Buy A Ticket

Bill was desperate. Every week he had gone to church, kneeled in the pew, and prayed to win the lottery.  Now for the 10th week, he knelt alone in the church, again praying to win.  A bright light shown through the stained glass, and a voice came through from above: "Bill Égo half way with me. Buy a ticket."

As orthopedists, we have our own games of political forces that impact our practice.  We have the games of insurance reimbursement, malpractice, and call coverage to name a few. We likewise need to be proactive, and Ôbuy a ticket' if we expect results. Unlike Powerball, our chances of winning are much higher. 

Consider the Prompt Payment Bill.  This law had its origins as a complaint from the lips of physicians standing in their office and doctors lounge at the hospital.  The OAO and OMA supported the bill through the legislative process.  Orthopedists are now being paid on time as a result of this proactive effort.

Further proactive efforts by the OAO now in process include the MVA PIP bill that increases the amount to $25,000, and a trauma bill that improves payment to physicians in hospital trauma management. The week of March 10, 2003 begins discussions of possible medical malpractice reforms.

We have conversations with peers and read about the problems with practicing medicine.  We complain.  We get upset.  Yet, how many of us have bought a ticket?  Sending in your dues for the OAO and Orthopedic PAC is buying a ticket.  It is also calling, writing, and contributing to your Oregon and US representative.  It is convincing your local colleagues to do the same.  It is participating in the OAO Web site questionnaires when they come on line.

This year as President I am committed to the following specific results:

220 OAO members (past membership range 170-210) OAO website by April 15, 2003 OAO database of orthopedists email addresses OAO website data base for insurance rebundling OAO website forum for call coverage strategies

The website will have a secure member section, where we can hear suggestions, and collect data in questionnaires.  The web site will allow us to track on a statewide basis the rebundling practices by insurance companies, and collaborate efforts regarding call strategies.  Email and the website will allow us a statewide communication so that we can support those in Salem working for our interests as orthopedists.

Be proactive.  Buy a ticket

Timothy L. Keenen, M.D.
President

Physician for a Day

Want to spend a day in the thick of activity at the State Capitol?  Volunteer to be Physician for a Day, a program initiated by the OMA.

During your day at the Capitol, you provide first aid services to legislators and their staffs, if needed.  We will arrange for you to meet your legislators, giving you an opportunity to discuss health care, liability reform and other issues of concern to you.

If you are interested, call Nan Heim/ Associates at 503-224-0007 and we will coordinate with OMA.

Report from the State Capitol

Budget Woes....Liability Reform...Trauma Funding...

Budget Woes.

March brought yet another gloomy state revenue forecast. The state will be at least $500 million short of what is needed to cover the Governor's proposed $11+ billion 2003-05 budget.

Without more revenue, it is clear that the Oregon Health Plan (OHP) cannot be saved in anything like its current form. By July, the OHP is likely to resemble traditional Medicaid. Oregon's health care providers will face thousands more uninsured patients.  

New tax proposals--even a sales tax --have surfaced at the Legislature.  But action on any major tax measure this session is unlikely, in spite of the revenue picture. First, Governor Kulongoski has said he will not support major tax re-

structuring until he sees that voters have more confidence in state government. 

An even greater obstacle to any tax measure passing is Oregon's initiative and referendum. As a practical matter, the Oregon Legislature cannot acquire major new tax revenue without a vote of the people. Even if the Legislature did muster a two-thirds vote to pass a tax measure, Bill Sizemore or Don McIntyre would almost certainly circulate petitions to put it on the ballot in a statewide election.

Here is the record of Oregon voters on state tax measures . . .

The last time Oregon voters passed a major new tax in a statewide election was more than seventy years ago--the income tax in 1930.       The last time Oregon voters increased an existing tax in a statewide election was thirty years ago--a cigarette tax increase in 1972. At least a dozen tax increase measures have been defeated in statewide votes since then. Oregon has voted on a state sales tax nine times--and defeated it every time.

This session of the Legislature will probably look very much like recent special sessions: a patchwork of spending cuts, funding transfers and smaller revenue measures.  Smaller measures could include taking reserves from SAIF, closing tax credit "loopholes," and even abolishing the tax refund "kicker."

Liability Reform.

It is still too early to tell what this Legislature is going to do to address the malpractice insurance crisis.  Here is what is happening so far:

In March, the House Judiciary Committee held hearings on a series of bills introduced by the OMA and the hospital association to mitigate the malpractice insurance crisis.  The bills propose several reforms, including requiring disclosure of expert witnesses in civil actions and limiting contingency fees in negligence cases against health professionals. Senator Frank Morse (R-Albany) has introduced SB 497, authorizing physicians and other health care providers to require patients to sign waivers to limit noneconomic damages that may result from negligence.  Senator Morse has also introduced a bill referring a measure to the voters to amend the Constitution to cap non-economic damages in malpractice cases.

The Legislature cannot pass a cap without a Constitutional amendment in this state. Amending the Constitution requires a statewide election. A similar measure failed in the 2000 statewide election.

Trauma Funding.

Physicians provide nearly $9 million worth of trauma care to Oregon Health Plan patients a year, but are currently reimbursed for only about $3.2 million of those charges. Rep. Alan Bates (D-Ashland), the only physician serving in the Legislature, has introduced House Bill 3394 to increase funding for trauma services, including reimbursement for physicians treating indigent trauma patients.

House Bill 3394: Increases the 9-1-1 telephone tax from 75¢ and dedicates most of the revenue to trauma services. Increases the Personal Injury Protection (PIP) minimum required for automobile insur-ance from $10,000 to $15,000. Payments from this increase would be dedicated to trauma services. Defines trauma services as those provided within 72 hours of a motorvehicle accident to a person entitledto receive PIP benefits by a hospital designated as a trauma hospital.

There are two other bills in the Legislature to increase PIP to $25,000.  However, these bills do not dedicate the increase to trauma, so much of the payments could end up going to attorneys and chiropractors. 

It will be an uphill battle to pass any tax increase this legislative session, even a small telephone tax for a good purpose.

Nan Heim & Gina Cole
OAO Lobbyists

AAOS Advocacy Makes Gains

Medicare Reimbursement, Tort Reform and EMTALA Education

The AAOS Washington, D.C. office has been working tirelessly on your behalf educating members of Congress about the flaw in the Medicare payment update for 2003. Due in part to these educational efforts, Congress has directed CMS to "fix" this problem and what was going to be a 4.4% decrease in the Medicare conversion factor for 2003 will be corrected to a 0.5% increase. This is a prime example of how your Academy is working for you. For further details on the implementation timetable of this correction go to www.cms.gov/regulations.

Both the Judiciary Committee and the Energy and Commerce Committee of the House are considering medical liability reform legislation. There is also bipartisan interest in the Senate for developing legislation on this issue. The AAOS Washington, D.C. office is also focusing on this issue with our congressional members and is hopeful that there will be some movement on this issue during this congressional session.

At the suggestion of your Board of Councillors, a task force on ER call and EMTALA issues was formed.  The product of this committee's work now includes a position statement on ER call coverage, endorsed by the AAOS, that calls for compensation from hospitals to orthopaedic surgeons for being on call that reflects the work and liability risk associated with providing these services.  This committee has also developed a compendium on EMTALA that is the best summation of EMTALA and its requirements, duties created, and ramifications that I have seen.  Both of these documents can be accessed on the AAOS website (www.aaos.org) under the Health Policy section.

The AAOS is taking a preliminary look at the program on expert witness testimony that The American College of Neurosurgeons (ACN) has had in place for the past few years. This program requires ACN members who give expert witness testimony to agree to disclose during their testimony when their testimony is not a view that would be held by the mainstream neurosurgical community.  The adoption of this program by the AAOS was suggested by the Florida Orthopaedic Society in response to their members' concerns about medical malpractice cases where plaintiffs' experts were providing opinions running blatantly counter to mainstream orthopaedic literature and consensus. The costs and legal ramifications of adopting and developing such a program are being looked at closely.

Your Academy has made progress for you over the past few months and will continue to work to provide educational opportunities and advocacy in economic and political arenas in the ongoing attempt to provide increasing value for your dues and support. As always, please feel free to contact me with any of your concerns.

Michael B. Vessely, M.D.
AAOS Board of Councillors

2003 Orthopedic Calendar

Bones Business
Better Orthopaedic Networking Exchange Society

Oregon BONES Practice Expense Survey

Questionnaires for the 2003 BONES Cost Survey (compiling 2002 data) have been mailed to all orthopedic practices in the State of Oregon. Completed questionnaires will be compiled by Moss Adams.

Remember that all participants receive a free copy of the report compilation in its entirety so be sure your clinic responds to the questionnaire.  The highlights of the compilation will be presented at the spring Oregon BONES conference in May 2003 and at the OAO business meeting in November 2003.  This project is such a valuable tool for our specialty.  It has already gained widespread recognition and support.  Do you know your cost per RVU?

Getting to know CCI (Correct Coding Initiative)

The Centers for Medicare and Medicaid Services (CMS) developed the National Correct Coding Initiative to promote national correct coding methodologies and to eliminate improper coding. Many commercial insurance carriers are now referencing the CCI edits produced for Medicare. Many carriers are not, however, referencing the modifier indicators that the CCI tables include. Practices may receive denials for reimbursement of second or third procedures based on the CCI edits when in fact some of the multiple procedures would be allowed if the modifier indicator attached to the code is considered. The edits are arranged by two sets of tables. One table contains the comprehensive primary code/component incidental code pair and the other table contains the mutually exclusive edits.  Each table is arranged in two columns as represented below:

Note that the codes in column 2 in the tables are not payable with the column 1 code unless the edit permits the use of a modifier associate with the CCI. Each code pair is assigned a correct coding modifier indicator of either a "0", "1", or "9". The "0" indicator means that no modifiers associated with the CCI are allowed to be used with this code pair, there are no circumstances in which both procedures of the code pair should be paid.  The "1" indicator means that modifiers associated with the CCI are allowed with this code pair when appropriate and may be paid.  Providers are responsible for applying the correct modifiers appropriately to support the codes they bill.  The "9" indicator is used on only those code pairs that have been deleted where the deletion date was retroactive to the effective date. CCI edits are updated quarterly and most edits are retroactive. If you find that a code edit has changed and is a code is no longer deemed incidental you may resubmit the claim for reimbursement.  The CCI Edits Manual must be purchased; you may contact NTIS for a complete copy by calling 800-553-6847. This article was based on information in the CMS website "CMS.HHS.GOV" search for correct coding initiative. Log on for additional information.

Wishing each of you success and a prosperous year.

Kathy Brown
Oregon BONES Association,"The Business of Orthopedics"

2003 Humanitarian Award: John R. Tongue, M.D.

John R. Tongue, M.D., was presented the fourth annual AAOS Humanitarian Award during opening ceremonies of the Academy's 70th Annual Meeting.  The AAOS Humanitarian Award acknowledges an orthopaedic surgeon who has gone to extraordinary lengths to make a positive impact on the lives and health of many people.  Dr. Tongue was recognized as a tenacious advocate for transportation safety issues and affected major change among the three main causes of traffic injuries and fatalities:  lack of safety belt use, drunk driving and excessive speed.

Dr. Tongue founded the Oregon Lifebelt Committee to create and pass a mandatory seat belt law and Pledge America, a nonprofit organization committed to educating civic organizations in the Northwest about the dangers of drunk driving.  As chair of the Oregon Transportation Committee, Dr. Tongue has vigorously and successfully opposed increased speed limits in Oregon.

On Call Issue

I urge all members to review the AAOS Position Statement on EMTALA.  You will find it under the Health Policy section on our academy's web page  (www.aaos.org). Current interpretations of EMTALA by hospitals place a tremendous burden on physicians scheduled to be on-call.

In most cases, in Oregon, orthopedic surgeons are not reimbursed by the hospital or managed care organizations for their on-call services. No other business or occupation is required to perform mandated services without expectation of remuneration.

Not only are orthopedic surgeons not compensated for on-call services, but they are exposed to increased liability risk.  We have a greater likelihood of being sued because of the complexity of the injuries and the lack of a pre-existing physician/patient relationship with persons treated in the emergency department. Therefore, I urge all orthopedic departments throughout the state to adopt the AAOS Position Statement regarding emergency department on-call coverage.

Once that is accomplished, you may begin negotiations regarding on-call compensation with your hospitals and managed care organizations. These negotiations will vary by community and orthopaedic groups throughout the state.  The compensation package will also vary by community.  Some groups will elect to be compensated on a "per day" on-call basis where as others will be compensated on a "per incident" basis while on-call. Some members may elect not to participate in on-call compensation.  We certainly respect that decision also.

I urge all members to speak to their fellow orthopaedic surgeons across the country and get a feel for their compensation packages. They will vary widely but most are being compensated for these services. Compensation for on-call services will help offset your rising malpractice premiums. Good luck in your negotiations.

Richard S. Jany, M.D.
OAO Secretary-Treasurer