The Threat to In-office Ancillary Services

The Threat to In-office Ancillary Services

Fred Redfern, MDFred Redfern, MDAAOS Board of Councilors ChairAAOS Board of Councilors Chair

David Teuscher, MDDavid Teuscher, MDAAOS Second Vice-President ElectAAOS Second Vice-President Elect

Stephen McCollam, MDStephen McCollam, MDChair, AAOS BOC State Legislative and Chair, AAOS BOC State Legislative and

Regulatory Issues CommitteeRegulatory Issues Committee

February 11, 2013February 11, 2013

1

What to Expect

The purpose of this webinar is to The purpose of this webinar is to provide you with background provide you with background information, compelling arguments, information, compelling arguments, and grassroots tools to effectively and grassroots tools to effectively advocate to protect in-office advocate to protect in-office ancillary servicesancillary services

2

The Stark Law

Physicians cannot refer patients to a facility for treatments Physicians cannot refer patients to a facility for treatments where the referring physician or his/her family has a where the referring physician or his/her family has a financial interest.financial interest. 1989 – Social Security Act1989 – Social Security Act

Limited self-referral for clinical labsLimited self-referral for clinical labs 1992 – Stark 11992 – Stark 1 1993 – Stark 21993 – Stark 2 2006 – Stark 32006 – Stark 3

3

The Stark LawIn-Office Ancillary Services Exception

IOASE

Exempts in-office ancillary services:Exempts in-office ancillary services:ImagingImagingOccupational/Physical therapyOccupational/Physical therapyLaboratory servicesLaboratory servicesOrthotics/prostheticsOrthotics/prostheticsOthersOthers

4

Imminent Threat

Congressional Budget Office to “Score”Congressional Budget Office to “Score” Estimates cost or savings generated by Estimates cost or savings generated by

eliminating the exceptioneliminating the exception Could be used to close budget gapsCould be used to close budget gaps

5

GAO Report(September 2012)

Argued that higher use of advanced imaging by Argued that higher use of advanced imaging by providers who self-refer cost Medicare $109M per providers who self-refer cost Medicare $109M per year ($1.1B over 10 yrs)year ($1.1B over 10 yrs)

Flawed methodology and assumptionsFlawed methodology and assumptions Excludes hospital referralsExcludes hospital referrals Appropriate referral rates not studiedAppropriate referral rates not studied

6

Recent Congressional Action We had a close call on Jan 1 fiscal deal, We had a close call on Jan 1 fiscal deal,

which expires March 1which expires March 1 There was an attempt to include language in There was an attempt to include language in

the fiscal cliff bill closing the Stark the fiscal cliff bill closing the Stark exceptionexception

AAOS advocacy efforts averted this AAOS advocacy efforts averted this provision of the billprovision of the bill

7

Current Threat

As we near the next “fiscal cliff” on March As we near the next “fiscal cliff” on March 1, the IOASE may once again be considered 1, the IOASE may once again be considered as an offset for federal spendingas an offset for federal spending

If comprehensive entitlement reform is If comprehensive entitlement reform is considered this spring, elimination of the considered this spring, elimination of the IOASE may be considered as an offset for IOASE may be considered as an offset for SGR fix.SGR fix.

8

AAOS Action

AAOS PAC relationships utilizedAAOS PAC relationships utilized COA involvement/fly-insCOA involvement/fly-ins AAOS OGR lobbying effortsAAOS OGR lobbying efforts Key Congressional committees targetedKey Congressional committees targeted Grassroots call to actionGrassroots call to action Combined efforts with affiliated Combined efforts with affiliated

organizations and coalitionsorganizations and coalitions

9

AAOS Action ResearchResearch

Economic study of the effect of physician Economic study of the effect of physician ownership on utilization of imaging ownership on utilization of imaging servicesservicesSignificant AAOS investmentSignificant AAOS investmentPhase 1 completed; phase 2 underwayPhase 1 completed; phase 2 underwayAnticipated completion spring 2013Anticipated completion spring 2013Funded by BOC SLRI CommitteeFunded by BOC SLRI Committee

10

Coalition Partners: CPCI(Imaging Only)

Coalition for Patient Centered ImagingCoalition for Patient Centered Imaging American Academy of NeurologyAmerican Academy of Neurology American College of CardiologyAmerican College of Cardiology American Congress of OB/GYNAmerican Congress of OB/GYN American Urological AssociationAmerican Urological Association 12 others12 others

11

Friends of IOASE

Cleveland Clinic Health SystemCleveland Clinic Health System Mayo Clinic Health SystemMayo Clinic Health System Geisinger Health System, Intermountain Geisinger Health System, Intermountain

HealthcareHealthcare Henry Ford Medical SystemHenry Ford Medical System OthersOthers

12

Opposition: AIM Coalition

Alliance for Integrity in MedicineAlliance for Integrity in Medicine American College of RadiologyAmerican College of Radiology American Clinical Laboratory AssociationAmerican Clinical Laboratory Association ASTRO (Radiation Oncologists)ASTRO (Radiation Oncologists) American Society for Clinical PathologyAmerican Society for Clinical Pathology

13

The Orthopaedic case for IOAS

If it is meant to be, it is up to WE.If it is meant to be, it is up to WE. You need to enlist your patients.You need to enlist your patients. We’ll educate you, and you, your patients.We’ll educate you, and you, your patients. What will you do?What will you do?

14

The Orthopaedic case for IOAS

Prevalence and vulnerable populationsPrevalence and vulnerable populations Compliance & convenienceCompliance & convenience Quality & coordinated careQuality & coordinated care Cost & outcomesCost & outcomes HOPD costs more for same servicesHOPD costs more for same services

15

Argument for IOAS: Prevalence

One in 4 Americans.One in 4 Americans. Prompt diagnosis and appropriate treatment.Prompt diagnosis and appropriate treatment. Reduce patient suffering and overall costs.Reduce patient suffering and overall costs. Costs of musculoskeletal disability.Costs of musculoskeletal disability.

16

Argument for IOAS: Discrimination

Only affects those covered by CMS policy.Only affects those covered by CMS policy. Discriminates against Most Vulnerable:Discriminates against Most Vulnerable:

Elderly & Disabled (Medicare)Elderly & Disabled (Medicare) Poor (Medicaid)Poor (Medicaid) Military families (Tricare)Military families (Tricare)

All others will have access to IOASAll others will have access to IOAS

17

Arguments for IOAS: Compliance & convenience

Improves adherence to treatment plans and Improves adherence to treatment plans and outcomes by;outcomes by; eliminating scheduling delays.eliminating scheduling delays. eradicating duplicate paperwork.eradicating duplicate paperwork. minimizing mobility and travel issues.minimizing mobility and travel issues. reducing costs of non-compliance.reducing costs of non-compliance.

18

Arguments for IOAS: Better Care Coordination

Physician availability and oversight to Physician availability and oversight to ensure improved quality of care in real ensure improved quality of care in real time.time.

Improve the imaging/treatment of patients Improve the imaging/treatment of patients without delay or costs to the patient.without delay or costs to the patient.

19

Arguments for IOAS: Rural Access Challenges

Transportation time and costs.Transportation time and costs. Scheduling off-site, especially hospitals, Scheduling off-site, especially hospitals,

typically means another return trip.typically means another return trip. Follow-up visits delayed by off-site referral.Follow-up visits delayed by off-site referral. Patients often alternatively access the ER.Patients often alternatively access the ER.

20

Arguments for IOAS:Costs of HOPD

Hospitals bill more for the same services, Hospitals bill more for the same services, 40% more according to MEDPAC.40% more according to MEDPAC.

Congress should avoid arbitrarily restricting Congress should avoid arbitrarily restricting access solely on physician investment.access solely on physician investment.

Consideration for the quality, convenience, Consideration for the quality, convenience, savings, value, and outcomes our patients savings, value, and outcomes our patients receive should be paramount.receive should be paramount.

21

Arguments for IOAS:Opposing Views

Overutilization based upon ownershipOverutilization based upon ownership ““Inappropriate” should be focusInappropriate” should be focus Scientific literature lacks consensusScientific literature lacks consensus

Same day services are less than ½ IOASSame day services are less than ½ IOAS Rehab scheduled over weeks but initial or Rehab scheduled over weeks but initial or

final evaluation can be same dayfinal evaluation can be same day Patient preference drives MRI schedulePatient preference drives MRI schedule

22

Arguments for IOAS: Saves Time and Money

Saves time & money Saves time & money on transportation and on transportation and time away from work or schooltime away from work or school

Saves money & time Saves money & time patientspatients spend on spend on transactional costs and paperworktransactional costs and paperwork

Saves time & money Saves time & money by providing timely by providing timely diagnosis and appropriate treatmentdiagnosis and appropriate treatment

Saves money Saves money outpatient vs. HOPDoutpatient vs. HOPD

23

Arguments for IOAS: Tell your Personal Story

It’s not about you or your ownership.It’s not about you or your ownership. Remember the MVP.Remember the MVP. Common, painful, disabling injury.Common, painful, disabling injury. Convenience and costs for patient Convenience and costs for patient and familyand family.. Time, travel and hassle factors.Time, travel and hassle factors. Quality, safety and outcomes.Quality, safety and outcomes. Bottom line: access to care!Bottom line: access to care!

24

GrassrootsOur Voice is Critical

Physicians are ideal advocates Physicians are ideal advocates CredibleCredible ExperiencedExperienced

Legislators need to hear from usLegislators need to hear from us Limited experience and knowledgeLimited experience and knowledge Unaware of the challenges of providing care to Unaware of the challenges of providing care to

patientspatients If we don’t tell our story, who will?If we don’t tell our story, who will?

25

What WE Can Do Meet with your CongressmanMeet with your Congressman

In-district office In-district office Washington, D.C.Washington, D.C.

Send a letter via the AAOS websiteSend a letter via the AAOS website Call the Congressional office in DCCall the Congressional office in DC Recruit patients to advocateRecruit patients to advocate Recruit patients to recruit: family, friends,..Recruit patients to recruit: family, friends,.. Recruit other doctors to do aboveRecruit other doctors to do above

26

Face to Face Meeting In the local district office (Feb. 25-28 OOS)In the local district office (Feb. 25-28 OOS) Washington, D.C.Washington, D.C. Bring an articulate patient who has benefitted Bring an articulate patient who has benefitted

from IOASfrom IOAS During the Meeting -- During the Meeting --

Be social: Greet, Congratulate, ThankBe social: Greet, Congratulate, Thank Succinct message -- Webinar/OGR materialsSuccinct message -- Webinar/OGR materials Compelling patient exampleCompelling patient example Repeat the message/Leave behindRepeat the message/Leave behind

27

Other Community Opportunities Attend a fundraiser/Make a contributionAttend a fundraiser/Make a contribution In-district eventsIn-district events

Town Hall meetings Town Hall meetings CoffeesCoffeesCheck legislator’s websiteCheck legislator’s website

Invite a Member of Congress to visit your Invite a Member of Congress to visit your officeoffice

28

Email/Call Send a letter via the AAOS website:Send a letter via the AAOS website:

Government Relations/Hot TopicsGovernment Relations/Hot Topics IOAS headerIOAS header Add a personal messageAdd a personal message

Call your CongressmanCall your Congressman Ask for Healthcare Liaison/StafferAsk for Healthcare Liaison/Staffer Ask for Budget/Finance stafferAsk for Budget/Finance staffer Have talking points organizedHave talking points organized

29

AAOS Home Page

30

31

32

33

Scroll down inside this box and type in personal message.

Patient Involvement

Post this sign in Waiting Room/Exam RoomPost this sign in Waiting Room/Exam Room

Ask your doctor about protecting yourAsk your doctor about protecting yourability to receive convenient therapy and ability to receive convenient therapy and

diagnostic services in this office.diagnostic services in this office.Ask about writing to Congress today!Ask about writing to Congress today!

34

Place This in the Waiting Room

35

Logistics Tip: Mass produce flyer at Kinkos/Send via email for order

Patient Involvement Engage patients for one minute at the end of the office visit Engage patients for one minute at the end of the office visit

-- Review Patient Talking Point Sheet-- Review Patient Talking Point Sheet Message must come directly from you – face to face, not staffMessage must come directly from you – face to face, not staff Explain about the need to protect their ability to get efficient Explain about the need to protect their ability to get efficient

carecare Have letter ready for them to personalize and sign Have letter ready for them to personalize and sign Fax or scan/e-mail to the Congressional officeFax or scan/e-mail to the Congressional office

Direct it to the specific staff personDirect it to the specific staff person AAOS OGR will send letter templates AAOS OGR will send letter templates

36

Patient to Patient Grassroots If Patients agree to advocateIf Patients agree to advocate Ask them to recruit other voting ageAsk them to recruit other voting age

Family membersFamily members FriendsFriends Co-workersCo-workers Members of their Soc. Org, i.e bowling, ..Members of their Soc. Org, i.e bowling, ..

Have extra Patient Flyers readyHave extra Patient Flyers ready

37

Patient Recruitment Social MediaSocial Media

Put link on Practice WebsitePut link on Practice Website Practice Facebook page Practice Facebook page Send a TweetSend a Tweet Let patients know their convenient access to therapy Let patients know their convenient access to therapy

and diagnostic testing is threatenedand diagnostic testing is threatened Give talking points and post sample patient letter.Give talking points and post sample patient letter. Copy link to : Write to CongressCopy link to : Write to Congress On AAOS Government Relations Page.On AAOS Government Relations Page.

38

Doctor to Doctor Grassroots

Call or email all your partnersCall or email all your partners Forward talking points and files sent by OGRForward talking points and files sent by OGR Send link to watch re-play of WebinarSend link to watch re-play of Webinar Contact other groups in your area that own Contact other groups in your area that own

Ancillary Services.Ancillary Services. Post Information Sheets in doctors loungesPost Information Sheets in doctors lounges Ask Local County/State Medical Societies for Ask Local County/State Medical Societies for

help.help.

39

Doctor to Doctor Info Sheet

40

Key Congressional Targets Majority Leader Reid (D-NV)Majority Leader Reid (D-NV) Minority Leader McConnell (R-KY)Minority Leader McConnell (R-KY) Senate Finance Chairman Max Baucus (D-MT)Senate Finance Chairman Max Baucus (D-MT) Senate Finance Ranking Member Orrin Hatch (R-UT)Senate Finance Ranking Member Orrin Hatch (R-UT) All other Senate Finance Committee MembersAll other Senate Finance Committee Members House Speaker John Boehner (R-OH)House Speaker John Boehner (R-OH) House Minority Leader Nancy Pelosi (D-CA)House Minority Leader Nancy Pelosi (D-CA) All members of House Energy and CommerceAll members of House Energy and Commerce All members of House Ways and MeansAll members of House Ways and Means

41

Thank You

Remember, if you don’t have a seat at Remember, if you don’t have a seat at the table, you are on the menu.the table, you are on the menu.

42

Staff Contact

Julie WilliamsJulie Williamsjwilliams@aaos.org

Catherine BoudreauxCatherine Boudreauxboudreaux@aaos.org

43

Presenter’s Contact

Fred Redfern, MDFred Redfern, MDRedfern.fred@gmail.com

David Teuscher, MDDavid Teuscher, MDsportdoctor@gt.rr.com

Steve McCollam, MDSteve McCollam, MDSteve@pocatlanta.com

44

Questions?

45