RUC Business
The RUC review of codes 29826 (arthroscopic acromioplasty), 29880 and 29881 (arthroscopic menisectomy codes) is almost complete. Next week we will present our survey results to the RUC for all three codes. I will report on their final revaluation in the summer newsletter.

PPACA and the
“Shared Savings Program”
The Patient Protection and Affordable Care Act (ObamaCare) has a section that describes a shared savings program for Medicare. The program is an attempt to have medical groups decrease the cost of treating patients and pass those savings on to Medicare. The participating groups would be entitled to share a certain portion of those savings. The model for the program is the Physician Group Practice Demonstration Project (PGP) that Medicare has been piloting for several years.

In March of this year, the department of Health and Human Services (HHS) published the preliminary rules governing the program and outlined a 60 day comment period for any interested parties. The rules describe the structure and function of Accountable Care Organizations, or ACO’s. An ACO is a group medical practice that will have the legal, medical and administrative ability to provide primary care to Medicare beneficiaries. The providers will be “accountable for the cost of care, and be rewarded for reducing unnecessary expenditures and be responsible for excess expenditures.” In reducing excess expenditures the providers “will have to continually improve the quality of care they deliver and must honor their commitment to do no harm to beneficiaries.”

An ACO can be a group practice, a network of providers, physicians and hospitals in a joint venture, hospitals and employed physicians, or any other “structure the Secretary (of HHS) determines.” To be eligible to become an ACO, a practice must: 1) Have sufficient primary care professionals for at least 5000 assigned beneficiaries, 2) Have a legal structure to receive and distribute shared savings, 3) Agree to participate in program for three years, 4) Have a leadership structure for clinical and administrative system, 5) Have processes for promoting patient engagement, reporting quality and cost data and evidence based medicine and 6) Meet “patient-centeredness criteria” such as use of patient and caregiver assessments or individualized care plans.

The ACO would share the economic risk of providing care in one of two ways; share only in savings generated or share in savings and be responsible for cost overruns. The former option would expire after the first two years of participation and become the second or “two-sided” risk model for the final year of the program. The potential shared saving would be greater in the two-sided model.

ACO’s will be able to negotiate rates with managed care organizations and will have some benefits in this regard with exemptions from Stark and anti-kickback legislation. ACO’s may also enjoy benefits with current anti-trust rules regarding the percentage of participating providers in a given service area.

Will this work? The experience of the PGP Demonstration project is a cautionary tale. The project had 10 well organized participants who spent an average of 1.7 million dollars per group to set up the infrastructure necessary to become involved with shared saving program. After three years, only 5 were eligible to share savings and it was estimated that it might take five to ten years to reasonably recoup the initial investment. ( See Inglehart New England Journal of Medicine, January 2011 and Haywood and Kosel NEJM March 2011)

Whether they work or not, ACO’s are mainly a primary care organization. Unless employed by a hospital or a multispecialty group, orthopaedic surgeons will most likely contract with one or multiple ACO’s; if they ever come to fruition. For anyone interested in this topic, the AAOS, AMA and CMS websites have more detailed information.

AANA Website Communities
AANA is launching a series of online communities on the website that will be available in the next few months. The communities will be “social networks” for all aspect of arthroscopic surgery and practice. There will be a Health Policy and Practice community where information on coding, practice management, EMR and health policy will be available; it will include a FAQ section on common coding questions. The communities should be a great place to get up to the minute information and advice and will provide an exciting new way to interact with other AANA members. The HPP community should be ready for use this Spring. Please visit the website for information on the start of the communities.