October 11, 2024 • 29 mins
Discover the transformative changes on the horizon for orthopaedic coding and payment models with our esteemed guest, Dr. Adam Bruggeman. Covered are the new CMS-mandated procedural-based bundles, specifically the "team" bundle affecting 25% of US hospitals. Dr. Bruggeman sheds light on the financial and administrative hurdles these mandates bring and compares them to the cost-saving success of physician-led bundles.
Prepare yourself for an in-depth exploration of the evolving landscape of hospital-based healthcare bundles and their profound implications for orthopaedic surgeons. The conversation reveals how these new regulations might shift financial risks between hospitals and doctors, leading to a rare alignment of interests in opposing mandatory bundles. We also dive into the CMMI's push for value-based care and its potential impact on the sustainability of Medicare, putting a spotlight on the delicate balance of cost and care quality.
Join us as Dr. Bruggeman shares his expert views on the future of medical coding, particularly within the contexts of fee-for-service models and ambulatory surgery centers. From CPT and ICD-10 codes to the Resource-Based Relative Value Scale (RUC), we cover the complexities that define this space. We also discuss the slow shift towards value-based care and the promising, albeit underused, concept of condition-based bundles. This episode is packed with insights and foresight into the future of orthopaedic surgery and healthcare reimbursement models.
Mark as Played
Transcript
Episode Transcript
Available transcripts are automatically generated. Complete accuracy is not guaranteed.
Speaker 1 (00:04):
Welcome to the AOA Future in Orthopedic Surgery
podcast series.
Speaker 2 (00:20):
Welcome to the AOA Future in Orthopedic Surgery
podcast series.
This AOA podcast series willfocus on the future in
orthopedic surgery and theimpact on leaders in our
profession.
These podcasts will focus onthe vast spectrum of change that
will occur as the futurereveals itself.
We will consider changes asthey occur in the domains of
(00:41):
culture, employment, technology,scope of practice, compensation
and other areas.
My name is Doug Lundy.
Host for the podcast series.
Joining us today is Dr AdamBruggeman.
Dr Bruggeman is currently thechair of the Advocacy Council
for the American Academy ofOrthopedic Surgeons, where he
(01:01):
spearheads the entire advocacyeffort in government relations
of the AAOS.
He completed his bachelor'sdegree in health administration
and policy at CreightonUniversity and then a master's
in hospital administration atTrinity University in San
Antonio.
After that he completed anadministrative internship at
Methodist Healthcare in SanAntonio and then he went on to
pursue his medical degree fromthe University of Texas Health
(01:24):
Science Center in San Antonioagain.
He completed his residency inorthopedic surgery at the
University of Florida and thenreturned back to Texas for his
fellowship in spine surgery atthe South Texas Spinal Clinic.
Adam is currently the owner ofthe Texas Spine Care Center in
San Antonio, texas.
Dr Bruggeman.
Welcome to the podcast, sir.
Speaker 3 (01:46):
Thanks, doug, it's a pleasure to be on here.
I really appreciate you havingme on today.
Speaker 2 (01:50):
And, as an SEC guy, I can't help but ask you are you
a Gator fan or are you moreTexas A Gator?
Speaker 3 (01:56):
Yep and more.
Nebraska than anything honestly, but Gator, that's fine.
Speaker 2 (02:00):
Okay, yeah, I'm SEC Wesley.
We're cool.
All right, my friend, todaywe're going to talk about
changes in coding and payermethodology and, as the chair of
the Advocacy Council, you havea number of important academy
committees you have, let's see,you have healthcare policy,
you've got medical liability,but you've also got CCRC, which
(02:21):
is what Coding coverage andreimbursement committee.
That's right, all right.
So nobody better than you, myfriend, that knows about this
stuff.
So we're talking about thefuture in orthopedic surgery
from your vantage point and Iwould argue you have probably
the best vantage point ofanybody in orthopedics to see
where advocacy, where governmentCMS stuff has taken us.
(02:41):
How do you see the changes incoding and pair methodology,
both on the government and onthe private side, occurring in
the future?
Speaker 3 (02:50):
Yeah, well, I mean good timing for this talk,
because just a few weeks ago wereceived notice that there was
going to be a new mandatorybundle.
Now we've had bundles in thepast, but they've not been
mandatory.
They've been.
If you would like toparticipate, you can participate
.
But suddenly they've come outwith a new bundle that no one's
ever seen before called team,and that bundle is going to be-.
Speaker 2 (03:12):
Sorry to interrupt.
They is CMS, right CMS, that'scorrect.
Speaker 3 (03:16):
Yes.
Speaker 2 (03:16):
Centers for Medicare and Medicaid Service.
Okay, sorry.
Speaker 3 (03:18):
And they're going to make that mandatory for 25% of
US hospitals.
So if you talk about where we'reheaded and what's happening,
the advice that CMS is receivingfrom the various advisors, such
as MedPAC, is that the reasonwhy things have not been
successful in value-based careis because they haven't made
them mandatory, which allowsthose who know they will succeed
(03:38):
to participate and those whoknow they will fail to stay out.
And so this new wave, perhapsthe trend that is coming is that
we will start seeing thesemandatory bundles and
unfortunately, we have verylimited input into how this
works before it gets rolled outand we are then at some point
responsible.
The other interesting partabout this mandatory bundle is
(04:01):
we've seen different bundleswhere they either make the
physician responsible for thebundle and financially as well,
as you know, administrativelyresponsible for the bundle, and
then we've seen bundles wherethey've made the hospital
responsible for the bundleadministratively and financially
.
What the data suggests is thatwhen the hospital is in charge
of the bundle, the bundle tendsto lose money.
(04:22):
When the physician is in chargeof the bundle, the bundle tends
to lose money.
When the physician is in chargeof the bundle, the bundle tends
to save money for thehealthcare system.
So this particular bundle, thisteam bundle, is again a
hospital-based bundle.
So some really intriguingthings happening, coming down
the pipe.
Speaker 2 (04:38):
Sounds like it.
Glad you're advocating outthere for us.
So just to clarify a few thingsthese are condition-based
bundles, not, I'm sorry,procedural-based bundles, not
condition-based bundles, right.
Speaker 3 (04:47):
That's exactly right.
Touching on your point, we haveput together a white paper as
the academy that's been writtenby some very intelligent people
Dr Bozic and Prakash over atAustin, as well as in
collaboration with severalothers from around the country,
to have a conversation aboutcondition-based bundles, and the
American College of Surgeonshas also been out there waving
the banner for condition-basedbundles and has put a ton of
(05:10):
work in identifying what is thecondition, what goes into the
condition, what isn't part ofthe condition, how would we
model that economically?
And yet again, the biggestproblem we're having right now
is that none of those ideas havebeen put forward.
As you said, we're stilllooking at procedural-based
bundles that look at a definedperiod of time around a specific
(05:30):
procedure, as opposed tocondition-based bundles, which
are looking at something likeknee pain and following that
through from start to finish.
Speaker 2 (05:38):
And the scary thing for them about condition-based
bundles is it gives control ofknee pain, hip pain, back pain
to us and everybody else is nowcut out.
We are the arbiters of who getswhat treatment, and that's got
to be kind of spooky to CMS.
Speaker 3 (05:54):
Yeah, it's interesting.
The things that have made themost money under the various
initiatives that have beenproposed by CMMI have largely
been ACOs.
These bundles have not donevery well.
Acos, on the other hand, havebeen proposed by CMMI, have
largely been ACOs.
These bundles have not donevery well.
Acos, on the other hand, havereturned a reasonable amount of
money back to CMMI and in fact Ibelieve it's next week the
Energy and Commerce Committee isgoing to be having a hearing
(06:15):
with Ms Fowler, who runs CMMI,to talk to her about why are
things not working 10 yearslater with CMMI?
What can we do to providebetter return on our investment
that we're putting into CMMI?
So it is probably scary to themand they really want to move
towards these ACO models.
But I think, as we all know, asmuch as we love our primary
(06:36):
care colleagues and I trust themfor many things and I go see my
own primary care doctor on aregular basis they're not the
experts in musculoskeletal care.
We are, as the group oforthopedic surgeons who manage
these patients at the end, andsometimes all the way at the
beginning of the problem andunfortunately that requires both
CMS as well as those primarycare groups and those ACOs to
(06:58):
give up control, or some control, to the orthopedic surgeons to
allow us to manage the part thatwe really know best, which is
knee pain, hip pain, fracturework, so on and so forth.
Speaker 2 (07:09):
Right, but to your point though, this is all about
procedural based bundles, right.
So what procedures are, in thismandatory bundle, coming up?
Speaker 3 (07:20):
Yeah, so in your world, hip fractures are going
to be in there Lower extremityjoint replacement, so hip and
knee replacement, and thenspinal fusions will also be in
the bundle.
So a little bit of everything,a smattering of all things.
Orthopedics there are someother non-orthopedic items that
will be in there.
I believe it's a majorabdominal surgery will be in
there and I think there's acardiac component that's in
(07:42):
there as well.
But as it relates toorthopedics, it's the four of
hip fractures total jointreplacements and spine surgery.
Speaker 2 (07:50):
Now, for many places, total knee and total hip
arthroplasty fit nicely in thebundles until you get to the
floor of where there's no moresqueeze left and everybody
starts taking a hit on theprocedures.
But hip fractures, man, that'sa tough thing to bundle right.
Speaker 3 (08:06):
Yeah, I think I mean you know as well as anyone does
the complexity that's involvedin taking care of a hip fracture
and all the various things thepatient comes in with.
That's not an electiveprocedure, unlike the other ones
that we have listed on theorthopedic requirements or the
procedures that will be in thereKnee replacements and hip
replacements.
If the patient's not ready forknee replacement or hip
(08:29):
replacements, they're diabetic,they have some sort of heart
issue that we want to hold offon.
We're going to hold off, butunfortunately, with a hip
fracture, there comes a point intime where you just have to do
the procedure and deal with thecomplications that are a result
of that, and so this is going tobe a very complicated bundle,
and making it mandatory willincrease the complications
revolving around it.
And I would tell you, thebundle includes the next 30 days
(08:49):
after care is rendered, so it'snot just the timing of the
hospitalization, it's also thenext 30 days after the procedure
is completed.
Speaker 2 (08:57):
Gotcha.
Yeah, I wonder how manyreadmissions are going to occur
32 days after the procedure.
You know so the two previousbundles were BPCI and CJR.
Can you briefly kind of telleverybody where those bundles
are and how they may differ fromthis new bundle?
What's the name of the newbundle, by the way?
So it's called team.
(09:17):
Oh, you said that.
Speaker 3 (09:19):
I'm sorry, yeah, it's unclear that they are ready to
sunset the other bundles, and sothis may be the replacement for
our current bundled systems.
It's unclear they are ready tosunset the other bundles, and so
this may be the replacement forour current bundled systems,
and so the timing of this linesup.
It would start January 1st 2026.
The assumption is they would benotifying the hospital systems
in 2025, who is going to berequired to participate.
(09:42):
Then, in January 1st 2026, theywould then begin participating,
and so I think that will likelymean the ending of our current
bundled systems and a transitionto these new bundles, at least
as it relates to CMS.
As we know, many of ourorthopedic colleagues across the
country have successfullyidentified excellent bundles to
be in with private payers andhave been very happy with those,
(10:04):
in contrast to the bundles thatwe've had so far with CMS Right
now some of the previousbundles, cjr and PPCI
specifically.
Speaker 2 (10:15):
In my impression or my recollection, very few people
got the downside of that bundleright.
They were CMS came back andsaid all right, we're clawing
back money or we're not going topay you as much on the next one
because you owe us.
Most of the people that wereparticipating in the bundle made
money on it right.
Speaker 3 (10:33):
They did, but remember that the problem was
that the target started moving,and so when the goalposts move
every year because you startgetting better at what you do
and now you're no longercompared to the average in your
community, you're compared tohow well you did it this year or
this past year and the savingsthat you generated you can no
longer continue to generate andit's like you hit this mark this
year.
(10:53):
See if you can exceed that markor you're going to end up
getting penalized.
And so a lot of groups werevery involved in the bundles and
then pulled out of the bundlesover time as the goalposts
started to move, because itsuddenly wasn't making any sense
.
And unfortunately, despite somefeedback that we've had so far
with CMMI, it appears that theyintend to move the goalposts
(11:15):
under the team model as well,and they have admitted as such
that that would make it verydifficult, but they feel that
they need to be able to move thegoalposts every year or every
two years.
Speaker 2 (11:26):
Right.
What I was trying to get at was, as opposed to the past, where
most people did well into thebundle and if you didn't, you
just pulled out the next yearand you quit.
It sounds like going forward.
There's going to be a lot oforthopedic surgeons who are
getting some nasty letters fromCMS saying you failed to meet
(11:46):
the target price and, as aresult, we're either clawing
back money or recapturing the.
I'll let you run with that.
Speaker 3 (11:53):
Yeah.
So it's interesting how this isgoing to work, because this
will be a hospital-based bundleagain, so the financial
responsibility will fall on thehealthcare system.
But the healthcare system hasthe ability under the new law or
under the proposed regulatory,to share upside and downside
with anyone else they want toshare it with.
So theoretically, whetheremployed or just providing
(12:17):
services in that hospital system, the hospital could come to our
employed doctors or to just ourcommunity physicians and say
we'd like to share some of theupside and downside with you,
because we recognize that youare going to be making many of
the decisions that help useither revenue positive or lose
money.
But it's theoretically possiblethat after that downside
(12:40):
penalties could come with thesharing risk with the hospital
system.
And so I think it's going to bevery interesting to see how
those contracts are drawn up,see whether or not the hospitals
agree to let doctorsparticipate in upside and
downside risk and whether or notthe doctors truly want to
participate in the upside anddownside risk for their various
bundles that they're involved in.
Speaker 2 (13:02):
Yeah, it's a great point.
And to your point earlier Icould see a group like my old
group saying we got this figuredout on total joint arthroplasty
.
Yeah, we'll go upside anddownside on that if the hospital
let us, and if you don't let usyou're going to have a horrible
time adjudicating this.
But I can tell you from my oldhospital we would run fast and
run hard from hip fracturesbecause, man, that's so hard to
(13:23):
get right.
Speaker 3 (13:24):
It is.
It's incredibly difficult toget correct and I just again,
we're still we're at the earlypoint of this.
We're still learning what'sgoing, how they're going to
actually administer this andwhat's going to be counted and
what's not going to be counted.
They do have a relativelylengthy document out there, but
I think it's going to becomplicated for fractures.
I do think some of our generalsurgical colleagues with major
(13:45):
abdominal surgery, similarproblem, these people are going
to come in with a problem thatyou can't say no to and you have
to take care of in thathospitalization and that may end
up as something that theyaren't really excited about
being a part of, or thehospitals themselves are not
excited about being a part of it.
So, interestingly, we findourselves advocating together
with the hospitals, whereas inmany, many different advocacy
(14:05):
efforts we found ourselves onthe opposite side of a
conversation.
In this one, we are findingthat the American Hospital
Association and the FAAH areboth saying you know, we really
don't want this bundle either.
This mandatory component of itis not a good idea.
Speaker 2 (14:18):
Now a couple times back you said CMMI.
Just for folks that aren'textensively in the advocacy
space, can you explain what CMMIis and who they work for?
Speaker 3 (14:27):
Yeah, so CMMI Centers for Medicare and Medicaid
Innovation is, I believe,value-based care but ways to
reduce the cost of the entirehealth care system.
(14:51):
How do we preserve Medicare?
By Congress, I believe it's $10billion has been allocated by
Congress to go to CMMI toidentify innovative ideas and
implement them, and they've gota lot of them.
There's not just orthopedicones, there's other ones in, say
, kidney disease and other areas.
But the goal of thatorganization again is to push
(15:13):
these new payment systems orinnovative structures that would
allow for a reduction in thecost of care for Medicare, to
try and preserve Medicarelong-term.
Speaker 2 (15:23):
Great, so you've got a lot of experience in this.
It sounds like, based on therecent past and then this
upcoming decision by CMS, thatthe federal government feels
that bundling healthcare is intheir best interest in the way
that they will proceed withcoding and payer methodology.
Would you agree with that?
Speaker 3 (15:46):
Yeah, I think the answer is they don't feel that
fee-for-service is the future.
That seems to be a inevitableexistential problem for Medicare
Right now.
The alternative to that isvalue-based care, whatever that
means, and I think that'sobviously been a term that's
been used by many differentpeople to mean many different
things.
But right now they are lookingto value-based care to replace
(16:10):
fee-for-service, as opposed tocontinuing to fund and push
towards what they feel is aninevitable cliff if we continue
down fee-for-service as the onlyway we pay for things, and so
they've put goals in place toeventually convert all of
payments over to some form ofvalue-based care payment system.
Speaker 2 (16:31):
So with terms of codes, so we use the codes for
fee-for-service right?
We submit our CPT codes andICD-10 codes to CMS or to the
insurance company.
We pay for what we do.
How do you see coding moving inthe future, specifically
overall, and how coding goes?
And then, if you want toexplain how the RUC works, what
(16:51):
the RUC is and how that mightchange, however you feel and
this is I'm asking you to guessout in the future.
So this is, we're not going tohold you to it, we just want to
know what you're thinking.
Speaker 3 (17:01):
Well, I would tell you on the subject of coding,
one thing that has really raiseda flag on our radar is the
coding in the ASC space.
So last year at the end of theyear, suddenly total shoulder
replacement showed up on the ASCcoding list, and ASC payments
(17:23):
are different than how we getpaid and they're different how
hospitals get paid.
There are essentially sixbuckets, or APCs, that determine
how much is paid, pays the sameamount unless it's a
device-intensive procedure thatcould get an additional payment
because that bucket justcouldn't possibly pay for the
(17:43):
device that would be necessaryto perform the procedure.
Total joint replacement is inthe highest bucket and pays at
the highest levels and otherspay less.
Unfortunately, just like thephysician fee schedule, it is
subject to budget neutrality andso as new procedures get
admitted onto the APC schedules,whichever bucket they drop into
(18:04):
ultimately causes everything inthat bucket to reduce, based on
the amount of projected volumefor that procedure and the
amount of projected expenditurefor that procedure.
So when total shoulders got putin, they were ultimately
adjusted up to APC6, which isthe highest level, which put
them in the total knee and totalhip.
(18:24):
Before that occurred, there wasan anticipation of a slight
increase in pay for that APC6bucket.
After it occurred, there wasactually a decline in pay for
total hip and total kneestarting this year at the ASC
level, and so one of the thingsthat we're keeping an eye on is
a lot of the more expensiveprocedures, such as spine
(18:44):
procedures, have not made theirway to the APC, and so we are
actually at the end of this yearbeginning with the coding
coverage and reimbursementcommittee to bring in experts on
ASC coding to say you know, alot of our surgeons have
interest in one way, shape orform in a surgery center and a
lot of our cases are shifting tosurgery centers.
(19:05):
If that is the case, what do weneed to be doing to help ensure
that cases are still viable?
We don't want to get to a pointwhere surgery center cases are
paid so poorly that there's notsufficient margin that the cases
then flip back to going fromASCs back to hospitals.
That's not in the best interestof us.
We've been talking aboutreducing the cost of care and it
(19:26):
would really hurt and harm manyof our private practicing
groups, and so this is going tobecome a really, really big
issue for orthopedics inparticular, who is going to be a
group that is going to see alot of their codes ending up in
the same buckets.
And how do we continue tocommunicate the value of that?
And how do we prevent all ofthe issues we've been having
(19:46):
since 1989, when we came outwith a singular conversion unit
for RVUs, and the continuedreimbursement decline we've seen
in the fee-for-service world?
How do we protect that on theAPC side to the extent that
fee-for-service is still around?
That's going to be a reallyimportant detail for us going
forward.
Speaker 2 (20:04):
All right.
So look ahead 10 years or so.
With the constant push onvalue-based care, where are we
going to be?
Are we going to?
Is fee-for-service still goingto exist at all?
Are we still going to be usingthe current coding and payer
technologies that we have, orwhat do you see?
Speaker 3 (20:21):
Yeah, I think we've still been so.
We've had such a difficult timeimplementing the processes that
we have in place right now, andwe've identified very few
things that can actually savemoney.
Value-based care has a lot ofpotential but not a lot of
actual revenue generationcurrently within the system, and
so I think it's going to stillbe very slow.
(20:43):
We're 10 years into thisprocess with CMMI and we've
really not been able to identifya key target that we can roll
out to all different specialties.
There's some hope aroundcondition-based bundles that we
can do it, but we need thelatitude to get that done and
you know currently it doesn'tappear that CMMI has an interest
(21:03):
in those types of bundles.
Other specialty organizationson the Hill talking about
protecting fee-for-service andensuring that it gets
inflationary updates, because wedon't see a quick and easy
(21:26):
transition to value-based careover the next decade.
Speaker 2 (21:30):
That's the best way I've ever heard that explained
to date.
I mean the way you said it interms of we've been doing it for
10 years, we haven't gottenanywhere.
So because when you read theCMS websites and such, they
pound out that, oh, we're goingto do this in no time at all.
And, to your point, if youcould even elaborate on this, as
we've said on this podcast andothers is, and see if you agree,
(21:53):
as CMS goes, so goes theprivate payers.
Speaker 3 (21:56):
Yeah, absolutely, and I would argue even that there
are many payers now who areusing CMS as the top, not the
bottom, meaning they'renegotiating percentage contracts
below Medicare reimbursementgoing forward and I think
they're just seeing how far theycan actually go before it stops
right, before they can'tcontract anymore and they don't
(22:17):
have enough doctors in a givencommunity.
That's crazy.
Speaker 2 (22:22):
Oh my gosh.
Okay, so earlier we had talkedabout the condition based bundle
and I think you talked about ita fair amount, but just to make
sure, could you further explainthat, just so everybody
understands where that is,because it is such an important
thing?
That is probably the way we'regoing in the future.
Speaker 3 (22:38):
Yeah, I mean really it's a.
It's a very intelligent designof how to take care of patients
and the way that we think abouttaking care of patients.
All of our training wasdesigned to take care of
conditions, not to take care ofepisodic problems, and this
concept is that, instead of justbeing the technicians who
(22:58):
operate on patients, we becomethe kind of stewards of
musculoskeletal care from startto finish.
So a group whether they'reemployed or they're in private
practice or they're part of auniversity group would be
provided with a population ofpatients and they would be paid
a set amount for every patientwho, let's say, develops knee
(23:19):
pain.
And some of those patients whodevelop knee pain have an ACL
tear and under the currentsystem you'd have to go through
prior authorization and do allthese different things to make a
decision about what to do withthat patient.
But you might know, hey, if Ican take that patient to the
operating room now, before theirswelling starts, I think I can
save six weeks of rehab and Ithink I can save that, get that
(23:40):
patient back to work faster.
Well, that's your money.
You're going to be paid a lumpsum of money to take care of
that knee pain.
Another patient might have justbeen playing on the weekend
basketball and tweaked theirknee and you see them one time
you might even just have a PA ora nurse practitioner see them
to evaluate them initially andsay, oh, that's just something
(24:01):
that's gonna get better with oneor two visits of physical
therapy and some ibuprofen.
And you send them on your wayand you get paid that same lump
sum of money.
And so as you make the rightdecision for patients at a
clinical level throughout theirprocess number one we think it
can probably get rid of a lot ofthe headaches administratively,
like prior authorization thatwe have and the hiccups and the
things that frustrate us abouttaking care of patients.
(24:23):
But number two it's going toreward us for everything we
learned in medicine.
I remember, you know, there'skind of that dictum of you know,
you don't just learn how tooperate in orthopedics, you
learn who to operate on.
And that's probably the thingyou learn, unfortunately, later
in your career as you make themistakes and you go gosh, I wish
I wouldn't have operated onthat person.
(24:43):
But what if we paid you forlearning who to operate on?
You know, if you think about it, today we get paid a small
amount for clinic visits.
We get paid a larger amount forsurgeries.
But what if I just told you I'mjust going to pay you for doing
the right thing for thatcondition?
Now we get to use our entireset of everything we learned in
orthopedics.
(25:03):
You know, that fracture, thatsupracondylar humerus fracture
in that four-year-old probablydoesn't need to get pinned.
So I'm just not going to pin it, I'm going to put it in a
splint and cast and send it out,or that that one actually
really does need to get pinnedand I'm going to make that
decision.
That's right for that patient.
So that's what condition-basedbundles is.
We pay for a set of apopulation for specific
(25:28):
conditions like knee pain orback pain or hip pain, as
opposed to paying for eachoffice visit and each physical
therapy visit and the surgerycenter and the doctor to do the
surgery.
It thinks more holistically andrewards people for making the
right decisions at variouspoints along the pathway.
Speaker 2 (25:44):
Very good, that's a good, good description of that.
I'm sure you've heard the quotetakes five years to learn when
to operate.
In a lifetime to learn when notto right.
That's right, that's right.
Last question for you, sotypical of the US political
process we tend to flip back andforth between the parties every
eight, four to eight years orso.
We typically tend to do thathere in the United States over
(26:06):
recent history, agnostic towho's running the Congress and
who's running the presidency.
Or do you think, other thanmild, of course there's going to
be mild flavors to it, but ordo you see this?
Do you think there's going tobe a greater impact if there's a
significant change inadministration?
Speaker 3 (26:32):
Yeah, that's a great question.
So I would tell you thatcurrently and again, cmmi holds
a lot of the purse strings forwhat we do with respect to
future coding.
Currently, cmmi is almost allcareer people in DC.
Therefore, uninfluenced by theadministrations that come and go
, while the heads of each ofthose organizations, like the
(26:52):
secretary of HHS, is a politicalappointee, the people who work
within CMMI are not.
There is a growing desire withinDC to potentially break that up
and say maybe the reason thishasn't been working is because
we've lived in an echo chamberwhere these people who eat,
(27:14):
sleep and breathe DC have no newideas and they keep telling
each other the same ideas andthat's why maybe they're not
listening to condition-basedbundles.
So maybe we need to infuse afew more political appointees
into CMMI and not have so manycareer people in CMMI.
And I see that as probablybeing a part of these hearings
(27:34):
coming up.
I see that as being a goal ofseveral of the people in DC to
say what can we do to shake thisup, to get something out of
CMMI?
Not blow it up, not kill it,but let's shake it up a little
bit.
And if that happens, we'recertainly going to see that, as
administrations ebb and flow,that's going to impact the
perspective towards differentvalue-based care solutions.
Speaker 2 (27:59):
All right, that is fantastic.
You've given us a very, verygood overview of the future in
this and I really appreciate it.
So I'd like to thank my guest,dr Adam Bruggemann.
As I said, he's currently thechair of the Advocacy Council
for the American Academy ofOrthopedic Surgeons and, as you
could tell, he has a very uniqueand very comprehensive view of
what's happening in terms ofthis area specifically, and I'm
(28:21):
so glad you're representing usat the academy level, and thanks
for all your service there, sir.
Speaker 3 (28:25):
Thank you.
I very much appreciate yourtime today and happy to educate
everybody on the issues we'refacing.
Speaker 2 (28:30):
Thanks again, and all the stuff that you're putting
out through the AOSno-transcript.
Welcome to the AOA Future in Orthopedic Surgery
podcast series.
Speaker 2 (00:20):
Welcome to the AOA Future in Orthopedic Surgery
podcast series.
This AOA podcast series willfocus on the future in
orthopedic surgery and theimpact on leaders in our
profession.
These podcasts will focus onthe vast spectrum of change that
will occur as the futurereveals itself.
We will consider changes asthey occur in the domains of
(00:41):
culture, employment, technology,scope of practice, compensation
and other areas.
My name is Doug Lundy.
Host for the podcast series.
Joining us today is Dr AdamBruggeman.
Dr Bruggeman is currently thechair of the Advocacy Council
for the American Academy ofOrthopedic Surgeons, where he
(01:01):
spearheads the entire advocacyeffort in government relations
of the AAOS.
He completed his bachelor'sdegree in health administration
and policy at CreightonUniversity and then a master's
in hospital administration atTrinity University in San
Antonio.
After that he completed anadministrative internship at
Methodist Healthcare in SanAntonio and then he went on to
pursue his medical degree fromthe University of Texas Health
(01:24):
Science Center in San Antonioagain.
He completed his residency inorthopedic surgery at the
University of Florida and thenreturned back to Texas for his
fellowship in spine surgery atthe South Texas Spinal Clinic.
Adam is currently the owner ofthe Texas Spine Care Center in
San Antonio, texas.
Dr Bruggeman.
Welcome to the podcast, sir.
Speaker 3 (01:46):
Thanks, doug, it's a pleasure to be on here.
I really appreciate you havingme on today.
Speaker 2 (01:50):
And, as an SEC guy, I can't help but ask you are you
a Gator fan or are you moreTexas A Gator?
Speaker 3 (01:56):
Yep and more.
Nebraska than anything honestly, but Gator, that's fine.
Speaker 2 (02:00):
Okay, yeah, I'm SEC Wesley.
We're cool.
All right, my friend, todaywe're going to talk about
changes in coding and payermethodology and, as the chair of
the Advocacy Council, you havea number of important academy
committees you have, let's see,you have healthcare policy,
you've got medical liability,but you've also got CCRC, which
(02:21):
is what Coding coverage andreimbursement committee.
That's right, all right.
So nobody better than you, myfriend, that knows about this
stuff.
So we're talking about thefuture in orthopedic surgery
from your vantage point and Iwould argue you have probably
the best vantage point ofanybody in orthopedics to see
where advocacy, where governmentCMS stuff has taken us.
(02:41):
How do you see the changes incoding and pair methodology,
both on the government and onthe private side, occurring in
the future?
Speaker 3 (02:50):
Yeah, well, I mean good timing for this talk,
because just a few weeks ago wereceived notice that there was
going to be a new mandatorybundle.
Now we've had bundles in thepast, but they've not been
mandatory.
They've been.
If you would like toparticipate, you can participate
.
But suddenly they've come outwith a new bundle that no one's
ever seen before called team,and that bundle is going to be-.
Speaker 2 (03:12):
Sorry to interrupt.
They is CMS, right CMS, that'scorrect.
Speaker 3 (03:16):
Yes.
Speaker 2 (03:16):
Centers for Medicare and Medicaid Service.
Okay, sorry.
Speaker 3 (03:18):
And they're going to make that mandatory for 25% of
US hospitals.
So if you talk about where we'reheaded and what's happening,
the advice that CMS is receivingfrom the various advisors, such
as MedPAC, is that the reasonwhy things have not been
successful in value-based careis because they haven't made
them mandatory, which allowsthose who know they will succeed
(03:38):
to participate and those whoknow they will fail to stay out.
And so this new wave, perhapsthe trend that is coming is that
we will start seeing thesemandatory bundles and
unfortunately, we have verylimited input into how this
works before it gets rolled outand we are then at some point
responsible.
The other interesting partabout this mandatory bundle is
(04:01):
we've seen different bundleswhere they either make the
physician responsible for thebundle and financially as well,
as you know, administrativelyresponsible for the bundle, and
then we've seen bundles wherethey've made the hospital
responsible for the bundleadministratively and financially
.
What the data suggests is thatwhen the hospital is in charge
of the bundle, the bundle tendsto lose money.
(04:22):
When the physician is in chargeof the bundle, the bundle tends
to lose money.
When the physician is in chargeof the bundle, the bundle tends
to save money for thehealthcare system.
So this particular bundle, thisteam bundle, is again a
hospital-based bundle.
So some really intriguingthings happening, coming down
the pipe.
Speaker 2 (04:38):
Sounds like it.
Glad you're advocating outthere for us.
So just to clarify a few thingsthese are condition-based
bundles, not, I'm sorry,procedural-based bundles, not
condition-based bundles, right.
Speaker 3 (04:47):
That's exactly right.
Touching on your point, we haveput together a white paper as
the academy that's been writtenby some very intelligent people
Dr Bozic and Prakash over atAustin, as well as in
collaboration with severalothers from around the country,
to have a conversation aboutcondition-based bundles, and the
American College of Surgeonshas also been out there waving
the banner for condition-basedbundles and has put a ton of
(05:10):
work in identifying what is thecondition, what goes into the
condition, what isn't part ofthe condition, how would we
model that economically?
And yet again, the biggestproblem we're having right now
is that none of those ideas havebeen put forward.
As you said, we're stilllooking at procedural-based
bundles that look at a definedperiod of time around a specific
(05:30):
procedure, as opposed tocondition-based bundles, which
are looking at something likeknee pain and following that
through from start to finish.
Speaker 2 (05:38):
And the scary thing for them about condition-based
bundles is it gives control ofknee pain, hip pain, back pain
to us and everybody else is nowcut out.
We are the arbiters of who getswhat treatment, and that's got
to be kind of spooky to CMS.
Speaker 3 (05:54):
Yeah, it's interesting.
The things that have made themost money under the various
initiatives that have beenproposed by CMMI have largely
been ACOs.
These bundles have not donevery well.
Acos, on the other hand, havebeen proposed by CMMI, have
largely been ACOs.
These bundles have not donevery well.
Acos, on the other hand, havereturned a reasonable amount of
money back to CMMI and in fact Ibelieve it's next week the
Energy and Commerce Committee isgoing to be having a hearing
(06:15):
with Ms Fowler, who runs CMMI,to talk to her about why are
things not working 10 yearslater with CMMI?
What can we do to providebetter return on our investment
that we're putting into CMMI?
So it is probably scary to themand they really want to move
towards these ACO models.
But I think, as we all know, asmuch as we love our primary
(06:36):
care colleagues and I trust themfor many things and I go see my
own primary care doctor on aregular basis they're not the
experts in musculoskeletal care.
We are, as the group oforthopedic surgeons who manage
these patients at the end, andsometimes all the way at the
beginning of the problem andunfortunately that requires both
CMS as well as those primarycare groups and those ACOs to
(06:58):
give up control, or some control, to the orthopedic surgeons to
allow us to manage the part thatwe really know best, which is
knee pain, hip pain, fracturework, so on and so forth.
Speaker 2 (07:09):
Right, but to your point though, this is all about
procedural based bundles, right.
So what procedures are, in thismandatory bundle, coming up?
Speaker 3 (07:20):
Yeah, so in your world, hip fractures are going
to be in there Lower extremityjoint replacement, so hip and
knee replacement, and thenspinal fusions will also be in
the bundle.
So a little bit of everything,a smattering of all things.
Orthopedics there are someother non-orthopedic items that
will be in there.
I believe it's a majorabdominal surgery will be in
there and I think there's acardiac component that's in
(07:42):
there as well.
But as it relates toorthopedics, it's the four of
hip fractures total jointreplacements and spine surgery.
Speaker 2 (07:50):
Now, for many places, total knee and total hip
arthroplasty fit nicely in thebundles until you get to the
floor of where there's no moresqueeze left and everybody
starts taking a hit on theprocedures.
But hip fractures, man, that'sa tough thing to bundle right.
Speaker 3 (08:06):
Yeah, I think I mean you know as well as anyone does
the complexity that's involvedin taking care of a hip fracture
and all the various things thepatient comes in with.
That's not an electiveprocedure, unlike the other ones
that we have listed on theorthopedic requirements or the
procedures that will be in thereKnee replacements and hip
replacements.
If the patient's not ready forknee replacement or hip
(08:29):
replacements, they're diabetic,they have some sort of heart
issue that we want to hold offon.
We're going to hold off, butunfortunately, with a hip
fracture, there comes a point intime where you just have to do
the procedure and deal with thecomplications that are a result
of that, and so this is going tobe a very complicated bundle,
and making it mandatory willincrease the complications
revolving around it.
And I would tell you, thebundle includes the next 30 days
(08:49):
after care is rendered, so it'snot just the timing of the
hospitalization, it's also thenext 30 days after the procedure
is completed.
Speaker 2 (08:57):
Gotcha.
Yeah, I wonder how manyreadmissions are going to occur
32 days after the procedure.
You know so the two previousbundles were BPCI and CJR.
Can you briefly kind of telleverybody where those bundles
are and how they may differ fromthis new bundle?
What's the name of the newbundle, by the way?
So it's called team.
(09:17):
Oh, you said that.
Speaker 3 (09:19):
I'm sorry, yeah, it's unclear that they are ready to
sunset the other bundles, and sothis may be the replacement for
our current bundled systems.
It's unclear they are ready tosunset the other bundles, and so
this may be the replacement forour current bundled systems,
and so the timing of this linesup.
It would start January 1st 2026.
The assumption is they would benotifying the hospital systems
in 2025, who is going to berequired to participate.
(09:42):
Then, in January 1st 2026, theywould then begin participating,
and so I think that will likelymean the ending of our current
bundled systems and a transitionto these new bundles, at least
as it relates to CMS.
As we know, many of ourorthopedic colleagues across the
country have successfullyidentified excellent bundles to
be in with private payers andhave been very happy with those,
(10:04):
in contrast to the bundles thatwe've had so far with CMS Right
now some of the previousbundles, cjr and PPCI
specifically.
Speaker 2 (10:15):
In my impression or my recollection, very few people
got the downside of that bundleright.
They were CMS came back andsaid all right, we're clawing
back money or we're not going topay you as much on the next one
because you owe us.
Most of the people that wereparticipating in the bundle made
money on it right.
Speaker 3 (10:33):
They did, but remember that the problem was
that the target started moving,and so when the goalposts move
every year because you startgetting better at what you do
and now you're no longercompared to the average in your
community, you're compared tohow well you did it this year or
this past year and the savingsthat you generated you can no
longer continue to generate andit's like you hit this mark this
year.
(10:53):
See if you can exceed that markor you're going to end up
getting penalized.
And so a lot of groups werevery involved in the bundles and
then pulled out of the bundlesover time as the goalposts
started to move, because itsuddenly wasn't making any sense
.
And unfortunately, despite somefeedback that we've had so far
with CMMI, it appears that theyintend to move the goalposts
(11:15):
under the team model as well,and they have admitted as such
that that would make it verydifficult, but they feel that
they need to be able to move thegoalposts every year or every
two years.
Speaker 2 (11:26):
Right.
What I was trying to get at was, as opposed to the past, where
most people did well into thebundle and if you didn't, you
just pulled out the next yearand you quit.
It sounds like going forward.
There's going to be a lot oforthopedic surgeons who are
getting some nasty letters fromCMS saying you failed to meet
(11:46):
the target price and, as aresult, we're either clawing
back money or recapturing the.
I'll let you run with that.
Speaker 3 (11:53):
Yeah.
So it's interesting how this isgoing to work, because this
will be a hospital-based bundleagain, so the financial
responsibility will fall on thehealthcare system.
But the healthcare system hasthe ability under the new law or
under the proposed regulatory,to share upside and downside
with anyone else they want toshare it with.
So theoretically, whetheremployed or just providing
(12:17):
services in that hospital system, the hospital could come to our
employed doctors or to just ourcommunity physicians and say
we'd like to share some of theupside and downside with you,
because we recognize that youare going to be making many of
the decisions that help useither revenue positive or lose
money.
But it's theoretically possiblethat after that downside
(12:40):
penalties could come with thesharing risk with the hospital
system.
And so I think it's going to bevery interesting to see how
those contracts are drawn up,see whether or not the hospitals
agree to let doctorsparticipate in upside and
downside risk and whether or notthe doctors truly want to
participate in the upside anddownside risk for their various
bundles that they're involved in.
Speaker 2 (13:02):
Yeah, it's a great point.
And to your point earlier Icould see a group like my old
group saying we got this figuredout on total joint arthroplasty
.
Yeah, we'll go upside anddownside on that if the hospital
let us, and if you don't let usyou're going to have a horrible
time adjudicating this.
But I can tell you from my oldhospital we would run fast and
run hard from hip fracturesbecause, man, that's so hard to
(13:23):
get right.
Speaker 3 (13:24):
It is.
It's incredibly difficult toget correct and I just again,
we're still we're at the earlypoint of this.
We're still learning what'sgoing, how they're going to
actually administer this andwhat's going to be counted and
what's not going to be counted.
They do have a relativelylengthy document out there, but
I think it's going to becomplicated for fractures.
I do think some of our generalsurgical colleagues with major
(13:45):
abdominal surgery, similarproblem, these people are going
to come in with a problem thatyou can't say no to and you have
to take care of in thathospitalization and that may end
up as something that theyaren't really excited about
being a part of, or thehospitals themselves are not
excited about being a part of it.
So, interestingly, we findourselves advocating together
with the hospitals, whereas inmany, many different advocacy
(14:05):
efforts we found ourselves onthe opposite side of a
conversation.
In this one, we are findingthat the American Hospital
Association and the FAAH areboth saying you know, we really
don't want this bundle either.
This mandatory component of itis not a good idea.
Speaker 2 (14:18):
Now a couple times back you said CMMI.
Just for folks that aren'textensively in the advocacy
space, can you explain what CMMIis and who they work for?
Speaker 3 (14:27):
Yeah, so CMMI Centers for Medicare and Medicaid
Innovation is, I believe,value-based care but ways to
reduce the cost of the entirehealth care system.
(14:51):
How do we preserve Medicare?
By Congress, I believe it's $10billion has been allocated by
Congress to go to CMMI toidentify innovative ideas and
implement them, and they've gota lot of them.
There's not just orthopedicones, there's other ones in, say
, kidney disease and other areas.
But the goal of thatorganization again is to push
(15:13):
these new payment systems orinnovative structures that would
allow for a reduction in thecost of care for Medicare, to
try and preserve Medicarelong-term.
Speaker 2 (15:23):
Great, so you've got a lot of experience in this.
It sounds like, based on therecent past and then this
upcoming decision by CMS, thatthe federal government feels
that bundling healthcare is intheir best interest in the way
that they will proceed withcoding and payer methodology.
Would you agree with that?
Speaker 3 (15:46):
Yeah, I think the answer is they don't feel that
fee-for-service is the future.
That seems to be a inevitableexistential problem for Medicare
Right now.
The alternative to that isvalue-based care, whatever that
means, and I think that'sobviously been a term that's
been used by many differentpeople to mean many different
things.
But right now they are lookingto value-based care to replace
(16:10):
fee-for-service, as opposed tocontinuing to fund and push
towards what they feel is aninevitable cliff if we continue
down fee-for-service as the onlyway we pay for things, and so
they've put goals in place toeventually convert all of
payments over to some form ofvalue-based care payment system.
Speaker 2 (16:31):
So with terms of codes, so we use the codes for
fee-for-service right?
We submit our CPT codes andICD-10 codes to CMS or to the
insurance company.
We pay for what we do.
How do you see coding moving inthe future, specifically
overall, and how coding goes?
And then, if you want toexplain how the RUC works, what
(16:51):
the RUC is and how that mightchange, however you feel and
this is I'm asking you to guessout in the future.
So this is, we're not going tohold you to it, we just want to
know what you're thinking.
Speaker 3 (17:01):
Well, I would tell you on the subject of coding,
one thing that has really raiseda flag on our radar is the
coding in the ASC space.
So last year at the end of theyear, suddenly total shoulder
replacement showed up on the ASCcoding list, and ASC payments
(17:23):
are different than how we getpaid and they're different how
hospitals get paid.
There are essentially sixbuckets, or APCs, that determine
how much is paid, pays the sameamount unless it's a
device-intensive procedure thatcould get an additional payment
because that bucket justcouldn't possibly pay for the
(17:43):
device that would be necessaryto perform the procedure.
Total joint replacement is inthe highest bucket and pays at
the highest levels and otherspay less.
Unfortunately, just like thephysician fee schedule, it is
subject to budget neutrality andso as new procedures get
admitted onto the APC schedules,whichever bucket they drop into
(18:04):
ultimately causes everything inthat bucket to reduce, based on
the amount of projected volumefor that procedure and the
amount of projected expenditurefor that procedure.
So when total shoulders got putin, they were ultimately
adjusted up to APC6, which isthe highest level, which put
them in the total knee and totalhip.
(18:24):
Before that occurred, there wasan anticipation of a slight
increase in pay for that APC6bucket.
After it occurred, there wasactually a decline in pay for
total hip and total kneestarting this year at the ASC
level, and so one of the thingsthat we're keeping an eye on is
a lot of the more expensiveprocedures, such as spine
(18:44):
procedures, have not made theirway to the APC, and so we are
actually at the end of this yearbeginning with the coding
coverage and reimbursementcommittee to bring in experts on
ASC coding to say you know, alot of our surgeons have
interest in one way, shape orform in a surgery center and a
lot of our cases are shifting tosurgery centers.
(19:05):
If that is the case, what do weneed to be doing to help ensure
that cases are still viable?
We don't want to get to a pointwhere surgery center cases are
paid so poorly that there's notsufficient margin that the cases
then flip back to going fromASCs back to hospitals.
That's not in the best interestof us.
We've been talking aboutreducing the cost of care and it
(19:26):
would really hurt and harm manyof our private practicing
groups, and so this is going tobecome a really, really big
issue for orthopedics inparticular, who is going to be a
group that is going to see alot of their codes ending up in
the same buckets.
And how do we continue tocommunicate the value of that?
And how do we prevent all ofthe issues we've been having
(19:46):
since 1989, when we came outwith a singular conversion unit
for RVUs, and the continuedreimbursement decline we've seen
in the fee-for-service world?
How do we protect that on theAPC side to the extent that
fee-for-service is still around?
That's going to be a reallyimportant detail for us going
forward.
Speaker 2 (20:04):
All right.
So look ahead 10 years or so.
With the constant push onvalue-based care, where are we
going to be?
Are we going to?
Is fee-for-service still goingto exist at all?
Are we still going to be usingthe current coding and payer
technologies that we have, orwhat do you see?
Speaker 3 (20:21):
Yeah, I think we've still been so.
We've had such a difficult timeimplementing the processes that
we have in place right now, andwe've identified very few
things that can actually savemoney.
Value-based care has a lot ofpotential but not a lot of
actual revenue generationcurrently within the system, and
so I think it's going to stillbe very slow.
(20:43):
We're 10 years into thisprocess with CMMI and we've
really not been able to identifya key target that we can roll
out to all different specialties.
There's some hope aroundcondition-based bundles that we
can do it, but we need thelatitude to get that done and
you know currently it doesn'tappear that CMMI has an interest
(21:03):
in those types of bundles.
Other specialty organizationson the Hill talking about
protecting fee-for-service andensuring that it gets
inflationary updates, because wedon't see a quick and easy
(21:26):
transition to value-based careover the next decade.
Speaker 2 (21:30):
That's the best way I've ever heard that explained
to date.
I mean the way you said it interms of we've been doing it for
10 years, we haven't gottenanywhere.
So because when you read theCMS websites and such, they
pound out that, oh, we're goingto do this in no time at all.
And, to your point, if youcould even elaborate on this, as
we've said on this podcast andothers is, and see if you agree,
(21:53):
as CMS goes, so goes theprivate payers.
Speaker 3 (21:56):
Yeah, absolutely, and I would argue even that there
are many payers now who areusing CMS as the top, not the
bottom, meaning they'renegotiating percentage contracts
below Medicare reimbursementgoing forward and I think
they're just seeing how far theycan actually go before it stops
right, before they can'tcontract anymore and they don't
(22:17):
have enough doctors in a givencommunity.
That's crazy.
Speaker 2 (22:22):
Oh my gosh.
Okay, so earlier we had talkedabout the condition based bundle
and I think you talked about ita fair amount, but just to make
sure, could you further explainthat, just so everybody
understands where that is,because it is such an important
thing?
That is probably the way we'regoing in the future.
Speaker 3 (22:38):
Yeah, I mean really it's a.
It's a very intelligent designof how to take care of patients
and the way that we think abouttaking care of patients.
All of our training wasdesigned to take care of
conditions, not to take care ofepisodic problems, and this
concept is that, instead of justbeing the technicians who
(22:58):
operate on patients, we becomethe kind of stewards of
musculoskeletal care from startto finish.
So a group whether they'reemployed or they're in private
practice or they're part of auniversity group would be
provided with a population ofpatients and they would be paid
a set amount for every patientwho, let's say, develops knee
(23:19):
pain.
And some of those patients whodevelop knee pain have an ACL
tear and under the currentsystem you'd have to go through
prior authorization and do allthese different things to make a
decision about what to do withthat patient.
But you might know, hey, if Ican take that patient to the
operating room now, before theirswelling starts, I think I can
save six weeks of rehab and Ithink I can save that, get that
(23:40):
patient back to work faster.
Well, that's your money.
You're going to be paid a lumpsum of money to take care of
that knee pain.
Another patient might have justbeen playing on the weekend
basketball and tweaked theirknee and you see them one time
you might even just have a PA ora nurse practitioner see them
to evaluate them initially andsay, oh, that's just something
(24:01):
that's gonna get better with oneor two visits of physical
therapy and some ibuprofen.
And you send them on your wayand you get paid that same lump
sum of money.
And so as you make the rightdecision for patients at a
clinical level throughout theirprocess number one we think it
can probably get rid of a lot ofthe headaches administratively,
like prior authorization thatwe have and the hiccups and the
things that frustrate us abouttaking care of patients.
(24:23):
But number two it's going toreward us for everything we
learned in medicine.
I remember, you know, there'skind of that dictum of you know,
you don't just learn how tooperate in orthopedics, you
learn who to operate on.
And that's probably the thingyou learn, unfortunately, later
in your career as you make themistakes and you go gosh, I wish
I wouldn't have operated onthat person.
(24:43):
But what if we paid you forlearning who to operate on?
You know, if you think about it, today we get paid a small
amount for clinic visits.
We get paid a larger amount forsurgeries.
But what if I just told you I'mjust going to pay you for doing
the right thing for thatcondition?
Now we get to use our entireset of everything we learned in
orthopedics.
(25:03):
You know, that fracture, thatsupracondylar humerus fracture
in that four-year-old probablydoesn't need to get pinned.
So I'm just not going to pin it, I'm going to put it in a
splint and cast and send it out,or that that one actually
really does need to get pinnedand I'm going to make that
decision.
That's right for that patient.
So that's what condition-basedbundles is.
We pay for a set of apopulation for specific
(25:28):
conditions like knee pain orback pain or hip pain, as
opposed to paying for eachoffice visit and each physical
therapy visit and the surgerycenter and the doctor to do the
surgery.
It thinks more holistically andrewards people for making the
right decisions at variouspoints along the pathway.
Speaker 2 (25:44):
Very good, that's a good, good description of that.
I'm sure you've heard the quotetakes five years to learn when
to operate.
In a lifetime to learn when notto right.
That's right, that's right.
Last question for you, sotypical of the US political
process we tend to flip back andforth between the parties every
eight, four to eight years orso.
We typically tend to do thathere in the United States over
(26:06):
recent history, agnostic towho's running the Congress and
who's running the presidency.
Or do you think, other thanmild, of course there's going to
be mild flavors to it, but ordo you see this?
Do you think there's going tobe a greater impact if there's a
significant change inadministration?
Speaker 3 (26:32):
Yeah, that's a great question.
So I would tell you thatcurrently and again, cmmi holds
a lot of the purse strings forwhat we do with respect to
future coding.
Currently, cmmi is almost allcareer people in DC.
Therefore, uninfluenced by theadministrations that come and go
, while the heads of each ofthose organizations, like the
(26:52):
secretary of HHS, is a politicalappointee, the people who work
within CMMI are not.
There is a growing desire withinDC to potentially break that up
and say maybe the reason thishasn't been working is because
we've lived in an echo chamberwhere these people who eat,
(27:14):
sleep and breathe DC have no newideas and they keep telling
each other the same ideas andthat's why maybe they're not
listening to condition-basedbundles.
So maybe we need to infuse afew more political appointees
into CMMI and not have so manycareer people in CMMI.
And I see that as probablybeing a part of these hearings
(27:34):
coming up.
I see that as being a goal ofseveral of the people in DC to
say what can we do to shake thisup, to get something out of
CMMI?
Not blow it up, not kill it,but let's shake it up a little
bit.
And if that happens, we'recertainly going to see that, as
administrations ebb and flow,that's going to impact the
perspective towards differentvalue-based care solutions.
Speaker 2 (27:59):
All right, that is fantastic.
You've given us a very, verygood overview of the future in
this and I really appreciate it.
So I'd like to thank my guest,dr Adam Bruggemann.
As I said, he's currently thechair of the Advocacy Council
for the American Academy ofOrthopedic Surgeons and, as you
could tell, he has a very uniqueand very comprehensive view of
what's happening in terms ofthis area specifically, and I'm
(28:21):
so glad you're representing usat the academy level, and thanks
for all your service there, sir.
Speaker 3 (28:25):
Thank you.
I very much appreciate yourtime today and happy to educate
everybody on the issues we'refacing.
Speaker 2 (28:30):
Thanks again, and all the stuff that you're putting
out through the AOSno-transcript.
Popular Podcasts
United States of Kennedy
United States of Kennedy is a podcast about our cultural fascination with the Kennedy dynasty. Every week, hosts Lyra Smith and George Civeris go into one aspect of the Kennedy story.
Stuff You Should Know
If you've ever wanted to know about champagne, satanism, the Stonewall Uprising, chaos theory, LSD, El Nino, true crime and Rosa Parks, then look no further. Josh and Chuck have you covered.
Dateline NBC
Current and classic episodes, featuring compelling true-crime mysteries, powerful documentaries and in-depth investigations. Follow now to get the latest episodes of Dateline NBC completely free, or subscribe to Dateline Premium for ad-free listening and exclusive bonus content: DatelinePremium.com