Perspective

Senate Finance Committee releases bipartisan report on concurrent surgery

A Senate Finance Committee staff report recently released by Committee Chairman Orrin Hatch (R-Utah) and Ranking Member Ron Wyden (D-Ore.) details the practices of concurrent and overlapping surgeries in hospitals.

The report entitled, “Concurrent and Overlapping Surgeries: Additional Measures Warranted,” was compiled after the committee queried 20 teaching hospitals about the practice of concurrent surgery in their institutions. According to a press release, the committee also examined guidance issued by CMS and the American College of Surgeons (ACS); policies; information gathered from stakeholders, such as the American Hospital Association; and other information provided to the committee by hospitals and others.

Although advocates of concurrent surgery hold the practice enables timelier access to high-skilled, in-demand surgeons by freeing up their time to perform more specialized operations, helps train medical professionals by partnering senior physicians with residents or fellows and improves the use of operating facilities, the report noted there is little data or research on the frequency, cost-effectiveness or impact of concurrent surgeries on surgical outcomes and patient health. The report also noted the Medicare billing requirements issued by CMS that pertain to the practice of overlapping surgeries only apply to the treatment of Medicare beneficiaries in teaching hospitals, and that the CMS has not routinely monitored or audited teaching hospitals for conforming with these restrictions. However, as a result of increased public awareness about the practice of concurrent surgery, the ACS modified its guidance to surgeons in April 2016, according to the report.

“The American Academy of Orthopaedic Surgeons (AAOS) was intimately involved with the development of the guidelines produced by the ACS on the ‘Intraoperative Responsibility of the Primary Surgeon’ and the AAOS Board of Directors formally endorsed those guidelines in April. Patient safety is always the first priority, and as is expressed in the guidelines, patient-physician communication is extremely important. We appreciate the work the Senate Finance Committee has done and we look forward to continuing this conversation with them in the coming year,” Gerald R. Williams, Jr., MD, president of the AAOS, said in a  statement to Orthopedics Today.

The Senate Finance Committee concluded the report by listing several concerns about patient safety that need to be resolved concerning concurrent surgery. According to the staff report, these include the following steps:

- develop a concurrent and overlapping surgical policy that distinctly prohibits concurrent surgery and regulates the practice of overlapping procedures in a manner consistent with ACS guidance;

- specify the critical portions of specific procedures, “to the extent practicable,” as well as those steps unsuitable for overlap;

- create processes to ensure patient consent discussions result in the patient completely understanding that his or her surgery will overlap with another patient’s;

- develop materials for surgeries, such as frequently asked questions;

- educate patients prior to surgery and give them ample time to review materials and their options;

- prospectively note the backup surgeon for overlapping surgeries when these are scheduled; and

- develop methods enforce the current concurrent and overlapping surgical policies, and to monitor and enforce the outcomes.

When it comes to improper payments, the committee noted the HHS Office of Inspector General should evaluate the controls in place to ensure hospitals and physicians are appropriately billed for services provided by teaching physicians. In addition, the report concluded “the administrator of CMS should review the agency’s billing requirements for services performed by teaching physicians to determine if those requirements should be established for other surgical facilities and scenarios.”

 “This report provides a crucial look at the little-known practices of concurrent and overlapping surgeries and lays the groundwork for improving the system moving forward,” Hatch and Wyden said in a press release. “While we are encouraged by the steps taken by the American College of Surgeons and a number of hospitals to address the concerns with concurrent surgeries, we remain concerned that the nearly 5,000 hospitals in America may lack thorough and complete policies covering these procedures and patient consent. By working with hospitals and surgeons in a collaborative manner, it is our hope we can continue to increase transparency and patient safety.”

Orthopedics Today published a Cover Story on concurrent surgery in its June 2016 issue. The Cover Story can be read here. Also, read commentaries about concurrent surgery by Orthopedics Today Chief Medical Editor Anthony A. Romeo, MD, and by Chief Medical Editor, Orthopedic Surgery for Spine Surgery Today Scott D. Boden, MD.

 

References:

www.finance.senate.gov/chairmans-news/hatch-wyden-issue-bipartisan-report-on-concurrent-and-overlapping-surgeries

www.finance.senate.gov/imo/media/doc/Concurrent%20Surgeries%20Report%20FINAL%20.pdf

www.finance.senate.gov/imo/media/doc/Summary%20on%20Concurrent%20Surgeries.pdf

A Senate Finance Committee staff report recently released by Committee Chairman Orrin Hatch (R-Utah) and Ranking Member Ron Wyden (D-Ore.) details the practices of concurrent and overlapping surgeries in hospitals.

The report entitled, “Concurrent and Overlapping Surgeries: Additional Measures Warranted,” was compiled after the committee queried 20 teaching hospitals about the practice of concurrent surgery in their institutions. According to a press release, the committee also examined guidance issued by CMS and the American College of Surgeons (ACS); policies; information gathered from stakeholders, such as the American Hospital Association; and other information provided to the committee by hospitals and others.

Although advocates of concurrent surgery hold the practice enables timelier access to high-skilled, in-demand surgeons by freeing up their time to perform more specialized operations, helps train medical professionals by partnering senior physicians with residents or fellows and improves the use of operating facilities, the report noted there is little data or research on the frequency, cost-effectiveness or impact of concurrent surgeries on surgical outcomes and patient health. The report also noted the Medicare billing requirements issued by CMS that pertain to the practice of overlapping surgeries only apply to the treatment of Medicare beneficiaries in teaching hospitals, and that the CMS has not routinely monitored or audited teaching hospitals for conforming with these restrictions. However, as a result of increased public awareness about the practice of concurrent surgery, the ACS modified its guidance to surgeons in April 2016, according to the report.

“The American Academy of Orthopaedic Surgeons (AAOS) was intimately involved with the development of the guidelines produced by the ACS on the ‘Intraoperative Responsibility of the Primary Surgeon’ and the AAOS Board of Directors formally endorsed those guidelines in April. Patient safety is always the first priority, and as is expressed in the guidelines, patient-physician communication is extremely important. We appreciate the work the Senate Finance Committee has done and we look forward to continuing this conversation with them in the coming year,” Gerald R. Williams, Jr., MD, president of the AAOS, said in a  statement to Orthopedics Today.

The Senate Finance Committee concluded the report by listing several concerns about patient safety that need to be resolved concerning concurrent surgery. According to the staff report, these include the following steps:

- develop a concurrent and overlapping surgical policy that distinctly prohibits concurrent surgery and regulates the practice of overlapping procedures in a manner consistent with ACS guidance;

- specify the critical portions of specific procedures, “to the extent practicable,” as well as those steps unsuitable for overlap;

- create processes to ensure patient consent discussions result in the patient completely understanding that his or her surgery will overlap with another patient’s;

- develop materials for surgeries, such as frequently asked questions;

- educate patients prior to surgery and give them ample time to review materials and their options;

- prospectively note the backup surgeon for overlapping surgeries when these are scheduled; and

- develop methods enforce the current concurrent and overlapping surgical policies, and to monitor and enforce the outcomes.

When it comes to improper payments, the committee noted the HHS Office of Inspector General should evaluate the controls in place to ensure hospitals and physicians are appropriately billed for services provided by teaching physicians. In addition, the report concluded “the administrator of CMS should review the agency’s billing requirements for services performed by teaching physicians to determine if those requirements should be established for other surgical facilities and scenarios.”

 “This report provides a crucial look at the little-known practices of concurrent and overlapping surgeries and lays the groundwork for improving the system moving forward,” Hatch and Wyden said in a press release. “While we are encouraged by the steps taken by the American College of Surgeons and a number of hospitals to address the concerns with concurrent surgeries, we remain concerned that the nearly 5,000 hospitals in America may lack thorough and complete policies covering these procedures and patient consent. By working with hospitals and surgeons in a collaborative manner, it is our hope we can continue to increase transparency and patient safety.”

Orthopedics Today published a Cover Story on concurrent surgery in its June 2016 issue. The Cover Story can be read here. Also, read commentaries about concurrent surgery by Orthopedics Today Chief Medical Editor Anthony A. Romeo, MD, and by Chief Medical Editor, Orthopedic Surgery for Spine Surgery Today Scott D. Boden, MD.

 

References:

www.finance.senate.gov/chairmans-news/hatch-wyden-issue-bipartisan-report-on-concurrent-and-overlapping-surgeries

www.finance.senate.gov/imo/media/doc/Concurrent%20Surgeries%20Report%20FINAL%20.pdf

www.finance.senate.gov/imo/media/doc/Summary%20on%20Concurrent%20Surgeries.pdf

    Perspective
    Anthony A. Romeo

    Anthony A. Romeo

    The report from the Senate Finance Committee, "Concurrent and Overlapping Surgeries: Additional Measures Warranted," reflects a legitimate concern over a long-standing practice in many surgical arenas, including both hospitals and surgicenters. Patient safety and patient consent have reportedly been compromised. This may be particularly evident in teaching hospitals, whereby the attending surgeon of record has residents or fellows operating in one OR while they are operating in a different OR on a different patient. While this method may provide benefits to a teaching program or a surgeon's ability to care for more patients, the patients are often not informed and are unaware of this practice, and therefore, the duty of the surgeon responsible for the patient's care has not been fulfilled.

    In many OR environments, overlapping of surgery is a mischaracterization of the actual practice of scheduling cases in two separate rooms. Before and after the key steps of the surgery are conducted, there is often ample time to be in another room performing surgery while the staff, other than the surgeon, manage the activities in the first OR. Frequently with orthopedic surgical cases, the time from completion of the key steps of one surgery until the initiation of the key steps of the next surgery in the same room is separated anywhere from 30 minutes to 90 minutes or more. During this time, the surgeon can be safely and proficiently performing surgery in another room. Care is not compromised. Interestingly, two recent studies from teaching institutions – University of California, San Francisco and the Mayo Clinic – have failed to demonstrate any difference in outcome with overlapping surgery.

    This report and future investigations from the government are likely to lead to a clearer definition of what constitutes key parts of a surgical procedure. Furthermore, systems are likely to be mandated to monitor the activities in the OR to document the behavior of the surgeon of record. Requirements for patient consent will be strict as patients have a right to know who is performing their surgery. Ultimately, high volume surgeons who alternate between ORs and are responsible for performing the key parts of every procedure will be able to continue to practice safe, efficient surgery. Surgeons who use other members of their team to perform the key steps without informing their patients should realize this is a betrayal of the patient-physician relationship. The Senate Finance Committee, HSS Office of Inspection and CMS are likely to work together to make this method of care a behavior of the past.

    • Anthony A. Romeo, MD
    • Chief Medical Editor, Orthopedics Today

    Disclosures: Romeo reports he receives royalties, is on the speaker’s bureau and a consultant for Arthrex; does contracted research for Arthrex and DJO Surgical; receives institutional grants from AANA and MLB; and receives institutional research support from Arthrex, Ossur, Smith & Nephew, ConMed Linvatec, Athletico and Miomed.