50% of Total Joint Surgeons in the Dark About RUC Codes Controversy

by Elizabeth Hofheinz, M.P.H., M.Ed., October 21, 2019

For years they have participated in bundled care programs, saving millions of dollars for the healthcare system while maintaining quality…and they are the last ones to leave when the complications hit the fan.

They are the hip and knee surgeons of America…and they are in trouble.

James Huddleston, M.D. is an Associate Professor of Orthopaedic Surgery at Stanford University Medical Center. Dr. Huddleston, who serves as Chair of the Advocacy Council of the American Association of Hip and Knee Surgeons (AAHKS), told OSN, “There are high-volume codes that are reviewed by the RVU Update Committee (RUC) every 5 years at the request of CMS. Because the high-volume hip and knee codes have not been reviewed since 2013 it is our turn.”

So far, so fair…

However, says Dr. Huddleston, things did not go as anticipated. “The current procedure (nomination) happened outside of the standard rule-making process and was put forth by Anthem, the largest for-profit health plan in the country. To make matters worse, CMS would not divulge who the nominator was until we asked them—which was months after the beginning of the process. The rule says that anyone can request a nomination, but that the requesting party should be made public. Given their monumental role in the U.S. healthcare system, Anthem has a clear conflict of interest.”

“The basis for Anthem’s nomination was a pilot study conducted through the Urban Institute, a project that was funded by CMS. The study involved five doctors and several interviews and Anthem’s takeaway point was, ‘The time that it took these five surgeons to do xyz operation was 15% less than the current standard of practice.’ We were caught completely off guard and shocked that this was happening. That data from the Urban Institute was never intended to be used to trigger a reevaluation process for high-volume codes.”

I quit…

Craig Della Valle, M.D. is a Professor in the Department of Orthopaedic Surgery and Chief of Adult Reconstructive Surgery at Rush University in Chicago and is the Immediate Past President of the AAHKS. He told OSN, “High-volume total hip and knee surgeries are being placed on a ‘potentially misvalued codes list’ and I would say roughly half of our total joint colleagues are in the dark about this situation. The implications are grave as we are looking not only at big cuts in reimbursement, but the work units of one of the most successful operations in orthopedics are being devalued. We may end up in a situation where the reimbursement drops so low that many surgeons say, ‘This isn’t worth it. I quit.’ The highest volume surgeons are still going to do these surgeries, but not those who only do them occasionally—and with the aging population we cannot afford to lose any total joint surgeons. We must preserve the value of these codes.”

Michael Bolognesi, M.D., Professor of Surgery and Chief of the Adult Reconstruction Division at Duke University School of Medicine, is President of the AAHKS. He commented to OSN: “It is our belief that total joint surgeons have served our profession and our patients with wisdom and dedication. We have been good stewards of Medicare resources and have always been at the ready to make improvements in our field. Indeed, we have participated faithfully in the bundled car programs, and have on many occasions been the first to enter into such programs.”

Registering concerns…not fruitful as of yet

Dr. Huddleston: “The AAHKS has a solid working relationship with CMS and with the CMMI, the innovation center within CMS, and our subspecialty leads the way in transitioning from a fee-for-service reimbursement model into a value-based one. The results of those efforts have been widely published. We have saved CMS a substantial amount of money, and to be the subject of this type of treatment is unjust.”

These physicians have sat down with representatives from CMS and have put their displeasure in writing as well. Thus far, there has been little response.

Dr. Della Valle: “Instead of being paid for each service, surgeons are given a lump sum for an episode of care from when we do the operation until 90 days after. Thus, as drivers of business, we have the most ‘skin in the game,’ and as a result, are most familiar with the episode of care. So our experience is a logical place to start reducing cost in a way that maintains quality…any redesign of care needs to be undertaken in collaboration with surgeons.”

And they are working for free…

Not to mention all of the unreimbursed time these total joint surgeons put into working on the BCPI and CJR, says Dr. Della Valle. “CMS establishes a ‘reference price’ i.e., ‘Here is x and if you, as the surgeon in charge of the bundle, charge less for that episode of care then you have a savings.’ So that initial reference price is based on historical averages (How much has an episode of care cost you per year over the last five years?). The next step up for historical referencing is to examine these costs for all total joint surgeons within 20 miles from you. Then they begin ratcheting the price below that regional price.”

Michael Zarski, JD is the Executive Director of the AAHKS. “When they came forward with a list of potentially misvalued codes there were other specialties on that list. The difference is that our surgeons specialize in hip and knee arthroplasty, so the great majority of their reimbursement comes from one or two codes.”

Elaborating on the process, Zarksi notes, “Once there is a recommendation from the RUC, then CMS can either decide to accept the recommended value or adjust it up or down. The last time around, CMS adjusted upward the 2013 RUC recommendations for hip and knee replacement. That rarely happens, but anything is possible.”

Dr. Della Valle: “We devote a lot of time and resources trying to understand how to optimize outcomes for our patients. For example, we spend more time with a smoker, who has a higher risk for complications. At Rush we enroll patients in a smoking cessation program—just one example of how hip and knee surgeons are being responsible and doing our best to optimize patients and lower costs.”

At the breaking point…

“ We have surveyed our members,” said Dr. Huddleston, “and they are at a reimbursement breaking point. We are essentially victims of our own success. Hip and knee replacement are two of the most effective medical interventions of all time.”

And they are being punished for it.

Dr. Huddleston sums it up: “It seems as if we have a target on our backs and the numbers are stacked against us. However, since we have good relationships with lawmakers, we have had some patients explain to these leaders the value of these operations. If the RUC and CMS make unfair recommendations, then we will take it to these lawmakers.”