Health Policy & Advocacy: Pages

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Sarah Meyer Hughes — Wed, 29 Oct 2008 19:11:27 GMT

Description: Learn more about how the Hand Society advocates on behalf of its members on issues such as medicare reform and physician reimbusement. Included are links to information on Congress and activities of the American Medical Association.

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Hand Transplantation Policy

The American Society for Surgery of the Hand recently adopted a new policy on hand transplantation. View the full statement here.

Government Affairs Newsletter

In the June 2013 Issue:

Supreme Court sides with doctors in dispute over insurer's pay practices
Federal judge lifts ban on public access to Medicare data
Most Doctors Don’t Meet U.S. Push for Electronic Records
Hand Society Legislative Update: By Bruce Leslie, MD, Chair, Government Affairs Committee

State and National Advocacy

AAOS State and National Activities: Provides information on issues, advocacy tools and listservs.

ASPS Health Policy and Advocacy: Provides information on key issues, programing and grassroots efforts.

AMA Advocacy

Join or renew your AMA membership now and help ensure the ASSH maintains representation in the AMA House of Delegates (HOD).

The AMA rules stipulate that in order to qualify for a seat in the AMA House of Delegates 25% of ASSH members must be AMA members.

The AMA is the primary voice of organized medicine in the United States. Furthermore, AMA institutions such as the CPT Editorial Panel and the Relative Value Update Committee (RUC) are vital to the best interests of ASSH members.

Within the realm of physician reimbursement the ASSH would be significantly disadvantaged should we lose our seat in the AMA HOD. Our ability to have advisors to the AMA RUC and CPT® Coding processes is predicated on our having a seat in the AMA HOD. Should we lose that seat we would still be able to participate in these processes but we would lose the advantages associated with those positions. We would lose our ability to directly interact with the AMA in regard to coding issues. We would not have access to the complete RUC database or to the other critical information that is contained in the agendas of the RUC and CPT Editorial Panel.

Practically, the loss of our HOD seat would force us to present our new RUC recommendations through the American Academy of Orthopaedic Surgeons (AAOS) or the American Society of Plastic Surgeons (ASPS). ASSH would not have a dedicated Advisor to bring forward new CPT codes for ASSH and we would lose the considerable influence of our advisor.

These are difficult times, and our seat in the AMA HOD gives us access to the bargaining table.

Click on the links to the left for past reports from your AMA delegates.

Medical Liability Reform

Doctors for Medical Liability Reform: Learn more about the national grassroots effort to protect patient access to care.

American College of Surgeons Medical Reform Action Guide: Tools to allow surgeons to more efficiently and easily contact elected representatives on both the state and federal levels.

ASSH-Hand-Transplantation-Policy,-June-2013-

Olivia Moran — Mon, 17 Jun 2013 13:51:46 GMT

Contact: Olivia Moran

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The first case of hand transplantation was performed by French surgeons in September 1998. Unfortunately, this unilateral transplantation resulted in re-amputation within several months, in large measure as a consequence of poor patient compliance. Shortly after this case the first American hand transplant was performed in Louisville, Kentucky. This individual’s transplanted hand has survived and functioned well. However, despite this clinical success, there have been substantial complications related to immunosuppression in subsequent hand transplant recipients including avascular necrosis of both femoral heads, requiring hip arthroplasties.

Worldwide there have been close to 65 hand transplants documented, although it is possible that a greater number of undocumented cases may have been performed. In addition to hand transplants, there has been transplantation done at a variety of proximal limb locations including above elbow levels and at the proximal forearm. Partial hand transplantations have also been reported. In addition to the upper extremity, vascularized composite allotransplants of the abdominal wall, larynx, the entire face and lower extremities have been reported.

For hand transplantation the variables that most affect outcome appear to be compliance both with an intensive program of hand therapy as well as with post-transplantation immunosuppressive therapy. Careful patient selection is fundamental to meeting these critical therapeutic objectives. As a result, in centers where hand transplantation is being performed, multidisciplinary teams that can fully assess candidates from not only a medical and surgical standpoint, but also from a psychosocial perspective, have proven to be essential.

The overall results from hand transplantation have, so far, been generally satisfactory. Functional and cosmetic outcomes, particularly for bilateral amputees, have been similar to or better than hand replantation following traumatic amputation. As is frequently the case with peripheral nerve injuries proximal to the wrist, intrinsic muscle function has not been restored to the transplanted hand in most instances. As expected, and consistent with the experience with major limb replantations, the return of motor function with transplantation of limbs above the wrist is determined by the quality of re-innervation of the extrinsic flexors and extensors, and this has been more reliable than the reinnervation of the intrinsic muscles with hand transplantation.

One of the main concerns related to hand transplantation is the long term effects of lifelong immunosuppression. However, it now appears clear that the level of immunosuppression required is equivalent to that used for kidney transplantation and the risks are approximately equal to those incurred by renal transplant recipients. Newer concepts in immunosuppression are also evolving. For example, a cellular based approach that uses donor bone marrow cell augmentation rather than a multiple drug regimen to prevent or truncate episodes of rejection has been used. However, complications from chronic immunosuppression continue to be a concern. Intimal hyperplasia leading to vascular compromise in the graft resulting in delayed thrombosis and transplant loss has been reported. Major systemic problems such as fulminating sepsis and diabetes have also occurred. Regardless of the nature of the immunosuppressive regimen, episodes of rejection of varying magnitude have been experienced by all patients who have undergone vascularized composite allotransplantation (VCA).

The number of cases that have been performed worldwide notwithstanding, hand transplantation is still considered an innovative intervention in most institutions, but several centers consider it to be standard of care for bilateral amputees. There are several centers in the United States that have demonstrated a dedication to the further development of knowledge in this field and, as experience increases, the number of institutions capable of carrying out these procedures will grow. Advances in solid organ transplantation, especially in the areas of tissue typing and refinement of immunosuppression protocols, have resulted in improved graft and patient survival. It seems likely that these advances will also benefit patients who undergo hand transplantation, although it is clear that a composite of skin, muscle, bone, nerve and tendon, presents a set of challenges for the control of rejection that is somewhat more complex than that associated with a solid organ transplant.

Public perception of what can be achieved with VCA is also changing. In some jurisdictions, organ procurement organizations have scripted documents specifically to request hand donation. However, despite the advances made in the technical and biologic aspect of VCA, ethical concerns are still expressed by some. The fundamental issue relates to the overall value of hand transplantation. Solid organ transplantation is unequivocally a life saving intervention in patients requiring heart or liver. VCA, including the hand, do not save life, and in fact may introduce a threat of decreased lifespan secondary to the complications of chronic immunosuppression. Nonetheless, there is a potentially dramatically improvement in the quality of life that may ensue from hand transplantation and, as a result, the cost/benefit analysis becomes one of quality versus quantity. Where this has been carefully studied in a hypothetical context using methods like the standard gamble, unaffected individuals have attributed a net benefit to the idea of undergoing hand transplantation. In a real world setting, issues of appropriate patient expectation and the expectation of truly informed consent to undergo this kind of treatment remain issues that require further development.

At this time the American Society for Surgery of the Hand recognizes that hand transplantation represents an alternative to prosthetic fitting and rehabilitation. However, advances should continue to be made in the areas of patient selection, surgical technique and immunosuppression. Additional challenges include the funding of patients for these procedures and for the lifelong immunosuppressive treatment. This procedure may have substantial merit in properly selected recipients; however for the present it should be carried out only in centers with extensive experience in both hand surgery and solid organ transplantation. It will be only in this type of setting that the combined expertise of hand surgeons and transplant physicians can be brought together to ensure the best results possible, while at the same time creating knowledge from gained experience. No less important will be the efforts of those with the responsibility of defining meaningful methods of evaluating those outcomes.

Landing Page Feature: No

Section Highlight: No

Audience: Abbreviated: Allied Health

Audience: Extended: Donors

Taxonomy: ASSH Program Area: Advocacy/Health Policy

Taxonomy: Anatomy: Anatomic Variations

Taxonomy: Physiology/Disease: Classification Systems

Taxonomy: Product Type: Book

Government-Affairs-Newsletter,-June-2013

Sarah Meyer Hughes — Mon, 10 Jun 2013 18:35:09 GMT

Contact: Sarah Meyer Hughes

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Supreme Court sides with doctors in dispute over insurer's pay practices
AMA
A decision Monday by the Supreme Court of the United States will allow individual physicians to come together as a group to fight unfair business practices of large health insurance companies. The ruling in Sutter v. Oxford Health Plans, a dispute between the East Coast insurer and New Jersey pediatrician John Sutter, MD, that dates back to 2003, means that thousands of physicians will be able to use class arbitration against an insurer that has underpaid them for more than a decade. Read more.

Federal judge lifts ban on public access to Medicare data
Reuters
A federal judge lifted a 33-year-old injunction barring public access to a confidential database of Medicare insurance claims, a decision that could lead to greater scrutiny of how physicians treat patients and charge for their services. Judge Marcia Morales Howard ruled Friday in favor of a motion by Dow Jones, publisher of the Wall Street Journal, that the U.S. District Court for the Middle District of Florida lift an injunction imposed in 1979. Read more.

Most Doctors Don’t Meet U.S. Push for Electronic Records
Bloomberg
Fewer than 1 in 10 doctors used electronic records last year to U.S. standards, according to a survey that shows the challenge facing a multibillion-dollar effort to digitize the health system for improved patient care. Only 9.8 percent of 1,820 primary-care and specialty doctors said they had electronic systems that met U.S. rules for "meaningful use," a list of tasks such as tracking referrals or filling prescriptions online. Less than half all those surveyed, or 44 percent, had any system in place, according to the report published by the journal Annals of Internal Medicine. Read more.

Hand Society Legislative Update

Bruce M. Leslie, M.D.
Chair, ASSH Government Affairs Committee

Each year the Government Affairs Committee (GAC) sends representatives to Washington D.C to attend the National Orthopaedic Leadership Convention (NOLC). The NOLC is sponsored by the AAOS. Members of the GAC attend seminars about health care and spend one day visiting with our respective legislators on Capitol Hill. This year the NOLC was scheduled during a time that most of the legislators were out of town. As a result attendees met with staff members. Typically that would not be the time to travel to Washington, but this year was a bit different. One or two staff members in each of the state’s delegations were willing to engage in frank and meaningful dialogue giving us the impression that our persistence may finally be paying off. This year’s issues:

1. Sustainable Growth Rate (SGR). The SGR is the method currently used by the Centers for Medicare and Medicaid Services (CMS) in the United States to control spending by Medicare on physician services. It is the SGR that has caused Medicare reimbursement to be effectively flat for the past 15+years. Every congressional office agrees that the SGR needs to be abandoned. In the past, the issue was how the government was going to offset the $335 billion price tag. The Congressional Budget Office (CBO) has rescored the ten year cost estimate based on savings realized in decreased utilization and revised expenditure forecasts. As a result, the White House’s Office of Management and Budget (OMB) has now priced the SGR fix at $138 billion. The decrease in this estimated cost has motivated Congress to act. Even the most reluctant democrats say that this is the year to fix the SGR and take advantage of an unexpected 60% discount. http://www.aaos.org/news/aaosnow/jul12/advocacy2.asp

2. In-office Exemption (Stark exemption). In their search for additional healthcare dollars some legislators have proposed elimination of this exemption. This exemption allows doctors to provide x-rays and splints in the office. Eliminating this exemption would make office visits much less convenient for patients and require that patients make multiple trips going from the doctor’s office to the x-ray suite, then back to the doctor’s office and then to the brace maker’s shop. Almost every legislator’s office saw the folly in eliminating the in-office exemption but surprisingly few were willing to champion our cause. Fortunately there is presently no bill to eliminate the in-office exemption, so at the moment this is just chatter.

3. IPAB (Independent Payment Advisory Board). This is the Board established by the Patient Protection and Affordable Care Act (PPACA) that will determine how much health providers will be paid. For those of you who have not been following past newsletters the IPAB adjustment will occur after CMS discounts what doctors will get paid based on the RVU system. In other words doctors will be hit with two reductions. Hospitals and Big Pharma are excluded from IPAB reductions until the year 2020. That means any IPAB reduction will only affect doctors and other medical professionals. The good news is that there is no anticipated IPAB reduction this year. Some of the smaller and less populated states are looking at IPAB as a way of redistributing moneys away from states that receive more healthcare dollars. In a world with fixed costs, redistribution means when a state gets more money another state must get less money.
http://www.aaos.org/news/aaosnow/jul10/advocacy1.asp

4. Medical Device Payments. For those of you who receive payments from medical device companies you should know that effective August 1, 2013 anything valued over $10 is reported to CMS. This includes travel and meals. Know that the payments are cumulative. If you receive something that is less than $10 in value but over the year the combined value reaches $100 your name will be reported to CMS. Research grants that are not assigned to a specific person are not reported. CME grants are not reported. At the moment the moneys reported to CMS are not reported to the IRS.

5. Accountable Care Organizations (ACO’s). Jonathan Blum, the deputy administrator and director of CMS, made it clear that patients can receive their care from any participating Medicare provider. Using his terms: ACO’s are layered on top of basic Medicare rights and one of those rights is the ability of Medicare patients to choose their provider. He did not address, however, the difficulties that patients may encounter when accessing care within an ACO, such as disparate EMR systems, differing practice cultures and the manner in which ACOs may affect primary care referrals to specialists.

6. Medicare. Mr. Blum made it very clear that CMS has the ability to look at their numbers geographically and by procedure. They know that the average 30 day hospital re-admission rate is 18%. Of most interest was his statement that there is little apparent correlation between Quality of Care and Cost of Care. This may be intuitively obvious, but it is an amazing statement and underscores CMS’s push to decrease the cost of providing care. It should also underscore the recent articles about variations in the cost of medical procedures across the country.

Fun Facts: Percent Medicare spending in 2011

a. Hospitals – 40.19%
b. Physicians – 16.29%
c. Prescription Drugs – 13.85%
d. Skilled Nursing – 7.05%
e. Home Health – 4.52%

The bottom line is patient access. Ten thousand new patients are enrolled in Medicare each day! More and more senior physicians are choosing to retire early rather than continue practicing. Medical Schools have increased the number of slots by 10-15%, but there are not enough post-graduate slots to accommodate the new graduates.

http://www.nytimes.com/2010/02/15/education/15medschools.html

There will be pressure to open more primary care post-graduate slot than subspecialty slots.

http://www.nytimes.com/2009/04/29/education/29iht-riedmedus.html

This means that there will be continued pressure on practicing hand surgeons to see more and more patients at what will probably be a lower reimbursement. Medical groups and the government need to work together to find solutions to this burgeoning problem. Nimble groups may be able find ways to provide appropriate care at a decreased reimbursement in the face of increasing patient demand.

Landing Page Feature: No

Section Highlight: No

Audience: Abbreviated: Allied Health

Audience: Extended: Donors

Taxonomy: ASSH Program Area: Advocacy/Health Policy

Taxonomy: Anatomy: Anatomic Variations

Taxonomy: Physiology/Disease: Classification Systems

Taxonomy: Product Type: Book