for AAOS’s extensive summary.

Some of the key concepts include (these are all proposals):

Medicare’s CY 2020 Physician Fee Schedule Proposal

The Centers for Medicare and Medicaid Services (CMS) released its proposal for the calendar year (CY) 2020 Physician Fee Schedule (PFS) on July 29, 2019.

The American Association of Orthopaedic Surgeons (AAOS) will provide a lengthy summary of the proposal and a response in the near future. In the meantime, TOA has provided a summary for its members. TOA members will receive a lengthy summary in the TOA member e-mail.

Click here to view CMS’s proposal:

Some of the key concepts include:

TOA members can turn to their e-mail newsletter or TOA’s website to view the full proposal.

Patient Perception of Surgeon Reimbursement

Click here or on graphic to enlarge!

Click here or on graphic to enlarge!

There Is a Correct Way to Address Surprise Billing

The 2019 Texas Legislature followed the lead of the New York Legislature by addressing surprise bills through an arbitration process that takes patients out of the middle by giving physicians an opportunity to challenge out-of-network payments made by commercial health insurance plans through an arbitration process.

The New York system has worked. Click here to learn more.

TOA members can access a summary of the new Texas law, SB 1264, by clicking here.  TOA submitted stakeholder comments to the Texas Department of Insurance on July 15, 2019.

Congress is considering several surprise billing proposals that pertain to ERISA plans during the summer of 2019.

Only one of the measures considered by Congress – H.R. 3502 – represents the correct way to address the surprise billing issue. H.R. 3502 takes the patient out of the middle and gives physicians an independent dispute resolution tool to challenge unfair payments made by commercial health plans.

Click here to learn more about the proposals in Washington from TOA’s president, Adam Bruggeman, MD.

 

Orthopaedic Residents Advocate on Capitol Hill

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TOA takes three orthopaedic residents to Washington, DC every June to visit with lawmakers about musculoskeletal issues that affect Texas patients. TOA’s goal is to introduce advocacy issues to residents at an early age.

Jordan Handcox, MD of San Antonio, Dylan Homen, MD of Lubbock and Max Danilevich, MD of Galveston were the three residents who joined TOA on Capitol Hill in June 2019. TOA interviewed Drs. Handcox and Homen about their Capitol Hill experience.

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Jordan Handcox, MD, Max Danilevich, MD and Dylan Homen, MD visiting the Texas Congressional Delegation with other Texas orthopaedic surgeons.

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Jordan Handox, MD visiting the Texas Congressional Delegation with San Antonio orthopaedic surgeons.

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TOA:  What did you think about educating lawmakers on Capitol Hill about musculoskeletal issues?  

Jordan Handcox: It was my first time engaging in advocacy efforts in DC, and I found our time there incredibly exciting and inspiring! Even though we were fairly focused on one or two narrow pieces of legislation, it really felt important that orthopedic surgeons as a group came together and unified for a common goal. Together, it genuinely seemed that we actually had the ability to move the legislative needle in a better direction for our patients and for the practice of our craft. It showed me that the value of our strength is in our unity of voice and message, and the AAOS National Orthopaedic Leadership Conference visit really made me feel that together, we actually can make some kind of a difference in this ever-changing health care landscape.

Dylan Homen: I thought it was an extremely valuable learning opportunity. I found it to be a unique step in my development as a young surgeon in training. More than just an interesting change of pace from typical clinical duties, this was a highly fulfilling experience and one that I hope to be a part of for years to come.

TOA: Not many residents jump at the opportunity to join TOA in its advocacy work. What sparked your interest?

Jordan Handcox: A physician’s life is relentlessly busy and full of competing interests for the precious commodity of our time. Often, we feel like we don’t have the time, energy or bandwidth for just one more additional thing in our life, and advocacy or legislative work can feel daunting and like something we just don’t have the time to understand and rally behind. The unfortunate result of this is that many of the people making actual health care policy decisions (legislators, lobbyists, administrators) are not the people who are actually on the ground caring for patients or running a practice.

I am a part of TOA because our group gives actual orthopedic surgeons and patients a voice on important health care issues and acts as an important bridge between surgeons/patients and the esoteric world of state health care politics. TOA does a great job of not only educating us on all the important issues, but it provides us with actual actionable things we can do (strategic phone calls, letters to legislatures, fundraising, etc.) to affect decision making in our state.

Dylan Homen: I am completing my training at a time when health care is on the forefront of the minds of United States citizens and a massively important facet of the current political landscape. We in medicine tend to think research activities when describing advancement of the field. This advocacy work, however, presents a different avenue to foster very real change in the field of orthopaedics and medicine in general. As a native-born Texan, the TOA allows me to channel an interest in health care politics, particularly as it pertains to my home state. It’s a rare and invaluable experience.

TOA:  What do you see our role in an advocacy standpoint following your residency?

Jordan Handcox: Right now is a very interesting time of change in health care policy, both locally within the state of Texas and nationally, as well. Because of the ever-shifting landscape of health care law, it can be difficult to keep up with where things are and where they are going. I hope to stay involved with TOA beyond residency and work to help orthopedic surgeons in our state understand the changes coming that will affect our practice in the short and long terms, where and when we should really pay attention and how we can strategically get involved with our limited time. The practice of orthopedic surgical care is constantly changing, and I hope to help local orthopedic surgeons stay involved and stay aware in a meaningful way.

Dylan Homen: I sincerely hope to remain involved with the Texas Orthopaedic Association and other advocacy organizations. My goal is to become increasingly well versed in the processes with each passing year, allowing me to be a more valuable asset to the association. I would like to continue to contribute and help in any way possible and I would strive to encourage the pursuit of similar interests in like-minded colleagues that follow me.

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Prescription Monitoring Program

The prescription monitoring program (PMP) is an important tool for physicians and pharmacists to deter some forms of “doctor shopping” for the illegal or inappropriate use of prescription drugs.

TOA worked with lawmakers in the 2019 Texas Legislature to:

Click here for the TSBP’s announcement to prescribers.

TOA Strongly Supports the Prior Authorization and Utilization Review Provisions Passed by the Texas Legislature

The Texas Orthopaedic Association (TOA) strongly supports the prior authorization and utilization review proposals that were added to SB 1742 in the 2019 Texas Legislature.

SB 1742 is now waiting for Governor Abbott’s consideration.

Click here to learn more.

TOA Supports HB 3284 

The Texas Orthopaedic Association (TOA) recently offered its support for HB 3284, which passed out of the 2019 Texas Legislature.

The bill, which is authored by Rep. JD Sheffield, DO and Sen. Jane Nelson, would delay the state’s prescription monitoring program (PMP) mandate by several months to ensure that physicians’ electronic health record (EHR) programs are ready to integrate the PMP into the EHRs.

In addition, HB 3284 would create an advisory committee of physicians, pharmacists, and EHR vendors to make recommendations on the PMP in the future.

TOA believes that the PMP is a valuable tool to stop some forms of “doctor shopping,” and the provisions found in HB 3284 would strengthen the PMP.

Click here to view TOA’s comment letter.

Texas Orthopaedic Surgeons Visit the Texas Congressional Delegation

Over a dozen Texas orthopaedic surgeons will visit Capitol Hill on June 6 to discuss issues related to out-of-network balance billing, hospital monopolies, and antitrust regulations related to commercial health insurance plans. The orthopaedic surgeons will discuss initiatives that can lower health care costs for patients.

The Texas Orthopaedic Association (TOA) will sponsor four orthopaedic residents’ trip to visit with the Texas Congressional Delegation. TOA believes that it is important to build the next group of physician leaders by educating orthopaedic residents about the public policy process at a young age.

Click on the links below to learn more about the issues.

Musculoskeletal Injuries & the Scooter Experience in Austin

TOA recently sat down with Austin orthopaedic surgeon Austin Hill, MD, MPH of the Dell Medical School at the University of Texas to discuss the orthopaedic trauma department’s experience with scooter injuries in Austin.

TOA: What were your thoughts when the scooters first went live and you first started seeing injuries?

Austin Hill: The first patient we treated was a young female hit by a car while on her way to work.  Initially this seemed to be a variation of an autoped injury, but over the following month we treated over 20 patients with isolated scooter trauma and quickly realized this was a significant new injury mechanism.  Sadly, we’ve had 3 fatalities so far in Austin from scooter collisions, and the public is largely unaware of the serious risks associated with operating scooters.

TOA: How many injuries a day are you all facing at the emergency department and what types of injuries are you seeing? 

Austin Hill: The ER sees 15 to 20 patients per month.  The most common injuries are orthopaedic: lower extremity are more common than upper extremity, facial fractures, and closed head injuries.

TOA: The Centers for Disease Control (CDC) released a study earlier this month finding that nearly half of all electric scooter injuries in Austin were “severe.” Are you all working with the CDC on this study?

Austin Hill: Our ER has a weekly update internally.  We are not enrolled in a CDC study; they apparently have other means of extracting and obtaining the data.  Our ER and Trauma Faculty have initiated routine public safety awareness commentary through local news media outlets to improve public awareness, particularly surrounding helmet use.

TSAOG Interview with Chris Kean

The San Antonio Orthopaedic Group (TSAOG) recently opened its WorkSmart Industrial Rehab Clinic, which focuses on physical and behavioral rehabilitation of injured workers.

TOA recently conducted a Q&A with Chris Kean, the chief operating officer of TSAOG, to learn more about the clinic.

TOA: What is the “WorkSmart Industrial Rehab Clinic”?

Chris Kean: WorkSmart Industrial Rehab Clinic focuses exclusively on the physical and behavioral rehabilitation of injured workers. Our goal is to return employees to the workplace in a safe and rapid manner using job-specific rehabilitation techniques.

The idea came about as we started to take a deeper dive into our population of patients that were coming to us with work related injuries.  We noticed an increasing amount of patients coming in from all sizes of organizations, and both the injured worker and employer wanted a reliable, medically supervised program to re-introduce them back in to the work environment after injury.

Our team is comprised of licensed professionals providing high quality physical and behavioral care in a rehabilitation setting that simulates the patients’ unique work environment. We work directly with the employer to gain specific information regarding job duties and a description of the physical working environment. We then craft an individualized program for that employee so they may successfully rejoin the workforce in a safe manner.

As an example, imagine an injured police officer who suffered a work-related injury and was off duty for several weeks. After treatment, and when the officer is ready to return to work, they may be deconditioned, and/or have certain limitations when performing their normal duties which could put the officer at risk for re-injury or worse. We will work one-on-one with the officer to perform general strength and conditioning exercises that may include utilizing a treadmill, stationary bike, lifting heavy objects, bending and twisting activities, and other modalities, for an entire day, sometimes five days per week up to a four-week period of time, to prepare them for re-entry into the police force.

We are proud to offer a program to our community that allows for a unique and seamless integration of admission, diagnosis, treatment, recovery, and discharge process designed specifically for injured workers. In creating this program, we provide a smarter, more effective way of rehabilitating work-related injuries that is specific to their needs as well as the employers by reducing lost work time and returning a conditioned, “work ready” employee. Hence the name, WorkSmart.

We currently offer:

Functional Capacity Evaluations (FCEs) – a screening method used to determine an employee’s ability to function in various job-related circumstances and tasks. This testing is typically four to five hours long and is used to gauge an employee’s ability to return to work.

Work Hardening – A program that simulates a worker’s specific job functions to help reintroduce the employee into the work environment.  This program includes both a physical and psychosocial component, where we have a licensed professional counselor available to assist with any stress factors experienced by the injured worker.

Work Conditioning Services – A four to seven hour per day program spread over four weeks that requires an employee to clock in and complete work-related tasks to prepare them for their return to work.  During these hours, the employee will focus on intensive conditioning and strengthening exercises to mirror the demands in the workplace.

TOA: Did you all work with local employers to develop this? How have San Antonio employers responded?

Chris Kean: Although we have not worked directly with local employers to develop the service line, we have and will continue to take their feedback into consideration as we expand our offerings. We are diligently working on providing an open-ended communication line with San Antonio and surrounding area employers to make sure we are meeting expectations and continuing to push the envelope in regard to what’s next.  The response has been great thus far, which energizes us to continue improving care for our workforce community.

TOA: Do similar models exist?

Chris Kean: There are organizations that offer similar type of work-related services, however, they do not integrate the kind of orthopaedic-specific care nor the infrastructure that TSAOG’s WorkSmart program brings to the table.

TOA Supports Initiative to Dispose of Unused Drugs

The Texas Orthopaedic Association (TOA) is supporting HB 2088, which would direct the Texas State Board of Pharmacy (TSBP) to maintain and publish a list of drop-off locations for unused drugs.

The legislation by Rep. Jay Dean (R-Longview) was heard in the House Public Health Committee on April 10, 2019.

TOA Supports HB 2367 by Rep. Greg Bonnen, MD

The Texas House Committee on Pensions, Investments & Financial Services will consider HB 2367 by Rep. Greg Bonnen, MD in a committee hearing on April 18. The bill would prohibit health plans from bidding on the state’s contracts if the plans participate in the practice of dropping a physician from a plan for notifying a patient of the full range of physicians and other providers, including out-of-network providers.

When individuals purchase a PPO product, they have a right to select the facility or provider that they feel is the best for the patient and condition, regardless of their network status. When employers select an insurance plan, they may want to provide their employees with the most choices by paying more for a PPO product. For both individuals and employers, they may be provided a network of providers when they sign up that then changes over time.

Despite the efforts of HB 574 from the 84th Legislature, we are still witnessing cases in which commercial health insurance plans are intimidating physicians into referring patients only to in-network providers. HB 2367 would address this problem.

Click here to read TOA’s support letter.

TOA Supports SB 2316 to Strengthen the PMP

The Texas Orthopaedic Association (TOA) testified in support of SB 2316 in both the House and Senate as a bill that would enhance the state’s prescription monitoring program (PMP). Offered by Senator Chuy Hinojosa and Representative Senfronia Thompson, SB 2316 would create an advisory committee of physicians, pharmacists, and electronic health record companies to provide expert feedback on the PMP.

The Texas Legislature has secured funding for the Texas State Board of Pharmacy to acquire the licenses for physicians.

Click here to learn more.

TOA Sports Bill to Protect Out-of-State Team Physicians

The Texas Orthopaedic Association will speak in support of Rep. Bobby Guerra’s legislation – HB 2299 – which would protect out-of-state team physicians when they travel with their teams to Texas. The bill would direct the Texas Medical Board to recognize the out-of-state licenses for those physicians while they are assisting their teams for competitions in Texas.

The Texas Medical Board passed a similar rule in the summer of 2019.

Dozens of other states have already passed similar laws.

Click here to view TOA’s support for the legislation.

Texas Bill Would Create “Timeshare ASC” Model

State Rep. Mary Gonzalez (D-El Paso) introduced HB 3468, which would allow multiple ASCs to operate within a single ASC on different days. Medicare recently approved the “timeshare ASC” model. However, Medicare indicated that state legislatures must approve the concept at the state level.

Kevin L. Kirk, DO

Kevin L. Kirk, DO is a board-certified orthopedic surgeon specializing in disorders of the foot, ankle and lower leg. Although he treats all general orthopedic conditions, he has a special interest in foot and ankle joint replacement, arthroscopy, reconstruction and trauma surgery.

Kevin Kirk, DO speaking at TOA’s 2019 Annual Conference in Houston.

Dr. Kirk received his Doctor of Osteopathic Medicine from the Philadelphia College of Osteopathic Medicine in 1999. He completed an internship in General Surgery and subsequent Orthopedic Surgery Residency at Walter Reed Army Medical Center in Washington, DC. He then went on to complete a fellowship in Foot and Ankle Surgery at Johns Hopkins University/Union Memorial Hospital in Baltimore, MD.

After completing fellowship, he was appointed the Chief, Foot and Ankle Surgery at Brooke Army Medical Center. In 2010, he became the Chief, Orthopedic Surgery Service at San Antonio Military Medical Center serving in that position until his retirement from the Army in 2013. He has recently relocated his practice from the University Orthopedic Associates in New Jersey where he was an orthopedic consultant to the athletic programs at Rutgers/Princeton and Rider Universities.

Dr. Kirk is a highly experienced orthopedic surgeon and a veteran of two deployments with forward surgical teams to Afghanistan in 2005 and 2011. He remains active in the orthopedic academic community. He has served on the faculty of the Uniformed Service University of Health Sciences, Baylor College of Medicine and Rutgers/ Robert Wood Johnson Medical School.

TOA: How did practicing orthopaedics in the military setting different from practicing in the civilian arena?

Kevin Kirk:

  1. Camaraderie versus competition. In the military, we are all one team working towards the goal of providing the best care for our soldiers/ beneficiaries, particularly in the deployed environment. The differences that you have between different specialties, anesthesiology and general surgery, evaporate in that environment since you realize your sole purpose is to save lives and limbs, so the coordination of care is much better with less conflict. (I still stay in touch with a lot of the guys that I served with, but I have never been able to replicate the collective sense of working for something greater than yourself in my six years of private practice).
    Whereas in the civilian side there is always competition to gain patients within and between groups/surgeons, so often there is conflict such as, “why is the sports guy doing trauma?” or “foot and ankle cases?” when it should go to the most qualified surgeon. In the military, especially at the medical centers, there was specialized care, such as sports/foot and ankle / trauma/hand, etc., so that the most qualified surgeon will perform the surgery. In an effort to fill ORs, some civilian surgeons will push the limits of their skill set rather than refer to a more appropriate surgeon.  (I know that that is not very politically correct, but it is honest.)
  2. Too many patients and not enough time versus too much time and not enough patients. Due to the number of beneficiaries and limited/inefficient resources in the military system, there are often long wait times for surgery or exams such as MRIs. Not that the quality is inferior, but without financial incentive, there is no need to work harder, so it leads to further delays. In the civilian side, it is a hustle to get as many patients as you can.
  3. Injury severity. Particularly with the recent conflicts in Iraq/Afghanistan, the use of improvised explosive devices (IEDs) injuries can be quite devastating, such as extensive soft tissue and bone loss coupled with contralateral limb loss. In fact, especially with open tibia fractures, there is an inverse pyramid of the severity with military open tibia fractures being primarily the worst (Grade III) and most prevalent when compared to civilian open tibia fractures being less severe (Grade I) and being the most prevalent.

Due to the high energy mechanism of injury coupled with the “up-armored vehicles” later in the conflicts led to severely comminuted fractures of the foot and ankle. Oftentimes in civilian practice, you will have more isolated severe fractures, such as calcaneus or pilon fractures, whereas in the military the fractures would be in combination (for example comminuted calcaneus, talus and tibia fractures coupled with spine injuries and possible closed head injuries). The severity of these fractures often led to posttraumatic arthritis in active young patients.

The onset of arthritis at such a young age caused an interesting dilemma. In most patients with arthritis of the foot or ankle, total ankle arthroplasty or fusions are usually a good option; however, these patients are often much older and less active. In the military population of active young patients with the same severity of post-traumatic arthritis, fusions are usually the only option. The decreased mobility of the ankle or foot after fusion often led to the inability to run which many of the soldiers equated to their full recovery, i.e., “being healed.”  Since they were not able to run, and having seen their buddies with amputations being able to run, caused a high number of delayed amputations, approximately 15 percent.

TOA: Foot and ankle is one of your specialties.  What are some of the most exciting advances in foot and ankle that you have witnessed over the past few years?

Kevin Kirk: 

  1. IDEO brace see above
  2. Total ankle arthroplasty- The improvement in the quality and design of the implants has steadily improved over the last several years, which has allowed for more patients to benefit from the technology. I have seen an increasing request by my patients for this procedure to allow for maintenance of ankle motion rather than the restricted motion of a fusion. With the improved designs, the implant survival rate has steadily improved (still not as good as TKA/THA) to where most patients can expect the implant to survive 10 years or greater. In appropriately selected patients, the implant can last their lifetime. As more of TAR being performed, it has also led to advances in revision procedures that are now able to be performed instead of resorting to a fusion procedure.
  3. Cartiva- implant arthroplasty- Arthritis of the big toe can be quite disabling. Prior to the Cartiva implant most patients would require fusion of the toe joint if they had extensive arthritis. This allows for the motion to be maintained and good long term results with improved pain. Most of the published literature demonstrates a greater than 90 percent improvement with follow-up greater than five years.

TOA: You have taken a particular interest in osteoporosis. 

Kevin Kirk: This may take a while … I attended the American Orthopaedic Association Meeting in Boston while I was a resident and walked into an Own the Bone Symposium. I really did not know much about osteoporosis and why orthopedic surgeons would be interested in this topic. I did not think much more about it during my time in the military since most patients were younger and injuries were mainly due to war trauma.

After my retirement from the Army in 2013, I took a job at Rutgers/University Orthopedic Associates in New Jersey where they had a robust osteoporosis screening and secondary fracture prevention program. I started to rekindle my interest in the Own the Bone program/osteoporosis and secondary fracture prevention.

From my deployment experiences, you returned changed and want to serve your patients better and have better treatment of diseases. I felt that this would be my way to make a lasting impact on my community and hospital system. So when I returned to join The San Antonio Orthopaedic Group in 2014, there were only a few surgeons ordering Dexa scans or referring for osteoporosis care. I saw the opportunity to develop a program within our group and within the Baptist Healthcare System. At the time I started to take general orthopaedic call as well and really saw the impact of osteoporosis and geriatric fractures.

According to the National Osteoporosis Foundation, an estimated 10 million adults in the US have osteoporosis and over 43 million have low bone mass. Osteoporosis is a silent disease often resulting in fractures from ground level falls so a patient doesn’t know that they have a problem until they fracture. Over 1 million fractures occur annually, which is a much higher annual incidence than new strokes, heart attacks or breast cancer combined. Once a patient fractures, there is a 30 percent mortality rate within the first year, and 50 percent typically do not return to their prior level of ambulation/function.

As orthopaedic surgeons, we would typically treat the fracture and never treat the underlying cause. Thereby the patient would be at a 40 percent risk of another fracture within the year following if the osteoporosis is left untreated. As orthopaedic surgeons we are the “tip of the spear” when it comes to identifying fractures related to poor bone quality. It is with those facts, I petitioned our TSAOG Executive Committee to start a secondary fracture prevention program.

I currently supervise the nurse practitioner for our Bone Health Institute, and her volume has steadily increased since starting the program. In addition, I have become the physician champion for the Own the Bone/ Secondary Fracture Prevention program at Mission Trail Baptist Hospital on the southside of San Antonio. We are currently in the process of seeking Joint Commission credentialing as a certified Osteoporosis/ Fragility Fracture program. My hope is that we can serve a model for the other programs within our system and duplicate the program at other facilities within the Baptist System.

TOA: Why do you think it is important for orthopaedic surgeons to engage in the public policy process with organizations like TOA and AAOS?

Kevin Kirk: If you are not at the table you are on the table: Physicians and surgeons are reluctant leaders. I think that it is critical that surgeons to remain active in organized medicine to assist policymakers with decisions that affect our patients and their care. We are the frontline of healthcare and truly understand the needs of our patients and the impact policy decisions can have on the delivery of that care. Therefore, we need to be at the table.

Mil Med. 2010 Dec;175(12):1027-9.
Prevalence of late amputations during the current conflicts in Afghanistan and Iraq.

Stinner DJ1Burns TCKirk KLScoville CRFicke JRHsu JRLate Amputation Study Team.
After identifying this as a problem, since this rate was three times greater than civilian trauma patients, our group set out to find a solution. The solution was the Intrepid Dynamic Exoskeleton Orthosis (IDEO). This innovative orthosis allowed patients with fused ankle to return to running and helped decrease the late amputation rate.

Comparative effect of orthosis design on functional performance.
Patzkowski JC, Blanck RV, Owens JG, Wilken JM, Kirk KL, Wenke JC, Hsu JR; Skeletal Trauma Research Consortium.
J Bone Joint Surg Am. 2012 Mar 21;94(6):507-15.

Management of posttraumatic osteoarthritis with an integrated orthotic and rehabilitation initiative.
Patzkowski JC, Owens JG, Blanck RV, Kirk KL, Hsu JR; Skeletal Trauma Research Consortium.
J Am Acad Orthop Surg. 2012;20 Suppl 1:S48-53

Can an integrated orthotic and rehabilitation program decrease pain and improve function after lower extremity trauma?
Bedigrew KM, Patzkowski JC, Wilken JM, Owens JG, Blanck RV, Stinner DJ, Kirk KL, Hsu JR; Skeletal Trauma Research Consortium (STReC).
Clin Orthop Relat Res. 2014 Oct;472(10):3017-25

Fortunately the success of the IDEO has translated to the civilian side and now is commercially available through Hangar Prosthetics as the Exosym brace. In fact, I have been able to get this type of brace for Workers’ Compensation patients with good results. It is actually a part of the ODG for Worker’s Comp. Well, that is all I have to say about that!

Texas Lawmakers Introduce Bills to Make Health Care More Efficient for Texans

Texas lawmakers recently introduced several bills that would address the health plans’ unnecessary delays that are resulting in delays for patients.

The Texas Orthopaedic Association strongly supports the bills that have been introduced by Sen. Dawn Buckingham, MD, Rep. Greg Bonnen, MD, Rep. Julie Johnson, and Rep. Sarah Davis.

Make the prior authorization process easier for patients and physicians. HB 2327 and SB 1186 would require HMOs to provide details to patients and physicians about what factors are used to determine a prior authorization formula. In addition, physicians who routinely have their prior authorizations approved would be exempt from further prior authorizations under a process that is set up by TDI.

Promote greater patient choice. Some health plans have dropped physicians from their networks for referring patients to out-of-network providers. In some cases, the most appropriate provider for that service may have no choice but to be out of network. HB 2367 would prohibit health plans that engage in this practice from bidding on state contracts.

Ensure that health plan reviewers have expertise regarding the reviewed service. HB 2387 and SB 1187 would require health plans to use a physician of a similar specialty for utilization reviews regarding a particular service.

Ensure that patients have accurate network directories. HB 1880 and SB 1188 would require health plans to update their network directories every two days. In addition, TDI would be required to perform network adequacy examinations at least every two years for PPO products.

Give patients information about their physicians’ network status and expected financial liability. HB 2520 would require health plans to tell the patient ahead of time about the network status of the physicians and the patient’s expected financial liability for an approved prior authorization.

Prohibit prior authorization for mandated benefits. HB 2408 would prohibit prior authorizations for state-mandated services, such as osteoporosis prevention.

Prescription Monitoring Program

Click here to view the Prescription Monitoring Program

TOA’s 2020 Annual Conference

Click here for the latest info for our upcoming 2020 Annual Conference.

Sponsorship details are coming soon!

TOA Supports HB 1005’s Efforts to Strengthen Medical Causation Reports

TOA issued support for HB 1005 by State Rep. Nicole Collier, which would direct Workers’ Compensation carriers to reimburse physicians for medical causation narrative reports.

Bobby Hillert, TOA’s executive director, stated:

“The medical causation report is an important tool that helps injured workers receive the care that they need. It is critical to have qualified experts, such as orthopaedic surgeons, available to produce the medical causation reports. TOA strongly supports Rep. Collier’s efforts through HB 1005 by ensuring that orthopaedic surgeons would be paid for their work.”

HB 1005 would direct insurance carriers to reimburse physicians for their work related to medical causation reports.

TOA Asks Lawmakers to Fund the Prescription Monitoring Program Licenses

The Texas Orthopaedic Association (TOA) is encouraging Texas lawmakers rely on the Legislature’s supplemental funding package to fund the Texas State Board of Pharmacy’s request to acquire physician licenses to access the prescription monitoring program (PMP) database.

The September 1, 2019 mandate for physicians to check the PMP is seven months away, and it is critical to ensure that the licenses are ready for physicians to connect to the PMP through their electronic health records (EHR) systems before the mandate begins.

The PMP mandate served as the centerpiece of the 2017 Texas Legislature’s efforts to address opioid addiction through the practice of “doctor shopping,” which is the practice of individuals who attempt to inappropriately acquire prescription drugs by visiting multiple physicians.

The 2017 Texas Legislature recognized that few EHR systems were ready to connect to the PMP in 2017. As a result, the Legislature delayed the mandate for physicians to check the PMP for certain drugs until September 1, 2019. Texas’ PMP collects a patient’s controlled substances prescription drug history, which allows pharmacists and physicians to review a patient’s prescription drug history.

TOA supports a robust PMP in Texas and views it as a helpful clinical tool that could help limit misuse and diversion in some cases. The 2019 Texas Legislature can ensure the PMP’s success by creating the funding necessary for physicians to check the PMP in a seamless manner through their electronic health record (EHR) systems.

Several other states have dedicated appropriations to pay for a gateway license for each physician user. The license allows a physician to connect her EHR system to the state’s PMP in a seamless manner. TOA encourages the Legislature to appropriate $5.1 million in funding to the Texas State Board of Pharmacy for Statewide Integration Purchase & Enterprise NarxCare & Clinical Alerts.

In addition, TOA encourages the Texas Legislature to create a PMP advisory board that is made up of physicians, pharmacists, and EHR vendors to provide technical expertise to the TSBP. In order for the PMP to be an effective clinical tool, Texas must ensure that it is functioning properly and as designed. The advisory board would be tasked with identifying challenges, assuring data integrity/security, monitoring progress towards systemwide integration, defining best practices, and evaluating how the PMP is functioning in clinical settings.

Texas House Speaker Dennis Bonnen Announced the Committee Assignments

Texas House Speaker Dennis Bonnen announced the committee assignments for the 86th Texas Legislature today.

Click here to view the assignments.

 

Texas Legislature’s Committee Releases Prescription Monitoring Program Recommendations

The Texas Legislature created a joint committee of the two bodies following the 2017 Legislature to address the future of the state’s September 1, 2019 mandate for physicians to check the state’s prescription monitoring program (PMP) before prescribing certain drugs. The committee, which is co-chaired by Senator Charles Schwertner, MD (R-Georgetown) and Representative JD Sheffield, DO (R-Gatesville), released its recommendations earlier today. Click here to view the report.

The committee made the following recommendations for the 2019 Legislature:

  1. Fund TSBP’s Exceptional Item request for enhancements to the PMP, including the integration of the system into electronic health record systems.The state should pursue opportunities for federal funding for these items. The enhancements will drastically increase the efficiency of the system.
  1. Delay the effective date for requiring prescribers and dispensers to check the PMP prior to prescribing for Schedules III-V, but maintain the September 1, 2019 effective date for schedule II prescriptions.This will allow prescribers and dispensers time to adjust to using the system, and will allow TSBP time to integrate the system with electronic health record systems, if the Exceptional Item is funded.
  1. Appoint an advisory committee to TSBP comprised of prescribers and dispensers.This advisory committee would examine data accuracy, data integrity, best practices, and address system weaknesses and workflow challenges.
  1. The Legislature and veterinarian stakeholders should continue to collaborate to ensure veterinarian dispensing of controlled substances is incorporated appropriately into the PMP within 30 days of dispensing.
  1. Establish legal penalties for wrongful access and misuse of the PMP and direct TSBP to increase financial penalties.Current penalties for inappropriate use of the PMP are in the form of fines ranging from $1,000 to $2,500.
  1. Continue integrating Texas’s PMP with other states’ systems.Texas’s system is currently integrated with the following states: Alabama, Arizona, Arkansas, Connecticut, Georgia, Idaho, Kansas, Louisiana, Maine, Massachusetts, Minnesota, Mississippi, Montana, New Mexico, New York, North Carolina, North Dakota, Ohio, Oklahoma, Oregon, Pennsylvania, South Carolina, Tennessee, and Virginia.
  1. Make PMP data available to a minor patient’s parent/guardian on behalf of the minor child.Texas is one of eight states that currently does not have a process for this.
  1. Provide legal immunity to practitioners not submitting data or accessing the PMP.Thirty other states have legal immunity in place to protect practitioners from civil lawsuits.
  1. Allow a state entity that is also a Centers for Medicare & Medicaid Services (CMS) Qualified Entity (QE) to access the PMP data for research and analysis. QEs are entities certified by CMS to meet the highest standards in analysis of health data, including protected health information. Currently, only TSBP has the ability to analyze PMP data. This recommendation would allow the data to be analyzed in relation to claims data to study rates and patterns.

TOA will be working on this issue in the 2019 Texas Legislature.

TOA Comments on Medicare’s Back and Knee Brace Proposal

The Texas Orthopaedic Association (TOA) submitted feedback on December 17, 2018 that expresses concern regarding the Centers for Medicare and Medicaid Services (CMS) proposal to add back and knee braces to Medicare’s new round of competitive bidding.

TOA expressed concern that this could limit the number of physicians who would be able to provide these braces, and this could compromise the coordinated care model.

TOA members can find the response on TOA’s website.

Texas House Select Committee Releases Opioid Findings

The Texas House Select Committee on Opioids and Substance Abuse released its report on December 3, 2018. The committee is chaired by Rep. Four Price of Amarillo.

An additional select committee, which is co-chaired by Senator Charles Schwertner, MD and Rep. JD Sheffield, DO, is expected to release a report on the state’s prescription monitoring program in December 2018.

Click here to view the report by the Texas House Select Committee on Opioids and Substance Abuse.

The report concluded:

The opioid epidemic and substance use disorder crisis in Texas is real. The data is alarming. Although the substance abuse and opioid crisis facing the state of Texas may not be as statistically poor as is reflected in some other states, Texas faces significant challenges.

Positive steps have been taken in Texas to address problems associated with opioid addiction and substance use disorders, but we must remain vigilant in our efforts to stay ahead of the deadly scourge. Improved prevention practices, better education, enhanced prescription monitoring, better supply management/medication disposal programs, and expanded treatment options, as well as, cooperation from all stakeholders, including manufacturers, prescribers, dispensers and patients alike, is essential for further progress and positive, meaningful and measurable outcomes for our state.

Continued engagement regarding this matter must remain a priority in Texas to maintain the state’s path to prosperity.

This report reflects a great amount of time, study and hard work by the membership and staff of this committee. The document should serve as a catalyst for considerations for enhancement of  current programs, for implementation of new programs, and as a framework for policy changes, legislative & non-legislative, to improve Texas’ ability to respond to the opioid epidemic and prevent further tragedies and costs.

Medicare Unveils Price Procedure Lookup Tool for ASCs and HOPDs

The Centers for Medicare and Medicaid Services (CMS) introduced the Price Procedure Lookup tool, which allows consumers to compare the prices of ambulatory surgery centers (ASCs) and hospital outpatient departments (HOPDs), on November 27.

The tool was created in January 2017 by the 21st Century Cures Act.

Click here to learn more from CMS.

TOA’s Getting to Know: John Hinchey, MD of San Antonio

John W. Hinchey, MD recently joined Ortho San Antonio and recently sat down with TOA to conduct a Q&A to discuss his thoughts on the future of orthopaedics in Texas.

Dr. Hinchey received his undergraduate degree from Southern Methodist University. He later attended The University of Texas Health Science Center at San Antonio (UTHSCSA) for both medical school and residency training.  Dr. Hinchey then continued his training with a fellowship in Shoulder and Elbow reconstruction, where he worked with world renowned surgeons at both UTHSCSA and the Mayo Clinic in Rochester, MN.  He is board certified in Orthopaedic Surgery by the American Board of Orthopaedic Surgery, and is a member of the American Shoulder and Elbow Surgeons (ASES) Association.

Dr. Hinchey treats all orthopaedic injuries, and subspecializes in the treatment of shoulder and elbow issues.

For the past five years, Dr. Hinchey provided care for our nation’s veterans as a full-time orthopaedic surgeon at the Audie L. Murphy VA Hospital in San Antonio, TX.  He currently is the Assistant Chief of Orthopaedics, and the Chief of the Shoulder and Elbow service.  In addition, he is the Assistant Program Director for the Rockwood Shoulder and Elbow Fellowship and holds a position of Adjunct Assistant Professor at UTHSCSA.

Dr. Hinchey is one of the Texas Orthopaedic Association’s five AAOS Board of Councilors.

Christy and John Hinchey, MD with State Senator Dawn Buckingham, MD

The following is a Q&A that TOA recently conducted with Dr. Hinchey.

TOA: What was your experience in the VA like?

John Hinchey: Working at the Audie L. Murphy VA (ALMVA) in San Antonio for the last five years as a full-time orthopaedic physician has been a wonderful experience.  I thoroughly enjoyed taking care of our nation’s veterans and working with the rotating residents and fellows from the associated medical school.  The orthopaedic service line at the ALMVA is a very busy service: We have at least one operating room running and full clinics each day.  I originally decided to join the ALMVA team in 2013 for a variety of factors, but the number one reason was that I could not turn down the opportunity to help take care of our nations’ heroes, while at the same time play a role in the education and training of future orthopaedic surgeons.

TOA: How did you choose your new practice? 

John Hinchey: In late 2017, a colleague and friend presented me with an opportunity to join Ortho San Antonio. I could not pass up the chance to expand my practice, while still assisting veterans at the VA on a part-time basis. Each physician in our group practices a different subspecialty, but we all complement each other, and are encouraged to be involved in “outside activities” we each find meaningful.

TOA: What changes have you witnessed in orthopaedics since you began your residency? 

John Hinchey: Since I started my residency in 2007, I have witnessed a great number of changes over the 10-plus years.  When I started training there were no duty hour regulations, and EMRs were just being talked about.  During my training, I had to transition from paper charts to electronic charts and begin logging duty hours to meet the ACGME requirements.  Oversight of residents has increased, which I feel is a good thing in general, but there still needs to be a graduated ladder of responsibility ultimately ending in essentially full autonomy toward the end of training.

I have seen many advances in “technology” and new implants, most of these without any evidence, just a higher price tag behind them.  I personally still practice by the motto of a mentor and current partner of mine, Jesse DeLee, MD: “Never be the first one to adopt usage of a new product.”  I have also seen aspects of medicine with excellent evidence which have changed my practice, such as the usage of tranexamic acid (TXA) in arthroplasty.

TOA: Where do you see orthopaedics in Texas ten years from now? 

John Hinchey: In my opinion, we will witness a number of changes in medicine over the next decade.  Most of these changes will most likely be legislative and/or regulatory mandated.  For example, there is the legislative mandate to check the Prescription Monitoring Program (PMP) starting in September 2019.  This will be a large change for most physicians, especially those still using paper charts, and the mandate will necessitate interoperability between EMRs and the PMP.  In addition, “scope of practice” issues are always on the legislative watch list.

Christy and John Hinchey, MD with Congressman Will Hurd

Specifically in regards to orthopaedic surgery, I have watched an increase in the number of residents and fellows choosing to be a hospital- or system-employed surgeon after training, compared to the number who are accepting a position with an academic or private practice setting.  I am worried that over time this trend will grow, which could slowly diminish the autonomy of practice.  If this occurs, surgeons may not be able to choose the implants of their choice, they may be told which patients to treat, their practice setting could be limited, and the amount they work may be controlled.

TOA: You are active in the political nature of medicine.  Why is this important to you?

John Hinchey: I am highly involved in what is commonly referred to as “organized medicine” at a local, state, and national level by sitting on multiple boards and committees.  I feel it is very important to protect the doctor-patient relationship, the practice of medicine, and improve appropriate access to care for patients.

As I have always been told, “if you are not at the table, then you are on the menu.”  If physicians do not advocate for the practice of medicine and their specialty, then who will do it for us?  I have seen the direct effects of legislative/regulatory actions which have impacted the way medicine is practiced.  One of the most memorable legislative wins is Texas tort reform in 2003, which changed the medical landscape in Texas by increasing access to medical care and the number of physicians practicing in Texas.  We continuously always have to defend tort reform and showcase its benefits to the public.

Texas Medicaid Proposes New Opioid Limits

The Texas Medicaid Vendor Drug Program has proposed a policy that would apply morphine equivalent dose (MED) limits per day and seven-day limits on opioids opioids that are used to treat acute pain in the state’s Medicaid managed care organizations (MCOs).

The Texas Health and Human Services Commission (HHSC) is accepting comments until November 14, 2018.

The following is the draft policy:

XI. OPIOIDS

Substance use disorder for many, start after initially receiving opioid prescriptions for an episode of acute pain. In an effort to encourage appropriate use and reduce opioid over prescribing, MCOs must adhere to the requirements listed in the sections below.

A. Morphine Equivalent Dose and Day’s Supply Limits

Morphine equivalent dose (MED) per day is used to describe the potency of one opioid to another for comparison. MED per day recommendations vary depending on clients’ prior history of opioid use. Additionally, CDC recommends to start opioid treatment with an immediate-release/short-acting (IR/SR) formulation at the lowest effective dose, instead of an extended-release/ long-acting (ER, LA) formulation.  Prescribing opioids for treatment of acute pain is rarely needed for more than seven days. Opioid prescriptions will be limited to a maximum of seven days for opioid naïve clients. This limitation is intended to reduce the risks of addiction or diversion of unused opioids.

With the exception of members who are receiving hospice care or palliative care, treatment for cancer, individuals who are residents of facilities who dispense drugs through a single pharmacy, or other individuals the state elects to exempt, MCOs must implement the policies listed below.

  1. Opioid naïve is defined as members who have taken opioids for a duration less than or equal to (≤) seven days in the prior 45 day period. For opioid naïve patients, the MCOs must require authorization for:

    a. An opioid prescription if the day supply exceeds seven days.

    b. A prescription for a long-acting opioid formulation.

    c. A claim with the total daily dose of opioids exceeds 90 MED.

    d. Duration of prior authorization approval may not extend beyond the days’ supply of the claim.

  2. For members who no longer meet the definition of opioid naïve, an authorization will be required if the total daily dose of opioids exceeds 90 MED.

B. Retrospective Reviews

MCOs must perform annual retrospective drug utilization reviews on opioid overutilization to monitor prescribers for outlier activities. If the MCO identifies outlier prescribing patterns, then the MCO must conduct a review and, if necessary, an intervention, such as a letter or phone call to the prescriber or a peer-to-peer review between the prescriber and the MCO.

C. Clinical Prior Authorization

HHSC has clinical prior authorization criteria approved by the Drug Utilization Review (DUR) Board related to opioid utilization. MCOs may choose to implement any of the approved criteria listed on the Vendor Drug Website.

Texas HHSC Proposes New Medicaid ASC Rates

The Texas Health and Human Services Commission (HHSC) has proposed new Medicaid rates for ambulatory surgery centers (ASCs).  Click here to download the .zip file for the “Medicaid Biennial Calendar Fee Review” dated January 1, 2019.

The proposal is a mixed bag for orthopaedic ASCs. TOA will join other stakeholders to provide comments.

HHSC will hold a public hearing on November 13, 2018.

TOA Update: Medicare Finalizes 2019 Physician Fee Schedule & ASC/HOPD Rules

The Centers for Medicare and Medicaid Services (CMS) released the final calendar year (CY) 2019 Physician Fee Schedule (PFS) rule on November 1, and CMS modified the controversial E/M proposal. CMS also released the hospital outpatient department (OPPS) and ambulatory surgery center (ASC) final payment policy rule for CY 2019 on November 2.

Click here to view AAOS’s summary of the potentially mis-valued THA/TKA codes.  Click here to view AAOS’s summary of the final Physician Fee Schedule rule.  Click here to view AAOS’s summary of the final ASC/HOPD rule.

In addition, TOA’s coding course on Friday, February 1, 2019 in Houston will cover many of the new coding changes. (Click here for details.)

CMS introduced the concept of eliminating the current E/M system this summer with a proposal that would have resulted in only two levels: level one and a new level to replace the current levels two through five. CMS indicated that this was an attempt to reduce paperwork. In addition, CMS pointed out that several specialties, including orthopaedics, would have witnessed an overall increase. However, certain sub-specialties that rely on the more complex codes would have witnessed a hit.

The initial proposal received tremendous pushback from stakeholders.

CMS’s final rule this week will result in three levels for E/M beginning in 2021:

CMS estimated that if the 2021 E/M policy went into effect in 2019, orthopaedic surgery would witness an aggregate 1 percent increase, hand surgery would witness a 3 percent increase, and podiatry would witness a 10 percent aggregate increase. Meanwhile, anesthesiology as an aggregate would witness a 2 percent decrease and neurosurgery would witness a 1 percent decrease.

Keep in mind that since this has not been scheduled until 2021, extensive changes could be made between now and then.

Axios Vitals summarized it in the following graphic:

Other Physician Fee Schedule and MIPS Issues

AAOS will have an extensive analysis of the rule in the near future.

TOA members should turn to their November 3, 2018 e-mail update for the full background on this issue.

CY 2019 Payment Policy for ASCs and HOPDs: A Big Day for ASCs

CMS finalized its CY 2019 payment policy rule for ASCs and hospital outpatient departments on November 2, 2018, and, as mentioned over the past few months, it was a monumental proposal for ASCs. ASCA, the Ambulatory Surgery Center Association, had been pushing many of these issues for many years.

The greatest victory for ASCs was CMS’s decision to finalize the proposal to align the annual payment update factor for ASCs and HOPDs. In the past, HOPDs received the higher annual market basket update (ASCs received an annual update that was tied to the lower inflation rate). As a result, the gulf between ASC and HOPD payments widened each year. While ASCs will continue to be paid less than HOPD services, that gulf is unlikely to grow every year due to the alignment.

In regards to new ASC services for Medicare in 2019, a dozen cardiac catheterization procedures and five additional procedures performed during cardiac catheterization procedures were added for the CY 2019 final rule.

Musculoskeletal services did not feature a large debate in the 2019 proposal. Last summer featured a debate over adding THA/TKA to ASCs for the 2018 Medicare payment proposal, and CMS eventually backed away from adding them to ASCs. However, CMS is likely to take a look at THA, TKA, shoulders, and some other services for ASCs in future proposals.

Several other musculoskeletal-related issues were confirmed in the CY 2019 final rule, including a lower device intensive procedure threshold and payment for non-opioid pain management therapy (Exparel).

Upcoming ASC vs. HOPD Price Comparison Website

CMS also used this rule as an opportunity to remind stakeholders that the 21st Century Cures Act, which was signed into law by then-President Obama in early 2017, directed HHS to create a website that allows patients to analyze the costs associated with ASCs and HOPDs:

For example, to provide for easier comparisons between hospital outpatient departments and ASCs, as previously discussed in the CY 2018 OPPS/ASC final rule with comment period (82 FR 59389), we stated in the CY 2019 OPPS/ASC proposed rule that we also will make available a website that provides comparison information between the OPPS and ASC payment and copayment rates, as required under section 4011 of the 21st Century Cures Act (Pub. L. 114-255). Making this information available can help beneficiaries and their physicians determine the cost and appropriateness of receiving care at different sites-of-service. Although resources such as this website will help beneficiaries and physicians select a site-of-service, we do not believe this information alone is enough to control unnecessary volume increases.

New Site Neutral Payments for Checks ups (Clinic Visits)

TOA has been talking about the concept of site neutral payments in its newsletters since 2012, so our hope is that every reader understands the concept, which has been embraced by both Democrats and Republicans in Congress and CMS. To summarize, if a service can be paid in two different types of settings, and one setting is being paid at a higher rate, then Medicare will pay for that service at the same rate in any type of facility.

CMS pointed out several stakeholder comments in the final rule’s commentary:

For certain cardiology, orthopedic, and gastroenterology services, employed physicians were seven times more likely to perform services in a HOPD setting than independent physicians, resulting in additional costs of $2.7 billion to Medicare and $411 million in patient copayments over a 3-year period. (Avalere, PAI: Physician Practice Acquisition Study: National and Regional Employment Changes, October 2016.)

This other comment by CMS will help you to understand CMS’s interest in the site neutral payment concept:

In the CY 2015 OPPS/ASC proposed rule (79 FR 41013), we stated that we continued to seek a better understanding of how the growing trend toward hospital acquisition of physicians’ offices and subsequent treatment of those locations as off-campus provider-based departments (PBDs) of hospitals affects payments under the PFS and the OPPS, as well as beneficiary cost-sharing obligations. We noted that MedPAC continued to question the appropriateness of increased Medicare payment and beneficiary cost-sharing when physicians’ offices become hospital outpatient departments and that MedPAC recommended that Medicare pay selected hospital outpatient at PFS rates (MedPAC March 2012 and June 2015 Reports to Congress).

CMS finalized its proposal to extend site neutral payments to clinic visits that are part of hospital outpatient departments for “check ups,” and these represent the most common service billed under the outpatient prospective payment system (OPPS). Per CMS:

Method to Control for Unnecessary Increases in Utilization of Outpatient Services
CMS is exercising its authority to utilize a method to control unnecessary increases in the volume of covered hospital outpatient department services by applying a Physician Fee Schedule (PFS)-equivalent payment rate for the clinic visit service when provided at an off-campus provider-based department (PBD) that is paid under the OPPS. The clinic visit is the most common service billed under the OPPS. Currently, Medicare and beneficiaries often pay more for the same type of clinic visit in the hospital outpatient setting than in the physician office setting.

This policy would result in lower copayments for beneficiaries and savings for the Medicare program in an estimated amount of $380 million for 2019, the first year of a two year phase-in we are utilizing to implement this policy. For an individual Medicare beneficiary, current Medicare payment for the clinic visit furnished in an excepted off-campus PBD is approximately $116 with $23 being the average beneficiary copayment. The policy to adjust this payment to the PFS equivalent rate would reduce the OPPS payment rate for the clinic visit to $81 with a beneficiary copayment of $16 (based on a two year phase-in), thus saving beneficiaries an average of $7 each time they visit an off-campus department in CY 2019.

No Action on New Clinical Families of Services for Site Neutral – Page 658

Congress passed a budget bill that was signed into law on November 2, 2015 that created a site neutral payment policy for certain services at off-campus, hospital-based provider-based department (PBD). Any PBD acquired after the effective date would no longer be paid the higher OPPS fee for certain services.

However, Congress did not make it clear whether a grandfathered PBD could begin offering a new service after November 2, 2015 and be paid the higher OPPS rate for that new service. CMS has indicated its belief that it has the statutory authority to limit new service additions at higher rates if they were not provided in a grandfathered PBD prior to November 2, 2015. However, CMS has received considerable pushback from hospital stakeholders and has declined to move forward at this time: “In response to public comments, we did not finalize our proposal to limit the expansion of excepted services at excepted off-campus PBDs.” (Page 661.)

CMS made the following comment in this rule:

However, while we continue to believe that section 1833(t)(21)(B)(ii) of the Act excepted off-campus PBDs as they existed at the time that Pub. L. 114-74 was enacted, and provides the authority to define excepted off-campus PBDs, including those items and services furnished and billed by such a PBD that may be paid under the OPPS, we are concerned that the implementation of this payment policy may pose operational challenges and administrative burden for both CMS and hospitals. After consideration of the public comments we received, we are not finalizing this policy as detailed below.

CMS commented in the rule:

In the CY 2015 OPPS/ASC proposed rule (79 FR 41013), we stated that we continued to seek a better understanding of how the growing trend toward hospital acquisition of physicians’ offices and subsequent treatment of those locations as off-campus provider-based departments (PBDs) of hospitals affects payments under the PFS and the OPPS, as well as beneficiary cost-sharing obligations. We noted that MedPAC continued to question the appropriateness of increased Medicare payment and beneficiary cost-sharing when physicians’ offices become hospital outpatient departments and that MedPAC recommended that Medicare pay selected hospital outpatient

CMS has CMS proposed to add additional clinical families of services to the excepted (grandfathered) HOPDs that were in place before November 2, 2015 and continue to get paid at the higher OPPS rate for certain services. However, CMS ultimately chose to not do so in this final rule:

In response to public comments, we did not finalize our proposal to limit the expansion of excepted services at excepted off-campus PBDs. (Page 661.)

Further Background on the HOPD/ASC Rule for CY 2019.

Stay tuned for AAOS’s upcoming summary. In addition, TOA’s coding course on Friday, February 1, 2019 in Houston will cover many of the changes – click here for details.

New Workers’ Compensation Neuromuscular Plan-Based Audit

The Texas Department of Insurance, Division of Workers’ Compensation (TDI-DWC) announced on October 12, 2018 that it will conduct a plan-based audit for neuromuscular testing.

Click here to view details of the plan-based audit.

The study will focus on the 10 providers who had the highest number of referrals for neuromuscular testing during the time period of July 1, 2016 to June 30, 2017.

TDI-DWC indicated that the scope will include:

Q&A with Henry B. Ellis, MD

Henry B. Ellis, MD is a pediatric orthopaedic surgeon at the Texas Scottish Rite Hospital for Children’s Center for Excellence in Sports Medicine. Dr. Ellis is an El Paso native who received his medical degree from the University of Texas Science Center San Antonio, conducted his residency at UT Southwestern Medical Center, and completed fellowships at the Steadman Clinic in Vail, Colorado and the Hospital for Sick Children in Toronto.

Dr. Ellis is a member of the AAOS Leadership Fellows Program and also serves on the Texas Orthopaedic Association’s Leadership Council.

Henry Ellis, MD speaking at TOA’s sports medicine panel during the 2018 annual conference

TOA recently conducted an interview with Dr. Ellis to get his thoughts on the future of orthopaedics in Texas. The following is the Q&A:

TOA: Many tend to think of the Texas Scottish Rite Hospital for Children (TSR) as an institution that focuses on scoliosis and other less common orthopaedic conditions. How did you decide to take your sports medicine focus to TSR and its Frisco campus?

HE: TSR has a long legacy of addressing the North Texas community by being a resource for kids with the greatest need.  In the early years, one of the hospital’s primary mission was in the treatment of polio in children.  Since the eradication of polio, we have focused on other orthopaedic problems in kids, such as scoliosis, clubfoot, and hip dysplasia, to name a few.

Now that sports injuries and overuse are such large epidemics in youth musculoskeletal care, Frisco is the right place to continue the mission of care of these kids.  Our main and primary focus is on the skeletally immature athletes and we hope to continue the hospital’s legacy and mission to treat the pediatric patient with the greatest need in our community.

The overwhelming popularity of youth sports that has subsequently evolved to have a resultant increase in pediatric sports-related acute and overuse injuries.  Secondly, newer surgical techniques have been developed and popularized, such as an extra-physeal ACL reconstruction, that have improved our ability to treat young athletes with severe injuries and with open growth plates.

TOA: What is the timeline for TSR’s new facility in Frisco?

HE: Our first patient at the new Frisco campus is on October 10, with the ambulatory surgery center opening shortly thereafter.  Our pediatric physical therapy and sport therapy service with a motion science lab will also begin to treat patients on October 10.  All pediatric orthopaedic specialty clinics will also begin on October 10.

Henry Ellis, MD (middle) speaking to Congressman Michael Burgess, MD during the TOA/AAOS Capitol Hill visit in June 2018

TOA: You have become more engaged in orthopaedic leadership over the past few years through the AAOS leadership, TOA’s Leadership Council, and visits with both TOA and AAOS to Washington, DC. What has surprised you about being engaged in orthopaedic leadership?

HE: The biggest surprise to me has been the value of advocacy and how is relates to my practice and the hospital.  My initial impression was there was little role for an orthopaedic surgeon or its organization to significantly influence more than just reimbursements.  But I have witnessed how TOA and AAOS plays a role in regulatory reform, opioid management, team physician protection, and on and on.   It has now become clear to me that there is an important value of a collaborative effort to protect our specialty.

TOA: What do you tell residents about how to prepare for their future practice?

HE: Once residents begin to get comfortable with the basic of orthopaedic surgery and the musculoskeletal system, they need to start opening their eyes and ears to the “how” to build a successful practice.  I learned most of my tricks in billing, not from a course, but from constantly asking mentors how they coded or billed for something or the finances behind their practice (ie overhead cost).

Secondly, no one in residency specifically teaches the importance of securing referral patterns.  There is an old saying (also referred to as the three “A’s” of medicine) that one must be available, affable, and able. This includes all phones calls, texts, or emails from referring providers no matter how frustrating or inconvenient it is at the time. Too often in residency we got over burdened with calls for, what we thought, were insignificant consults. When starting a practice, these “insignificant consults” become valuable and you will transition your response to be more welcoming to develop a relationship with the referring provider.

TOA: You have many years of practice ahead of you in the Dallas-Fort Worth area. Looking into your crystal ball, what do you see for the future of orthopaedics in Texas?

HE: Tough question. Telemedicine will certainly be an invaluable and integral part of an orthopaedic surgeon’s practice, and especially in Texas with the large rural countryside and underserved areas. During our recent trip to DC, Congressman Beto O’Rourke asked us (TOA) how we could recruit quality orthopaedic surgeons to rural Texas.  As we know the answer may be complex, however, telemedicine would certainly allow for a provisional discussion with a patient, video examination, and radiographic review. Telemedicine will be in the future of orthopaedics in Texas and not only for rural Texas, but for urban urgent care consultation or for a follow up assessment. There is no substitute for a live history and physical for definitive treatment recommendations, but we make many of our decision today largely based on the x-ray and MRI.  I have used a limited version of telemedicine and have found value, convenience, and patient satisfaction with its use.

Texas Legislature to Review the Texas Prescription Monitoring Program

A special committee of the Texas Legislature chaired by State Senator Charles Schwertner, MD and State Representative JD Sheffield, DO will meeting on October 3, 2018 to review the state’s prescription monitoring program (PMP). Click here to view TOA’s position paper.

Medicare Proposes Favorable New Rules for ASCs

The Centers for Medicare and Medicaid Services (CMS) released proposed changes to the Conditions of Participation for ambulatory surgery centers (ASCs), hospitals, and other segments of the health care industry on Monday. CMS indicated that it has gathered feedback from stakeholders, and this proposal would address 55 percent of the issues. As a result, CMS may release more proposals in the future.

The proposal indicated that it is addressing several issues that the ASC Association brought to CMS’s attention. Click here to download the proposal.  Click here to read CMS’s fact sheet.

ASC Transfer Agreements with Hospitals
The proposal would eliminate the requirements for ASCs to have a written transfer agreement with hospitals or physicians performing services at ASCs to have privileges at transfer hospitals. CMS indicated that this policy has been “rendered obsolete by other patient protections.”

Per CMS (page 9 and page 27):

We propose to remove the requirements at 42 CFR 416.41(b)(3), “Standard: Hospitalization.” This would address the competition barriers that currently exist in some situations where hospitals providing outpatient surgical services refuse to sign written transfer agreements or grant admitting privileges to physicians performing surgery in an ambulatory surgical center (ASC). The Emergency Medical Treatment and Labor Act emergency response regulations would continue to address emergency transfer of a patient from an ASC to a nearby hospital.

New ASC Requirements for H&P
Per CMS (page 9 and page 27):

We propose to remove the current requirements at § 416.52(a) and replace them with requirements that defer, to a certain extent, to the ASC policy and operating physician’s clinical judgment to ensure that patients receive the appropriate pre-surgical assessments tailored to the patient and the type of surgery being performed. We still would require the operating physician to document any pre-existing medical conditions and appropriate test results, in the medical record, which would have to be considered before, during and after surgery. In addition, we have retained the requirement that all pre-surgical assessments include documentation regarding any allergies to drugs and biologicals, and that the medical history and physical examination (H&P), if completed, be placed in the patient’s medical record prior to the surgical procedure.

It is important to note the commentary by CMS on page 33:

Our proposed change would simply eliminate the requirement for a pre-operative H&P, while allowing patient-specific physician decisions and ASC-wide policy decisions to determine what examinations and tests are necessary for each patient. Such decisions could be informed by specialty societies, medical literature, past experience, or other factors. We believe the proposed changes will reduce burden and provide flexibility for patients while maintaining a balance of health and safety requirements for providers.

In reading the discussion that follows, it is important to understand that the requirement for making a patient assessment at the ASC, on the day of surgery and before surgery commences, remains unchanged. This assessment addresses any new surgical risks for the patient with procedure-specific or patient-specific questions (for example, has the patient had a fever in the last 24 hours or, for a patient with diabetes, have there been any recent changes to random blood glucose levels with at-home monitoring?). The questions focus on any recent changes or updates to the patient’s condition since the last H&P that might adversely impact the outcome of the procedure for the patient. This assessment must occur before proceeding with the procedure. Furthermore, we are not proposing to eliminate or discourage comprehensive pre-surgical H&Ps where warranted. To replace the current arbitrary 30-day rule applying to all patients, regardless of procedure or risk, we propose that each facility make an independent determination as to which procedures and which patient profiles would dictate requiring a …

New Hospital H&P for Outpatients
Per CMS (page 10):

We propose to allow hospitals the flexibility to establish a medical staff policy describing the circumstances under which such hospitals could utilize a pre-surgery/pre-procedure assessment for an outpatient, instead of a comprehensive medical history and physical examination (H&P). We believe that the burden on the hospital, the practitioner, and the patient could be greatly reduced by allowing this option. In order to exercise this option, a hospital would need to document the assessment in a patient’s medical record. The hospital’s policy would have to consider patient age, diagnoses, the type and number of surgeries and procedures scheduled to be performed, comorbidities, and the level of anesthesia required for the surgery or procedure; nationally recognized guidelines and standards of practice for assessment of specific…

CMS Asks for Additional Comments on ASCs
CMS placed a strong emphasis on ASCs in this summer’s calendar year (CY) 2019 Medicare payment proposal for ASCs and hospital outpatient departments when CMS pushed favorable proposals for ASCs. In this latest proposal, CMS hinted that it will introduce future initiatives that are favorable for ASCs:

We seek to reduce burdens for health care providers and patients, improve the quality of care, decrease costs, and ensure that patients and their providers and physicians are making the best health care choices possible. Therefore, we are soliciting public comments on additional regulatory reforms for burden reduction in future rulemaking. Specifically, we are seeking public comment on additional proposals or modifications to the proposals set forth in this rule that would further reduce burden on ASCs and create cost savings, while also preserving quality of care and patient health and safety. Consistent with our “Patients Over Paperwork” Initiative, we are particularly interested in any suggestions to improve existing requirements, within our statutory authority, where they make providing quality care difficult or less effective.

Unified and Integrated Quality Assessment System for Hospitals
CMS is proposing to allow multi-hospital systems to have a unified and integrated Quality Assessment and Performance Improvement system and a unified infection control program for all member hospitals.

Portable X-Ray Services
CMS made new proposals related to portable x-ray services, which are primarily used for chest and extremity studies in nursing homes, long-term care facilities, and homebound scenarios. CMS is proposing to remove certain training requirements for radiological technicians.

Q&A with David Brigati, MD

David Brigati, MD is a fellow in adult reconstructive surgery at the Dell Medical School at the University of Texas at Austin. Upon completion of his fellowship, Dr. Brigati hopes to go into practice in the Fort Worth area.

Dr. Brigati, a Texas native, performed his orthopaedic residency at the Cleveland Clinic. He performed his undergraduate work at Washington University in St. Louis and attended medical school at the University of Texas Health Science Center at San Antonio.

The following is a recent Q&A that TOA conducted with Dr. Brigati about his views on the future of orthopaedics in Texas.

TOA: What was it like to leave Texas for your residency and train at the Cleveland Clinic?

David Brigati: It was an incredible privilege to train at Cleveland Clinic on so many levels:

(1) The amazing medically and surgically complex patients that come to a quaternary referral center.

(2) The 61 diverse teaching staff specialty practices, including 12 high-volume joint surgeons each with their own styles/techniques.

(3) The well-rounded hospital settings including academic referral, orthopedic-focused subspecialty, small community, and county-funded trauma.

(4) The massive infrastructure care delivery innovation with vertical integration of a full suite of health resources including a tiered system of 11 hospitals, an inpatient rehab / skilled nursing center, their own home health providers, and a network of community outpatient health centers for preoperative optimization and outpatient follow up.

(5) Not least of all was the gem of a city itself with an unbelievably low cost of living on a resident salary, incredible performances by the Indians and the Cavaliers (both treated by Cleveland Clinic Orthopedics, a nice perk), and the most welcoming House Staff Spouse and Family association that I have ever seen!

I couldn’t be more pleased with my residency. I will never forget these once-in-a-lifetime training experiences that I was lucky enough to land and look forward to joining an incredible cast of alumni that I will interact with for decades to come.

TOA: What brought you back to Texas for your fellowship?

David Brigati: While I was born in Candyland (Hershey, Pennsylvania), I grew up in Fort Worth, Texas since the age of 9. This was also where I met my fantastic high-school sweetheart wife. After four grueling years of long distance undergraduate training (I was at Washington University in St. Louis and she was the University of Texas in Austin), I was eager to come home for medical school in San Antonio, which is where we eventually married during my fourth year. Five wonderfully cold years of residency plus an additional research year in Cleveland during which we added my two daughters Eloise (4) and Penny (2.5) to the family only made the decision to move closer to my parents, in-laws, siblings and cousins easier.

Since fellowship is a match, I was ecstatic to learn I could return to Texas one year earlier while getting to train with some incredible faculty in Kevin Bozic, Karl Koenig, and Randall Schultz at the brand-new Dell Medical School at the University of Texas at Austin. After the year in Austin, I intend to return back home to my favorite place on Earth, Fort Worth, Texas to start a joints-focused practice surrounded by my extended family.

TOA: Your focus is arthroplasty. Have you witnessed any major trends in arthroplasty since the beginning of your residency?

David Brigati: A better question might be: What hasn’t changed in hip and knee replacement during the seven years I have been in orthopedics? While the fundamental surgical principles and overall good outcomes remain, everything else has been flipped on its head! I began residency right when Cleveland Clinic was finishing the design of their hip and knee replacement “Carepath,” which is aimed at reducing unnecessary interprovider care variation while encouraging the adoption of evidenced-based best practices, and right before they started their first delve into the Bundled Payments for Care Improvement initiative.

It was mind-boggling to watch mid- and late-career established joint surgeons wrestle over having to abandon what was considered outdated dogma from their past and the modern “uncomfortable” best practices that would result in reduced costs while maintaining their outcomes. I watched our average length of stay plummet from 3.5 days to 1.2 to 2.3 days, depending on the hospital, in just over eight months! I watched our message change from “you may need a couple weeks at a skilled nursing facility” for 66 percent of our patients to “home with your loved ones help is the best place to recover” for 85% percent of our patients again over about 8-12 months.

Then, just when I thought that the massive infrastructure vertical integration approach of Cleveland Clinic was the only path forward to survive in these daunting modern times, I joined the young and agile Dell Medical School in Austin. These folks are taking it to a whole new level … forget just focusing on hip and knee replacement SURGERY, they are solving the much more important societal need for 360 degree musculoskeletal health! I stand side-by-side every day in the “lower extremity” clinic with a social worker, physical therapist, nurse practitioner, physician assistant, radiology technician, medical assistant and joint surgeon caring for a wider range of pathology than was ever previously possible. As surgeons, we all have patients every day that we say to ourselves, “I wish I could help this person, but I can’t change their social situation and mental health that are driving down their quality of life.” This is exactly what the Dell Medical School at the University of Texas at Austin is doin … and doing well!

TOA: As somebody who is finishing up his fellowship and about to go into practice, how do you view the future of orthopaedics in Texas?

David Brigati: The future of primary and revision joint replacement is bright, and I am thrilled to be finishing fellowship training soon. Texas is a great place to practice because all three major models are available, including academic/employment/salary-based opportunities, small group private practice, and large both single and multi-specialty private practices. I can’t say the same is true in other markets that I have seen, so I’m counting my blessings. Yet with great choices comes big decisions. There are certain tenets of modern practice success that I believe I will need to find as I try to identify my best future opportunity more or less in this order: (1) integrity, (2) economy of scale, (3) multidisciplinary teams, and (4) adaptive.

Above all else in medicine, every member, partner, or associate of your practice must have the highest level of professional integrity – otherwise any reputation or success unequivocally will falter. Modern practice requires a certain economy of scale with sufficient volumes to keep the care team engaged daily in process improvement, the hospital interested in resource investment, the payers responsive to your initiatives, and patients excited about your progress. Thus, I need to identify joints partners willing to merge our care algorithms and volumes to leverage our success. Multidisciplinary teams are the only way to succeed in modern practice, and they involve diverse clinical care members, IT support for quality reporting, hospital leadership for navigating the changing healthcare landscape as it affects your practice, and contracting support to formalize care partnerships in bundled payment environments. Finally, and most challenging, is a balance that involves having enough physical infrastructure to support your busy practice while remaining agile enough to quickly change direction as the rules, laws, regulations, and policies surrounding your practice oscillate and morph. The good news is that all of these tenets are available in all three major practice types, but with important caveats that I am learning more about every day.

In summary, I am looking to join a practice with high integrity physicians who are willing to merge our best practice ideas to drive down our variability and costs while keeping up our procedure volumes and quality who are invested in a team approach to success while remaining open to the changes that will certainly come our way as physicians in the modern era.

Texas Begins Re-Write of Trauma and Stroke Rules

The Texas Department of State Health Services (DSHS) will dedicate the rest of 2019 and 2020 to re-writing its trauma and stroke rules. TOA is joining the Texas Medical Association and other stakeholders to make recommendations.

DSHS has announced the following stakeholder meetings for the rest of 2019:

Orthopaedic Residents Go to Capitol Hill

Three members of TOA’s Residency Council – Max Danilevch, MD (UTMB), Jacob Murphree, MD (Texas Tech) and Joey Romero, MD (UT Southwestern) joined the Texas Orthopaedic Association for its annual trip to meet with the Texas Congressional Delegation on Capitol Hill in June 2018.

The three orthopaedic surgeons … click here to view the entire article.

TOA’s 2019 Annual Conference

Click here for the latest info for our upcoming 2019 Annual Conference.

Sponsorship details are coming soon!

Medicare Extends Site Neutral Policy in 2019 HOPD/ASC Payment Proposal; ASC Victories

A discussion related to approving hip and knee replacement surgeries for Medicare payment in ASCs dominated last year’s hospital outpatient department (HOPD) and ambulatory surgery center (ASC) payment proposal for Medicare. (Ultimately, CMS simply removed TKA from the inpatient only list.) The 2019 proposal, which was released on July 25, 2018, only addressed the anesthesia portion of TKA.

A new site neutral payment proposal that focuses on standard office visits (HCPCS code G0463) and potential new victories for ambulatory surgery centers (ASCs) have made the biggest headlines in the 2019 proposal. Under the 2019 proposal, the Ambulatory Surgery Center Association (ASCA) achieved most of its advocacy goals.

TOA members have been provided a lengthy proposal of the summary, which includes:

Practice Perspective – Data-Based Management’s Effect on Staffing and Duty Allocation

By Joseph Mathews

How much is just enough? This is an ongoing conversation for practices regarding staffing as we face lower profit margins, increasing overhead and patient populations that demand both quick processes and high levels of customer service. However, this conversation and the decisions that follow can become less tedious and stressful if practices can begin to use data as their guide.

Using benchmarks from MGMA (Medical Group Management Association) and orthopedic-specific resources like AAOE (American Alliance of Orthopaedic Executives) and OrthoForum/OrthoConnect, our practice has not only established certain service levels for our scheduling departments (as mentioned in the previous article), but we have used collected data to determine the appropriate staffing levels and duty allocations. As a result, we assess these levels on a regular basis.

Benchmarking suggested that one full-time staff member should be able to handle 70 to 80 calls with full patient registration each day. Using the reporting features of our new, comprehensive phone system, we are able to assess call volume on a daily basis and develop strong reporting models that help identify trends that dictate the practice’s needs. For example, we are able to determine that normal monthly call volume is 8,000 to 10,000 calls, which averages to 400 to 475 calls per day in a 21-day working month. Benchmarking standards then determine that in the busiest month we will need roughly five to six full-time staff to cover this volume. However, the data allow us to dig even further.

Daily data collection assesses specific trends for each working day to establish our busiest and slowest periods. This allows for more finite assessment of practice staffing needs per day. For example, we determined that Monday, Tuesday, and Wednesday are our busiest call volume days, and this requires the six full-time staff members to function in our appointment cue. However, Thursday and Friday often only necessitate five staff members. So, what are we to do with the other staff member?

This data need-based assessment allows for staffing models that specifically account for these volume changes by hiring only five full-time staff and one part-time staff to cover the busier days. Another option would be to cross train other available staff in medical records or associated departments and management to assist on the busiest days by offloading other duties or stepping into the cue to field calls. These assessments can be completed as frequently as is deemed necessary – the data are readily available. That may mean monthly or when turnover and rehiring occurs, but it allows for better decision making that combats some of the challenges that practices face.

Data-based management helps to take out the guess work and establishes clear standards for the staff necessary to efficiently manage workloads and allocate duties. This also helps accountability as we expect our staff to perform at a service level (calls answered by a live person in the first minute) at 90 percent or better; and we want to “right size” the department by helping them to achieve the quality metric required. We’ll have more about service levels in future articles.

Joseph Mathews, PT, DPT is the practice administrator for Advanced Orthopaedics and Sports Medicine in the Houston area. In addition to serving on the Texas Orthopaedic Association’s Board of Directors, he serves on the American Association of Orthopaedic Executives’ Advocacy Council.

Medicare’s 2019 Physician Fee Schedule and Quality Payment Program Proposal Released

The Centers for Medicare and Medicaid Services (CMS) released the calendar year 2019 payment rule for the Medicare Physician Fee Schedule (PFS) and Quality Payment Program for MACRA on July 13, 2018. Comments are due on September 10, 2018.

TOA’s members are invited to review TOA’s analysis of the proposal, which can be found in the e-mail newsletter or by visiting the website.

The following proposals relate to orthopaedics in the proposal:

Practice Perspective: Data-Based Management of the Patient Experience; Starting with Scheduling

By Joseph Mathews

While the patient experience should begin with a seemingly uncomplicated call to schedule an appointment, the patient journey is often marred by hard-to-understand greetings and instructions, abandoned calls, being sent to voicemail, or sitting on hold for long wait times while listening to a barrage of promotions about the organization. These are quite often the result of the “shackles” placed on practices by technology or other complex details of their practice workflows. So, how can collecting data and managing each of these processes from this perspective change the patient experience?

In 2013, our practice began establishing benchmarks for an expected service level in our scheduling department by using data that we had. This helped us determine what we would need moving forward. Service level was calculated as the percentage of calls answered within the first minute by a live person. We identified our “shackles” and began to realize that many other practices experience the same struggles:

While we could not fix everything, our practice began to address the items we could control. We moved to a more comprehensive phone system that allowed for more extensive data collection and meaningful reporting, established more effective call routing, created a common appointments que, and established the ability to research calls and call history. We were even able to monitor calls in real time.

We made modifications to our main company greeting that ultimately decreased the length from one and a half minutes, which we previously allocated as “wait time” for the patient, to only 30 seconds.

Our phone tree was in essence a que within a que that required patients to press various buttons to simply reach the correct person who could schedule for physician. Once the patient reached the correct phone line for the scheduler, the patient then had to wait on that extension until their call could be answered. We used call data to analyze and manage our phone tree more efficiently, making it less complicated and reducing patient’s extended hold time. The modified phone tree removed all prompts and allowed for scheduling to be done by the employee who answered the call. This also led to a more capable and multi-faceted staff that is able to handle scheduling for all our physicians, thus adding value to their roles within the practice.

We further addressed the demands of our medical teams by spreading some responsibilities to the medical assistants and moved towards standardization of our physician protocols by decreasing the amount of triage performed at the appointments level. We focused on empowering our scheduling staff through increased training and support, minimizing the additional duties that they were assigned, and removing some of the rules that previously prevented them from attaining the highest levels of productivity and efficiency.

All aspects of the patient scheduling experience were benchmarked, and parameters for tracking and reporting were established. The parameters include average time to answer calls, average time to call abandonment, percentage of voicemails left, total of abandoned calls and total calls received. This has allowed for a stronger management approach where we are able to go beyond month-to-month analysis and measure on a day-to-day basis, which allows for improvement on a daily basis. The journey was tedious, but the move to data-based management increased our scheduling service level from 58 percent in 2013 to 84 percent in 2017. We now have measureable and attainable goals for our staff, managers, and practice to ensure that every point of the patient experience reflects our desire for excellence.

Joseph Mathews, PT, DPT is the practice administrator for Advanced Orthopaedics and Sports Medicine in the Houston area. In addition to serving on the Texas Orthopaedic Association’s Board of Directors, he serves on the American Association of Orthopaedic Executives’ Advocacy Council.

 

Texas Medical Board Approves Protections for Team Physicians

The Texas Medical Board (TMB) approved a rule on June 15, 2018 that will recognize the out-of-state licenses for team physicians when they travel with their teams to Texas. Texas joins over 35 states that have passed similar measures.

State Senators Charles Schwertner, MD and Don Huffines and State Representative Bobby Guerra worked with TOA to pass the rule.

Click here to read TOA’s support letter.

TOA in Washington DC

Every year, over a dozen Texas orthopaedics go to Washington, DC to participate in the American Academy of Orthopaedic Surgeons’ National Orthopaedic Leadership Council (NOLC) to educate the Texas Congressional Delegation about musculoskeletal issues that affect Texans.

On June 7, 2018, Texas orthopaedic surgeons will discuss two Medicare issues that are specific to Texas – bundled payments (BPCI-Advanced and CJR) and a September 2017 Medicare hospital survey memo that affects some surgical hospitals.

In addition, the orthopaedic surgeons will be discussing three issues that orthopaedic surgeons in other states will be discussing with their Members of Congress: opioids, Good Samaritan liability laws, and regulatory burdens.

More information about issue can be found below.

BPCI-Advanced/CJR Conflict

Medicare’s September Hospital Survey Memo

Opioids & AAOS

Good Samaritan Liability Laws & AAOS

Regulatory Burdens & AAOS

Orthopaedics in Texas: Area Snapshots
Amarillo Austin DFW Harris County
Harris County Suburbs Lubbock San Antonio Tyler • Longview

TOA & AAOS Support Texas Medical Board’s Team Physician Proposal

Andrew Palafox, MD of the Texas Orthopaedic Association and David Halsey, MD of the American Association of Orthopaedic Surgeons submitted a letter to the Texas Medical Board in support of its proposed rule that would recognize the out-of-state licenses of team physicians when they travel with their teams to Texas for athletic competitions.

The move follows similar efforts in dozens of other states that recognize the licenses of Texas’ team physicians when they travel with Texas teams to other states.

Representative Bobby Guerra and Senator Don Huffines introduced legislation in the 2017 Texas Legislature.

Click here to view the letter from TOA and AAOS.

A Look at the Center for the Intrepid with Joseph F. Alderete, MD

Col. Christopher J. Roach, MD, FAAOS – the chair of the Department of Orthopaedics at the San Antonio Military Medical Center – presented on the Center for the Intrepid (CFI) at the Texas Orthopaedic Association’s 2018 Annual Conference.

Click here to view Dr. Roach’s PowerPoint presentation from the conference.

The following is a Q&A that TOA performed with Joseph F. Alderete, MD.

TOA: Why was the CFI created?  What makes it different from existing centers?  

 Joseph Alderete: In the spring of 2005, Arnold Fisher and the board of directors of the Intrepid Fallen Heroes proffered a rehabilitation facility. Secretary of the Army Harvey accepted the proffer, and funds for the facility were received from over 600,000 Americans. Ground was broken for the four-story, 65,000 square foot outpatient rehabilitation facility and two new 21 handicap accessible suite Fisher Houses on 22 September 2005. The ribbon cutting for the CFI and the new Fisher Houses was held on 29 January 2007 and patient care began in the facility on 15 February 2007.

The threefold mission of the CFI is to provide rehabilitation for OIF/OEF casualties who have sustained amputation, burns, or functional limb loss, to provide education to DoD and Department of Veteran’s Affairs professionals on cutting edge rehabilitation modalities, and to promote research in the fields of Orthopaedics, prosthetics and physical/occupational rehabilitation. The staff and equipment for the building were selected to provide the full spectrum of amputee rehabilitation, as well as the advanced outpatient rehabilitation for burn victims and limb salvage patients with residual functional loss.

Through the collaboration of a multi-disciplinary team, we will provide state-of-the-art amputee and limb salvage care, assisting our patients as they return to the highest levels of physical, psychological and emotional function.

The Intrepid is so special because it is run by a partnership of Orthopedic Surgeon and Physical Medicine and Rehabilitation doctors, and employs the most experienced prosthetists, physical therapist, occupational therapist, and behavioral health providers to facilitate optimal care in targeted medicine.

TOA: Many of the trauma cases that you witness in the military are different than what an orthopaedic surgeon in the civilian world may encounter.  What lessons have you learned from military orthopaedic trauma cases that could translate to civilian trauma cases?  

JA: We have set the bar for limb salvage in massive trauma by incorporating advanced resuscitation, tissue regeneration and regenerative medicine to facilitate limb salvage. The IDEO, or Intrepid Dynamic Exoskeletal Orthosis, was designed and is manufactured at the Intrepid to offload arthrosis, skin or skeletal defect, or neuropathic pain making limb salvage easier. When limb salvage is not possible, we have learned the most optimal amputation techniques for facilitating high levels of function to include advanced tissue myodeses, targeted muscle reinnervation for both neuromotor control of prosthetics, as well as relief of neuroma related pain, and finally Osseointegration.

TOA: What new research is being conducted at the CFI?

JA: We are looking at the use of artificial intelligence through Department of Energy supercomputing capability to interpret raw clinical data made pre-hospital, en-route care, initial resuscitation, and then transport through the echelon continuum of care to predict life threatening medical conditions or en-route complications in evacuation to a military treatment facility.

TOA: If orthopaedic surgeons wanted to visit the Intrepid to learn more about what you are doing, would it be possible for orthopaedic surgeons to visit you?

JA: Absolutely, please reach out to joseph.f.alderete.mil@mail.mil or snjalderete@gmail.com. I would be happy to arrange a tour and we welcome military-civilian collaboration in forwarding the science of Orthopaedics and Trauma care.

Joseph F Alderete MD
LTC, MC
Chief, Orthopaedic Oncology
Surgical Director, Center for the Intrepid San Antonio Military Medical Center
Office 210.916.7627 Pager 210.513.9797

TMB Proposes Protection for Team Physicians

Rep. Bobby Guerra (D-McAllen) and Sen. Don Huffines (R-Dallas) pushed legislation in the 2017 Texas Legislature that would direct the Texas Medical Board (TMB) to recognize the out-of-state physician licenses for team physicians when they travel to Texas to provide support for their teams while in Texas. The legislation died due to un-related matters.

TOA believes that this issue is important because it will encourage other states to pass similar measures to recognize the Texas licenses of our team physicians when they travel to other states.

Sen. Charles Schwertner, MD, the chair of the Senate Health and Human Services Committee, directed TMB to develop a rule to recognize these out-of-state licenses. As a result, TMB published a proposal on March 23, 2018 to do so.  TMB’s next meeting – June 15, 2018 – is the earliest date that TMB can accept this proposal.

Q&A with Don Buford, MD

Don Buford, MD, Director, Dallas PRP and Stem Cell Institute is a board-certified orthopaedic surgeon who has been practicing in the Dallas area for 18 years. He grew up in Los Angeles and attended Stanford University. While at Stanford, he was a member of the baseball team and had a double major in economics and pre-med. He eventually transferred to USC to continue his athletic and academic pursuits.

In 1998, he was awarded the Woody Hayes NCAA Division I Academic All-American Award, which recognized the single most outstanding NCAA Division I male student-athlete. After graduation from USC, he signed his first professional baseball contract with the Baltimore Orioles. At the same time, he enrolled a UCLA Medical School.

After graduating from the UCLA School of Medicine, Dr. Buford completed an orthopaedic residency at UT Southwestern in Dallas. Dr. Buford also completed a one-year sports medicine fellowship at the Southern California Orthopaedic Institute.

Dr. Buford’s practice includes a specialization in non-surgical orthobiologic injections for orthopaedic conditions such as joint pain, back pain, and sports injuries.

The following is a Q&A that TOA performed with Dr. Buford on the stem cell issue.

TOA: Can you talk about the promise of stem cells in orthopaedics? How could they improve the treatment of orthopaedic conditions?

DB: Advances in orthopedics over the past 125 years have primarily resulted from advances in materials, implant design, and surgical techniques.  We are now at an exciting time in orthopaedics where we are learning how to repair and restore the musculoskeletal system by using human biology.  As orthopaedic physicians, our goal is to return the body back to its pre-injury or pre-dysfunctional state.  For many orthopaedic conditions we have reasonable nonsurgical and surgical options to accomplish our goal.  However, after 150 years of modern orthopedics, there are many orthopedic injuries and degenerative conditions where our current solutions can still be significantly improved.

The allure of using stem cells and human biology is that we can better restore the body to its pre-injury or pre-dysfunctional state by harnessing biology that all of us have access to already.  In the near future there may be many conditions where our understanding of stem cells and human biology gives us a treatment option better than current nonsurgical and surgical choices.  There may also be situations where surgical outcomes can be improved by using stem cells and human biology at the right time and in the right “amounts” to get a superior outcome to surgery alone.  A lot of the basic science and translational research is ongoing and being clinically evaluated right now …. making this an exciting time to be a physician specializing in orthopaedics.

TOA: How are stem cell treatments effective? What are the potential risks or side effects?

DB: In my opinion, there continues to be some misperception regarding what stem cells actually do in current orthopedic clinical treatments.  In the lab, there are ways to make stem cells differentiate into many different orthopaedic tissues, and, in fact, this is one of the ways that we identify harvested cells as stem cells.  However, once injected into the body, stem cells do not simply differentiate into tissues as might be suggested by what happens in the controlled lab environment.  Stem cells make proteins called cytokines that have many effects on cell communication and control of our body’s healing response.  In fact, many researchers and clinicians now believe that it is the production of appropriate cytokines in an area of orthopaedic injury or degeneration that is the most important role of stem cells.  The most important role of the stem cell in orthopaedic applications may be to function as the producer and manager of the local cytokine environment.  For example, I never tell patients that a stem cell therapy will regenerate the cartilage in an arthritic joint, and, in fact, I think we are doing patients a disservice if we are giving them that expectation.  However, I do think it is currently accurate to counsel patients with arthritis that a stem cell injection can give them years of significant pain relief and possibly even slow the progression of arthritis.  There is good clinical data supporting the effectiveness of stem cells for restoring discrete cartilage defects in a joint, but it still isn’t appropriate to conclude that an arthritic joint can be restored “like new” with current stem cell treatments.  Wherever we are injecting stem cells, it is likely their local cytokine production that is the more important feature that is giving good clinical results.  Of course, some cells may be “transforming” into other tissues, but overall I think the current orthopaedic thought trend is that stem cells have their biggest clinical impact by modifying the local healing environment.

Orthopaedic physicians are continuing to do clinical research to show effectiveness and to compare stem cell therapies to other established alternatives.  For degenerative orthopaedic conditions like knee arthritis there is mounting published evidence that a stem cell therapy can provide pain relief and some functional improvement to patients who don’t have other better options.  Although we have the potential to impact nearly every orthopaedic condition by using stem cells, the human clinical trials to prove success are only now being designed and started for many orthopedic conditions.  There will be more interest and earlier published results in those areas where current treatment options leave significant room for improvement or that affect a larger number of people.  Arthritis will be at the forefront for ongoing research because it is a universal orthopedic condition responsible for disability and a source of significant expense for society.

The good news is that many independent researchers have published on the safety of bone marrow and adipose derived stem cells in orthopedic uses. However, current regulations in the USA preclude the use of adipose derived stem cells in orthopedics without significant additional regulatory approval so we continue to use bone marrow as our source for stem cells.

For orthopedic uses where the cells are injected into a joint or into soft tissues such as ligament, tendon, muscle…these procedures have been shown to be very safe with minimal risk of infection or disease transmission since the cells are from the same patient (autologous).  In the United States, we cannot culture stem cells or bank stem cells and give them back to the patient without significant additional regulatory approvals.  As a result, we give patients back their stem cells on the same day and this is a very safe orthopedic procedure.

TOA: Can stem cells regrow cartilage in a joint with arthritis?   If not, what evidence is there that stem cells are useful for cartilage injuries?

DB: For a defined cartilage defect, there are excellent clinical studies supporting the conclusion that the stem cells need to be held in the defect with a “patch” or a biologic scaffold.  Orthopedic surgeons have been using autologous chondrocytes for cartilage lesions for nearly two decades.  However, the procedure required 2 surgeries and was technically challenging and was expensive.  More recently we have an allograft chondrocyte product (cartilage cells) on the market in the USA that also requires a biologic glue to hold the cells in place in the cartilage defect.  This new option eliminates the need for a second surgery and is cheaper than the prior solution with autologous cultured cartilage cells.  In Italy, there has been exciting clinical research showing restoration of articular cartilage defects in the knee by using a scaffold soaked in autologous stem cells and placed in a single surgical procedure.  The results were followed for a minimum of two years and the success rate is above 80%.  The exciting aspect of using stem cells for cartilage injuries is that the cartilage that regrows appears to be nearly identical to normal articular cartilage.  The scaffold used to hold the stem cells in place in the cartilage defect is currently in clinical trials in the USA and if approved it will be more evidence of how we can use stem cells in conjunction with surgery to actually lower cost even further and improve outcomes for patients.   In the outpatient, nonsurgical setting, we don’t have a way to hold the stem cells in position in a defect so most outpatient research and treatments are for patients with more generalized cartilage loss as seen in arthritis.  There are other surgical concerns and options for treating patients with cartilage injuries, but the prospect of using autologous stem cells as a major part of future treatment is exciting.

TOA:  Is harvesting patient’s stem cells one of the hurdles that is hindering their widespread use? Are stem cells obtained from donors safe for recipients? 

DB: In my clinic, we harvest bone marrow to make a stem cell injection in a safe one hour procedure done under local anesthesia and ultrasound guidance.  We have done many hundreds of these procedures in the office which makes it convenient and less stressful and more affordable for patients.  As a result, I don’t think the hurdle of harvesting stem cells should hinder their widespread use.

In the USA, the are several factors that limit the more widespread use of stem cells in orthopaedics:

  1. There is a lack of published human outcome data comparing stem cell therapies to current established therapies.
  2. Stem cell procedures are not covered by insurance.
  3. Stem cell procedures are relatively expensive to the patient….the average cost for one joint in the USA is about $4000.
  4. The legitimacy of stem cell therapies has been hurt by the rise of retail “clinics” in the US selling amniotic and umbilical cord products as a “stem cell” therapy.  These clinics either violate FDA regulations on allograft living cell transplants or in fact do not have living stem cells when given to the patient.  Unfortunately, as these clinics are continually exposed, the media and patients get the message that all stem cell procedures are “shams”.

For clinicians with no training in harvesting bone marrow, training and mentoring is necessary to make sure they understand how to do an effective bone marrow aspiration and concentration to maximize stem cells and cytokines and to minimize the red blood cells in the final product.  Based on established human biology and published human outcome studies, I strongly believe that the best bone marrow stem cell product requires centrifuging the bone marrow in a process that takes about 12 minutes in the office.

The use of stem cells harvested from donors, so-called allograft stem cells, may be safe for recipients but in my opinion the risk profile must be clinically well defined first. Doctors and patients need to know exactly what the risks and benefits are for an allograft stem cell procedure in order to properly judge when to use it.  We need to ensure safety and we need to ensure that the transplanted cells will not bring any risk of infection, rejection, or tumors.  There are many ethical concerns surrounding embryonic stem cells and their overall safety may be harder to define.  As a result, researchers are looking at other ways to “make” or “reprogram” other cells in our bodies to become stem cells.  One day we may not need to harvest bone marrow to get stem cells but rather could take a small skin sample and simply reprogram the cells into stem cells.  The future direction of orthopedic stem cell therapies will be exciting to watch as more of the basic science is translated into proven clinical treatments.

Texas Senate Examines Opioid and Substance Abuse

San Antonio orthopaedic surgeon Adam Bruggeman, MD – the Texas Orthopaedic Association’s second vice president – testified before the Texas Senate Committee on Health and Human Services’ hearing on opioid and substance abuse.

The Texas Legislature will continue examining the opioid issue in the months leading up to the 2019 Texas Legislature.

TOA is educating lawmakers about the American Academy of Orthopaedic Association’s pain management toolkit. David Ring, MD, PhD will discuss pain management at TOA’s April 2018 Annual Conference.

Click here to learn more about the AAOS pain management toolkit.

 

A Look at Muve Health’s Joint Replacement Strategy in Austin

Muve Healthcare opened a joint replacement-focused ambulatory surgery center (ASC) in Lakeway outside of Austin in 2017. TOA recently conducted a Q&A with Marshall Maran of Muve to learn more about the concept.

TOA: Prior to your entrance into the Texas market, what has the ASC volume for lower extremity joint replacements been like in the state of Texas?

Marshall Maran: Total joint replacements in an ASC across the country are still in the very formative stages. Today, only 3 percent of the Medicare-certified ASCs list total joint replacements as a part of their service offerings. In Texas, the number of TJAs done in an ASC setting is also very low, but we expect that to increase in the months and years ahead.

TOA: How often do you all determine that a patient is not appropriate for your ASC setting?

MM: Our delivery model is a highly engineered, highly protocol driven care model. As a part of that, we do have a specific set of patient evaluation criteria we utilize to determine if a patient can be qualified to have their TJA performed in our facility. These criteria (such as BMI, A1C, active malignancies, tobacco use, etc.) are those typically employed by the nationally recognized joint centers in the country. However, the presence or the failure of a patient to meet our criteria doesn’t automatically exclude them as a joint replacement candidate at Muve. Rather, we’ll work with that patient to optimize their conditions to convert them into a qualified status. So if a patient’s BMI is above 40, we’ll work with them on a weight loss program or if they smoke tobacco, we’ll get them into a 30-day smoking cessation program. In the end, we’re not just “cherry picking” cases, but really working to use good clinical judgement and practices to optimize our patients for the best possible outcomes.

TOA: What separates Muve Healthcare from other joint replacement models?

MM: Muve is a hyperspecialized, full-episode program of care. It is not multi-specialty, and it is not “simply” an ASC, although an ASC is one of the elements that comprise the program. We enable an enhanced patient experience, greater physician control, and more optimized outcomes. Some of the specific factors that differentiate us from the traditional multispecialty ASC model:

  1. A hyper-specialized outpatient approach, focused only on orthopedic procedures.
  2. Implementation of purpose-built integrated care pathways and protocols, proprietary technology, and customized staff training all aimed toward enabling optimizing outcomes and reducing unnecessary variation in Total Joint Replacement care delivery.
  3. 48 hours of post-operative care and monitoring in our innovative Muve Suites environment. This setting is designed to kickstart recovery and better empower patients to take control of their own self-care, thus reducing post-op complications and unnecessary return visits.
  4. Dedicated Muve Navigator-Patient partnership from pre-surgery all the way through a patient’s one-year anniversary with their new joint. This partnership better prepares patients for an optimal outcome, srtreamlines communication, and helps us collect valuable patient data and insights throughout the continuum of care.

TOA: How are you all approaching bundled payments in both commercial and Medicare markets?  

MM: Muve’s business model is predicated on driving the utilization of value based reimbursement (VBR), and the model we’ve chosen to employ is a prospective bundled payment arrangement. Although we’ve been hearing a lot in the healthcare press about commercial-based bundles and VBR, this market talk has largely been aspirational rather than functional. As an example of how under-developed VBR is in Texas, we’re the only ASC we know of to have a 90-day prospective bundle for joint replacements for commercially insured beneficiaries. We believe the use of VBR models will expand over time and we’re poised to drive that expansion, but we hope more in the provider community will embrace this approach as it really creates a triple win in the market for patients, payers and surgeons.

As it relates to BPCI and BPCI-A, we’re not currently engaged with any of these models, as our focus is largely on the commercial segment coupled with the current limitations CMS has put on the provision of TJA procedures in freestanding ASCs. As CMS expands the delivery of TJA procedures to ASCs, we fully anticipate we’ll be serving the Medicare market place in the near future.

TOA: How are other physicians to the Muve Healthcare model?

MM: The orthopaedic surgeon community in Texas and markets throughout the U.S. is responding very favorably to Muve and our care delivery model. We often hear comments like “this is the future of healthcare” or “this is how I want to be providing care to my patients.” Back to the concept of design-based care delivery, when you create a model of healthcare that is purposefully built for it’s intended stakeholders, you can really create something special and achieve the Triple Aim objectives that have seemingly been so elusive for the industry.

TOA: What are the next plans for Muve Healthcare?

MM: We are expanding in Texas and have new facilities under development in four other states. Our focus will continue to be on lower extremity joint replacement, but we are also creating a program around certain spine procedures which we believe our model is well suited to provide. In the next three years, we plan to have 30 Muve facilities throughout the country and believe we’ll be one of the largest providers, by case volume, of joint replacement procedures in the U.S. by that point.

Texas Updates Spinal Screenings to Meet Latest Science

The Texas Department of State Health Services (DSHS) announced on March 9, 2018 new spinal screening standards for the 2018-19 school year. The changes come as a result of HB 1076 in the Texas Legislature. Sponsored by Rep. Tom Oliverson, MD and Sen. Don Huffines, HB 1076 reflects the latest science regarding scoliosis treatment.

Click here to view the new DSHS policy.

Click here to view TOA’s information on the subject.

TOA Urges Lawmakers to Contact Congress on BPCI Advanced/CJR Conflict

BPCI Advanced – Medicare’s new physician-led bundled payment program that was announced in January 2018 – will not allow orthopaedic surgeons located in Texas’ five Comprehensive Center for Joint Replacement (CJR) to lead their own bundles for lower extremity joint replacements in the new BPCI Advanced program.

Due to the upcoming March 12, 2018 application deadline, TOA is encouraging TOA members in these CJR markets to contact their Members of Congress to contact the Centers for Medicare and Medicaid Services to allow orthopaedic surgeons to lead their own BPCI Advanced bundles in CJR markets.

The physician groups that have been participating in the existing BPCI Model 2 have demonstrated significant savings for Medicare. A study conducted by the largest BPCI physician group practice (PGP) convener of 15 private practice orthopaedic groups across the nation found that they saved Medicare $3,214 (15 percent) per LEJR episode in 2015 (compared to the 2009-2012 historic baseline data).

TOA has told Congress that patients and orthopaedic surgeons practicing in the CJR markets should not be penalized based on their geographic location.

Click here to view the sample letter.

Click here to view the CJR hospitals around the country.

 

IPAB and Physical Therapy Included in Congress’ Medicare Extender Package

The U.S. House and U.S. Senate approved a funding resolution on February 9 that includes several Medicare provisions that affect musculoskeletal care:

Physician-owned Hospitals:  No Relief. An effort by Texas lawmakers to allow physician-owned hospitals located in areas affected by the recent hurricane to expand by 50 percent was not included in the bill. However, Congressman Brian Babin of Texas is circulating a request for CMS to provide relief.

IPAB Elimination.  The Independent Payment Advisory Board (IPAB), which was created by the Affordable Care Act to address rising Medicare costs, was eliminated.

Physical Therapy’s Cap. Medicare’s existing “hard” physical therapy cap has been repealed (effective December 31, 2017).  However, it comes at a cost, and Congress relied on several offsets to help pay for it:

Explanation of the “New Cap” for Outpatient Medicare Part B

The threshold for targeted medical review will be lowered from $3,700 to $3,000 through 2027. However, not all claims that go over $3,000 will be subject to medical review. Instead, only a sample of the claims that meet certain criteria, such as high claims denial percentage or certain billing patterns, will be subject to the review.

The $3,000 per beneficiary applies to combined physical therapy and speech language pathology services – or $3,000 in occupational therapy claims alone.

Therapy claims for outpatient Medicare Part B that go over $2,010 (adjusted annually) will require the KX modifier for medical necessity.

Congress gave HHS the regulatory authority to address the manual medical review.

Physical Therapy Assistants Payment Reductions

The legislation will reduce payments to physical and occupational therapy services provided by a therapy assistant to 85 percent.  The payment reduction is scheduled to begin in January 2022 for outpatient therapy services.

The text of the therapy cap provision can be found on page 19. (Click here to view the bill’s language.)

Orthotist and Prosthetist Notes. Orthotist and prosthetist notes are now part of the medical record for purposes of Medicare medical necessity and claims audits.

Per the legislation:

SEC. 50402. ORTHOTIST’S AND PROSTHETIST’S CLINICAL NOTES AS PART OF THE PATIENT’S MEDICAL RECORD.
13 Section 1834(h) of the Social Security Act (42 U.S.C. 1395m(h)) is amended by adding at the end the following new paragraph:”
(5) DOCUMENTATION CREATED BY ORTHOTISTS AND PROSTHETISTS. – For purposes of determining the reasonableness and medical necessity of orthotics and prosthetics, documentation created by an orthotist or prosthetist shall be considered part of the individual’s medical record to support documentation created by eligible professionals described in section 1848(k)(3)(B).”.

Stark Modernization. Commentary on the Stark laws begins on page 136 (click here). It exempts holdover lease arrangements and personal service arrangements from the definition of a prohibited compensation arrangement.

Meaningful Use. The bill contains parts of the Health Information Technology for Economic and Clinical Health Act by removing a mandate that meaningful use standards must evolve to be more stringent over time.

MIPS. The bill prohibits CMS from scoring an eligible clinician on improvement in the second, third, fourth, and fifth years (for which MIPS applies to payments).

Both the House and Senate bills block CMS from ever raising cost cutting to more than 30 percent of a physician’s scores.

Physician Fee Schedule. The updated will be reduced from 0.5 percent to 0.25 percent in 2019.

Medicare Data Demonstrate Price Differences Among Texas Cities for Joint Replacements

The Centers for Medicare and Medicaid Services (CMS) proposed the latest physician-led bundled payment model – BPCI Advanced – in January 2018. March 12, 2018 is the deadline to apply.

Click here to learn more from TOA.

Publicly available data gathered by Archway Health on lower extremity joint replacement surgeries for 2015 Medicare payments demonstrate a variety of costs within Texas cities.  The data include costs related to both the surgery, post-acute care service, and readmissions.

Medicare Announces New Bundled Payments

The Centers for Medicare and Medicaid Services (CMS) announced on January 9, 2018 that it is creating the voluntary Bundled Payments for Care Improvement Advanced (BPCI Advanced) demonstration that requires participants to take on financial risk. In addition, the program, which includes outpatient and inpatient episodes of care, would count as an Advanced APM for MACRA (Medicare’s physician payment program) for a 5 percent provider bonus.

Unfortunately, the proposal could have a harmful effect on markets that are affected by the Comprehensive Center for Joint Replacement (CJR) mandate. Those markets may not be able to participate in BPCI Advanced. Click here for full information.

TOA’s April 13-14, 2018 Annual Conference in Fort Worth will include a panel discussion on Medicare’s new bundled payment program.

Medicare-certified acute care hospitals and physician group practices (PGPs) may participate as either Convener Participants or Non-Convener Participants. The application ends on March 12, 2018. The next application period will not occur until January 1, 2020.

Some of the new program’s highlights include:

The CMS Innovation Center will hold a Q&A Open Forum on Tuesday, January 30, 2018 from 11 a.m. – 12 p.m. CST. This event is open to those who are interested in learning more about the model and how to apply. Please register in advance here.

Click here to learn more about the model.

Thirty-two types of clinical episodes will be included. Three outpatient episodes have been added to the inpatient episodes in the earlier BPCI model. Most of the episodes are found in the original BPCI model. However, an episode related to liver disorders is new.

For a list of the 29 Inpatient Clinical Episodes, please see below:

For a list of the 3 Outpatient Clinical Episodes, please see below:

Key Dates
March 12, 2018 – Application portal closes.

May 2018 – CMS distributes target prices.

June 2018 – CMS offers participant agreements.

August 2018 – Signed participant agreements are due.

October 1, 2018 – Model goes live.

March 31, 2019 – First date for Advanced Alternative Payment Model (APM) qualified participant determination.

January 1, 2020 – Next application period.

December 31, 2023 – End of the first cycle.

 

Medicare’s Removal from TKA from Inpatient-Only: Clarification

The Centers for Medicare and Medicaid Services (CMS) removed total knee arthroplasty from Medicare’s inpatient-only (IPO) list for the 2018 final rule. However, this does not mean that Medicare will pay for TKA in ambulatory surgery centers (ASCs).

The American Association of Orthopaedic Surgeons (AAOS) produced the following FAQs to answer questions. Click here to view it.

Click here to read TOA’s summary of the final rule.

BPCI Advanced Website Update:  “Conceptual Overview” physician focused webcast available now – REVISED “Application Process” Link

Greetings,

Thank you for your interest in the newest CMS model – Bundled Payments for Care Improvement Advanced (BPCI Advanced).  We are excited about the enthusiastic response to our model announcement on January 9, 2018. We continue to receive a high volume of inquiries in the BPCI Advanced inbox and will address most of the more complex inquiries during our Open Forums on January 30, 2018 and February 15, 2018

We now have available on demand a new physician-focused model overview webcast “Conceptual Overview” as well as a physician-focused Frequently Asked Questions document.

We are currently updating the MS – DRGs Exclusion from Clinical Episodes List and a new version will be posted soon.

For the more general model design and timeline specific questions, we urge you to visit the new BPCI Advanced webpage. CMS will continue to make available a variety of materials to educate you on the new model.

Currently available on the BPCI Advanced webpage at the CMS Innovation Center website are the following resources:

Click here to register for one of the BPCI Advanced Open Forums on January 30, 2018 from 12 pm – 1 pm EST or February 15, 2018 from 12 pm – 1 pm EST.

CMS BPCI Advanced Support Team
E-mail: BPCIAdvanced@cms.hhs.gov
BPCI Advanced Application Portal
BPCI Advanced Website

TDI-DWC Approves Lumbar Spine Audit Plan

Per the Texas Department of Insurance, Division of Workers’ Compensation (TDI-DWC):

On November 20, 2017, The Texas Department of Insurance, Division of Workers’ Compensation (TDI-DWC) solicited and received constructive input from workers’ compensation system participants on the proposed Lumbar Spine Magnetic Resonance Imaging (MRI)  Plan-Based Audit (Plan-Based Audit).  TDI-DWC appreciates the input provided by system participants.  All comments were carefully considered and discussed.  The Commissioner of Workers’ Compensation W. Ryan Brannan, approved the Plan-Based Audit on January 23, 2018.

All medical quality reviews initiated on or after January 1, 2018, will follow the approved Medical Quality Review Process (Process) in effect.  The Process and Plan-Based Audit are posted on the TDI website here.

Joseph Mathews, who serves as the practice administrator representative on TOA’s board of directors, provided the following summary:

ODG (Official Disability Guidelines) does not recommend MRI for uncomplicated low back pain, with radiculopathy, until after at least one month of conservative therapy unless symptoms of a severe or progressive neurologic deficit were present.

Subject Selection:

Purpose for Plan-Based Audit

Evaluate the appropriateness of a doctor’s decision and recordkeeping that supports the ordering of lumbar spine magnetic resonance image (MRI) prior to one month of conservative therapy.

Click here to read complete details from TDI-DWC.

TDI-DWC Informal Language Examines Differences Between CARF-Accredited and Non-Accredited Programs

The Texas Department of Insurance – Division of Workers’ Compensation (TDI-DWC) announced that it is accepting comments regarding potential changes to the rules related to Commission on Accreditation of Rehabilitation Facilities (CARF)-accredited programs. The Workers’ Compensation Research and Evaluation Group recently published a report entitled “Outcome Comparisons of Return to Work Rehabilitation Programs by Accreditation Status,” and the report concluded that there was no statistical difference in the disability duration, measured by the length of temporary income benefits, between CARF-accredited and non CARF-accredited programs.

The informal working draft is available here and the comment period closes on February 2, 2018 at 5 p.m. Central time.

The informal working draft is not a formal rule proposal and comments received will not be treated as formal public comments for the purposes of the Administrative Procedure Act. There will be an opportunity to formally comment once the rule is proposed and published in the Texas Register. Informal comments may be submitted by email to InformalRuleComments@tdi.texas.gov or by mail or delivery to:

Texas Department of Insurance, Division of Workers’ Compensation
Maria Jimenez
Workers’ Compensation Counsel MS – 4D
7551 Metro Center Drive, Suite 100
Austin, Texas 78744 -1645

Senate Bill 1494 of the 85th Legislative Regular Session amended Labor Code §413.014 to require preauthorization and concurrent utilization review for health care facilities providing work-hardening (WH) or work-conditioning (WC) programs.  The bill no longer requires but instead permits the commissioner, by rule, to exempt a credentialed health care facility providing WH and WC services from preauthorization and concurrent review requirements.  Currently, health care facilities that are accredited by the Commission on Accreditation of Rehabilitation Facilities (CARF) are exempt from preauthorization and concurrent review requirements for WH and WC.

The division proposes amendments to 28 TAC §134.600 to remove the exemption status from CARF-accredited facilities to implement Senate Bill 1494.  The division also proposing amendments to 28 TAC §134.230 to set one fee schedule for WH and WC services, regardless of a facility’s accreditation status by removing the increased payment to CARF-accredited facilities providing WH or WC services.  Amendments to 28 TAC §134.230 also include several non-substantive changes for readability.

TMB Pain Clinic Rule Could Unintentionally Include Orthopaedists

The Texas Medical Board (TMB) released a proposed rule in November 2017 to identify physicians who have failed to properly register as a pain clinic.  Unfortunately, as written, the proposed rule could unintentionally include orthopaedic surgeons in the pain clinic registration, despite the fact that orthopaedic surgeons are not operating as pain clinics.

TOA will testify at the December 8, 2017 TMB meeting.

Click here to learn more.

Proposed Medicaid Rates

Texas HHSC has proposed new Medicaid rates for musculoskeletal services (effective January 1, 2018).

Click here to view the proposed rates.

The Texas Orthopaedic Association and Texas Medical Association submitted a response to Texas HHSC.  Click here to view the response.

 

Congress Introduces Legislation to Enhance Medicare Care Coordination

Congressman Kenny Marchant (R-Coppell) joined three other colleagues to introduce “The Medicare Care Coordination Improvement Act of 2017.” H.R. 4206 was introduced to address certain aspects of the Stark Law and physician self-referral laws that are preventing MACRA’s alternative payment models (APMs) from performing.

The updates to the Stark Law are needed for Congress to meet its goal of shifting the Medicare program from a fee-for-service system to a coordinated care model. U.S. Senator Orrin Hatch of Utah expressed his interest in updating the Stark and self-referral laws last year.

Click here to read the one-pager created by Congress.

Click here to read support from.

Medicare’s Quality Payment Program Rule for Year 2 (MIPS/MACRA)

The Centers for Medicare and Medicaid Services (CMS) released the final rule for the Quality Payment Program’s second year on November 2, 2017.

Click here for an extensive overview of the rule.

Click here for an executive summary of the rule:

 

Among the highlights:

From 90 Days to a Full Year
Physicians will be required to report quality measures for a full year.  The current standard is a 90-day period.

Cost Counts for MIPS
A physician’s Merit-based Incentive Payment System (MIPS) score is made up of four categories: quality, cost, improvement, and Advancing Care Information (ACI), which takes into account the use of EHRs.

Next year, CMS will count performance on cost measures for 10 percent of a physician’s score, even though CMS indicated earlier that it would delay factoring cost into a physician’s score for 2018.

CMS stated that it will use the Medicare spending beneficiary and total per-capital cost measures to calculate the cost performance category score for the 2018 MIPS performance period. Physicians will not be required to take any action because CMS will calculate the scores. The two measures carry over from the Value Modifier program.

The agency said that is developing new episode-based measures on cost with stakeholder input and soliciting feedback on some of those measures in the fall of 2018. CMS also said that it expects to propose new cost measures in future rules and solicit feedback on episode-based measures before they are included in MIPS.

Certified EHRs
The rule will allow physicians to use 2014 edition and/or 2015-certified HER technology in year two of the ACI performance category. A performance will be given for using only 2015 CEHRT.

Low-volume Threshold Exception
Physicians were excluded in 2017 if the practice had no more than $30,000 in Part B charges or saw no more than 100 beneficiaries in a year. For 2018, physicians will be excluded if they have no more than $90,000 in Part B charges or see no more than 200 beneficiaries.

Small practices that do participate in MIPS will be provided five bonus points.  Solo and small practices will also have the opportunity to form virtual groups.

Alternative Payment Models (APMs)
As we have stated in the past, not too many orthopaedic services qualify for the Advanced APM portion of MACRA.  As a result, most orthopaedic surgeons are focusing on the MIPS portion for MACRA.

CMS has hinted in the past that it would like to create more opportunities for surgeons to participate in an Advanced APM.  As a result, we are expecting CMS to announce new physician-led bundled payment models in the near future.  Hospital-led bundled payments typically do not qualify as Advanced APMs.

There is extensive commentary regarding APMs in the rule.  For example, CMS indicated that it plans to develop a demonstration project to look at how physicians participating in Medicare Advantage alternative pay models can qualify for bonus payments.

Twenty-one New Improvement Activities
CMS stated:

In this final rule with comment period, we are finalizing updates to the Improvement Activities Inventor. Specifically, as discussed in the appendices (Tables F and G) of this final rule with comment period, we are finalizing 21 new improvement activities (some with modification) and changes to 27 previously adopted improvement activities(some with modification and including 1 removal) for the Quality Payment Program Year 2 and future years (2018 MIPS performance period and future years)Improvement Activities Inventory.

Medicare’s 2018 Physician Fee Schedule Final Rule

The Centers for Medicare and Medicaid Services (CMS) released the CY 2018 final payment rule for the Medicare Physician Fee Schedule on November 2, 2017.

The following is a summary of the final rule.  TOA’s summary of the CY 2018 proposed rule, which was released this summer, can be found following this summary.

Appropriate Use Criteria Mandate for Imaging
The final rule extends the AUC mandate for advanced imaging (MRI, CT, etc.) to January 1, 2020. The summer proposal called for a 2019 start date.

Key considerations:

Physician Employment: Off-campus Provider-based Departments:
“CMS believes that this adjustment will provide a more level playing field for competition between hospitals and physician practices by promoting greater payment alignment.”
Hospital stakeholders have expressed strong opposition to the provision in the final rule that will cut payments to certain off-campus outpatient provider-based hospital departments.

To review: Some physician services are paid at a higher rate if they are affiliated with a hospital (“off-campus provider-based departments”). The Medicare Payment Advisory Commission (MedPAC) has been discussing the concept of site neutral payments, which is a concept in which a service is paid the same amount, no matter the site of service.  For example, if a cardiology service is being paid at a higher rate than in a physician’s office because the cardiology practice is affialited with a hospital, a site neutral payment policy would pay the hospital-based service at the physician office rate.

The Bipartisan Budget Act of 2015 addressed the concept of hospitals acquiring physician practices and turning them into outpatient departments.  Existing off-campus hospital outpatient departments were grandfathered in when the bill was signed into law: November 2, 2015. As a result, they will continue to be paid at the higher rate. Any new acquisitions after that were acquired after November 2, 2015 are now subject to the lower payments, which caused great opposition from hospital stakeholders.

Last year’s 21st Century Cures Act, which was signed into law, exempted hospital outpatient departments that were in development when the site-neutral law went into effect on November 2, 2015. For off-campus sites that were not mid-build, Medicare paid half of hospital outpatient rates in 2017.

This summer, CMS proposed to pay 25 percent of hospital rates for its 2018 rule.  However, the final rule indicated that it will pay 40 percent of hospital outpatient rates in 2018.

America’s Essential Hospitals President and CEO Bruce Siegel responded to the CY 2018 final rule:

We are deeply disappointed by today’s final rule on the 2018 Medicare Physician Fee Schedule (PFS), which aggravates already damaging cuts to support for clinics and other outpatient services in the nation’s most underserved communities. In these health care deserts, essential hospitals work to overcome practitioner shortages by extending primary and specialty care services to off-campus clinics in their communities. But today’s final rule puts expansion of services further out of reach for these communities and threatens access to care where access is needed most.

AMA’s RUC  Recommendations
CMS announced that it will accept many of the American Medical Association’s Medicare Association-Relative Value Scale Update Committee (RUC) recommendations. 

Telehealth – Therapy
Telehealth opportunities specific to musculoskeletal care remain somewhat limited in Medicare.  The new codes for 2018 in the physician fee schedule will expand telehealth to: determine low dose computed tomography eligibility, interactive complexity, health risk assessments, care planning for chronic care management, and psychotherapy for crisis.

There was extensive discussion regarding telehealth for therapy.  However, that will remain limited.  Per CMS (on page 141):

Comment: Several commenters disagreed with our decision not to add various physical and occupational therapy, and speech language pathology services to the Medicare telehealth list.

Response: As noted above, the majority of the codes requested are finished by therapy professionals over 90 percent of the time, and we believe that adding therapy services to the telehealth list are furnished by professionals not included on the statutory list of distant site practitioners could result in confusion about who is authorized to bill for these services when furnished via telehealth.  Additionally, some of the codes involve physical manipulation of the patient, which cannot be accomplished via an interactive telecommunications system.

Physical Therapy Caps
Congress is examining the concept of eliminating the therapy cap for Medicare. Meanwhile, the CY 2018 final rule will increase the Medicare therapy cap from $1,980 to $2,010 in 2018.

E/M Comment Solicitation
Per CMS:

Most physicians and other practitioners bill patient visits to the PFS under a relatively generic set of codes that distinguish level of complexity, site of care, and in some cases whether or not the patient is new or established. These codes are called Evaluation and Management (E/M) visit codes. Billing practitioners must maintain information in the medical record that documents that they have reported the appropriate level of E/M visit code. CMS maintains guidelines that specify the kind of information that is required to support Medicare payment for each level.

We agree with continued feedback from stakeholders that these guidelines are potentially outdated and need to be revised.

CMS thanks the public for the comments received in response to the proposed rule’s comment solicitation on the E/M guidelines and summarizes these comments in the final rule. Commenters suggested that we provide additional avenues for collaboration with stakeholders prior to implementing any changes. We will consider the best approaches for such collaboration, and will take the public comments into account as we consider the issues for future rulemaking.

2018 Value Modifier
Per CMS:

In order to better align incentives and provide a smoother transition to the new Merit-based Incentive Payment System under the Quality Payment Program, we are finalizing the following changes to previously-finalized policies for the 2018 Value Modifier:

Physician Quality Reporting Systems (PQRS)
Per CMS:

Under the PQRS, individual eligible professionals and group practices who did not satisfactorily report data on quality measures for the CY 2016 reporting period are subject to a downward payment adjustment of 2.0 percent in 2018 to their PFS covered professional services. 2016 was the last reporting period for PQRS. The final data submission timeframe for reporting 2016 PQRS quality data to avoid the 2018 PQRS downward payment adjustment was January through March 2017. PQRS is being replaced by the Merit-based Incentive Payment System (MIPS) under the Quality Payment Program (QPP). The first MIPS performance period is January through December 2017.

CMS proposed and is finalizing a change to the current PQRS program policy that requires reporting of 9 measures across 3 National Quality Strategy domains to only require reporting of 6 measures for the PQRS with no domain requirement. We are also finalizing similar changes to the clinical quality measure reporting requirements under the Medicare Electronic Health Record Incentive Program for eligible professionals who reported electronically through the PQRS portal.

We finalized these changes based on stakeholder feedback and to better align with the MIPS data submission requirements for the quality performance category. For MIPS, eligible clinicians need only report 6 quality measures for the quality performance category, except those reporting via the Web Interface, and there is no requirement to ensure that the measures span across 3 National Quality Strategy domains.

Summary of This Summer’s Proposed Rule for 2018
The summary of the CY 2018 proposed rule that was released this summer can be found below.

— From July 14, 2017 —

CMS Calls for an Overhaul of E/M Codes; CY 2018 Medicare Physician Fee Schedule Proposed Rule

The Centers for Medicare and Medicaid Services (CMS) called for an overhaul of the E/M codes in the CY 2018 Medicare Physician Fee Schedule proposed payment rule on Thursday.

Other highlights include:

You are encouraged to also review TOA’s analysis of the CY 2018 HOPD/ASC proposed payment rule because many of the issues compliment each other.

The following is TOA’s overview of the issues that relate to orthopaedics.  Click here to view CMS’s fact sheet.

Telehealth and Therapy
CMS’s proposed payment adjustments for telehealth do not relate to orthopaedic services.  However, CMS does provide commentary regarding the concept of physical therapists being paid for Medicare telehealth services (beginning on page 85).

CMS indicated that because the discussed codes are furnished by therapists over 90 percent of the time, it would not be possible to reimburse therapists for the services due to the fact that they are not recognized in statute to provide Medicare telehealth services.

Incentive to Transition away from Traditional X-ray Imaging
CMS describes its proposal on page 110:

Physician Employment and PBDs
Much like with the CY 2018 HOPD/ASC proposed rule, CMS provides commentary on physician employment provisions related to higher payments for provider-based departments (PBDs) of hospitals.

In the MPFS proposal for CY 2018, CMS asks for comments regarding whether CMS should adopt a different PFS Relativity Adjuster, such as 40 percent, that represents a relative middle ground between the CY 2017 PFS Relativity Adjuster and the proposed CY 2018 PFS Relativity Adjuster.

CMS goes on to state:

Mis-valued RVUs
As always, CMS uses its annual proposal to identify potentially mis-valued codes. Some of the codes that CMS identified in the CY 2018 proposed rule include:

E/M Guidelines
Beginning on page 373, CMS describes its desire to update E/M guidelines and asks for comments.

AUCs
More information regarding appropriate use criteria (AUC) for advanced diagnostic imaging can be found in TOA’s summary of the CY 2018 Medicare OPPS/ASC proposed rule.  CMS includes commentary in the MPFS proposed rule beginning on page 418.

The start date has been pushed back to January 1, 2019, and this period would be an “educational and operations testing year.”

PQRS for the 2018 PQRS Payment Adjustment
Beginning on page 439, CMS provides commentary on PQRS and 2016 data:

ACOs
CMS provides some guidance and updates to accountable care organizations (ACOs) in the proposed rule.  However, they are unlikely to affect orthopaedic surgeons.

Value-based Payment Modifier and Physician Program
According to CMS:

In order to better align incentives and provide a smoother transition to the new Merit-based Incentive Payment System under the Quality Payment Program, we are proposing the following changes to previously-finalized policies for the 2018 Value Modifier:

Commentary on this issue begins on page 534.

MACRA Patient Relationship Categories and Codes
MACRA facilitates the attribution of patients and episodes to one or more clinicians.  Commentary on this concept begins on page 550.