Nicholas Grosso, MD, president of The Centers for Advanced Orthopaedics in Bethesda, Md., spoke to Becker's about how CMS' physician fee and reimbursement cuts will affect orthopedic surgeons and how orthopedic care delivery will change in the coming years.
Note: Responses are lightly edited for style and clarity.
Question: How will CMS' physician fee cuts and reimbursement cuts affect your practice next year?
Dr. Nicholas Grosso: They're going to be huge because commercial payers tend to mirror whatever CMS does. Right now, our commercial contracts are pretty good, but we can certainly anticipate the downward pressure if CMS' cuts are allowed to stand. There's a bill in Congress, both on the House and Senate side, to negate the cuts going forward because we're getting hit twice. We're getting hit not only on our physician fees, but our [physical therapy] is also getting cut 9 percent.
That could be very significant as far as limiting access for patients. It's going to be very hard for some of these smaller groups to survive. You're going to see a bunch of independent physical therapy practices start to go under as they're hanging on by a thread right now. Coming off this pandemic, where a lot of them have been shut down, to then get a 9 percent cut as you hope to ramp up again is going to be very tough.
Q: Have you any insight as to how commercial payers will react to CMS' reimbursement cuts?
NG: I don't know how commercial payers are going to react. We're pretty much locked in with our contracts. Our biggest contract coming up to renewal is with Blue Cross Blue Shield, which is every three years. We're going back and forth with them, but we don't know what position they're going to take. They're the 800-pound gorilla in our state. Unlike a lot of states, where it's mostly even across the board with payers, 80 percent of the commercial business in Maryland is Blue Cross Blue Shield.
Q: How do you see orthopedic care delivery developing in the coming years?
NG: We're not going anywhere. With the baby boomers getting older, the need for orthopedics is going to increase, especially on the joint replacement side. Looking at some of the trends of total knees and total hips expected to be done in the U.S. in the coming years, it's almost a vertical line up. We're already starting to see that volume.
I think we'll see an acceleration of these surgeries being moved outpatient. The pandemic hastened that process because a lot of people just don't want to go to the hospitals. Surgery centers that have the capacity are doing more procedures to try and take up some of that volume. We'll see an acceleration of the transition of site of service out of the hospitals to outpatient surgery centers. This has been very good for orthopedics because most of us are owners in our surgery centers. That may help keep the market going and maybe offset some of the CMS cuts.
Q: How is CAO looking at value-based care in orthopedics over the next two to three years?
NG: We've realized that bundled payments is kind of a race to the bottom. Now what we're looking at is shared savings as a start into value-based care, which works differently than bundles. Ultimately, our goal is to get to where we can take risk on our contracts. That risk is most likely going to have to have upside and downside risk in order to be effective. We're laying the foundation now for us to be able to accept risk in the future. That requires certain strategies to be put in place, such as common EMR and billing across the whole platform and ways to monitor performance. We're implementing these now so we'll be ready in a year or so when the market is better.
Q: What volumes are you and your practice operating at now?
NG: Last week was my busiest week since March. But I'm afraid volumes may start slowing down again, depending on how the COVID-19 pandemic trends in the state. I follow the numbers every day and it looks like we're finally turning a corner in terms of the number of hospitalizations. In terms of volumes, we're still down overall. I think people have gotten to the point where they realize they can't put off getting evaluated forever. Patients may be a little leery, but they are coming back into the office.
Q: How would CAO cope with a second elective surgery shutdown? What would it mean for smaller orthopedic groups in the area?
NG: If we were to see another elective surgery shutdown, that would be crushing for a lot of the smaller orthopedic groups, which are already hurting. CAO is a larger group and has taken a lot of steps to limit our costs, so we should be in pretty good shape even if the state did curtail elective surgeries again. However, having an elective surgery backlog is not always a bad thing. When postponed surgeries come back online, it may increase patient waiting times to get the surgeries done, but surgeons never complain about having too many surgeries on the schedule.
Q: What are you most excited about in 2021?
NG: I'm excited about getting this pandemic behind us and getting back to some sense of normalcy. In orthopedics, we deal with a lot of elderly patients. Even though my volume is picking back up to a more normal level, I know there are a lot of people who are sitting at home in pain that we can help, but just aren't coming out for fear of the virus. The hope is that people get back to a point where they feel safe enough to come back out and get the care they need.
Medicine is changing very fast. This virus threw a monkey wrench into the way things are going, but there have been a few positive things that have occurred. A lot of people are using telehealth now that never thought they would be in 2020. In 2021, CMS is also solidifying E&M payments for telehealth. I would love to see them improve physical therapy through telehealth initiatives as you currently can't do therapy remotely. That would be another hugely positive development.