Chris Tucker:                      Welcome to the Arthroscopy Association's Arthroscopy Journal podcast. The views expressed in this podcast do not necessarily represent the views of the Arthroscopy Association or the Arthroscopy Journal. 

                                                I'm Dr. Chris Tucker from the Walter Reed National Military Medical Center and founding editor of the podcast. Today on the podcast, we are discussing the current state of surgical work reimbursement and the fee system under which orthopedic surgeons deliver care. I'm humbled and honored to be joined in this discussion by two familiar leaders in the field of orthopedic sports medicine, Doctors Louis McIntyre and Bill Beach. Not only are both of these men past presidents of the Arthroscopy Association, but they are also diligent advocates on the behalf of orthopedic surgeons in the realm of billing and coding, reimbursement, and fair business practice. Gentlemen, welcome to the podcast. 

Dr. Beach:                           Thanks, Chris. 

Dr. McIntyre:                     Thanks. Great to be with you Chris. 

Chris Tucker:                      Doctors McIntyre and Beach, you jointly authored an editorial commentary in the arthroscopy journal titled “A Rigged Game: Surgeon Reimbursement Under the Resource Based Relative Value System, Current Procedural Terminology, and The Affordable Care Act.” 

                                                First of all, congratulations on the commentary and thank you for your ongoing efforts to advocate for all orthopedic surgeons. I'm hoping today we can highlight some important aspects of the debate and gain some better insight into the issues at hand facing all orthopedic surgeons. In that light, Dr. McIntyre, can you start us off by leveling the playing field and briefly defining for us the current state of affairs with respect to surgeon reimbursement, government policy and the definition of value under the resource based relative value scale? 

Dr. McIntyre:                     Sure, Chris, and unfortunately it's not a level playing field. RBRVS, you talked about the resource based relative value scale was instituted after an act of Congress in 1989 and was put into full utilization in 1992. So we've been at it now for almost 30 years. The stated goal of RBRVS was to actually level the reimbursement levels between the cognitive fields of medicine and the procedural side of medicine. So I guess you'd have to say that in that regard it's been a resounding success. 

                                                Unfortunately, it doesn't lead to a level playing field and we don't think recognizes the inherent value of what surgical skills bring to the field of healthcare and to wellness for patients in the United States. In addition, certain things have happened over the last 25, 26 years that have accelerated that trend. These mostly have come out of CMS in regards to certain policies initiated in regards to decreased surgical reimbursements for high volume Medicare type procedures. And also then the use of bundling techniques where certain procedures are deemed to be reported enough times together that they should really be one procedure and you should only get paid basically for one code. 

                                                This has led to an actual about 40% decrease in the absolute value of certain surgical codes since 1992. If you look at the comparison in 1992 dollars, it's actually closer to 60%. So this is what we're confronted with and we've figured out ways to get around that, but at some point in time, it's going to be impossible, especially as certain aspects of these procedures move forward. As we alluded to in the article, I think the goal will be eventually to make the time spent, doing whatever doctors do, the same. So they already consider the value of our time and that of everyone else in medicine to be the same. So my time is the same as a pediatrician's, is the same as an internist's, but eventually what'll happen is that all those time values will be the same. So that at some point in time, it will be more economically feasible to stay in the office all day than to go to the operating room. That I think is the end game of these policies. 

Chris Tucker:                      A sad reality. Dr. Beach, now that we have a better understanding of the baseline parameters. Can you explain for us why you titled this commentary A Rigged Game? 

Dr. Beach:                           Well, I agree a hundred percent with Lou. We have almost no input. We argue. We face a disappointing ruling by CMS that the shoulder was one anatomic site and we send... I had to send a dozen letters. We made three trips to CMS to talk to them in person, despite the fact that there are anatomic parts of the body, which are obviously way smaller than the shoulder, which are not deemed one anatomic site. CMS deemed one anatomic site. So we battled and battled and battled to try to get corrected. It was not until almost two years ago, and we probably fought that for 10 years, did we finally get them to say that the shoulder was not one anatomic site. 

                                                So interestingly then what happened was then they decided, "Okay, if it's not going to be one anatomic site, we're basically going to start to bundle codes together." Like Lou mentioned, if a code's done 50% of the time with another code, then it runs the risk that it will be bundled in with that other code. So we have seen acromioplasty go to a add on code. We have seen extensive and limited debridement now being resurveyed to see if we can bring the value down to those. So my point to Lou was that this doesn't happen anywhere else in society. We'll use a common example. 

                                                So if you go to a restaurant, a well known hamburger spot, and get a combination meal, you still have to pay for all the combos, even though you get them at a discount. What CMS and the insurance companies want us to do is they want all of the meal, they want to pay for the hamburger. They don't want to pay for anything else other than the main index code, which to me is basically just robbing us of our intellectual property and our work. 

                                                For instance, how many codes are there? We have quite a few CPT codes for our scope of surgery. If you do more than one, you basically give them a 50% discount or sometimes some of the insurance companies now are taking a 65% discount because you're done at the same time. So why would they be bundled together? They're individual procedures, whether you do them frequently together or infrequently together, it's still work and it's unfair and it's rigged and that's why we titled it A Rigged Game. 

Chris Tucker:                      I think your McDonald's analogy to help explain this multiple procedure, minimum discount rule and the bundled payments was relatable and easy for me to understand, and I think other readers based on some feedback on social media I've seen. It clearly shows how unfair and biased against surgeons the system is. So one recommendation from your commentary was for orthopedic surgeons to take control and establish price as the value signal in medicine. Can you just help clarify for the listeners what you mean by the term value signal and how surgeons can go about redefining that? 

Dr. Beach:                           Sure. So the biggest problem we face in the economic sphere of medicine is the fact that we do not have price in our equation. Everybody else in the whole society does we don't. And the reason for that is that we have a Medicare fee schedule. So basically the government sets the fee for every medical procedure, every medical encounter, every medical device, everything in medicine, and it's all reflected in a code and Medicare puts a price on it. It's fixed. It's price fixing. Tom Scully who headed a Medicare under the Bush administration said that Medicare was the biggest price fixing scheme on the planet. That was from the administrator, not from a doctor. 

                                                So what we have is this fee schedule that Medicare has, and then all the insurance companies base their reimbursement levels on that fee schedule. So it really has no relationship to reality in regards to how much it costs to bring a service to market or what kind of inputs are there. I mean, they make an attempt to do that, but it's really all just done by algorithm and it doesn't reflect market principles. So as a result, since there's no price and there's no price signal in the market, therefore what happens is we have all these other, what I call price surrogates, come up. A price surrogate would be a way to try to limit access to care since there's no price in an attempt to supplant market forces. That would be things like PQRS, Physician Quality Reporting System, or MIPPs, Merit Based Incentive Payment Program or any one of another dozen alphabet soup entities including EMR utilization and meaningful use. 

                                                These are all used to restrict access and to try to come up with quotation mark reimbursement instead of price. If we had a price, all that other stuff would go away. You wouldn't need RBRVS. You wouldn't need PQRS. You wouldn't need MIPPs. You wouldn't need any of this stuff because everything would be done on price. And we would compete not only on quality, but we would compete on price. The problem with that is that if the government were to do that, they would give up control of medicine and that's what they really want. They want the control. They want to be able to inject themselves into the marketplace in this fashion, because in that way, they really control medicine. 

                                                So I don't foresee any time soon that what really has to happen to get price back into the equation will occur. I think rather what will happen is it will have to be a grassroots effort led by surgeons as a work around to let payers and patients see the value in certain new payment paradigms so that we can re-inject price into the marketplace. 

Chris Tucker:                      So along the lines of these alternative payment methodologies in your commentary, bundled payments was offered as one mechanism for establishing price. How exactly would that work and what potential side effects might you see there be from that, and are any of them potentially negative? 

Dr. Beach:                           Well, sure. I mean, obviously it would be a major disruption of the way things are now. I mean, most orthopedic surgeons have figured out how they can still make a living with RBRVS and everything else inside. So what we do is we add ancillary services and we turn our practices into high volume focused factories, and that way we can continue to turn a profit, in most parts of the country. In some parts of the country that's not even possible anymore. For example, where I live. 

                                                So what bundled payments would do would be to establish an episode of care. Orthopedics lends itself very readily to this because we have a procedure. It has a start date. It has relatively known fixed costs and complication rates. It has a recovery period, and we know the cost in that episode of care. In addition, we can mitigate for complications because we know the rates of complications for things like total joint replacement, spine, sports medicine procedures like rotator cuff repair and ACLs. So we put the costs in, all the inclusive costs, which would be the procedure itself, the facility fee, the anesthesiology fee, the surgeon's fee, any DME that's involved, drugs, et cetera, skilled nursing facilities if you're going to use them, all of that stuff, and then some insurance to mitigate against complications. You add that up, you put a price on it, and then you sell that to insurance companies or to self insured employers, which is even better because then you're going right to the source and you cut out the insurance middleman. 

                                                The downside of that is once you've established price, there is going to be negative pressure on the price because people are going to compete on the price, but I would much rather compete on a price than I would try to set up all these machinations to try to come to reimbursement. 

                                                Think of all the FTEs that any given practice employs just to manage this reimbursement machine. It's ridiculous. I mean, when you think about all the FTEs you need in your business office to manage your revenue cycle or to call insurance companies, to call patients, it adds up and it's a huge driver of overhead. So if we were able to have a price, then boom, you have the procedure you get paid, you don't have to worry about not getting paid because you didn't send in the op note or because the insurance company decided that it didn't want to pay you because it just wanted to hold onto the money. It would be, I think, much more transparent and certainly the downside, I think, would be that there would be negative pressure on that price, but it would then behoove us to maintain or improve quality to cut costs as much as we could and then to compete along those lines. 

Chris Tucker:                      Now, some listeners may not understand the link between surgeon reimbursement and the greater issue of patient access to orthopedic services. Dr. Beach, can you help clarify that connection and why patient care delivery is at significant risk with our current system? 

Dr. Beach:                           Well, I mean, there's a whole bunch of different examples of that, but just take one of the biggest pains for orthopedic surgery nowadays is all this pre-certification and this peer to peer. So all the peer to peer things that we're doing basically are a way to try to decrease our utilization of services, i.e. limit patient access to what they really need from our hands is surgery. 

                                                For instance, if you dictate a note and forget to say that there's pain at the AC joint, and let's say that the MRI is read as moderate osteoarthritis of the AC joint, and you try to bill for 29824, arthroscopic resection of the distal clavicle. Those will probably get denied either because the MRI didn't support it, or you didn't say it in your note. So bottom line is it's getting harder. There's all kinds of small little tricks that are being developed to try to limit what we think patients need and what their access to care is. 

                                                The other thing is... When Lou was talking, I thought all these steps. That is I think one of the greatest inventions ever is if you want to decrease how much you got to pay an orthopedic surgeon, what would you do? Well, why don't we make a whole bunch of jobs for him to do so he can't see as many patients, or she. Well, let's do MIPPs. Let's do PQRS. Let's make the surgeon do as many things as he can... Because I can tell you my ability to see patients went down about 20%. Ingenious. It was ingenious. 

                                                If you look at all these things that we have to do to try to see patients and take care of patients and pretty much dot all the I's and cross all the T's so we don't get in trouble with Medicare, CMS, Medicaid. These things basically are what's drive and what Lou would call limiting access to care because some of it's time, some of it's expense. The bundled payments is a good example. If you see or make a mistake on your bundle payment, and let's say you have two or three people who end up with an infection, ended up in the hospital, end up in the emergency room, you can essentially blow your bundle for an extended period of time. So you've got to be really good at it. 

                                                The problem with orthopedic surgeons nowadays, in my opinion, is because it's getting more and more and more complicated to do this and be educated and try to advocate for yourself and your patients, what's the response? Going to the system. I'm going to go work for a medical system, healthcare system so I don't have to battle this on my own. I can tell you, at least in my opinion, I don't think that that's going to improve our ultimate fate in this particular endeavor in that I don't think the... 

                                                This article that we're talking about that Dr LaPrade just wrote. The healthcare systems are taking care of the healthcare systems. Their payments continue to increase while ours either stay the same or decrease. So we've got a lot of conflicts here in terms of our ability to move forward, and one of the biggest conflicts... I think one of the biggest problems with doctors in general is that we don't like the subject. We don't really want to sit and look at the numbers. We don't really want to be involved in the business side of medicine, but I can tell you if we aren't... What's the old saying? You're not going to be invited to the dinner, you're going to be dinner. 

Chris Tucker:                      Yeah. Fantastic illustrated examples, which I think brings this home for everybody listening. Truly informative discussion for me. Before we close, I'd like to ask each of you, if you would, share one take home point with respect to surgeon reimbursement, and maybe what you might suggest each listener could do to help work towards a solution. Dr. McIntyre, why don't you go first? 

Dr. McIntyre:                     Sure. Well, I think to Bill's point, you really need to be involved in this in your own practice, because if you're not, then you're going to be leaving money on the table. There are ways to maximize your reimbursement levels, even inside of the system. I think that this article points out very nicely, that eventually though, we're not going to be able to do that. We're not going to be able to work around continuous decreased levels of reimbursement and that's either going to do one or two things. It's either going to say, "Okay, we just won't do the procedures," i.e. limitation of care, or we're going to have to jump into systems like Bill says, or we're going to have to change the way we practice medicine completely. 

                                                For example, some guys just do surgery all day and some guys just see patients all day. It's going to come to some type of fork in the road. So I think that while there's still a rather robust private practice of medicine in the United States, still about 40% of our AOS brethren are in a private practice mode, they need to start to think about ways of getting away from RBRVS coding and these types of maneuvers. I think the bundled payment option offers a good one. 

                                                Now, it's not the bundled payments that you hear about through CJR, which is run by the hospital and which is dictated and mandated by CMS. That program is never going to work for orthopedic surgeons. I'm talking about bundled payment programs that are designed, implemented and run by orthopedic surgeons out of their practices, and that are negotiated by orthopedic surgeons with payers and employers. That works and there's all sorts of places all over the country that works brilliantly, especially in the total joint market. Now, if you look at the literature on this, it's pretty clear. Not only is it better for patients with better outcomes and decrease complications, it's better for costs and it's better for the orthopedic surgeon because they have a higher profit. 

Chris Tucker:                      Dr. Beach, any closing thoughts? 

Dr. Beach:                           So, yeah. I think we we kind of, as orthopedic surgeons, need to kind of either get in the game or get out of the game and to get in the game, you got to get dedicated to the subject matter. I can't tell you how many times Lou and I've been teach a course and ask how many people look at their EOBs and it's almost zero. So unfortunately we aren't educated enough to be good for our own patients and our own practices. We don't look at our business. We don't look at our income statements. We don't look at explanation of benefits so we know what the patients are even charged for. We don't know what the surgery center gets reimbursed. We don't know where the practice gets reimbursed. We don't know what our costs are. 

                                                So what I would say is that we need to probably, as societies, as an academy, do a better job educating the young guys who are, I think, so busy trying to be good doctors, but they don't have time or energy to be businessmen and then they get to be 60 like Lou and I are, and we're frustrated and irritated that it's been a rigged game that we've been involved in for 30 years. 

                                                My ask would be that we get more focused on the business side and that we, societies, subspecialty societies including the Academy, start to push the subject matter. Otherwise, we're going to continue to lose like we have over the last 30 years. 

Chris Tucker:                      Great. Thank you both again so much for sharing your time and thoughts with us today. I commend you both for being our educators and our advocates, and I join you and encouraging everyone invested in the practice orthopedics to get smart on this for all of our benefit. Doctors McIntyre and Beach, thank you again for joining us. 

Dr. Beach:                           Thanks Chris. 

Dr. McIntyre:                     Thanks for a great job you do on the podcast. 

Chris Tucker:                      Dr. McIntyre and Dr. Beach's commentary titled “A Rigged Game: Surgeon Reimbursement Under The Resource Based Relative Value System, Current Procedural Terminology, and the Affordable Care Act” can be found in the Arthroscopy Journal, which is available online at www.arthroscopyjournal.org. 

                                                This concludes this edition of the Arthroscopy Journal Podcast. Thank you for listening. Please join us again. Next time.