Published 7/1/2007

Setting AAOS Now Straight

Retirement, reimbursement generate responses

Retiring physicians?
I read the article by Charles D. Hummer III, MD, in the May issue of AAOS Now (“The Aging Surgeon: How old is too old?). You recommended [that older surgeons] do something like volunteer work.

I am about to be retired by my group involuntarily in a month. To receive a free “tail” from my medical liability carrier, I am not allowed to do any medicine for 5 years, or I will have to repay the tail, which is approximately $36,000.

The problem with the tail also prevents me from teaching medical students and residents and takes away a good means of utilizing my talents of 43 years.

It is definitely a frightening feeling to consider getting up in the morning with nothing to do in the afternoon; tennis and workout take care of the mornings.

I am going to do chart review for one of the insurance companies and I hope this will be satisfactory enough to make me still feel like a doctor and an orthopaedic surgeon.

I am going to be 77 years old and am in good physical and mental condition. I am not ready mentally to stop the practice of orthopaedic surgery, although I have not done surgery in my group for the last 8 years.

Hugh Unger, MD
Aventura, Fla.

Dr. Hummer replies:
I very much appreciate Dr. Unger’s comments. The main purpose of the article was to educate AAOS fellows about the current status of “age in relation to competence,” and to address possible medical liability issues. As I pointed out, little case law exists to offer guidance, presumeably because of the Americans With Disabilities Act. Unfortunately, issues of medical liability and insurability—rather than competence—often drive decisions about continuing active practice.

Dr. Unger’s situation seems to be just such a circumstance.

Therefore, I restate the points in my article: First, the AAOS should consider promoting clinical options for senior orthopaedic surgeons that would allow them to continue to use their clinical skills. One such option might be a “surgical assistance” program in which senior/retired surgeons serve as surgical assistants, thereby enabling them to share their expertise. A similar program might be promoted for in-office mentoring/teaching. Participants in these programs should be protected by legislation and immune from medical liability prosecution.

Second, the AAOS and the American Board of Orthopaedic Surgery should optimize current objective measures of competence so that orthopaedic surgeons cannot be forced out of practice by fear of medical-legal consequence or “retired” against their will simply based on age.

Chip Hummer, MD

Disappointed in answers
This letter is regarding one that was published in the March/April 2007 AAOS Now by Douglas G. Nuelle, MD, from Georgia. I am also an orthopaedic surgeon who started practice in 1978 and I am well aware of the reimbursement issues that Dr. Nuelle outlined in his letter.

Over the years, I have been somewhat disappointed in the Academy’s response to perennial shrinking reimbursement for the work that we do. I would appreciate at least an editorial response regarding what an individual practitioner can do.

The answers of increasing volume in a shrinking reimbursement/growing overhead environment, selling partial shares of physician-owned imaging facilities and surgical centers, and doing more workers’ compensation orthopaedics—which for some reason is reimbursed at a higher level—seem like hollow answers to the problem.

Thomas M. Hawk, MD
St. Louis, Mo.

Dr. Halsey responds:
In all honesty, there is little an individual orthopaedist or any other physician can do to combat decreases in reimbursement. Certainly, some of us may be able to cut our practice costs, increase volume (where appropriate), and provide revenue-generating ancillary services to offset payment decreases elsewhere. Others may be able to negotiate more favorable contracts with health plans, although this is extremely rare.

Unfortunately, we have two problems as individual physicians. One is that anti-trust laws prevent us from banding together to negotiate collectively with health plans. The second is that health plans, particularly Medicare, will not stop payment decreases until patients really start having widespread trouble getting medical services. And we have not yet seen the kind of access problems that get payors’ attention.

This is not to say, however, that as a profession, we cannot have any impact on reimbursement. Your colleagues who work in the AAOS volunteer structure, along with our professional staff, have obtained reasonable fees for hundreds of orthopaedic procedures through our work on a physician advisory body to Medicare called the Relative Value Scale Update Committee (RUC).

Last year, for example, you may have heard about our success in convincing the Centers for Medicare and Medicaid Services (CMS) not to lower fees for total hip and knee procedures. If CMS had gone ahead with its original decision, there would have been double-digit payment cuts for these procedures, resulting in more than $130 million in lost revenue for orthopaedics. We also averted severe payment cuts for other orthopaedic procedures and even obtained increases for some services. (See February 2007 AAOS Now article, “Cooperative efforts help avert big Medicare payment cuts” online at www.aaos.org/now)

Although we would have preferred seeing increased payments for all our services, the sad truth is that the federal government, particularly the U.S. Congress, will not act until there is a real access crisis.

So what else can individual orthopaedists do besides cut expenses and find new ways to make money? Because Medicare is the foundation for many other health plans, we must focus our attention on the federal government. This means getting involved politically to make sure we have representatives in Congress who understand our issues and don’t want to wait for a health care crisis to materialze before taking action.

How do you get involved? The easiest way is to support the Orthopaedic Political Action Committee (PAC). The reality is that money talks and, although it does not necessarily buy influence, it does help open doors. Physicians have been among the least politically active groups and this has hurt us. The most successful lobbies all have powerful, well-funded PACs.

Many orthopaedists are involved as volunteers. They take the time to learn about and then immerse themselves in the complex regulatory and political processes that are part of the physician payment policy arena. They are truly unsung heroes who volunteer their time on behalf of their profession, often at great personal expense.

My recommendation is to do what you can in your own practice to decrease your expenses and increase your revenue streams. But, more importantly, learn about the regulatory and political processes that affect your reimbursement. Give to the Orthopaedic PAC and support the efforts of your colleagues who fight on your behalf. Get involved in the fight yourself if you have the time and inclination. And, by all means, let us keep hearing from you. Your comments and suggestions are most appreciated.

David A. Halsey, MD
Chair, Council on Advocacy