Proposed Changes in CMS Rule Undervalue Orthopaedic Care, AAHKS and AAOS Say

    A new rule proposed by the Center for Medicare and Medicaid Services (CMS) devalues the care orthopaedic surgeons provide to Medicare patients, according to statements from the American Association of Hip & Knee Surgeons (AAHKS) and the American Academy of Orthopaedic Surgeons (AAOS), and if finalized, could deal a financial blow to surgeons who are still struggling to recover from being unable to operate for months due to the COVID-19 pandemic.

    The proposed policy changes under the Physician Fee Schedule (PFS), which would go into effect for services performed beginning on January 1, 2021, reduces reimbursement for orthopaedic surgical services by approximately 5%. The CMS proposal will also reduce the work relative value units (RVU) for hip and knee arthroplasty by an additional 5.4%.

    CMS has set the calendar year 2021 PFS conversion factor to $32.26 in the new rule, a decrease of $3.83 from the calendar year 2020 PFS conversion factor of $36.09.

    The American Medical Association’s Relative Value Scale Update Committee (RUC) recommended that CMS reduce the RVU used to measure the value of total joint arthroplasty by a little more than 1 unit. This move, AAHKS said in a prepared statement, devalues the procedures surgeons and their healthcare team perform to improve functioning and relieve pain among Medicare patients with degenerative joint disease.

    The RUC review was triggered by a commercial insurance company that exploited the CMS public nomination process for potentially misvalued codes, AAHKS said, possibly to drive down reimbursement to their contracted physicians who are paid a percentage of Medicare rates. The RUC’s evaluation of these codes noted a reduction in physicians’ postoperative time due to emerging efficiencies under value-based care arrangements but did not recognize corresponding increases in physicians’ preoperative time, which has successfully improved clinical outcomes for hip and knee replacement patients, AAHKS said.

    CMS has acknowledged that the time surgeons spend before surgery with Medicare patients is not currently accounted for. “AAHKS is deeply disappointed that the AMA RUC and CMS, despite our extensive advocacy efforts over the last 21 months, chose not to give us credit for the pre-optimization work that they acknowledged is being done by our surgeons,” said James I. Huddleston III, MD, AAHKS Advocacy Committee Chair.

    Joseph A. Bosco III, MD, President of AAOS, noted that in proposing the changes to the RVU and PFS, CMS disregard the discussions and data presented by AAOS against the cuts.

    “Devaluing the time and effort that orthopaedic surgeons spend prioritizing value-based care communicates a larger plan by the agency to gradually reduce the value of these procedures,” he said. “Not to mention the fact that our surgeons have the highest participation rates across medical subspecialties in alternative payment models, where they work to optimize care and improve patient outcomes all while reducing costs.

    C. Lowry Barnes, MD, AAHKS President, concurred. “If these Medicare cuts are finalized, it sends a strong signal: When providers in the vanguard of value-based care begin to achieve some efficiencies in the delivery of care, CMS will use those positive developments as a justification to cut Medicare fee-for-service reimbursement regardless of the extra work that goes into achieving these outcomes,” he said.

    Both organizations intend to continue working to educate CMS and their allies in Congress about the care orthpaedic surgeons provide before, during, and after surgery in an effort to reverse the changes.

    “The AAOS urges CMS to reconsider the significant preoperative work that is required to make value-based care both cost-effective and high-quality, and to refrain from finalizing both of these punitive cuts on the value of orthopaedic care,” Dr. Bosco said.

    “We will continue to work with [CMS] to facilitate a mechanism by which this critically important work can be incorporated into their methodologies,” Dr. Huddleston added.