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  • New in the Literature: No Significant Difference Between Surgery and Physical Therapy for Meniscal Tear and Knee Osteoarthritis (NEJM. 2013 Mar 19.)

    There were no significant differences in functional improvement after 6 months between patients who underwent surgery with postoperative physical therapy and those who received standardized physical therapy alone, say authors of an article published in the New England Journal of Medicine.

    The multicenter, randomized, controlled trial involved 351 symptomatic patients aged 45 years or older with a meniscal tear and evidence of mild-to-moderate osteoarthritis. Subjects randomly were assigned either to surgery and postoperative physical therapy or to a standardized physical therapy regimen (with the option to cross over to surgery at the discretion of the patient and surgeon). Patients were evaluated at 6 and 12 months, primarily using the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) physical-function score (ranging from 0 to 100, with higher scores indicating more severe symptoms) 6 months after randomization.

    In the intention-to-treat analysis, the mean improvement in the WOMAC score after 6 months was 20.9 points (95% confidence interval [CI], 17.9 to 23.9) in the surgical group and 18.5% (95% CI, 15.6 to 21.5) in the physical therapy group (mean difference 2.4 points, 95% CI, -1.8 to 6.5). At 6 months, 51 active participants in the physical therapy alone group (30%) had crossed over to undergo surgery, and 9 patients in the surgery group (6%) had not undergone surgery. The results at 12 months were similar to those at 6 months, say the authors, and the frequency of adverse events did not differ significantly between the groups.

    The authors say their findings suggest that both options are "likely to result in considerable improvement … over a 6-12 month period." However, they continue that "these data provide considerable reassurance regarding an initial nonoperative strategy."

    MACPAC Recommendations Aim to Improve Enrollment Stability, Align Medicaid With ACA

    As states work to implement the Affordable Care Act (ACA) and improve Medicaid and CHIP for current beneficiaries, the Medicaid and CHIP Payment and Access Commission (MACPAC) made 2 recommendations Friday to Congress on eligibility policy.

    MACPAC's March 2013 Report to the Congress on Medicaid and CHIP reflects the key priorities facing program administrators: implementing Medicaid eligibility provisions; managing the policy and operational interactions among Medicaid, CHIP, and coverage through new health insurance exchanges; and pursuing delivery system and payment innovations for individuals dually enrolled in Medicare and Medicaid, who are among the highest need and highest cost enrollees in both programs.

    In its report, the commission recommends that Congress create a statutory option for states to implement 12-month continuous eligibility for children enrolled in CHIP and adults enrolled in Medicaid, as is now the case for children in Medicaid. This recommendation is designed to reduce frequent enrolling and disenrolling from different health plans in a short period and decrease the administrative burden of the eligibility determination process. It would enable states to enroll eligible individuals for a full year, regardless of changes in income. The commission is making the recommendation to ensure that the option, which would otherwise be removed under new income-counting eligibility standards, remains available to states.

    The second recommendation calls for Congress to permanently fund transitional medical assistance (TMA), which provides additional months of Medicaid coverage to millions of families who might otherwise become ineligible and uninsured due to an increase in earnings. MACPAC's recommendation would allow states that expand Medicaid to the new adult group to opt out of TMA. If the recommendation were implemented, it would provide certainty that funding will be available for states that choose not to expand eligibility, and it would reduce administrative burden for states that do expand.

    The report also continues the commission's work on people who are dually eligible for Medicare and Medicaid. This group is of great interest to Congress because of the complexity and cost of the health care needs of "dual eligibles."

    An executive summary of the report is available at this link.

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