Resident Health Policy Committee Agenda Friday, 9 March 2018

6:30 – 7:45am Central Time Room 278, Convention Center Kevin Cronin, MD, Chairman

6:30am Call to Order

6:35am Motion to approve new Chairman

6:40am 2017 Year in Review, Nicholas Bonazza, MD, Immediate Past Chair

6:50am Legislative Update

7:00am Review Ongoing HPC Action Items

7:15am Guest Speaker: Stu Weinstein, MD

7:35am Planning for 2018

7:50am Adjourn

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RA Committee Charges

RESIDENT ASSEMBLY COMMITTEES – CHARGES AND GOALS

EXECUTIVE COMMITTEE:

1. Shall be the governing body of the AAOS Resident Assembly. 2. Review all AAOS Resident Assembly Committee reports and actions. 3. Reports to the Candidate, Resident, Fellows Committee. 4. Submit Resident Assembly approved actions to the Candidate, Resident, Fellows Committee. 5. Promotes the Resident Assembly among residents and residency programs. 6. Educates residents and residency programs about the Resident Assembly. 7. Provides orientation to Resident Assembly leadership and membership.

2017-2018 Goals 1. Continue to identify and develop leaders early in their training. 2. Continue to develop innovative ways to improve resident education. 3. Increase resident participation in advocacy. 4. Develop resources for medical students. 5. Develop and implement delegate communication strategy.

NOMINATING COMMITTEE:

1. Solicit applications for the following positions: Chair, Vice-Chair, At-Large Members of the Executive Committee.

2. Review the involvement, contributions, and leadership of the various Resident Assembly Committee chairs and the At-Large members of the Executive Committee to select Chair and Vice-Chair.

EDUCATION

COMMITTEE: 1. Review educational resources and provide educational opportunities for residents, including

a. Resources for OITE/ABOS preparation and b. Information for study symposia.

2. Provide a forum for collaborative discussion of educational issues among and between residents and the AAOS.

3. Educate residents about critical education issues. 4. Promote ideas and develop projects that advance orthopaedic education. 5. Develop, refine, and present education actions to the executive committee.

2017-2018 Goals 1. Improve Education Committee communications. 2. Improve pre-residency education for incoming interns. 3. Improve resident access to surgical courses 4. Improve fellowship search process & establish a buddy mentorship program. 5. Creation of curated reading list for orthopaedic surgery residents. 6. Improve the resident bowl. 7. Establish the model residency program concept.

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RA Committee Charges

HEALTH POLICY COMMITTEE: 1. Address issues affecting the field of orthopaedic surgery and orthopaedic residency training. 2. Develop, refine, and present health policy actions to the executive committee. 3. Collaborate with AAOS to promote resident engagement in political issues locally and nationally. 4. Educate residents on the Orthopaedic Political Action Committee (PAC) and current political issues

impacting orthopaedics.

2017-2018 Goals 1. Develop a health policy webinar. 2. Develop a series of articles for publication. 3. Increase resident PAC participation. 4. Review the Washington Health Policy Fellows program goals and incorporate into the Resident

Assembly, where applicable.

PRACTICE MANAGEMENT/CAREER DEVELOPMENT COMMITTEE: 1. Provide information on starting a career in orthopaedics, including:

a. Fellowship opportunities and b. Employment opportunities.

2. Develop, refine, and present practice management actions to the executive committee.

2017-2018 Goals 1. Present 3-4 webinars. Current topics include:

• Finance 101 (7/18) • Investing Overview - White Coat Investor • Student Loan Repayment • Young Practitioner’s Forum

2. Publish 2 AAOS Now articles. Current topics include: • Coding Basics

RESEARCH COMMITTEE:

1. Promote research opportunities available to residents, including: a. Awards, b. Grants, and c. Sub-specialty research activities.

2. Promote the value of orthopaedic research among the orthopaedic resident community. 3. Develop, refine, and present research actions to the executive committee

2017-2018 Goals 1. Encourage involvement of members within the committee

• Develop member-led subcommittees to develop and improve projects • Utilize video conferencing to encourage member participation • Use the AAOS Community

2. Develop and refine content for the Resident Research Toolkit 3. Promote resources to residency programs through grassroot programs and coordination with the Resident

Delegates of the AAOS Resident Assembly. 4. Webinars:

• Host two webinars • Identify topics and create content for two additional webinars

5. AAOS Now • Submit two articles • Identify topics and create content for two additional articles

6. Resident Committee Study

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RA Committee Charges

• Question: Can we identify certain factors that will lead to a better performance in residency to create scholarly activity?

TECHNOLOGY COMMITTEE: 1. Identify, develop, test or promote new technologies to facilitate resident productivity, education and

optimize healthcare. 2. Develop, refine, and present technology actions to the executive committee.

2017-2018 Goals 1. Explore new and better ways for AAOS to engage residents with the new AAOS.org web site by providing specific feedback on current site features that could be improved to better serve residents, and suggestions on new site features that they feel would realistically improve the web site experience for residents and young orthopaedic surgeons. 2. Actively involved in the pilot study for the AAOS Community Portal which will be open to all Resident Assembly delegates and Committee members. The Committee will discuss and present specific feedback RA Committee Charges throughout the process, and make specific recommendations for changes that will increase residents’ participation in the Community after it’s formally launched. 3. Work jointly with the Education Committee to develop a potential resource guide of digital content that is most useful to residents in different stages of their residency. Additionally, the Committee will give careful consideration and specific recommendations on the most appropriate ways to deliver this content to the target audiences. 4. Engage with the AAOS on social media to support its use and gain online engagement

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AAOS Resident Assembly Health Policy Milestones CURRICULUM DRAFT

Health Policy Committee 2017-2018 Nicholas A. Bonazza, M.D.

Chris Hoedt, M.D. Christian A. Pean MD, MS

Introduction

The impact of health policy on healthcare and, specifically, orthopaedic surgery is growing. The Medicare Access and CHIP Reauthorization Act (MACRA) of 2015 repealed the former Sustainable Growth Rate (SGR) payment track but opened a host of new policy initiatives that will change the way we deliver care for years to come. Comprehensive Care for Joint Replacement (CJR) is another example of how government policy is driving change in orthopaedics. Policy intervention in healthcare is certainly not new nor will these be the only changes we will see in the next generation of orthopaedics. Preparing for change and being a part of change are entirely different. To continue to advocate for our patients and the future of orthopaedic care, we must speak up and push for a voice in policy discussions so that we may have a hand in the policies driving care of our patients. To be a part of those discussions, we must start with a basic understanding of how policies are made and where we, as orthopaedic surgeons, can get involved. The American Academy of Orthopaedic Surgeons (AAOS) already does this in many ways, but few residents understand health policy and the existing efforts to promote positive change for the future of orthopaedics.

In accordance with Resident Assembly Action Item #5 from the Second Resident Assembly General Assembly in Orlando, Florida on March 3, 2016, and as approved by the AAOS Council on Education to be developed by the AAOS Office of Government Relations (OGR) and Resident Assembly Health Policy Committee, these Milestones are aimed at helping residents to build a better understanding of health policy and how we all can become advocates now and throughout our careers.

Curriculum

Online Instruction

The program will consist of two distinct components. The first component consists of 5 self-directed modules that residents will access online. The modules will contain written and verbal instruction through Text files, Microsoft PowerPoint, video and recorded webinar platforms. Completion of each module will be recorded within the resident’s AAOS account. Modules will cover the following topics:

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1) How does health policy affect the daily actions of all orthopaedic surgeons? 2) I want to be a physician advocate- what do I do now? 3) Building relationships- how to make it work

Experiential Learning

Upon completion of the online modules, individuals will be given the designation of resident advocate and have access to learning opportunities through the AAOS OGR. These opportunities will consist of three types of experiences, accessible based on availability for the individual resident due to location, cost and time:

1) In-person visit with state or local legislator accompanied by AAOS Fellow or AAOS staff member

2) In-person visit with federal legislator or staff member accompanied by AAOS Fellow or AAOS staff member

3) Attendance to NOLC with state delegation or as guest of AAOS OGR

Module 1

“How does health policy affect the daily actions of all orthopaedic surgeons?

Nicholas A. Bonazza, M.D.

1) Intro to Health Policy

a) Power Point 2) Examples of Policy’s Impact

a) Patient Interaction

i) HIPAA

(1) The Adverse Effects of HIPAA on Patient Care; http://www.nejm.org/doi/full/10.1056/NEJM200307173490324

(2) Health Information, The HIPAA Privacy Rule, And Health Care: What Do Physicians Think?; http://content.healthaffairs.org/content/24/3/832.full

ii) Informed Consent (1) Pennsylvania Supreme Court rules doctors must obtain informed

consent; https://www.klinespecter.com/blog/pennsylvania-supreme-court-rules-doctors-must-obtain-informed-consent.html

iii) Electronic Health Records

(1) Allocation of Physician Time in Ambulatory Practice: A Time and Motion Study in 4 Specialties;

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http://annals.org/aim/article/2546704/allocation-physician-time-ambulatory-practice-time-motion-study-4-specialties

b) Reimbursement i) Position Statement - Alignment of Physician and Facility Payment and

Incentives; https://www.aaos.org/uploadedFiles/PreProduction/About/Opinion_Statements/position/1171%20Alignment%20of%20Physician%20and%20Facility%20Payment%20and%20Incentives%20(formerly%20Gainsharing).pdf

ii) MACRA

(1) Talks?

iii) Bundled Payment (1) AAOS Physicians Discuss the New CMS Bundled Payment

Program; https://www.youtube.com/watch?v=tV2hs3UPL4E

(2) Talks?

c) Career and Practice Decisions

i) Physician-Owned Hospitals

d) As Residents

i) GME funding

(1) The Evolution of GME Funding - https://www.aaos.org/AAOSNow/2014/Sep/advocacy/advocacy3/

3) Policy Snapshots

a) 3, 5 minute videos

b) Include resident discussion

c) Contrast practice types, sizes, systems

Module 2

“I want to be a physician advocate- what do I do now?”

Christian A. Pean MD, MS

1) Identify the issues relevant to your profession and your patients. a) Orthopaedic PAC Resident Toolkit b) AMA Legislative and Regulatory Dashboard

i) https://www.ama-assn.org/about/national-advocacy c) ACS Legislative Tools https://www.facs.org/advocacy

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2) Build legislative contacts in your community and your state a) Find out who your representatives are and learn their stance on the issues

important to you. https://www.govtrack.us/ b) Consider attending a fundraiser and get to know your councilperson,

congressperson, state senator, and U.S. Senator 3) Become involved in your specialty PAC

a) Donate to the PAC i) Where does the money go? Why?

(1) PAC 101 (2) PAC, COA? (3) Annual Report

ii) Involve residency iii) Join Capitol Club/Futures Capitol Club

b) Join at AAOS NOLC and learn what it means to lobby c) AAOS Resident Advocacy Fellowship

https://www.aaos.org/Advocacy/ResidentFellowship/ 4) Vote early and often! 5) Consider expanding your knowledge through formal education

a) Pursue an MPP, JD, MBA or MPH b) Apply for a policy fellowship

i) https://www.profellow.com compilation of competitive funded fellowships

ii) Nick Littlefield Fellowship http://www.nehi.net/about/nick-littlefield-fellowship

iii) Commonwealth Fund Mongan Fellowship in Minority Health Policy iv) Many many more!

Module 3

“Building Relationships - How to Make It Work”

Chris Hoedt, M.D.

AAOS - Building Relationships: An Advocacy Axiom https://www.aaos.org/AAOSNow/2015/Sep/advocacy/advocacy3/?ssopc=1

AAOS How to Connect to Congress via Social Media

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https://www.youtube.com/watch?v=Tc8I9arooew&list=PLSfV9OcfPQGiec5xrRo6M_DXpWfc4WSUe&index=5

App that makes following & contacting local legislators easy https://www.countable.us/

● Maybe the academy should create something similar or pair with an existing app

AMA - How to make your voice heard by Congress https://www.ama-assn.org/sites/default/files/media-browser/public/washington/communicating-with-congress_0.pdf

AMA Grassroots Training & Legislative update: how to talk with legislators https://cc.readytalk.com/cc/playback/Playback.do?id=fa1v1a

Texas Medical Association ● High-yield Lobbying

https://www.texmed.org/Template.aspx?id=5455 ● Message Tips for your Legislative Testimony: dos and don’ts

https://www.texmed.org/Template.aspx?id=35193

How Do Physicians Lobby Their Members of Congress: legislative assistants interviewed and reported physicians make effective lobbyist http://jamanetwork.com/journals/jamainternalmedicine/fullarticle/485561

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My Day in DC Orthopaedic PAC’s new Resident Fellow shares experiences Jacob G. Calcei, MD

As the new resident fellow on the American Association of Orthopaedic Surgeons (AAOS) Political Action Committee (PAC), I recently had the opportunity to visit the AAOS Office of Government Relations in Washington, DC, and to meet with several members of Congress. Sitting on the train from New York to DC, I could feel the anticipation and excitement setting in. I was going to represent the orthopaedic profession on Capitol Hill!

I had never met with a legislator before, and health care is such a critical issue these days. Reviewing my agenda for the day, I was not sure what to expect. The names on my schedule included members of Congress who held important positions on different committees and subcommittees. They were addressing issues such as Medicare regulatory relief and proposals to challenge, amend, or overturn the Affordable Care Act.

How exactly did I end up on their schedules and invite lists? What could I, as an orthopaedic surgery resident, contribute to their day? Why did they care to meet me? Thankfully, I quickly learned how vital it is to share my experiences with these policymakers and how large an impact the Orthopaedic PAC can have on ensuring that the collective voice of orthopaedic surgeons is heard.

Learning about the issues With the overwhelming amount of information available on the current healthcare system, the changes that are scheduled to occur, and the changes that are currently being proposed, it can be daunting to know where to start learning about the issues. I focused on two websites—www.congress.gov and www.aaos.org/dc. Both have a wealth of information that prepared me for the many issues (medical liability, physician-owned hospitals, meaningful use) and acronyms (MIPS, MACRA, CHIP, HIT, SGR) that I would need to know.

AAOS staff, including Stacie Monroe, senior manager of political affairs, and Meredith Allison, political affairs assistant, were also helpful in preparing for my visit. I had the chance to meet both legislative and regulatory staff in the AAOS Office of Government Relations and learn more about what their days look like.

Every day, the government relations staff in DC are hard at work ensuring that the voices of orthopaedic surgeons around the country are heard and that we, and our patients, are protected as new bills and regulations are proposed. Staff members work as a team to comb through every page of proposed legislation and determine if and how it will affect orthopaedic surgeons. They then work with AAOS leadership to formulate a response.

This information is passed along to the PAC and our lobbyists, who serve as the “boots on the ground” as they interact with members of the various congressional committees and

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subcommittees. They bring attention to the issues that are important to orthopaedic surgeons. You can reach out to any of the DC staff by emailing dc@aaos.org or calling 202-546-4430. They are happy to provide more information and answer questions on this process.

My day on the Hill My day on Capitol Hill began with a breakfast fundraiser just a block from the Capitol building. I was met by Catherine Boudreaux, AAOS senior manager of government relations, who took me inside and introduced me to many of the elected officials who make daily decisions on how this country is run.

I quickly saw that, despite being surrounded by corporate lobbyists for big business, powerful financial institutions, and prosperous pharmaceutical companies, members of Congress and their staff recognized and respected the AAOS presence. This is a testament to the hours that AAOS staff, leadership, and members have spent in Washington, DC, advocating for us as orthopaedic surgeons and the issues that affect our specialty.

As I was about to start eating, a gentleman behind me noted that breakfast is the most important meal of the day. I turned to see the congressman from North Carolina who was the first on my scheduled list of elected officials to meet. After being introduced, I was able to thank him for his support of physicians and many of the issues that are important to orthopaedic surgeons, including recent legislation on medical liability reform. I was struck by the fact that he wanted to speak to me and hear about issues from the orthopaedic surgeons’ perspective. I was also impressed that, at the end, he thanked me for taking the time to talk to him. This was a recurring theme throughout the day: the legislators want to hear from us directly. They want to know how legislation affects us and our ability to deliver care to our patients.

Only 20 out of more than 500 members of Congress are doctors, and many aren’t familiar with the daily life of physicians. Although they are certainly well-versed on many issues, they are not familiar with the delivery of health care and rely on us to share our clinical expertise and the impact of their decisions on patients.

What’s next? As the AAOS Orthopaedic PAC resident fellow, I have the opportunity to share my passion with others and raise awareness about policies and decisions that will have an impact on our everyday lives as physicians and engaged citizens.

With the ever-changing political climate and the increasing impact that health care has on our country, now more than ever, physicians and residents need to be more involved and engaged in advocacy and policy. If we are educated and active, meaningful changes can be made that affect and protect us, as well as our patients, colleagues, and future trainees.

The Orthopaedic PAC, at $3.5 million in annual contributions, is one of the largest and most influential medical society PACs in the country. It is imperative that we, as orthopaedic surgeons, give both our time and our money to support the PAC and important advocacy issues.

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The Orthopaedic PAC is nonpartisan and represents the interests of orthopaedic surgeons before Congress by supporting candidates who understand, defend, support, and often champion the issues that we face on a daily basis. The PAC also creates opportunities for surgeons to meet with members of Congress and other elected and appointed officials to establish and maintain an open dialogue. Legislators want to hear from us. The PAC opens the door and we must go through it. To learn more, visit www.aaos.org/pac or email pac@aaos.org.

I am looking forward to the year ahead and the impact that we, as orthopaedic surgeons, can make on The Hill and around the country. I want all residents to feel they have a voice and their opinions matter, and I want to take my colleagues’ temperature on how we are doing. Recently, we distributed the second resident survey on the PAC. We had more than 500 responses, which I discussed with the PAC Executive Committee at their board retreat. Stay tuned for a full report and action plan.

As the resident fellow on the PAC Executive Committee, I serve as the voice of residents. I want to hear from residents and fellows. I hope to get the chance to meet many AAOS members during the coming year. If you are interested in getting more involved in the PAC, I encourage you to reach out to me or Stacie Monroe with questions or concerns at pac@aaos.org.

Jacob G. Calcei, MD, is an orthopaedic surgery resident from Hospital for Special Surgery, New York, and the new AAOS Orthopaedic Political Action Committee (PAC) Resident Fellow.

(SIDEBAR)

An Interview with Dr. Calcei

While in Washington, DC, Jacob G. Calcei, MD, sat down with Stacie Monroe in the AAOS Office of Government Relations to discuss his background and role as the new resident fellow on the AAOS Orthopaedic PAC executive committee.

Stacie: Welcome to the PAC Executive Committee. At first glance, what do you see as opportunities for resident involvement in the PAC?

Dr. Calcei: I am honored and excited to be the new Orthopaedic PAC resident fellow. I want to congratulate and thank Chad A. Krueger, MD, my predecessor, for his service. Chad significantly increased resident awareness of and participation in the Orthopaedic PAC. We began our PAC advocacy program in 2014 and during the past 2 years, under Chad’s leadership, the annual resident participation in the PAC has increased from 85 residents to 330. Six programs reached 100 percent resident participation last year. I hope to continue the momentum and see this incredible growth in advocacy continue to rise.

Stacie: How did you get involved?

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Dr. Calcei: My passion for healthcare policy stems from a summer in college, when I lived in Washington, DC, and worked as a summer research fellow at the National Cancer Institute. It was there, surrounded by the world’s political leaders and great scientific minds, that I began to see the intricate relationship between policy and the distribution of healthcare resources (clinical, educational, and research).

As a medical student who served rotations at the Manhattan VA Hospital, Bellevue Hospital, and NYU Medical Center, I interacted with patients from all backgrounds, each with an amazing story. I experienced the impact of policies at the state and national levels on the access to health care and the complexities of our healthcare system. I furthered my interest in health policy as a resident through the Resident Assembly Health Policy Committee.

Stacie: Can you tell us a little bit more about yourself?

Dr. Calcei: I am the oldest of four boys in a sports and science family from Northeast Ohio. My parents are both public school teachers and fostered our interest in science, our love for sports, and our dedication for caring for others, which, for me, turned into a passion for orthopaedic surgery sports medicine. I attended Kenyon College in Gambier, Ohio, where I majored in biology and was a captain on the baseball team. I then came to New York City for medical school at NYU School of Medicine and married my amazing wife, Shanna. I am currently in my 4th year of residency at Hospital for Special Surgery and I am applying for a fellowship in sports medicine.

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Evidenced-Based Advocacy: The Argument for POHs Nicholas A. Bonazza, MD

One of the less-discussed provisions of the Affordable Care Act is the ban on the expansion of existing physician-owned hospitals (POHs) and the formation of new ones. The ban was founded on concerns about physician self-referrals and possible conflicts of interest. Similar concerns led to the passage of the Stark Act in 1989, which prevented self-referral of Medicare patients.

One theory regarding physician behavior as it relates to demand for services is the supplier-induced demand (SID) hypothesis. The SID hypothesis suggests that physicians promote their self-interests by prescribing care beyond what is clinically necessary. When applied to POHs, the expectation is that POH physicians would disproportionately promote activities that profit the hospital. This may mean prescribing more tests or suggesting more surgery for a given diagnosis. According to claims made by the American Hospital Association, which opposes POHs, it may also mean “cherry-picking” profitable patients, such as those who are less ill or those who have private insurance.

Although previously substantiated by some studies, these concerns are not supported by recent evidence. While it is difficult to measure specific prescribing patterns for a hospital, overall costs of care can be measured. For example, results of a 2015 study found no significant difference between POHs and non-POHs with respect to mean costs of care and mean Medicare reimbursements for acute myocardial infarction, congestive heart failure, and pneumonia admissions. In addition, data from a study that examined physician-owned and hospital-owned provider groups in California revealed that total annual medical expenditures per patient were 19.8 percent lower for physician-owned organizations.

The 2015 study also evaluated patient demographics. Patients at POHs were statistically younger (77.4 vs. 78.4 years), less likely to be discharged to hospice (1.8 percent vs. 2.8 percent) and more likely to be discharged home (68.6 percent vs. 62.3 percent) than patients at non-POHs. However, no differences existed between the two groups of patients with regard to comorbidities, predicted mortality scores, insurance type, or ethnicity.

Many of these study outcomes differ from the 2006 Medicare Payment Advisory Commission (MEDPAC) findings, which reported that POHs had higher utilization of services per patient as well as higher costs of care, but little effect on the revenue on competing community hospitals. If these findings were true today, despite more recent studies to the contrary, we would expect this higher utilization and higher costs to result in worse or at least similar outcomes, per the SID hypothesis. However, by Medicare’s own quality performance standards, four of the top five hospitals as rated by total performance score are physician-owned.

Thus, at least with regard to POHs, recent evidence indicates that the concerns regarding self-interests and self-induced demand may not be valid. Additionally, Medicare data on quality

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suggests POHs may actually lead to innovative ways of improving quality of care without higher costs, a characteristic that makes revoking their current ban seriously worth considering.

References for the studies cited may be found in the online version of this article, available at www.aaosnow.org

Nicholas A. Bonazza, MD, is Chairman of the Resident Health Policy Committee

References (for online only):

American Hospital Association. (2017). Physician self-referral to physician-owned hospitals. Retrieved from http://www.aha.org/content/15/fs-physicianowned.pdf

Blumenthal, D.M., Orav, E.J., Jena, A.B., Dudzinski, D.M., Le, S.T., & Jha, A.K. (2015). Access, quality, and costs of care at physician owned hospitals in the United States: Observational study. British Medical Journal, 351:h4466. Retrieved from http://www.bmj.com/content/bmj/351/bmj.h4466.full.pdf

Medicare. (2017). The total performance score information. Retrieved from https://www.medicare.gov/HospitalCompare/Data/total-performance-scores.html

Medicare Payment Advisory Commission. (2006, August). Report to the Congress: Physician-owned specialty hospitals revisited. Retrieved from https://asipp.org/documents/PhysicianOwnedSpecialtyHospitals.pdf

Robinson, J.C., & Miller, K. (2014). Total expenditures per patient in hospital-owned and physician-owned physician organization in California. JAMA, 312(16), pp. 1663-1669. Retrieved from http://jamanetwork.com/journals/jama/fullarticle/1917439

Santerre, R.E., Neun, S.P. (2013). Health economics: Theory, insights, and industry studies (6th ed.). Mason, OH: SouthWestern, Cengage Learning.

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2017 PAC Resident Survey Report

American Academy of Orthopaedic Surgeons

Department of Research, Quality, and Scientific Affairs

October 13, 2017

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2017 PAC Resident Survey

Survey work is conducted for the benefit of and is owned by AAOS. Not to be duplicated without consent.

October 13, 2017

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Table of Contents

EXECUTIVE SUMMARY .................................................................................................................................................. 3

INTRODUCTION .............................................................................................................................................................. 4

METHODOLOGY ............................................................................................................................................................. 4

RESULTS ......................................................................................................................................................................... 5

APPENDIX A: COPY OF SURVEY INSTRUMENT ....................................................................................................... 21

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2017 PAC Resident Survey

Survey work is conducted for the benefit of and is owned by AAOS. Not to be duplicated without consent.

October 13, 2017

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Executive Summary 1. Of the 5,624 Residents invited, 489 responded giving a response rate of 8.69%. 2. Majority of respondents have heard of the Orthopaedic PAC (67%). One third of respondents are

not familiar with the Orthopaedic PAC. 3. Of those who have not heard of the Orthopaedic PAC, 64% are interested in learning more about

the Orthopaedic PAC and its legislative priorities while 36% are not interested. 4. Of those who have heard of the Orthopaedic PAC, the majority (74%) have not donated. Only 26%

of respondents indicated they have donated to the PAC. 5. Respondents who indicated they have donated to the PAC were asked their reasons for donating.

The top three reasons for donating were that it is important for orthopaedic surgeons to have a voice in Washington (84%), to help solve problems facing orthopaedic surgeons (62%), and being encouraged by colleagues to donate (54%).

6. Respondents who indicated they have not donated to the PAC were asked their reasons for not donating. The top three reasons for not donating were “other” (54%), that no one has asked them (23%), and they don’t know how or where to donate (17%).

7. Respondents indicated that physician payment (80%), medical liability reform (62%), and physician ownership (55%) are the issues most important to them. Electronic health records (32%), quality and research (38%), and graduate medical education (43%) were the least important issues.

8. Majority of respondents indicated they would be interested in attending a local PAC event (62%), while 38% indicated they would not be interested.

9. Majority of respondents indicated they would not be interested in leading or participating in PAC efforts at the state or regional level for residents (60%). Forty percent indicated they would be interested.

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2017 PAC Resident Survey

Survey work is conducted for the benefit of and is owned by AAOS. Not to be duplicated without consent.

October 13, 2017

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Introduction The 2017 PAC Resident Survey was developed by the AAOS Survey Research Unit in conjunction with the AAOS Office of Government Relations. This survey was exploratory in nature, intended to obtain an overview of the level of awareness AAOS Residents have of the Political Action Committee and their involvement.

Methodology

On August 28, 2017, AAOS Resident members were invited via email to participate in a web-based 2017 PAC Resident Survey. Participants were given until September 25th to complete the survey and were provided with one reminder email for those who had not responded. Of the 5,624 Residents invited, 489 responded giving a response rate of 8.69%. It is important to note that no tracking was used in the survey, so it may be possible that an applicant could have submitted more than one response. Data are reported in actual counts, percentage, and means when appropriate and include 95% confidence intervals (CI) to illustrate the range of responses expected in the full population. Confidence intervals are included in Appendix A. A copy of the survey can be found in Appendix B.

Data gathered were analyzed by the AAOS Department of Research, Quality, and Scientific Affairs and are used for AAOS purposes only.

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2017 PAC Resident Survey

Survey work is conducted for the benefit of and is owned by AAOS. Not to be duplicated without consent.

October 13, 2017

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Results Majority of respondents have heard of the Orthopaedic PAC (67%). One third of respondents are not familiar with the Orthopaedic PAC.

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2017 PAC Resident Survey

Survey work is conducted for the benefit of and is owned by AAOS. Not to be duplicated without consent.

October 13, 2017

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Of those who have not heard of the Orthopaedic PAC, 64% are interested in learning more about the Orthopaedic PAC and its legislative priorities while 36% are not interested.

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2017 PAC Resident Survey

Survey work is conducted for the benefit of and is owned by AAOS. Not to be duplicated without consent.

October 13, 2017

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Of those who have heard of the Orthopaedic PAC, the majority (74%) have not donated. Only 26% of respondents indicated they have donated to the PAC.

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2017 PAC Resident Survey

Survey work is conducted for the benefit of and is owned by AAOS. Not to be duplicated without consent.

October 13, 2017

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Respondents who indicated they have donated to the PAC were asked their reasons for donating. The top three reasons for donating were that it is important for orthopaedic surgeons to have a voice in Washington (84%), to help solve problems facing orthopaedic surgeons (62%), and being encouraged by colleagues to donate (54%).

Participants who indicated “other” reasons for donating were asked to specify. Verbatim responses can be found below.

1 Because if we adopt a single payer system I'm not going to practice surgery.

2 Jacob Giovanni Calcei

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2017 PAC Resident Survey

Survey work is conducted for the benefit of and is owned by AAOS. Not to be duplicated without consent.

October 13, 2017

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Respondents who indicated they have not donated to the PAC were asked their reasons for not donating. The top three reasons for not donating were “other” (54%), that no one has asked them (23%), and they don’t know how or where to donate (17%).

Participants who indicated “other” reasons for not donating were asked to specify. Verbatim responses can be found below.

1 (Shamefully) have been apathetic

2 350k in medical debt

3 As residents I don't have a lot of money

4 Broke

5 Broke as a Joke

6 Broke resident

7 Budget

8 Can't afford to

9 current financial state does not lend itself to donations

10 currently a resident, limited salary

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Survey work is conducted for the benefit of and is owned by AAOS. Not to be duplicated without consent.

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11 currently resident and dont have extra money to donate

12 Didn't have $$

13 Do not agree with the politicians the PAC supports

14 Do not have enough expendible income to spend to make a difference

15 Do not have money to donate

16 Do not make enough money

17 Don't feel i have the money to give

18 don't have any money

19 Don't have any money to donate

20 Don't have extra money as a resident

21 Don't have extra money to donate

22 Don't have money

23 don't have the $

24 don't have the money as a resident

25 Don't like the idea of donating to politicians without knowledge of their agenda etc

26 donations to other programs

27 Dont agree with PAC/AAOS positions on issues

28 Dont have any money

29 dont have the money to donate

30 Feel like don't have enough $$$ to donate atm

31 Finances

32 financial constraints

33 Financial contraints

34 Financial issues

35 financial limitations as a resident

36 Financial reasons

37 financial situation

38 Fundamentally opposed to all PACs and money in politics

39 hard to donate on resident salary

40 have no money

41 Haven't had money in the past, I plan to in the future

42 Higher priorities for my money

43 i already donate to numerous organizations

44 I am a resident with little money

45 I am paid barely enough to cover my rent and living expenses

46 I am struggling to survive on a resident salary

47 I disagree with some of its policies and its agenda

48 I don't have extra money to spare

49 I don't think I support what the PAC wants (conservative goals that benefit wealthy citizens over poorer ones)

50 i don't want to spend my money on that

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Survey work is conducted for the benefit of and is owned by AAOS. Not to be duplicated without consent.

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51 I have no money

52 I have not seen an easy way to donate

53 I have way too many student loans to donate to stuff like this right now

54 I keep forgetting!

55 I make under minimum wage

56 I plan to donate this year

57 I worry the PAC's approach to policy may conflict with my personal political beliefs

58 I'm a poor resident

59 I'm a resident and I'm poor

60 I'm a resident. Will donate when I have an attending salary.

61 I'm broke

62 Im a resident, will donate when and if I make real money.

63 In debt from medical training

64 In residency

65 lack of income/still in training

66 Limited funds

67 Limited funds as a resident

68 Limited money being used elsewhere

69 limited resources

70 Limited resources pal

71 Low funds

72 Low income currently

73 Minimal cash on hand in residency

74 Money is tight as a resident

75 Money is tight!

76 Money, what money? Seriously.

77 need money

78 No discretionary income at this time.

79 No enough money in residency. Will start contributing this year as an attending

80 no extra money available

81 No money

82 No money (family on residents salary)

83 No money in the bank account to donate

84 No money to donate

85 No spare change

86 not educated on topic

87 not enough income

88 not enough money as a trainee to donate to any causes

89 Not enough money to currently donate

90 Not focused on function of PAC at this time

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Survey work is conducted for the benefit of and is owned by AAOS. Not to be duplicated without consent.

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91 Not interested

92 Not sure what their views/stances/causes are and I won't donate without knowing that

93 Other financial obligations

94 Over 450k dollars of medical school debt

95 Plan to when I have more discretionary income

96 Poor

97 Poor during residency

98 Poor income to expense ratio - student loans

99 Poor Resident

100 resident and not enough cash

101 resident on a budget. will donate in 2 years

102 resident salary

103 Resident salary

104 Resident salary with 2 kids

105 Resident salary with loans

106 Resident Salary, Student Loans

107 Resident- limited resources

108 Resident- very limited budget

109 Resident, no money

110 saving money right now

111 Short on money as a resident plan to donate later

112 Still in training

113 There is already too much money in politics

114 too much debt

115 too poor

116 Too poor

117 unable to afford it

118 waiting to finish training

119 Was a poor resident

120 Will donate in future

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Survey work is conducted for the benefit of and is owned by AAOS. Not to be duplicated without consent.

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Participants were asked what benefit they would like to see as a PAC donor that they do not currently receive. Verbatim responses can be found below.

5. What benefit would you like to see as a PAC donor that you do not currently receive (i.e. what would you like to get out of your involvement with the PAC)?

1 A contributing political voice

2 A good way to encourage PAC donation is through hosting events and Gala's with politicians. It bolsters the sense of society and encourages contribution. Perhaps these already exists, but I have not heard of them.

3 A matching program through attending orthopaedic surgeons

4 actual change favoring ortho and patients, seems like government drives the ship no matter what potential contributions surgeons make

5 Advocacy for patients, Orthopaedics surgeons

6 Appropriate

7 Better informing of the general orthopedist of what is going on and why the Pac is important. Most of my colleagues see politics as dirty or tainted and refuse to participate. We need to change that perception.

8 Better reimbursements

9 Better understanding of where policy is headed and what we can do to direct it in a way that is beneficial for us but mostly for our patients

10 blank

11 Continued advocacy to protect orthopedists in our ever-changing political climate

12 Continuous representation in policy decisions and brief feedback/minutes from meetings

13 Discounted annual academy meeting registration fees

14 Discounted registration fees for the annual meeting or other AAOS conferences.

15 Don't even know

16 Don't need benefits will donate when not in debt.

17 Draw a harder line in Washington

18 Education about policy. We probably get that but I miss it somehow with all the information that floods my invox

19 Eliminate my student loans

20 evidence of changes PAC makes for the future of the profession

21 Further information on the current PAC activities

22 Getting more personalized information about how PAC money is being used in Washinton.

23 Greater influence in politics

24 Greater negotiating power in Washington

25 Have the PAC advocate for the welfare of economically or otherwise disadvantaged citizens, which includes having very wealthy citizens picking up some of the slack financially

26 Having more information about how the Association works in DC and how to get involved politically.

27 Help me understand how I can donate once I have more money, resident budgets are tight

28 I already realize what i would get out of it, the reason I Don't donate is purely financial.

29 I am not a current PAC donor

30 I am not aware of any specific benefits at this time. I also don't have a good sense for what I would want from a PAC. I am concerned about the interface of orthoapedic foot and ankle surgeons with podiatrists.

31 I don't agree with the politics of the PAC, thus will not donate.

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32 I don't expect benefits. I expect results. And my impression from (somewhat) following the activities of the PAC is that they achieve results.

33 I don't have enough info to answer that question

34 I don't know

35 I don't know what benefits PAC donors have

36 I don't need any specific benefit except that the interests of Orthopedic Surgeons are represented and protected in DC.

37 I would like to see measurable results of exactly what you accomplish

38 I would like to see results of what the PAC does. Show me it would be worth it (ie reimbursement rates going up)

39 I wouldn't mind getting more involved after fellowship

40 I'm a DO, please accredit my residency and take the boards

41 I'm not sure what the PAC does.

42 I'm not sure, it's sometimes difficult to discern as a resident

43 If you can make it apparent how my donation will benefit my patients and my ability to provide care for them (efficiently, with less headache, and with less interference from administrators) then I may be inclined to donate.

44 Increased funding for PAs to offload some of the busy work given increasing volume seen at most hospitals. Increased protection from Podiatry encroaching on foot and ankle procedures with inadequate training.

45 increased networking ability with other orthopaedic surgeons in different parts of the country.

46 information at a basic level to help explain fundamentals

47 information on all proposed legislation

48 information on changes/advocacy that they have accomplished thus far

49 Information relevant to the changing medical policies

50 Informed of advocacy initiatives and the ability to participate in them

51 Involvement in debates and division making/proposals

52 Just knowing I helped

53 Know current issues and lobbying efforts

54 Know what PAC does, what's in it for me (especially if I'm donating), some tangible benefit for my training/practice/patients/ability to provide care.

55 Lobbying CMS/Congress for increased resident salaries.

56 Maybe a BRIEF email update on upcoming legislation in laymans terms. Succinct and quick to read.

57 monthly email stating directly what has been accomplished by the PAC on a political level

58 More awareness of where the donated money goes

59 More frequent updates on relevant policy change/addendums

60 More frequent updates on the activities of the PAC would be great

61 More info about PAC is needed

62 More info regarding impact

63 More information on policy change and how our contribution is being spent

64 More information on the exact things the PAC has done, or attempted to do, with the donated funds.

65 More resident involvement

66 More tangible outreach to residents

67 More updates as to issues the PAC is involved in

68 more updates on policies that will affect me.

69 More updates on progress the PAC has made.

70 n/a

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71 N/a

72 N/A

73 Na

74 NA

75 no answer

76 none

77 None

78 none. I would like to have more funds I could donate

79 not sure

80 Not sure

81 Not sure right now.

82 Not sure what benefits are available for joining a PAC

83 Not sure what I could get out of donating. Not sure what policies are advocated

84 Nothig

85 Nothing comes to mind

86 nothing, I am happy with what the PAC does

87 Nothing.

88 Nothing. I just want to know that AAOS is advocating for Orthopedic surgeons' interests in DC

89 Opportunities to be involved

90 our voice heard by politicians that protects our profession

91 policy changes making positive impact on my profession and personal career.

92 Potect physician rights and income

93 Protect the interests of orthopaedic surgeons.

94 Quarterly report of what the PAC has accomplished that is relevant to my education or practice.

95 Reassurance of reimbursements

96 Regular updates on actions taken, current issues, and future plans. Twitter or Facebook would be good venues for this.

97 Regular updates on what PAC is doing and what it has accomplished legislative. I want to see the impact of my dollars.

98 Relevant updates affecting insurance, reimbursements, etc.

99 Resident trips for policy making / lobbying in DC

100 See them become as productive as other groups in Washington. Podiatry has no bundling, we are caving to everything.

101 Seeing that orthopaedic surgery becomes more accessible for patients from all backgrounds. Better cost control efforts.

102 Specific feedback about what is taking place with the PAC

103 Specific updates on The Who what where and why. Policies that make direct impact on residents

104 Stronger support from congress for pro physician laws

105 Surveys reflective of the PAC position on specific issues

106 The PAC already advocates for me

107 To know where the money is being spent (if this is not already reported).

108 Understand the representation and its political views

109 Understand what the PAC does and how it impacts me

110 Understanding the efforts and current projects the PAC is working on.

111 unsure

112 Unsure

113 updates about the PAC activity and contributions

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114 Updates as to ongoing work of the PAC

115 Updates on how my money is working in Washington.

116 Updates on political changes and landscapes that relate to orthopedic surgeons

117 Updates on specific policy the PAC is advocating

118 Updates on what impact the PAC is making in congress etc

119 Voice on the hill

120 Will likely not be a donor until I make more money.

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2017 PAC Resident Survey

Survey work is conducted for the benefit of and is owned by AAOS. Not to be duplicated without consent.

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Respondents indicated that physician payment (80%), medical liability reform (62%), and physician ownership (55%) are the issues most important to them. Electronic health records (32%), quality and research (38%), and graduate medical education (43%) were the least important issues.

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2017 PAC Resident Survey

Survey work is conducted for the benefit of and is owned by AAOS. Not to be duplicated without consent.

October 13, 2017

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Majority of respondents indicated they would be interested in attending a local PAC event (62%), while 38% indicated they would not be interested.

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2017 PAC Resident Survey

Survey work is conducted for the benefit of and is owned by AAOS. Not to be duplicated without consent.

October 13, 2017

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Majority of respondents indicated they would not be interested in leading or participating in PAC efforts at the state or regional level for residents (60%). Forty percent indicated they would be interested.

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2017 PAC Resident Survey

Survey work is conducted for the benefit of and is owned by AAOS. Not to be duplicated without consent.

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Respondents were asked if there are anything else they would like to share. Verbatim responses can be found below.

9. Is there anything else you would like to share with us?

1 Continue reaching out to established orthopedic surgeons for donations and strengthening of our PAC so we don't work for pennies and tons of regulations down the road. I believe $ is crucial for PAC to advance their cause.

2 I am now a fellow.

3 I know my perspective differs from a number of orthopedic surgeons, for example Tom Price, but I appreciate you listening and thinking about advocating for disadvantaged Americans

4 I'm passionate about the PAC! Let me know if I can help.

5 It's hard to be involved as a resident with everything that's going on - I hope to be involved in the ortho community as an attending

6 Keep up the good work!

7 n/a

8 na

9 no

10 No

11 NO

12 No. Thank you for your effort

13 None

14 Nope

15 Nope.

16 Please make it clear that as an organization we won't stand for a single payer system. Drive the point home that care will suffer if anyone attempts to turn us into civil servants.

17 Thank you for the email and survery -- this has given me more interest in pursuing the PAC activity and events.

18 Thank you for your hard work

19

The AAOS, similar to the AMA over the past 10 years has done a decent job advocating for orthopaedic surgeons, but a terrible job advocating for patient care, which is the veiwpoint we need to take in order to get anything done politically. Further, the AAOS has failed its membership by supporting candidates like Tom Price who is a terrible role model for taking care of patients. The AAOS has been blinded by seeking to maintain income at the cost of doing the right thing for patients. Until this changes, I will not support any further involvement with the AAOS political advocacy agenda.

20 The orthopedic PAC doesn't represent the views of all orthopedic residents thus will not be supported by all residents.

21 There should be a larger push to get residents involved in political activism with the AAOS. More committees and opportunities should be opened up, and residents should be strongly encouraged to participate.

22 Will be more interested in helping once I have established my practice

23 Would like to see physicians involved in medical legislation in order to decrease the amount of idiotic paperwork they keep piling on us.

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2017 PAC Resident Survey

Survey work is conducted for the benefit of and is owned by AAOS. Not to be duplicated without consent.

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APPENDIX A: Copy of Survey Instrument

2017 PAC Survey for Residents

Start of Block: Intro

Intro

Thank you for taking the time to participate in this survey.

End of Block: Intro

Start of Block: Q1

Q1 Have you ever heard of the Orthopaedic PAC?

o Yes (1)

o No (2)

End of Block: Q1

Start of Block: Block 4

Display This Question:

If Have you ever heard of the Orthopaedic PAC? = No

Q1b Are you interested in learning more about the PAC and its legislative priorities?

o Yes (1)

o No (2)

End of Block: Block 4

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2017 PAC Resident Survey

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Start of Block: Regular submit

SUBMIT

Please click the SUBMIT button below to finalize and send us your responses.

Thank you!

End of Block: Regular submit

Start of Block: Default Question Block

Q2 Have you ever donated to the Orthopaedic PAC?

o Yes (1)

o No (2)

Page Break

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2017 PAC Resident Survey

Survey work is conducted for the benefit of and is owned by AAOS. Not to be duplicated without consent.

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Display This Question:

If Have you ever donated to the Orthopaedic PAC? = Yes

Q3 Please indicate below your reasons for donating (check all that apply):

▢Being politically involved is important to me (1)

▢ It is important for orthopaedic surgeons to have a voice in Washington (2)

▢My views align with those of the PAC (3)

▢To help elect physicians and pro-physician candidates (4)

▢To help solve problems facing orthopaedic surgeons (5)

▢Encouraged by my colleagues (6)

▢Other (please explain): (7) ________________________________________________

Page Break

Display This Question:

If Have you ever donated to the Orthopaedic PAC? = No

Q4 Please indicate below your reasons for not donating (check all that apply):

▢No one has asked me (1)

▢Don't know how/where to donate (2)

▢Don't care about politics or advocacy (3)

▢Don't think it makes a difference for me (4)

▢Do not understand what the PAC does (5)

▢Other (please explain): (6) ________________________________________________

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Page Break

Q5 What benefit would you like to see as a PAC donor that you do not currently receive (i.e. what would you like to

get out of your involvement with the PAC)?

________________________________________________________________

________________________________________________________________

________________________________________________________________

________________________________________________________________

________________________________________________________________

Page Break

Q6 What issues are most important to you?

▢Quality and Research (1)

▢Physician Payment (2)

▢Medical Liability Reform (3)

▢Electronic Health Records (Meaningful Use) (4)

▢Graduate Medical Education (5)

▢Physician Ownership (Ancillary Services and Physician Owned Hospitals) (6)

▢Other (7)

Page Break

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Survey work is conducted for the benefit of and is owned by AAOS. Not to be duplicated without consent.

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Q7 Would you be interested in attending a local PAC event?

o Yes (1)

o No (2)

Page Break

Q8 Would you be interested in leading or participating in PAC efforts at the state or regional level for residents?

o Yes (5)

o No (6)

Page Break

Q9 Is there anything else you would like to share with us?

________________________________________________________________

________________________________________________________________

________________________________________________________________

________________________________________________________________

________________________________________________________________

End of Block: Default Question Block

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AAOS Legislative and Regulatory Wins The American Association of Orthopaedic Surgeons (AAOS) Office of Government Relations monitors a wide variety of issues related to advancing the highest quality musculoskeletal health. Each year, the Council on Advocacy reviews and updates its Unified Advocacy Agenda, which guides the Office of Government Relations’ work in the legislative and regulatory arenas. With the primary objectives of enhancing access to and quality of orthopaedic care for our patients, major legislative and regulatory initiatives include Medicare reimbursement reform, addressing health information technology, increasing research funding, protecting in-office ancillary services, ensuring access to high-quality care, shaping emerging opioid legislation, and increasing congressional awareness of the large and growing prevalence of musculoskeletal diseases.

Federal Legislative Accomplishments 2017 was a year of important wins for health care policy. With health care reform again at the forefront of political debates on Capitol Hill, the AAOS Office of Government Relations worked hard to continue to ensure physician priorities – including medical liability reform, ownership issues, and IPAB repeal – were heard and advanced. Below is a list of some accomplishments achieved during 2017 and 2018.

Sports Medicine Licensure Clarity Act and the Medical Controlled Substances Transportation Act The Sports Medicine Licensure Clarity Act, designed to ensure team providers are properly covered by their professional liability insurance when traveling with athletic teams, passed in the House of Representatives by voice vote. Read more online here. A Senate companion bill was introduced in April and has 22 cosponsors.

From high school to college to professional levels, it is important that the men and women who are trained to protect and care for athletes and who best know the players’

medical histories are able to engage in the treatment of injured athletes.

On July 12, 2017, the House of Representatives passed the Medical Controlled Substances Transportation Act of 2017. The bill would update the Drug Enforcement Administration registration process for mobile medical practitioners and team physicians to ensure they can administer controlled substances at locations other than their principal place of business while complying with new limitations on timing of transport and related recordkeeping requirements.

FOR MORE ON THESE ISSUES, VISIT: www.aaos.org/advocacy/MLR/

Antitrust Reform On March 22, 2017, the House easily approved a bill that makes needed reforms to the McCarran-Ferguson Act to reduce health care costs for consumers by ensuring competition. AAOS has raised the issue of the current exemption for health insurers, commenting that the antitrust exemption, “together with the recent health care industry consolidations,” has enabled a select few health plans to dominate the health care market. As a result, physicians are frequently placed in positions of diminished bargaining strength, and health plans can impose unilateral, non-negotiable contracts.

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On February 14, 2018, AAOS released a statement related to a House Energy and Commerce Subcommittee hearing on health care consolidation, which urged Congress to secure passage of this legislation as soon as possible. Read the statement online here. FOR MORE ON THE ISSUE OF ANTITRUST, VISIT: www.aaos.org/advocacy/antitrust/ Medical Liability Reform The House of Representatives passed the Protecting Access to Care Act. This legislation—which contains important reforms such as a cap on noneconomic damages, limits on attorney fees, and a 3-year statute of limitation—was one of the issues discussed by nearly 400 orthopaedic surgeons who attended the National Orthopaedic Leadership Conference in Washington, D.C., in April. Currently, there is no Senate companion, but the nonpartisan Congressional Budget Office estimates the legislation would save the government approximately $1.5 billion, an important first step in passing legislation into law.

“These reforms will ensure negligently injured patients are compensated promptly and equitably, and they will, importantly, improve our overall health care system even before

the filing of a lawsuit, by lowering health care costs, improving patient safety, and preserving the patient-physician relationship.” – AAOS President William J. Maloney, MD

Additionally, AAOS continued to build support for the Good Samaritan Health Professionals Act. On February 14, the House Energy and Commerce Committee approved the legislation, which helps protect health care professionals who volunteer their services when a major emergency arises. Specifically, H.R. 1876 provides clear liability protections to licensed health care professionals who volunteer health care services to victims during a declared national disaster. Notably, the legislation respects existing medical liability laws and does not protect providers in cases of willful or criminal misconduct, gross negligence, or reckless misconduct. Read a Feb. 14, 2018 letter sent by AAOS and the Orthopaedic Trauma Association on this issue online here.

FOR MORE ON THE ISSUE OF MEDICAL LIABILITY REFORM, VISIT: www.aaos.org/advocacy/MLR/

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CHIP, NIH, and Defense Department Funding On February 9, 2018, Congress passed legislation that includes an additional $2 billion in funding for the National Institutes of Health (NIH) requested by AAOS (read more online here and here), another extension of the Children’s Health Insurance Program (CHIP) funding, and further funding to address the opioid epidemic.

After CHIP authorization expired, AAOS and POSNA combined forces in advocating for the nearly 9 million children enrolled in the program. “The POSNA leadership would like

to thank its membership for their involvement in the process, particularly the many members who participated in the grassroots effort. We feel that the combined voice of POSNA members had a profound effect on energizing the process, and we are proud of

our organization's history of advocating for our patients.”

The Senate on Nov. 16, 2017 approved the final version of the National Defense Authorization Act (NDAA), which removed harmful language that would have impeded vital defense health research. Specifically, the language would have instituted a prohibition on conduct of certain medical research and deployment projects like the Peer Reviewed Orthopaedic Research Program (PRORP). The PRORP, championed by AAOS, works to help military surgeons find new limb-sparing techniques to save injured extremities, avoid amputations, and preserve and restore the function of injured extremities. AAOS successfully advocated for $30 million in funding for the Peer Reviewed Orthopaedic Research Program through the Department of Defense Congressionally Directed Medical Research Program. Once the FY2018 defense appropriations money is allocated, this program will have received more than $330 million in funding since its inception in 2009. FOR MORE ON THESE ISSUES, VISIT: www.aaos.org/advocacy/researchappropriations/ The Medicare Access and CHIP Reauthorization Act (MACRA) Legislation signed into law Feb. 9, 2018 included a number of encouraging updates to MACRA requested by AAOS. For example, the legislation excludes Medicare Part B drug costs from MIPS payment adjustments and from the low-volume threshold determination; eliminates improvement scoring for the cost performance category for the third, fourth, and fifth years of MIPS; allows CMS to reweight the cost performance category to not less than 10 percent for the third, fourth, and fifth years of MIPS; and allows CMS flexibility in setting the performance threshold for years three through five to ensure a gradual and incremental transition to the performance threshold set at the mean or median for the sixth year. The legislation also permanently repeals the outpatient therapy caps beginning on Jan. 1, 2018 and removes the current mandate that meaningful use standards become more stringent over time. This eases the burden on physicians as they would no longer have to submit and receive a hardship exception from HHS. FOR MORE ON THE ISSUE OF MACRA, VISIT: www.aaos.org/MACRA/ Independent Payment Advisory Board (IPAB) While no members had been appointed to the IPAB yet, repealing this board – which was charged with making recommendations to cut Medicare expenditures if spending growth reaches a certain level – has been a top priority for AAOS over the years. Even without board members, the Secretary would be directed to develop and implement proposals automatically if the IPAB protocol was triggered. Further, not only did the IPAB

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limit congressional authority with little accountability and preclude meaningful opportunity for stakeholder input, but AAOS had deep concerns about the specific impact that IPAB-directed cuts would have on patient access to quality musculoskeletal care. In November 2017 and as a result of AAOS efforts, the U.S. House passed a bipartisan measure introduced by Reps. Phil Roe, M.D. (R-TN) and Raul Ruiz, M.D. (D-CA). In February 2018, IPAB repeal was included in a bipartisan budget deal that was signed into law by President Trump.

“IPAB repeal has been a topic at the NOLC as well as the subject of the grassroots efforts that many of you supported. Hundreds of orthopaedic surgeons have gone to Capitol Hill and/or talked to their elected representatives about this issue, and we are happy to see

our voices heard.” – AAOS President William J. Maloney, MD

Physician-Owned Hospitals Important progress was also made this year toward lifting the moratorium on new or expanded physician-owned hospitals. The House bill, sponsored by Rep. Sam Johnson (R-Texas), has received 64 cosponsors, more than double what it received in past years. Moreover, for the first time, the legislation has a Senate companion, which was introduced by Sen. James Lankford (R-Okla).

FOR MORE ON THE ISSUE OF PHYSICIAN-OWNED HOSPITALS, VISIT: www.aaos.org/advocacy/IOAS/ In-Office Ancillary Services and Stark Law Reform AAOS prevented the in-office ancillary services exception from being used as a pay-for in any legislation, despite legislative threats, and continued work with the IOAS Working Group to pursue an aggressive legislative strategy. Further, AAOS also worked on Stark law reform efforts, including support of the Stark Administrative Simplification Act and the Medicare Care Coordination Improvement Act of 2017. The Stark Administrative Simplification Act, H.R. 3173, would limit the penalties for technical violations of the Stark law and create an expedited process for their resolution. The Medicare Care Coordination Improvement Act,

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H.R. 4206, creates new flexibilities, waivers, and exceptions to the Stark law to accommodate alternative payment models. The President’s 2019 budget reinforced the need for these modifications, recommending reform of the Stark self-referral law to better support and align with alternative payment models. Additionally, in the 2018 budget agreement, language was included to modernize application of the Stark law under Medicare, codifying changes made in CMS rulemaking to “streamline and clarify” certain rules for providers. FOR MORE ON THE ISSUE OF IN-OFFICE ANCILLARY SERVICES AND STARK LAW, VISIT: www.aaos.org/advocacy/IOAS/ Opioids and FDA AAOS has worked with Congress on a number of opioid-related measures, ensuring the primacy of the doctor-patient relationship is protected. Read a Feb. 16, 2018 letter sent to the Senate Finance Committee online here. Additionally, AAOS supported introduction of H.R. 4236, the Monitoring and Obtaining Needed Information to Track Opioids Responsibly Act of 2017, which would aid orthopaedic surgeons in addressing this issue by establishing minimum standards that Prescription Drug Monitoring Programs (PDMPs) must meet in order to receive funding from the Account for State Response to the Opioid Crisis.

On August 18, 2017, President Trump signed H.R. 2430, the FDA Reauthorization Act of 2017, into law. H.R. 2430 reauthorizes the FDA’s critical medical product user fee programs, ensuring the agency has the tools it needs to more efficiently deliver safe and effective drugs, devices, and treatments to patients. TO READ MORE ABOUT THE ISSUES OF OPIOIDS AND THE FDA, VISIT: https://www.aaos.org/advocacy/FDA/

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Trauma Care AAOS worked with Representative Burgess (R-TX) to introduce H.R. 880, the Mission Zero Act, and the legislation was passed by the U.S. House of Representatives on February 26, 2018. This bill will provide grants and allow Department of Defense trauma surgeons to be assigned to civilian trauma centers. The legislation is intended to help fill gaps in care and ensure that advances in military trauma care are brought home for civilian patients. AAOS, working with the Orthopaedic Trauma Association (OTA), participates in the Trauma Coalition, which worked to formulate and advance this legislation.

VA Provider Equity Act AAOS successfully amended legislation that would have included language elevating podiatrists to the same status as physicians under the Veterans Health Administration (VA). Related, on Tuesday, May 2, 2017, orthopaedic surgeon Col. James Ficke, MD (ret.) testified on behalf of AAOS and the American Orthopaedic Foot and Ankle Society (AOFAS) before the House Veterans’ Affairs Subcommittee on Health on the issue of lower extremity injuries among veteran patients. Read more on this testimony online here.

Emergency Medical Services (EMS) The Protecting Patient Access to Emergency Medications Act was signed into law on November 17, 2017. Introduced by Reps. Richard Hudson (R-NC) and G.K. Butterfield (D-NC), the AAOS-supported legislation would provide a statutory framework to allow EMS agencies, professionals, and medical directors to fulfill their mission to save lives and alleviate pain, while also enabling the DEA to continue with appropriate oversight to prevent drug diversion.

Site Neutral Payments AAOS provided comments to the House Energy & Commerce Committee on the Medicare site-neutral payments issue and mentioned the issue in a statement following a House Energy and Commerce Subcommittee on Oversight and Investigations hearing on health care consolidation. Read it online here.

Expanding site-neutral payment policy – and in particular, equalizing rates for office visits and in-office procedures as well as ASC procedures – will continue the progress

made towards addressing health care choice and consolidation.

Orthopaedic PAC 2017 was an exciting year for the Orthopaedic Political Action Committee (PAC). In addition to the growth of the Advisors’ Circle and record-breaking resident involvement, the Orthopaedic PAC had unprecedented access and representation at more than 600 political events, an increase of more than 30 percent from last election cycle. The strength of the PAC has allowed orthopaedists to have a seat at the table and educate members of Congress about the importance of musculoskeletal care. Visit the PAC website online here.

Federal Regulatory Accomplishments The AAOS Office of Government Relations’ regulatory efforts ensure that orthopaedic concerns are addressed even after the conclusion of the legislative process and throughout agency rulemaking and implementation stages. To this end, the regulatory staff works closely with Department of Health and Human Services agencies such as the Federal Drug Administration (FDA), Centers for Medicare & Medicaid Services (CMS), Agency for Healthcare Research and Quality (AHRQ), and the Centers for Disease Control and Prevention (CDC). In addition, expertise in coding, reimbursement, and payment policy is shared across the Academy and with our

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members. The Office of Government Relations also houses the AAOS’ practice management information and educational efforts. Both of these are key services to our fellowship and members.

Scoliosis Screening On January 9, 2018, the United States Patient Safety Task Force (USPSTF) released updated guidance on screening for adolescent idiopathic scoliosis. The guidance was upgraded from “D”, discouraging screening, to “I”, indicating the data is inconclusive on the effectiveness of screening. POSNA and SRS led a letter in June 2017 signed by 13 other BOS societies as well as AAOS and the American Academy of Pediatrics urging the USPSTF to upgrade their recommendation. Read the USPSTF’s announcement here.

Medicare Access and CHIP Reauthorization Act (MACRA) and the Quality Payment Program The Quality Payment Program—which replaces the flawed Sustainable Growth Rate (SGR) formula as required by MACRA—includes two tracks: the Merit-based Incentive Payment System (MIPS) track and the Advanced Alternative Payment Models (APMs) track. AAOS has been working closely with CMS to address a number of concerns related to the Quality Payment Program, including the need for additional flexibility and simplification, as well as protection for small, solo, and rural practices.

Most recently, AAOS submitted comments to CMS on its proposed rule that would make changes in the second year of the Quality Payment Program, including participation requirements for 2018. The 2018 Quality Payment Program proposed and final rules took significant steps to respond to AAOS’ concerns for needed flexibility and simplification, as well as protection for small, solo, and rural practices.

Specifically, AAOS applauded a number of provisions in the MIPS track to decrease the burdens on solo and small practices (defined as 15 or fewer eligible clinicians). These provisions included:

higher low-volume threshold (now $90,000 or 200 Medicare beneficiaries) significant hardship exemption from Advancing Care Information

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a 5-point bonus to the MIPS final score 3-point scoring for measures that do not meet data completeness.

AAOS also commented on new proposals for virtual groups and the need for provision of clinician/practice data. Finally, AAOS commented that we look forward to working on “redesigning Medicare value-based payment models such that they are voluntary, physician-led, have accurate price setting, and provide access to data for all participants.” Read the entire AAOS comment letter online here.

“The Quality Payment Program remains overly complex and there are continued issues regarding access to data and Advanced APM qualification for specialists, but we are

encouraged by proposals that improve the program for providers and ensure quality care for Medicare beneficiaries.” – Wilford K. Gibson, MD, Chair, AAOS Council on Advocacy

VISIT THE AAOS MACRA RESOURCE PAGE FOR ALL MATERIALS AND UPDATES: www.aaos.org/macra. FOR ANY QUESTIONS, CONCERNS, OR COMMENTS, EMAIL macra@aaos.org. Bundled Payment Models In August of 2017, CMS announced changes that address significant concerns raised by AAOS related to mandatory bundled payment programs. First, the changes reduce the number of mandatory geographic areas participating in the Center for Medicare and Medicaid Innovation’s Comprehensive Care for Joint Replacement (CJR) model from 67 to 34. In addition, the changes would allow CJR participants in the 33 other areas to participate on a voluntary basis. CMS also proposed to make participation in the CJR model voluntary for ALL low volume and rural hospitals in all of the CJR geographic areas. Finally, CMS is proposing to cancel the Surgical Hip and Femur Fracture Treatment (SHFFT) payment model and others that were scheduled to begin on January 1, 2018.

“AAOS applauds Secretary Price, Administrator Seema Verma, and others at CMS for clearly hearing concerns of orthopaedic surgeons related to these mandatory payment

models.” – AAOS President William J. Maloney, MD

On January 9, 2018, CMS announced a new voluntary bundled payment model that will qualify as an Advanced Alternative Payment Model (APM) under the Quality Payment Program. This new model, called “Bundled Payments for Care Improvement Advanced” (BPCI Advanced), requires participants to bear financial risk, have payments under the model tied to quality performance, and use Certified Electronic Health Record Technology. AAOS has some related concerns – including interaction with CJR, the semi-annual reconciliations, and benchmark price consideration – but is working to ensure interested orthopaedic surgeons have the tools and resources to participate. This includes a webinar, which aired on February 21, 2018. FOR THE WEBINAR AND TO READ MORE ABOUT THESE ISSUES, VISIT: www.aaos.org/advocacy/medicarepaymentCMS/ Regulatory Relief Throughout the year, the HHS has issued several requests for information, proposed rules, and other documents that indicate their commitment to reducing many of the day-to-day burdens that orthopaedic surgeons face. For example, CMS recently launched the “Patients Over Paperwork” Initiative, a cross-cutting, collaborative process that evaluates and streamlines regulations with a goal to reduce unnecessary burden, increase efficiencies, and improve the beneficiary experience. According to CMS, this effort emphasizes a

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commitment to removing regulatory obstacles that get in the way of providers spending time with patients. The recently-released Medicare Physician Fee Schedule final rule includes the following as part of this initiative: (1) reducing reporting requirements and (2) removing downward payment adjustments based on performance for practices that meet minimum quality reporting requirements.

“We recognize and appreciate that CMS has recently released a number of RFIs and has encouraged stakeholder input on new policies to better achieve transparency, flexibility,

program simplification, and innovation.” – AAOS President William J. Maloney, MD

Additionally, AAOS responded in July 2017 to a CMS RFI on reducing regulatory burdens. Issues raised by AAOS included MIPS reporting requirements, Medicare claims data, the need for Stark law reform, and issues related to the restrictions on physician-owned hospitals. Read the entire comment letter online here. As a result, AAOS was pleased with a CMS announcement in January 2018 about the creation of an interagency task force to review the federal Stark law. Total Knee and the Inpatient Only List (IPO) On November 1, 2017, CMS finalized the Hospital Outpatient Prospective Payment System (OPPS) and Ambulatory Surgical Center (ASC) Payment System rule, which includes updates to the 2018 rates and quality provisions, and other policy changes. Importantly, the rule finalizes changes to the Medicare IPO list for CY 2018. AAOS applauded CMS for removing total knee arthroplasty (TKA) from the IPO list and for acknowledging this decision should be “made by the physician based on the beneficiary’s individual clinical needs and preferences.” AAOS further acknowledged CMS for noting that the surgeons, clinical staff, and medical specialty societies who perform outpatient TKA and possess specialized clinical knowledge and experience” are most suited to create guidelines to identify appropriate candidates. Read the AAOS press release on the announcement online here. AAOS continues to work with stakeholders as this change is implemented. To that end, AAOS recently released a FAQ document with answers to questions related to this decision. Read the FAQ online here. Orthotics/Prosthetics After AAOS communicated serious concerns to CMS, the agency withdrew a proposed rule that would have added substantially more onerous qualifications needed for practitioners to furnish and fabricate prosthetics and custom-fabricated orthotics than current law requires. AAOS applauded the decision to withdraw it and avoid adding burdensome and unwarranted requirements related to prosthetics and orthotics. Read the AAOS press release on this issue online here. Accrediting Organizations (AOs) In early 2017, CMS proposed to revise the application and re-application process for Accrediting Organizations (AOs), specifically related to transparency by requiring AOs to post provider/supplier survey reports and plans of corrections from CMS-approved accreditation programs on their public-facing websites. AOs currently do not make their survey reports and acceptable PoCs from their CMS-approved accreditation programs publicly available. AAOS opposed the publication of quality improvement surveys and plans of correction by accrediting organizations (AO) in current form. After consideration of the comments received, CMS decided that it would be best if the proposal was not finalized and instead, the proposal was withdrawn.

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Accounting for Social Risk Factors and Risk Stratification In comment letters to CMS, AAOS has argued that risk stratification and adjustment are equally significant components of valid quality assessment. Providers should not be financially penalized when caring for patients with greater needs. CMS has recognized the importance of risk stratification and adjustment and has said they will consider the analyses and recommendations from a report that analyzes the effects of certain social risk factors in Medicare beneficiaries on quality measures and measures of resource use used in one or more of nine Medicare value-based purchasing programs, as well as reports that include considerations for strategies to account for social risk factors in these programs. Furthermore, CMS awaits the recommendations of the National Quality Forum (NQF) trial on risk adjustment for quality measures. Coding After consideration of comments from AAOS and others that CMS received, CMS is reassigning TAR procedure codes from MS DRG 470 to MS DRG 469, even if there is no MCC (Major complication or comorbidity) reported for FY 2018. As the Medicare claims data demonstrated, there is substantial cost difference between TAA and other lower extremity joint replacements. Read more online here. AAOS continues to work on issues related to coding and reimbursement including the proposed National Correct Coding Edits (NCCI) procedure-to-procedure edits, the proposed CMS Medical Unlikely Edits, and issues related to ICD-10CM and ICD-10PCS. In addition, AAOS develops educational material in preparation for the 2016 ICD-10CM and ICD-10PCS implementation and updates to the Academy’s coding products such as the Global Service Data for Orthopaedic Surgery publication and Code-X.

State Advocacy Accomplishments AAOS, in conjunction with individual state societies, worked hard in 2017 to ensure that problematic bills that address out-of-network or “surprise” bills are not signed into law. To best address the root causes of the problem and protect patients from these unanticipated out-of-pocket costs, state orthopaedic societies have advocated for policies that ensure all health insurance companies provide adequate access to in-network physicians, including physicians who practice in hospitals, and that insurance companies provide coverage as promised when a patient goes out-of-network. Responding to a 2013 study on bracing for scoliosis, the Texas Legislature passed HB 1076, a bill heavily lobbied for by the Texas Orthopaedic Association (TOA), physician groups, and nursing groups. The bill will update the state’s scoliosis screening standards in schools to match the latest science, which determined that bracing is effective when scoliosis is found early. With recent proposed classification changes at the U.S. Preventive Services Task Force on scoliosis screening standards, AAOS will adopt lessons learned from the TOA to create a nationwide campaign urging the requirement of early childhood spinal screenings. Governors in Nevada, Georgia, Tennessee, Missouri, and Maine recently signed laws allowing visiting sports team physicians to practice in a state where they are not licensed so long as the physicians maintain licensure in another state. The model legislation and campaign was developed through a partnership between AAOS and the American Orthopaedic Society for Sports Medicine (AOSSM) and implemented by state orthopaedic societies and AOSSM members. Texas, Idaho, Wisconsin, Massachusetts, Maine, Oklahoma, Kansas, and New York are currently working on recognizing visiting sports team physicians.

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AAOS Resident Advocacy Fellowship � Do you want to learn about the political process and contribute to policymaking? � Do you have fresh ideas and a willingness to tackle health care issues? � Do you want to communicate with other residents about the importance of

involvement in the health policy process? The American Association of Orthopaedic Surgeons (AAOS) Resident Advocacy Fellowship is designed to encourage participation of orthopaedic residents in the national health policy arena and foster the development of orthopaedic surgeons interested in health policy. This program offers orthopaedic residents the opportunity to gain a greater understanding of the health policy process and contribute to the development of new policies and programs.

The Fellowship will run from January through November; residents should be PGY3 or PGY4 to start the program.

It is important that an applicant and his/her program chair/director understand that participation in the Fellowship, while flexible, requires a considerable time commitment. The AAOS Office of Government Relations (OGR) will work with the selected applicants to design a flexible program that meets his/her needs, interests and schedule. Sample expectations: � Attend the National Orthopaedic Leadership Conference in Washington DC, June 6-9, 2018 � Spend a week in Washington, DC in the fall of 2018 working directly on policy issues � Remain in communication with the Lead Volunteer of the Fellowship and the AAOS OGR � Develop a topic for presentation to be completed by November of 2018 Through interaction with senior AAOS management, work on various staff projects and participation in the development and implementation of a cohesive health care policy strategy, AAOS Resident Advocacy Fellows develop a strong foundation toward becoming leaders in a challenging and exciting health care environment.

Visit www.aaos.org/advocacy/residentfellowship/ for application instructions. To be considered for acceptance into the program,

all applications must be received no later than November 15, 2017. Applications and inquiries should be directed to: Julie Williams, Senior Manager AAOS Office of Government Relations 317 Massachusetts Ave, NE Washington, 2002 202-546-4430 jwilliams@aaos.org

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RESIDENT ASSEMBLY (RA) ADVISORY OPINIONS

AAOS COUNCIL ON EDUCATION (CoE) and MEMBERSHIP COMMITTEE ACTION and IMPLEMENTATION

March 2016 - Present

DATE & PLACE INTRODUCED

STATEMENT NUMBER

TITLE (as revised by the RA)

RA/EPC (CRFC) Action AAOS CoE/Membership Committee ACTION

IMPLEMENTATION

March 2016 Orlando, FL

RA Action Item #1

State and Federal Regulatory Changes to Protect Resident Physicians Prescribing of Narcotics

CRFC adopt as amended. Adopted June 18, 2016. Referred to Council on Advocacy.

TBD

RA Action Item #2

Credit for Elective Resident International Rotations

CRFC adopt as amended. Adopted June 18, 2016. Referred to project team comprised of 2 CRFC members, 2 RA members and 2 International Committee members.

Task force calls, Initial recommendation presented to Council on Education and edited recommendations developed.

RA Action Item #3

Global Health Scholarships CRFC adopt as amended. Not adopted. No action.

RA Action Item #4

Creation of an Online Distance Learning Educational Program for Incoming Orthopaedic PGY1

RA not adopted. No action. No action.

RA Action Item #5

Publication of Advocacy and Health Policy Milestones for U.S. Orthopaedic Surgery Residents

CRFC adopt as amended. Adopted June 18, 2016. Referred to OGR and RA Health Policy Committee.

Conference calls and milestones in development.

RA Action Item #6

Encourage State Orthopaedic Society to include a Resident Member on its Board of Directors

CRFC adopt as amended. Adopted June 18, 2016. Referred to BOC State Orthopaedic Societies Committee.

Model state guidelines amended by BOC SOS Committee on May 6, 2016.

RA Action Item #7

Promote Advocacy and Health Policy Leadership Opportunities for Orthopaedic Surgery Residents through NOLC involvement

CRFC adopt as amended. Adopted June 18, 2016. Referred to BOC, BOS Health Policy Committee, OGR and RA Health Policy Committee.

Resident session on Friday, April 28, 2017: Resident Advocacy Engagement

March 2017 San Diego, CA

RA Advisory Opinion #1

Support for the Accreditation Council for Graduate Medical Education (ACGME) Task Force Recommendations Revising the Common Program Requirements

RA adopted. Adopted October 6, 2017. TBD

RA Advisory Opinion #2

Creation of Global Health Scholarships for U.S. Orthopaedic Residents and Fellows

RA adopted. Adopted October 6, 2017. MLDC referred to International Committee.

TBD

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RA Advisory Opinion #3

Appointing a Resident Assembly Member to the AAOS Delegation to the AMA House of Delegates and Resident & Fellow Section

RA adopted. MLDC do not adopt. Request Membership and Leader Development Committee assess whether criteria should be expanded to include residents.

TBD

RA Advisory Opinion #4

Promote the Physician Payment Sunshine Act’s Exclusion of Reporting Manufacturer Payments to Resident Physicians in the Open Payments Database by the Centers for Medicare and Medicaid Services

RA adopted. MLDC do not adopt. Refer to appropriate RA committee to communicate resources.

TBD

RA Advisory Opinion #5

Proposal to develop AAOS position statement on identification of medical residents in “Public Reporting of Provider Performance”

RA adopted. Adopted October 6, 2017. Refer to RA Health Policy Committee.

TBD

RA Advisory Opinion #6

Development of Professionalism, Accountability and Ethics Guidelines for Orthopaedic Surgeons and Residents Participating in International Surgical Relief Efforts

RA tabled. No action necessary. TBD

RA Advisory Opinion #7

Promotion and Standardization of Residency Parental Leave Policies

RA adopted. MLDC no action pending survey results. Seek input of AOA Council of Residency Directors for future direction.

TBD

RA Advisory Opinion #8

Evaluate the need and potential benefit of an preparatory educational program for incoming orthopedic PGY1 residents to even clinical knowledge gaps and provide a smoother transition into postgraduate orthopedic surgery training

RA adopted. Adopted October 6, 2017. Refer to RA Education Committee.

TBD

Updated: 8/2/2017

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Informational Items

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AAOS Mandatory Disclosure Policy Page 1

AAOS MANDATORY DISCLOSURE POLICY: Governance Groups (except Board of Directors), Continuing Medical

Education Contributors, Senior Management Team Members, and Others Philosophy In order to promote transparency and confidence in the educational programs and in the decisions of the American Academy of Orthopaedic Surgeons and the American Association of Orthopaedic Surgeons (hereinafter collectively referred to as “AAOS”), the AAOS Board of Directors has adopted this mandatory disclosure policy. The actions and expressions of Fellows or Members providing education of the highest quality or in shaping AAOS policy must be as free of outside influence as possible and any relevant potentially conflicting interests or commercial relationships must be disclosed. Because the AAOS depends upon voluntary service by Fellows and Members to conduct its educational programs and achieve its organizational goals, this disclosure policy has been designed to be realistic and workable. The AAOS does not view the existence of these interests or relationships as necessarily implying bias or decreasing the value of your participation in the AAOS. Who Must Disclose Each participant in the AAOS CME program or author of enduring materials, member of the AAOS Board of Directors, Board of Councilors, Board of Specialty Societies, Councils, Cabinets, Committees, Project Teams or other official AAOS groups (collectively “AAOS governance groups”), editors-in-chief and editorial boards and AAOS clinical practice guidelines, appropriate use criteria and performance measures development workgroups, has the obligation to disclose all potentially conflicting interests. Each participant in the AAOS CME program or author of enduring materials, AAOS governance groups, editors-in-chief and editorial boards and AAOS clinical practice guidelines, appropriate use criteria and performance measures development workgroups must disclose relevant activities or relationships through the AAOS Orthopaedic Disclosure Program. Responsibility of the Individual Who Discloses Using a uniform form approved by the AAOS Board of Directors, participants are responsible for providing information to the AAOS Orthopaedic Disclosure Program regarding the nature of their relationships with commercial entities relating to orthopaedics. Participants are responsible for the accuracy and completeness of their information. In addition, participants have an obligation to review and update their personal information in the AAOS Orthopaedic Disclosure Program at least semiannually (usually April and October). It is strongly recommended that participants note any changes to the AAOS Orthopaedic Disclosure Program as soon as possible after they occur. All orthopaedic surgeons are encouraged to participate in the AAOS Orthopaedic Disclosure Program.

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AAOS Mandatory Disclosure Policy Page 2

Consequences for Failing to Disclose A failure of a required participant to participate in the AAOS Orthopaedic Disclosure Program will result in the participant being asked not to participate in the AAOS CME program, the AAOS governance group, as editor-in-chief or on an editorial board and AAOS clinical practice guidelines, appropriate use criteria and performance measures development workgroups. The most current version of the AAOS Policy for a Fellow or Member Who Fails to Disclose Conflicts of Interest When Required shall govern all actions taken under this provision. Public Disclosure of AAOS Orthopaedic Disclosure Program Information The information in the AAOS Orthopaedic Disclosure Program shall be available to the public and to other AAOS Fellows and Members. In addition, a list of all participants in the AAOS CME program, AAOS governance group or AAOS clinical practice guidelines, appropriate use criteria and performance measures development workgroups, along with their disclosures, will be included in all meeting materials. Disclosure of Potential Conflicts of Interests at AAOS Governance Meetings As indicated above, a list of all participants in the AAOS governance group, along with their current disclosures, will be included in all meeting materials. Participants in AAOS governance groups (except for the Board of Councilors and Board of Specialty Societies) have an obligation to indicate any potential conflicts they may have during discussions affecting their personal interests during the meeting of the AAOS governance group. At each meeting of the AAOS governance group, members of the group will be reminded that full disclosure must be made of any potential conflict of interest when a matter involving that interest is discussed. The chair of the governance group shall also have the prerogative of requesting a participant to provide further information or an explanation if the chair identifies a potential conflict of interest regarding that participant. The chair shall be guided by the most current version of the Protocol for the President to Use in Handling Potential Conflict of Interest Issues Before the AAOS Board of Directors. Based on the information provided in the AAOS Orthopaedic Disclosure Program and/or upon a further review, the chair of the AAOS governance group may determine that the participant shall: Disclose the potential conflict and continue to participate fully in the AAOS governance group’s

discussions and vote; [“Disclosure Option”] Disclose the potential conflict, address any questions other members of the group have on the

subject, then leave the room and not participate in further discussion and vote [“Recusal from Vote option”] or

Depart from the room until the matter has been fully discussed and acted upon. [“Recusal from Discussion and Vote option”].

If one of these actions is taken, it should be reflected in the minutes of the AAOS governance group’s meeting. Adopted: February 2007; Revised: December 2009; February 2012

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As adopted September 2011

AAOS POLICY FOR A FELLOW OR MEMBER WHO FAILS TO DISCLOSE CONFLICTS OF INTEREST

WHEN REQUIRED

AAOS Orthopaedic Disclosure Program Background

1. Each Fellow or Member participating in an AAOS CME program, serving as an author of enduring materials, as a member of the AAOS Councils, Cabinets, Committees, Project Teams or other official AAOS groups, editors-in-chief and editorial boards or AAOS guideline development workgroups has the obligation to disclose all potentially conflicting interests through the AAOS Orthopaedic Disclosure Program.

2. Each Fellow or Member is responsible for providing accurate and complete information

to the AAOS Orthopaedic Disclosure Program regarding the nature of his or her relationships with commercial entities relating to orthopaedics, which must be updated at least semiannually (usually April and October). It is recommended that participants note any changes to the AAOS Orthopaedic Disclosure Program as soon as possible after the changes occur.

3. The AAOS Orthopaedic Disclosure Policy expressly provides that “a failure of a required participant to participate in the AAOS Orthopaedic Disclosure Program will result in the participant being asked not to participate in the AAOS CME program, the AAOS governance group, as editor-in-chief or on an editorial board and AAOS guideline development.”

4. All Fellows and Members are encouraged to participate in the AAOS Orthopaedic

Disclosure Program. Directions for Handling Failure of Fellow or Member to Disclose When Required 1. Upon receipt of notice that an AAOS Fellow or Member has failed to disclose a conflict

of interest when required, AAOS staff shall discuss the disclosure matter with the Fellow or Member who failed to disclose. If unsuccessful in obtaining the disclosure, AAOS staff shall then talk with the appropriate Committee/Project/Group Chair. From these discussions, AAOS staff will follow AAOS Orthopaedic Disclosure Policy in an effort to obtain the Fellow or Member’s disclosure, time permitting.

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As adopted September 2011

2. If unsuccessful in obtaining a disclosure, staff will prepare a summary with recommendations on handling the matter, including the following information:

a. The identity of the Fellow or Member and his/her role within the project/program; b. Background on the project/ program/guideline involved; c. Documentation on attempts to have the Fellow or Member complete the

Disclosure Report; and d. Any materials related to known conflict(s) of interest (e.g., prior disclosures;

industry website disclosure report, if available/applicable).

3. The summary will be presented to the Department Manager and/or Executive Team member for review and resolution of the disclosure issue in conjunction with the Committee/Project/Group Chair.

4. If the issue cannot be satisfactorily resolved and there is no disclosure, AAOS staff shall

submit an updated summary, with supporting materials, to the Office of General Counsel. The Office of General Counsel shall determine the appropriate action for AAOS to take. The Office of General Counsel will inform the Presidential Line of any actions under consideration for failure to report. In addition, as appropriate, the Office of General Counsel will request the assistance of the Committee on Outside Interests regarding appropriate actions for failure to report.

5. All incidents of failure to disclose must be submitted to the Office of General Counsel. 6. On an annual basis, the Committee on Outside Interests will review a report developed by

the Office of General Counsel documenting any and all incidents of nondisclosure within Academy programs.

The AAOS disclosure and conflict of interest processes are being developed and reviewed with the goal of transparent and appropriate decision-making. This protocol was developed to provide guidance to the various Committee/Program/Group Chairs, Editors, and appropriate staff on challenging conflict of interest issues. This protocol may be modified as other AAOS policies and procedures are developed. Adopted: September 23, 2011

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As revised December 2011

AAOS POLICY FOR A FELLOW OR MEMBER WHO FAILS TO DISCLOSE CONFLICTS OF INTEREST ACCURATELY

AND COMPLETELY

AAOS Orthopaedic Disclosure Program Background

1. Each Fellow or Member participating in an AAOS CME program, serving as an author of enduring materials, as a member of the AAOS Councils, Cabinets, Committees, Project Teams or other official AAOS groups, editors-in-chief and editorial boards or AAOS guideline development workgroups has the obligation to disclose all potentially conflicting interests accurately and completely through the AAOS Orthopaedic Disclosure Program.

2. Each Fellow or Member is responsible for providing accurate and complete information

to the AAOS Orthopaedic Disclosure Program regarding the nature of his or her relationships with commercial entities relating to orthopaedics, which must be updated at least semiannually (usually April and October). It is recommended that participants note any changes to the AAOS Orthopaedic Disclosure Program as soon as possible after the changes occur.

Directions for Handling Failure of Fellow or Member to Disclose Accurately and Completely 1. Upon receipt of notice that an AAOS Fellow or Member has failed to disclose a conflict

of interest accurately or completely, AAOS staff shall discuss the disclosure deficiency with the Fellow or Member. If unsuccessful at obtaining accurate and complete disclosure, AAOS staff shall then talk with the appropriate Committee/Project/Group Chair. From these discussions, AAOS staff will follow AAOS Orthopaedic Disclosure Policy in an effort to obtain the Fellow or Member’s accurate and complete disclosure, time permitting.

2. If unsuccessful in obtaining an accurate and complete disclosure, staff will prepare a

summary with recommendations on handling the matter, including the following information:

a. The identity of the Fellow or Member and his/her role within the project/program; b. Background on the project/ program/guideline involved; c. Documentation on attempts to have the Fellow or Member complete the

Disclosure Report accurately and completely; and

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As revised December 2011

d. Any materials related to known conflict(s) of interest (e.g., prior disclosures; industry website disclosure report, if available/applicable).

3. The summary will be presented to the Department Manager and/or Executive Team

member for review and resolution of the disclosure deficiency issue in conjunction with the Committee/Project/Group Chair.

4. If the issue cannot be satisfactorily resolved, AAOS staff shall submit an updated

summary, with supporting materials, to the Office of General Counsel. The Office of General Counsel shall advise the President regarding the appropriate action for AAOS to take. The President of AAOS shall make the final decision regarding matters of accurate and complete disclosure.

As appropriate, the Office of General Counsel will request the assistance of the Committee on Outside Interests in developing recommendations for the President regarding appropriate actions for failure to accurately and completely report.

5. All incidents of failure to accurately and completely disclose must be submitted to the

Office of General Counsel. 6. On an annual basis, the Committee on Outside Interests will review a report developed by

the Office of General Counsel documenting any and all incidents of failure to accurately and completely disclose within Academy programs.

The AAOS disclosure and conflict of interest processes are being developed and reviewed with the goal of transparent and appropriate decision-making. This protocol was developed to provide guidance to the various Committee/Program/Group Chairs, Editors, and appropriate staff on challenging conflict of interest issues. This protocol may be modified as other AAOS policies and procedures are developed. Adopted: September, 2011 Revised: December 2011

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1

AAOS ANTITRUST REMINDER Discussions at meetings of the American Academy of Orthopaedic Surgeons and the American Association of Orthopaedic Surgeons (collectively “AAOS”) often cover a broad range of topics pertinent to the interests or concerns of orthopaedic surgeons. As a general rule, except as noted below, discussions at AAOS meetings can address virtually any topic without raising antitrust concerns if the discussions are kept scrupulously free of even the suggestion of private regulation of the profession. However, a number of topics that might be (and have been) discussed at AAOS meetings may raise significant complex antitrust concerns. These include:

• Membership admissions, rejections, restrictions, and terminations;

• Professional compliance actions – reprimands, censures, suspensions and expulsions;

• Adoption of and revisions to Standards of Professionalism;

• Method of provision and sale of AAOS products and services to non-

members;

• Restrictions in the selection and requirements for exhibitors at the AAOS Annual Meeting or in CME activities;

• Collecting and distributing certain orthopaedic practice information,

particularly involving practice charges and costs;

• Obtaining and distributing orthopaedic industry price and cost information;

• Professional certification programs;

• Group buying and selling; and

• Inclusions or exclusion of other medical societies in organizational activities or offerings.

When these and related topics are discussed, the convener or members of the AAOS group should seek counsel from the AAOS Office of General Counsel.

AAOS staff has been trained to identify potential antitrust matters. The AAOS relies on the judgment of its staff regarding these matters. AAOS urges its Board, committees and other groups not to participate in discussions that may give the appearance of or constitute an agreement that would violate the antitrust laws. Notwithstanding this reliance, it is the responsibility of each AAOS Board or committee member to avoid raising improper subjects for discussion. This reminder has been

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prepared to ensure that AAOS members and other participants in AAOS meetings are aware of this obligation.

The “Do Not’s” and “Do’s” presented below highlight only the most basic antitrust principles that may come before medical associations, like AAOS. AAOS members and staff participating in AAOS meetings should consult with the AAOS Office of General Counsel in all cases involving specific questions, interpretations or advice regarding antitrust matters.

Do Nots

1. Do not, in fact or appearance, discuss or exchange information regarding:

a. Individual company prices, price changes, price differentials, mark-ups,discounts, allowances, credit terms, etc. or any other data that may bear onprice, such as costs, production, capacity, inventories, sales, etc.

b. Raising, lowering or “stabilizing” orthopaedic prices or fees;c. What constitutes a fair profit or margin level;d. The availability of products or services;e. The allocation of markets, territories or patients.

2. Do not suggest or imply that AAOS members should or should not deal with certainother persons or firms.

3. Do not foster unfair practices regarding advertising, standardization, certification oraccreditation.

4. Do not discuss or exchange information regarding the above matters during socialgatherings, incidental to AAOS-sponsored meetings.

5. Do not make oral or written statements on important issues on behalf of AAOSwithout appropriate authority to do so.

Do

1. Do adhere to prepared agenda for all AAOS meetings, ideally distributed in advance.Agendas should be sufficiently detailed to disclosure the nature of the discussions tobe held. It is generally permissible for agendas to include discussions of such variedtopics as professional economic trends, advances and problems in relevanttechnology or research, various aspects of the science and art of management, andrelationships with local, state or federal governments.

2. Do require that a member of the AAOS professional staff participate in every AAOSmeeting, either in person or by conference call. If any meeting is expected to dealwith sensitive competitive issues, counsel from the AAOS Office of General Counselshould ordinarily be present. Committee staff should consult with AAOS legalcounsel to determine whether the presence of counsel is advisable. If AAOS legal

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counsel is not at the meeting, members and staff should not hesitate to consult the AAOS Office of General Counsel as necessary.

3. Do ensure that a record of all meeting, consisting of formal minutes or a memo to the

file, should be made by AAOS committee staff. 4. Do object whenever meeting summaries do not accurately reflect the matters that

occurred. 5. Do consult with AAOS counsel on all antitrust questions relating to discussions at

AAOS meetings. 6. Do object to and do not participate in any discussions or meeting activities that you

believe violate the antitrust laws; dissociate yourself from any such discussions or activities and leave any meeting in which they continue.

Special Guidelines for Collecting and Distributing Information The collection and distribution of information regarding business practices is a traditional function of associations and is well-recognized under the law as appropriate, legal and consistent with the antitrust laws. However, if conducted improperly, such information gathering and distributing activities might be viewed as facilitating an express or implied agreement among association members to adhere to the same business practices. For this reason, special general guidelines have developed over time regarding association’s reporting on information collected from and disseminated to members. Any exceptions to these general guidelines should be made only after discussion with the AAOS Office of General Counsel. These general guidelines include: 1. Member participation in the statistical reporting program is voluntary. The statistical

reporting program should be conducted without coercion or penalty. Non-members should be allowed to participate in the statistical reporting program if eligible; however, if there is a fee involved, they may be charged a reasonably higher fee than members.

2. Information should be collected via a written instrument that clearly sets forth what is being requested.

3. The data that is collected should be about past transactions or activities; particularly if the survey deals with prices and price terms (including charges, costs, wages, benefits, discounts, etc,), it should be historic, i.e., more than three months old.

4. The data should be collected by either the AAOS or an independent third party not connected with any one member.

5. Data on individual orthopaedic surgeons should be kept confidential.

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6. There should be a sufficient number of participants to prevent specific responses or data from being attributable to any one respondent. As a general rule, there should be at least five respondents reporting data upon which any statistic or item is based, and no individual’s data should represent more than 25% on a weighted average of that statistic or item.

7. Composite/aggregate data should be available to all participants – both members and

non-members. The data may be categorized, e.g., geographically, and ranges and averages may be used. No member should be given access to the raw data. Disclosure of individual data could serve to promote uniformity and reduce competition.

8. As a general rule, there should be no discussion or agreement as to how members

should adjust, plan or carry out their practices based on the results of the survey. Each member should analyze the data and make business decisions independently.

CONCLUSION This reminder has been written to avoid any violation of the law by AAOS members and staff and any activity that might give the appearance of illegality. However, no set of guidelines can address every possible type of inappropriate or unlawful activity. AAOS members and staff should use careful judgment to identify situation where AAOS activities, or discussions at AAOS-sponsored meetings, may violate federal or state law or may be perceived as doing so. In those cases, it is the responsibility of the member and staff to avoid these situations and consult with the AAOS Office of General Counsel when necessary. Adopted: June 2005 Revised: December 2014

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American Academy of Orthopaedic Surgeons December 2015

AAOS Strategic Plan: 2018 - 2022

AAOS Mission: Serving our profession to provide the highest quality musculoskeletal care.

AAOS Vision: Keeping the world in motion through the prevention and treatment of musculoskeletal conditions.

Core Values: The following values reflect our inviolable guiding principles: o Excellence: Develop, encourage and reward the highest standards in all of our endeavors. o Professionalism: Account for the highest professional, clinical and ethical standards to our peers,

our patients and the public with integrity and transparency. o Leadership: Champion the development and advancement of future leaders, through example,

education and experience in our organization, our practices and the world. o Collegiality: Embrace diversity and unity with our patients, our profession and our stakeholders. o Lifelong Learning: Commit to professional education by advancing the science and art of

orthopaedic medicine for the needs of our patients.

Strategic Domains: Each domain is equally critical to the successful achievement of the AAOS’ mission and vision: o Accountability: Maintain an efficient, nimble and fiscally accountable organization responsive to

member needs. o Advocacy: Champion the interests of the orthopaedic profession to provide access to care and be a

resourceful ally for orthopaedic surgeons and musculoskeletal patients. o Education: Promote AAOS as the premier resource for orthopaedic learning. o Membership: Anticipate, understand and respond to the needs of our current and future members. o Organizational Excellence: Maintain an efficient, nimble and lean governance and operational

organization responsive to member needs. o Quality and Patient Value: Empower orthopaedic surgeons to be leaders in quality musculoskeletal

healthcare teams as a means to deliver value to our patients through evidence-based cost efficient practices.

Essential Components: Each component is critical to the successful achievement of the AAOS mission and vision. The components resonate through some or all of the strategic domains: o Communications o International Initiatives o Partnerships o Research o Technology

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AAOS Code of Ethics for Governance and Management – Page 1

AAOS CODE OF ETHICS FOR GOVERNANCE AND MANAGEMENT

The American Academy of Orthopaedic Surgeons and the American Association of Orthopaedic Surgeons (collectively “AAOS”) expects all of its volunteers and its employees to act in accordance with the highest standards of personal and professional integrity in all aspects of their activities; to comply with all applicable laws, rules, and regulations; to deter wrongdoing; and to abide by all duly adopted AAOS policies and procedures. This AAOS Code of Ethics applies to members of the Board of Directors, Council or Cabinet Chairs, Advisory Board Chairs, Committee Chairs, the Executive Management Team, and the Senior Management Team. This AAOS Code of Ethics is intended to supplement the AAOS Standards of Professionalism and Code of Medical Ethics and Professionalism for Orthopaedic Surgeons (for orthopaedic volunteers) and the most recent edition of the AAOS Personnel Policy Manual (for AAOS employees). Those to whom this AAOS Code of Ethics applies agree to:

Engage in and promote honest and ethical conduct, including the ethical handling of actual and potential conflicts of interest between personal and professional relationships;

Recognize conflicts of interest and disclose to the Board of Directors, Council/Cabinet, or Executive Management Team (as appropriate for your position) and to the Committee on Outside Interests any material transactions or relationships that reasonably could be expected to give rise to such conflicts;

Respect the confidentiality of information acquired in the course of your duties; Provide colleagues with information that is accurate, complete, objective, relevant, timely

and understandable; Comply with applicable laws, rules and regulations of federal, state and local

governments; Act in good faith, with due care, competence, and diligence, without misrepresenting

material facts or allowing independent judgment to be subordinated; Assure the responsible use of and control of all assets, resources, and information in the

possession of the AAOS and related organizations; and Promptly refer any questions about or any alleged violations of this Code of Ethics to the

President of the AAOS. The AAOS Board of Directors shall have the discretionary authority to approve any deviation or waiver from this AAOS Code of Ethics and shall determine what action, if any, is appropriate for any real or alleged violation. Adopted: June 2004 Revised: December 2014

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FUTURE AAOS MEETINGS 2018-2021

Annual Meeting

• March 12-16, 2019 – Las Vegas, NV• March 24-28, 2020• March 9-13, 2021

National Orthopaedic Leadership Conference (NOLC)

• June 6-9, 2018 – Washington, DC• June 5-8, 2019 – Washington, DC

Fall Meeting

• October 25-27, 2018 – San Antonio, TX• October 24-26, 2019 – Nashville, TN

Note: The AAOS Travel Policy only applies to the AAOS Annual Meeting. The AAOS NOLC and the AAOS Fall Meeting have separate travel policies.

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Early Housing Reservations 2019 Annual Meeting – Las Vegas, NV

Meeting Dates: March 12-16 Exhibit Dates: March 13-15

AAOS members attending the Annual Meeting are encouraged to book sleeping room reservations EARLY for the 2019 Las Vegas meeting at the Venetian/Sands Expo.

Reservations can be made online or at the 2018-19 Housing Desk located in Academy Hall B at the Morial Convention Center.

2018 - 2019 Housing Desk Date(s) & Time(s)

Morial Convention Center Academy Hall B

Monday, March 5 2:00 PM 6:00 PM Tuesday, March 6 7:00 AM 6:00 PM

Wednesday, March 7 7:00 AM 6:00 PM Thursday, March 8 7:00 AM 6:00 PM

Friday, March 9 7:00 AM 6:00 PM

2019 Online Housing Date(s)

https://www.wynjade.com/aaos19 March 5 – March 30, 2018

Rooms at the Venetian and Palazzo Hotels will go fast. Don’t miss out! This offer ends March 30.

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