I agree with Dr. Doug Nuelle (March/April 2007 AAOS Now) that we are all helpless and defenseless in the marketplace controlled by government and large insurance companies.

A solution is to level the playing field (marketplace) by exempting physicians from the Taft-Hartley Act restrictions on collective bargaining. Rather than drop all insurance, I would prefer grouping together and negotiating fair payment for our valuable services. The legislature can make the appropriate changes to the Taft-Hartley Act if we demand it.

Richard R. Tavernetti, MD
San Francisco

On the horizon
I appreciate Dr. Hilibrand’s discussion of the complex issues involving Medicare reimbursement (“Access to care for the elderly: An emerging issue?” June 2007 AAOS Now). It is clear that the annual corrections that Congress has implemented for the past few years are not a good long-term solution. Although many healthcare providers diligently care for Medicare patients despite the terrible economic impact, a growing number have restricted access to these patients, and others have “opted out” in favor of more lucrative plans.

As a new faculty member at a university hospital, I can attest to the shift of Medicare patients to the tertiary setting. Many have significant medical comorbidities or require complex operative care and have been referred out of private practices. Just as often, however, patients are sent to our practice because of their insurance coverage. In the intermountain area, this often means that patients must travel hundreds of miles by car or plane to be seen in Salt Lake City despite the availability of surgeons closer to home.

From a purely financial standpoint, it makes sense for many of our colleagues to avoid Medicare recipients. The reimbursement is low, the risks are higher, and the outcomes in older patients are generally not as good as in young, active patients.

Pay for performance measurements, a hot topic in Washington, D.C., will ultimately reflect poorly on individuals and institutions who care for an elderly patient population and favorably on those who bypass them.

I have often looked at the large percentage of my patients who have Medicare coverage and wished I could “opt out.” My conscience simply will not allow it. I could not look in the mirror knowing that I took the “easy way” out of such a difficult situation. Our society and our government do enough to marginalize the elderly without the help of physicians. This generation of individuals guided our nation through many wars and many economic hardships. It is our responsibility to care for them.

Obviously, the reimbursement schedule needs to be revised to accurately account for the costs of a medical practice and of medical malpractice insurance. The use of the MEI (Medical Economic Index) would be a strong first step. Malpractice reform would be a giant leap. Realistically, however, it is unlikely that Medicare reimbursement will eclipse that of private insurers.

Physicians are easy targets for critics to label as “greedy,” “uncaring,” and “selfish.” Our strongest asset in this public relations war is the care we give to our patients. I encourage our orthopaedic leaders to continue to fight for access to care for the elderly.

I urge my colleagues to try to look beyond the dollar signs, at the patients that are coming to them for help. Do not turn them away.

Alpesh A. Patel, MD
Salt Lake City

Dr. Hilibrand responds:
Dr. Patel’s experiences reflect the nationwide effect of physicians’ beginning to opt out of Medicare.

In the short term, this may go unnoticed by elderly advocacy groups like the AARP, because tertiary hospitals and physicians like Dr. Patel will provide excellent care to these patients. However, in the longer term, it may become more readily apparent to the nation’s seniors that their Medicare coverage is “no longer welcome” at their local physician’s office. At that point, if it is reached, there may be a significant outcry among the elderly for changes in Medicare, including fixing the formula for reimbursement for physician services.

Alan S. Hilibrand, MD
Vice-Chair, AAOS Communications Cabinet