STATEWIDE SURVEY OF ORTHOPAEDIC SURGEONS FINDS INEFFICIENCY, CARE DELAYS AND PATIENT HARM CAUSED BY “PRIOR AUTHORIZATION” REQUIREMENTS
Findings Align With Recent AMA Survey; Provide Powerful Evidence Supporting Reform Proposal Introduced by Senator Breslin and Assemblymember McDonald
Albany, New York — The New York State Society of Orthopaedic Surgeons (NYSSOS) today released the findings of a statewide survey of NYSSOS member orthopaedic surgery practices concerning their experiences in complying with “prior authorization” requirements implemented by insurance companies.
The survey results were consistent, with nearly every respondent reporting that the requirements delayed needed care and often caused preventable harm, debilitation and pain for patients.
As healthcare utilization has increased, programs such as prior authorization have been implemented with the intention of ensuring more cost effective care. However, as these programs have proliferated, patients often experience unnecessary delays and denials for care deemed necessary by their treating physician. In addition, the indiscriminate growth of these practices has created enormous administrative burdens for orthopedic surgeons, limiting the time they have available to provide direct patient care.
Specifically, the survey found:
- 97% of respondents reported that prior authorization fails to achieve its intended purpose of reducing healthcare costs.
- 88% reported having patients abandon care due to delays associated with prior authorization.
- 94% had patients experience a deterioration of prognosis or quality of life due to prior authorization delays.
- 96% had patients experience sustained or increased pain and/or symptoms due to prior authorization delays.
- 89% had patients experience a delayed return to employment due to prior authorization delays.
- 97% say that removing prior authorization would result in more expedient care for their patients.
- 94% say that removing prior authorization would improve the quality of care their patients receive.
- 94% say the administrative burden prior authorization places on their practice has gotten worse in recent years.
The complete NYSSOS survey findings, which can be found at: https://nyssos.org/News/12777960, are very similar to the findings of a recent nationwide American Medical Association (AMA) survey concerning the same issue https://www.ama-assn.org/system/files/prior-authorization-survey.pdf.
A proposal has been introduced recently in the state Legislature to address this issue. The bill, S.8299/A.9908-A, introduced by Senator Neil Breslin (D-Albany) and Assemblymember John T. McDonald III, RPh (D-Cohoes), would create what is known as a “Gold Card” program that would provide an exemption from prior authorization for health care professionals who receive at least 90 percent approval for a particular health care service over a six-month period. NYSSOS strongly supports this legislation.
Senator Neil D. Breslin, Chair of Senate Committee on Insurance, said: “Current prior authorization requirements result in notable delays in medical care, interfere with continuity of care, while at the same time, impose unnecessary administrative work on health care professionals. The Gold Card bill that I am sponsoring will make sure patients receive the treatment they need in a more timely fashion, resulting in a higher quality of care.”
Assemblymember John T. McDonald III, RPh said, "I sponsor the Gold Card bill to help streamline the prior authorization process and ease the burdens that patients face when accessing care. When someone is facing a medical issue, we want to make it easier for the patients to receive necessary treatment and for providers to provide the care needed. I believe this is a commonsense measure that would address some of the challenges that too many face, and builds toward a better healthcare system."
A similar proposal was recently enacted into law in Texas. https://www.ama-assn.org/practice-management/sustainability/new-physician-gold-card-law-will-cut-prior-authorization-delays
NYSSOS President Dr. John DiPreta said: “It ’s time that we confront a growing problem that is present in virtually every treatment room in our state. The proliferation of prior authorization activities is causing unnecessary delays in care, harming patients and driving avoidable administrative burdens for practitioners. We are calling on state leaders to end the unnecessary patient suffering and debilitation that is directly caused by current prior authorization practices, and we are hopeful that the solution proposed by Senator Breslin and Assemblymember McDonald quickly makes its way through the Legislature and is delivered to the Governor ’s desk.”
About NYSSOS: Representing more than 800 orthopaedists across New York State, NYSSOS advocates for orthopaedic surgeons, patients and musculoskeletal health in New York State. NYSSOS is the orthopaedic community’s primary source of information and expertise concerning: legislative/regulatory advocacy (local, state and federal levels); practice trends and change; leadership training for national, state, and local issues and opportunities; assistance with establishing and maintaining a practice; and familiarity with state practice guidelines impacting the profession and patient care. Learn more at www.nyssos.org
Delayed musculoskeletal care comes at a tremendous cost not only to the patient in terms of quality of life and productivity but to the overall health care system. According to the American Public Health Association, musculoskeletal conditions are a leading cause of disability in the U.S. accounting for more than 130 million patient visits to health care providers annually and the number one reason individuals to see their physician.
Despite relatively low peer-to-peer denial rates, insurer’s prior authorization and utilization reviews continue to focus on micromanagement aspects of care, typically driven by financial factors. These techniques are in direct conflict with the patients interests since the results pose unnecessary delays in routine musculoskeletal care and treatment.
In April 2022, NYSSOS conducted a statewide survey of its membership concerning their experiences in complying with “prior authorization” requirements implemented by insurance companies.
The survey results were consistent, with nearly every respondent reporting that the requirements delayed needed care and often caused preventable harm, debilitation, and pain for patients. Specifically, the survey found:
- 97% of respondents reported that prior authorization fails to achieve its intended purpose of reducing healthcare costs by denying truly ineffective or unnecessary care.
> See the complete results
"Gold Card Legislation"
A proposal has been introduced recently in the state Legislature to address this issue. The bill, S.8299/A.9908-A, introduced by Senator Neil Breslin (D-Albany) and Assemblymember John T. McDonald III, RPh (D-Cohoes), would create what is known as a “Gold Card” program that would provide an exemption from prior authorization for health care professionals who receive at least 90% percent approval for a particular health care service over a six-month period. NYSSOS strongly supports this legislation.
“It ’s time that we confront a growing problem that is present in virtually every treatment room in our state. The proliferation of prior authorization activities is causing unnecessarily delays in care, harming patients and driving avoidable administrative burdens for practitioners. We are calling on state leaders to end the unnecessary patient suffering and debilitation that is directly caused by current prior authorization practices, and we are hopeful that the solution proposed by Senator Breslin and Assemblymember McDonald quickly makes its way through the Legislature and is delivered to the Governor ’s desk.” - John DiPreta, MD, FAAOS, NYSSOS President.
Statement from New York Physician & Hospital Organizations Calling on Legislature to Include Telehealth Payment Parity in Final Enacted Budget for FY 2022-23
The New York State Society joined its fellow physician and hospital colleagues in calling on the legislature to include telehealth payment parity. Ensuring fair payment for Telehealth services through payment parity is necessary to ensure this patient care delivery mechanism can continue to be offered by community based physician practices. We look forward to working with lawmakers to provide additional expertise and resources on the importance of unfettered patient access to Telehealth services as they negotiate the final budget.
Dr. John DiPreta, President of the New York State Society of Orthopaedic Surgeons
“Greater access to Telehealth services provides numerous benefits including increased patient access to orthopaedic surgeons and surgical teams, reductions in patient travel burden, improvements to clinical workflows and practice efficiencies, and enhanced follow-up. These benefits have proven especially advantageous to vulnerable populations and patients with impairment who may lack appropriate transportation or access to specialty care. We are encouraged that patients have embraced the technology and convenience of telemedicine and we anticipate its adoption will continue post-pandemic. We therefore urge the Assembly to join with the Governor and Senate in supporting Telehealth payment parity."
(Albany, New York) The American Academy of Orthopaedic Surgeons (AAOS) has appointed two members of the New York State Society of Orthopaedic Surgeons (NYSSOS) Board of Directors to national leadership posts.
Matthew DiCaprio, MD, has been named chair of the AAOS Board of Councilors Communications Committee. Dr. DiCaprio is professor of orthopaedic surgery, director of orthopaedic oncology, and professor of pathology at Albany Medical Center. He is also a member of the NYSSOS Board of Directors where he chairs the Membership Committee.
The AAOS Communications Committee supports AAOS’ strategic plan by advising on the development and implementation of communications programs designed to enhance the image of the orthopaedic surgeon ’s role in the highest quality of musculoskeletal patient care and to engage members of the Academy at all stages of their careers.
Also tapped for an AAOS leadership post is NYSSOS Board of Directors member Dr. Barry Kraushaar, who has been appointed as Vice Chair of the AAOS State Orthopaedic Societies Committee. Dr. Kraushaar is a dual-board certified orthopedic surgeon and sports medicine specialist, and serves as an AAOS Board of Councilor representative for New York.
In his capacity as committee vice chair, Dr. Kraushaar will aid AAOS in pursuing strategies to strengthen and foster development of state orthopaedic societies, and administering and monitoring the effectiveness of the AAOS State Orthopaedic Society Assistance Fund.
John DiPreta, MD, NYSSOS President, said: “Dr. DiCaprio and Dr. Kraushaar exemplify the leadership qualities that abound in New York’s orthopedic physician community. Their appointment to AAOS national leadership positions is apt recognition of their continuing contributions to advancing musculoskeletal care.”
By John DiPreta, MD, President, New York State Society of Orthopaedic Surgeons
“The Governor made clear that health care is among her top priorities in the new year. Many challenges await her within that arena, as do many perspectives. We are hopeful that her policy and budget priorities will be founded on demonstrable, evidence-based approaches to care provision that will best ensure New Yorkers have access to the highest quality care delivered by the most qualified professionals.
“The New York State Society of Orthopaedic Surgeons will remain committed to being a productive partner and technical resource to the Governor and her team as, together, we address the challenges before us.”
Governor Kathy Hochul today announced a $10 billion multi-year investment in healthcare, the largest in State history, to rebuild and grow the healthcare workforce and strengthen the healthcare system as part of the 2022 State of the State. The plan will invest $10 billion in New York State’s healthcare sector, including more than $4 billion to support wages and bonuses for healthcare workers, and will invest in the healthcare workforce development pipeline to meet the current and increasing demand for medical professionals. > Read more
STATEMENT ON GOVERNOR HOCHUL’S 2022
STATE OF THE STATE ADDRESS
“Governor Hochul’s State of the State address was a thoughtful and hopeful articulation of the opportunities that abound in New York State when our government acts not as a barrier to progress, but as a partner in achieving it.
STATEMENT ON STATE’S ORDER TO DELAY “ELECTIVE” SURGICAL PROCEDURES THAT TAKES EFFECT TODAY
“Governor Hochul’s order to begin limiting certain surgical procedures is well-intended policy that unfortunately may do more to increase the suffering of New York’s patient population. The intent of the order is to reserve hospital capacity for potential COVID patient surges. However, as a blanket policy, it fails to consider and incorporate several critical factors.
“Primarily, it’s important to challenge the notion that certain procedures are ‘elective’ — a term that often is misunderstood to indicate that such procedures are ‘optional’ and therefore not critically important to a patient’s health and well being. For many patients, orthopaedic surgical procedures are essential interventions that resolve profound pain and debilitation that undermine both the physical and mental health of those who suffer.
“Unfortunately, due to policies earlier in the pandemic that prohibited ‘elective surgeries,’ and despite enhanced safety protocols and progress in the fight against COVID-19, thousands of patients in New York State with debilitating pain were not allowed to receive treatment, and were also hesitant to engage or re-engage with the healthcare system resulting in delays to care. These delays in surgeries and procedures ultimately resulted in prolonged pain and suffering, significant medical deterioration, and materially impacted patients’ prognoses, morbidity and/or treatment plans. It is important the Legislature, the Executive and regulatory partners understand how detrimental framing ‘elective surgeries’ as optional interventions has become for patients.
“Secondarily, the order unintentionally sends an erroneous signal that accessing healthcare of any kind presents a danger to the patient. Providers have instituted broad and effective COVID-19 protocols that have resulted in demonstrably safe access to care. Nevertheless, we saw volumes across many service lines, including primary care and chronic disease management, fall off significantly as the pandemic evolved. Thousands of seriously and chronically ill patients stopped or limited their pursuit of care vital to their lives and livelihoods. That cost has yet to be fully measured or understood, and should not be exacerbated.
“Lastly, as a blanket state policy the order is generally unnecessary. Providers and hospitals are most knowledgeable about their patients’ needs and their communities’ status and needs, including relative to COVID-19. They should be the ultimate decision makers regarding the appropriate site of service for their patients, keeping in mind quality, safety, and associated risks. With state guidance and coordination, hospitals and ambulatory surgical facilities can best determine the appropriate level of elective cases that can be performed while also maintaining pandemic response readiness.”
RECENT PUBLIC HEALTH STUDY PRESENTED AT NYSSOS ANNUAL MEETING FINDS LINK BETWEEN CHRONIC CANNABIS USE AND UNFAVORABLE JOINT REPLACEMENT SURGERY OUTCOMES
Albany, New York — A new study by researchers at the Maimonides Medical Center found a significant association between cannabis use disorder and unfavorable outcomes following total knee replacement. The study’s preliminary findings were unveiled at the New York State Society of Orthopaedic Surgeon’s (NYSSOS) annual meeting and symposium on October 22 by Dr. Miriam D. Weisberg, an orthopedic resident at the Maimonides Department of Orthopaedic Surgery, who was part of a team of researchers led by Maimonides’ research fellow Dr. Rushabh M. Vakharia.
The researchers collected data on more than 50,000 patients who had undergone total knee replacement surgeries, known as total knee arthroplasty, or TKA. Almost 10,000 of these patients had a clinical diagnosis of cannabis use disorder (CUD), which is generally defined as the persistent use of cannabis leading to impairment and social hinderance. The aim of the study was to determine whether cannabis use disorder patients undergoing primary TKA have higher rates of in-hospital lengths of stay, complications and increased healthcare costs.
The study concluded that:
- The majority of patients undergoing TKA with cannabis use disorder are between 45-65 years old.
- CUD patients were found to have nearly twice as long of an in-hospital length of stay following surgery (about 4-days compared to 2-days). This was also found to be increasing over the 8-year study period.
- CUD patients were 1.5 times more likely to have a medical complication, such as pneumonia, respiratory failure or heart attack, within 90-days following surgery.
- CUD patients were found to be up to 56 percent more likely to experience prostheses-related complications, such as loosening or infection, compared to their counterparts, within two years of their knee replacement.
- Day of surgery costs and total global 90-day episode of care costs were found to be nearly 20 percent higher in the CUD group compared to the case-matched cohort.
NYSSOS President Dr. John DiPreta said: “The study strongly suggests that all of the impacts of broader cannabis use are not yet fully understood, and that more research and diligent impact analysis is necessary as we move forward. We are hopeful that the state’s cannabis policy makers and regulators move cautiously, and more importantly, reflect on the health of all New Yorkers as they implement New York’s legalized cannabis program to ensure that any potential unanticipated consequences of increased cannabis use are effectively addressed and, if possible, mitigated. To that end, we stand ready to provide any assistance possible as it relates to the musculoskeletal health of New Yorkers and these consequences of cannabis use.”
The Maimonides research was one of several studies presented at the NYSSOS annual meeting and symposium. The full Maimonides study has been submitted for publication to the Journal of the American Academy of Orthopaedic Surgeons and is currently under review.
NYSSOS TO CONVENE NOVEMBER 9TH MULTIDISCIPLINARY WEB CONFERENCE TO ADDRESS CONCUSSION MANAGEMENT
Experts to Share Strategies on Recognizing Concussions and Providing Proper Treatment, Especially Among School Aged Children
Virtual Program Provided in Conjunction With the Brain Injury Association of New York State, Sports Medicine Concepts and Syracuse Orthopedic Specialists Will Provide Critical Guidance to a Wide Range of Education, Athletics and Medical Professions
Albany, New York — The New York State Society of Orthopaedic Surgeons today announced plans to convene a multidisciplinary virtual conference on November 9th to share evidenced-based approaches to recognizing concussions and providing proper treatment, especially among school-aged children.
The webinar event, which is also sponsored by the Brain Injury Association of New York State (BIANYS), Sports Medicine Concepts, and Syracuse Orthopedic Specialists, is targeted to a wide variety of education, athletics and medical professions, including: athletic trainers; athletic directors; school nurses, counselors, psychologists, social workers, and medical directors; teachers; primary care physicians; concussion clinics; physical therapists; speech and language therapists; pediatricians; occupational therapists and orthopaedists, among others.
Child and adolescent head injuries are far more common than previously thought. According to the federal Centers for Disease Control and Prevention, 11.7 percent of children aged 15 to 17 have experienced a serious head injury, creating a clear and emergent call to action.
The primary goal of the November 9th virtual conference is to provide each professional discipline with an understanding of its shared role in the concussion management care circle, and to actively apply concepts learned from the day's event.
NYSSOS President Dr. John DiPreta said: “Orthopaedists are focused on the health of the entire musculoskeletal system, including the head, spine and associated nervous system. The focus in recent years on concussion injuries at the professional athletics level has generated a far broader realization that athletes at every age and level must be protected from concussion injuries, and just as importantly, that the education, athletic and medical professionals who respond to and/or treat concussions are fully up to date on the most effective concussion recognition and treatment strategies available.”
Program elements of the conference include:
• Initial Assessment, Acute Management and Typical versus Prolonged Recovery, including: recognizing signs and symptoms of concussion; selecting and utilizing appropriate sideline assessment tools; identifying appropriate care and red flags for immediate referral/emergency transport; identifying “typical” recovery times/stages; and selecting appropriate referrals and rehabilitation tools to manage prolonged recovery.
• The Concussion Management Care Circle, with learning objectives that include: defining components of multidisciplinary concussion management teams; identifying rolls and responsibilities of each profession within the care circle; creating interdisciplinary communication plans; creating a concussion protocol that can address different severities of concussion; identifying strategies to manage patient expectations; and patient-provider communication.
• Navigating New York State Legislation and Regulations, with learning objectives that include: demonstrating understanding of the differences between state legislation, local guidelines, and specific organization policies; creating a concussion protocol that adheres to local and state regulations for your profession and patient population; and demonstrating understanding of pending legislation.
A full program agenda including faculty and eligibility for continuing education credits can be found at https://nyssos.org/concussion/
Advocating for the orthopaedic surgeon, patients and musculoskeletal health in New York.
Address: PO Box 38004, Albany, NY 12203