Healthcare reform gains momentum in Washington, D.C.

More than 300 orthopaedic surgeons from across the country met in Washington, D.C., April 29–May 2, for the American Association of Orthopaedic Surgeons (AAOS) National Orthopaedic Leadership Conference (NOLC). Attendees participated in nearly 100 face-to-face meetings with members of Congress and their staffs to educate, express concern, and raise the profile of the orthopaedic community in the healthcare debate.

“The timing couldn’t have been better,” said Peter Mandell, MD, chair of the Council on Advocacy. “Health care reform is moving very quickly and the sense of urgency was palpable.”

Ramping up to Hill visits
Prior to making their visits to Capitol Hill, NOLC participants attended educational briefings on a wide range of issues, from congressional protocol to issue-specific symposia. Part of that training included an instructional video, produced by the Advocacy Resource Committee and featuring Sen. John A. Barrasso, MD (R-Wyo.) and Rep. Tom Price, MD (R-Ga.). The video provided new NOLC attendees with a step-by-step look at how to conduct a successful meeting with their Congressional representatives.

In his address to attendees, Rep. Ron Kind (D-Wis.) stressed the importance of communicating the serious issues physicians face to legislators. During the question-and-answer session that followed, Andrew P. Kant, MD, president of the Texas Orthopaedic Association, asked about the “pay-as-you-go” provisions of current federal healthcare funding proposals.

“The government didn’t have pay-as-you-go when it bought up the mortgage companies” he pointed out. “It didn’t have pay-you-go when it bought up Wall Street. Why put this on doctors?” His point was well taken by the audience, which broke into supporting applause.

In response, Rep. Kind noted that pay-as-you-go had been a viable fiscal strategy in the 1990s and resulted in 4 years of federal budget surpluses. A Republican White House, however, had since doubled the national debt.

“We have become inordinately dependent on foreign countries for financing,” Rep. Kind said. “This clearly is not sustainable in the long run. We have to be fiscally disciplined to turn this around. We have to work within the environment of pay-as-you-go-rules—but do it in a way that is focused on quality of care.” He then stressed that Congress was open to suggestions from physicians on how to approach that task.

In the halls of Congress
NOLC participants brought a clear message to their Congressional representatives: In the healthcare reform debate, orthopaedic surgeons deserve a seat at the table.

“Musculoskeletal conditions affect more than one in four Americans,” said Joseph D. Zuckerman, MD, AAOS president. “Orthopaedic surgeons provide care that not only saves lives, but also improves the quality of life for millions. We want to ensure that patients have access to these treatments and that physicians are not unduly burdened by regulatory mandates.”

As attendees visited their legislators on Capitol Hill, they focused on the issue at hand: how to approach the need to provide everyone in the United States with consistent access to quality, patient-centered, timely, unencumbered, affordable, and appropriate health care—in particular, musculoskeletal specialty care—and the government’s role in that process.

Participants expressed their desire and ability to assist in efforts to curb high administrative costs, fix the medical liability system, combat the increase in prevalence of chronic disease, avoid unnecessary patient care, and ease cost-shifting from the uninsured to the insured.

“We spent an hour with Rep. Stark’s chief of staff, and another hour with Speaker Pelosi’s senior budget and health policy advisor,” said Thomas C. Barber, MD, Board of Councilors chair, who is from California. “It was an amazing amount of time, considering the offices they represent. We were asked about total joint registries, which made us wonder whether a registry was under consideration.”

Following their meetings with lawmakers, attendees had an opportunity to discuss their experiences with each other in an open forum. Sharing their experiences with the group gave attendees a clearer understanding of the broader political climate in Washington.

A “reverse commute” of sorts followed the various Hill visits, with several legislators attending an AAOS reception held in to honor five members of Congress for their continued support of orthopaedic surgeons. (See “NOLC applauds Congressional leaders”)

Condition critical
Following the Hill visits, NOLC attendees heard presentations from a range of experts on topics related to healthcare reform, including the role of healthcare information technology (HIT).

According to Mark Frisse, MD, of the Vanderbilt Center for Better Health, the economic stimulus package may include some attractive financial incentives for adopting HIT. He suggested, however, that NOLC attendees—especially those with strong billing, claims, and picture archiving and communications (PAC) systems already in place—carefully consider whether it is smart to do anything radical simply to take advantage of those incentives. He cautioned that, although HIT implementation has the goal of simplifying delivery of care, it can actually conceal complexity.

“Now is not the time to start learning about technology,” said Dr. Frisse. “It is the time to ask ‘How can I make my practice simpler?’”

Sen. Jack Reed (D-R.I.) used the term “critical” when he addressed the gathering. Sen. Reed asked attendees to provide their insight and advice to Congress regarding improvements in the infrastructure of health care. The $20 billion investment in HIT under the economic stimulus package is a “down payment” on the effort to reform healthcare, he said.

According to Steve Ondra, MD, senior policy advisor on health affairs, Department of Veterans Affairs, the reason for the growth in healthcare spending is that physicians can do more. “Today we have very sophisticated medical technology that allows us to provide better care and treat patients we couldn’t treat before. But it comes with a price.”

And despite “conventional wisdom” that the United States has the best health care in the world, Dr. Ondra said no evidence exists to support this and most evidence disputes it. The United States excels in the extremely sophisticated clinical aspects of care, but little difference exists in the general care received by most patients.

• Dr. Ondra outlined the following implications of heathcare reform for physicians and patients:
• With tighter budgets, there will be fiscal winners and losers.
• Comparative clinical effectiveness, outcome studies, and quality analyses will be starting points for most decisions.
• Protocol-driven care, outcome review, and public access to physician outcome results will increase.
• Technology will need to demonstrate not just effectiveness but relative value.

To survive as a profession, he continued, physicians will need to take the following steps:

• Align their interests with those of the nation
• Decrease costs while maintaining quality
• Consider alternative reimbursement methodologies
• Eliminate unnecessary procedures
• Develop outcomes studies for efficacy and relative cost effectiveness
• Defend the patient’s access to treatment

The White House perspective
Robert Kocher, MD, special assistant to the President, National Economic Council, provided the perspective of the White House on reform. A fundamental difference between current efforts and those of 1993 is that cost, quality, and access are being addressed together. “Another significant difference,” he said, “is that we’re not writing a 1,000-page bill, springing it on Congress and saying, ‘Pass this.’”

According to Dr. Kocher, President Obama has three priorities for healthcare reform: reduce costs, maintain choice, and improve the quality of care in terms of both clinical outcomes and patient experiences. The $630 billion the President has put forward in the budget, Dr. Kocher said, is a “credible down payment on healthcare reform” and demonstrates that the President’s priority is achieving successful healthcare reform.

A different flavor
The 2009 NOLC may well be remembered by many attendees as one with a different flavor than years past. As Dr. Barber said, “It was terrifically informative, and we had fantastic speakers for the most part. The problem was that the message was difficult for most of us to swallow, so we didn’t come away with a warm fuzzy feeling about healthcare reform.”

“The NOLC has grown to represent the entire orthopaedic community, and that community participated actively in the Hill visits, sending a unified message to our representatives and senators,” said Dr. Robb. “This extraordinary year, we found that the reform agenda is in motion and a majority of the Hill appears ready to move forward—with or without us.”

G. Jake Jaquet is executive editor of AAOS Now. He can be reached at jaquet@aaos.org

Nick Piatek is the communications specialist in the AAOS office of government relations. He can be reached at piatek@aaos.org

AAOS principles of healthcare reform
NOLC participants urged members of Congress to consider the following AAOS principles of healthcare reform:

• In any consideration of changes to the healthcare financing and delivery system in the United States, the well-being of the patient must be the highest priority.
• As policymakers consider healthcare reforms, they should make certain that patients are empowered to control and decide how their own healthcare dollars are spent, ensure unencumbered access to specialty care, make healthcare coverage more affordable, improve the quality of care, extend both coverage and access for the uninsured and underinsured, and avoid establishing new unsustainable programs.
• Meaningful medical liability reform at the federal level and/or constitutionally sustainable state medical liability reforms are a necessary component of any viable healthcare reform proposal.
• A permanent fix to Medicare’s flawed Sustainable Growth Rate (SGR) formula should be enacted—one that is fully paid for without borrowing from future Medicare payments, is sustainable long-term, and more closely reflects the actual increased practice cost as measured by the Medical Economic Index.
• Patient empowerment and individual responsibility are necessary components of healthcare reform.
• The healthcare marketplace, which has suffered from the lack of competition, should be strengthened by adoption of policies that restore equity and enhance market competition.

What orthopaedic leaders heard in Washington
“We are at a critical juncture. We have to systematically reform healthcare. This is not going to be just another exercise. The President is committed to moving forward with healthcare reform, and we’re serious about this effort.”
Sen. Jack Reed (D-R.I.)

“The theme we keep hearing over and over again from physicians is ‘I’m worried that I’m going to buy something that is not going to work the way I want it to work.’”
Louis Finkel, Director of Policy and Outreach, Committee on Science and Technology

“The one thing that is not on the table is the status quo. We can’t afford the status quo; the nation doesn’t need the status quo; we need to change.”
Steve Ondra, MD, senior policy advisor on health affairs, Department of Veterans Affairs

“It is important for us to hear from you,” he said. We’ve got to have a political consensus to do this. As long as we can find ways to dramatically cost costs, improve access and affordability, and provide universal coverage, you will find the political support that will enable you to practice your profession to the best of your ability and be fairly compensated.”
Rep. James Moran (D-Va.)

“I’m very enthusiastic and feel that we can be successful with reform this year. We’re working with both Republican and Democratic members of Congress to create a plan that makes sense. This is only the second time in the past 50 years that we have had a Democratic president and have gained seats in both houses of Congress, so I think it bodes well for our opportunity to get the job done this year. And, frankly, if not this year, I fear it may be many, many more years.”
Robert Kocher, MD, special assistant to the President, National Economic Council

Fellows respond to Congressional meetings
In their meeting with lawmakers, NOLC participants expressed their desire and ability to assist in healthcare reform efforts. Although all recognized the importance of dialogue and raising the level of awareness in Congress, some fellows expressed concern in the open forum that followed the meetings.

“I felt like the lawmakers I met with were pretty open to the suggestion we were making, and I think it helps that we are keeping up our relationships,” said Stuart L. Weinstein, MD, chair of the Orthopaedic Political Action Committee (PAC).

“We were well received,” agreed Thomas C. Barber, MD, chair of the Board of Councilors, who met with Debbie Curtiss, chief of staff for Rep. Fortney “Pete” Stark (D-Calif.), and Wendell Primus, senior budget and health policy adviser to Speaker of the House Nancy Pelosi (D-Calif.).

“But we came away with the distinct impression that healthcare reform legislation has already been written and sent to the Congressional Budget Office for evaluation prior to being released.”

Board of Specialty Societies chair William J. Robb, III, MD, a member of the Illinois delegation, recounted a somewhat similar experience.

“We were greeted warmly on the Hill, but found no real interest in a political dialogue on the Democratic side,” said Dr. Robb. “With respect to healthcare reform, there appears to be a commitment to increased access in primary care, wellness, and preventive services, with a new publicly financed plan option as the main core elements of reform legislation.

“Republicans seemed to be interested in developing an alternative proposal, but such a proposal may not have the political ‘legs’ it needs to influence a majority of the House and a soon-to-be-super-majority in the Senate,” he added.

“Educating your respective members of Congress on the issues affecting orthopaedic surgeons is paramount as we engage a new Congress and President,” said AAOS President Joseph D. Zuckerman, MD. He urged members to continue advocacy efforts through participation in the Orthopaedic PAC and through grassroots efforts such as the AAOS Key Contact program.

Fast facts on health care

• National expenditures for health care are rising much faster than the consumer price index (CPI). National expenditure per capita for health care in 2005 was almost 20 times the level of 1970 spending; the 2005 CPI was only 5 times the 1970 level.¹
• Increases in healthcare spending are outpacing the growth of the U.S. gross domestic product (GDP). Per person spending for health care is growing at an average annual rate of 8.8 percent, but the GDP is increasing at a rate of 6.1 percent.²
• Healthcare spending is consuming an increasing proportion of the U.S. GDP. Currently, healthcare spending accounts for about 17 percent of the GDP and is projected to increase to 20 percent by 2015.³ Most other industrial nations spend about 6 percent of their GDPs on health care.
• Spending on government healthcare programs such as Medicare and Medicaid is growing at an unsustainable rate. Today, Medicare, Medicaid, and other government healthcare programs account for 35 percent of all healthcare expenditures; by 2018, they will account for 50 percent of all health spending in the United States.⁴
• The cost of healthcare insurance—$12,500 and rising for a family of four—is being increasingly shifted to the public. A healthcare-related bankruptcy occurs every 2 minutes.⁵
• The number of healthcare administrators is far outpacing the number of healthcare providers. In the past 10 years, the annual rate of growth of administrative staff in healthcare settings exceeded that of nurses and physicians by more than 2,000 percent.⁶

References:

1. Wells Fargo Insurance Services.
2. Office of Management and Budget: The Nation’s Fiscal Outlook.
3. Keehan, S. et al: Health Spending Projections Through 2017. Health Affairs Web Exclusive W146: 21 February 2008.
4. Executive summary, report from Congressional Budget Office.
5. Norton's Bankruptcy Advisor, May 2000.
6. Bureau of Labor Statistics & Himmelstein/Woolhandler/Lewontin analysis of CPS data.

Additional References and Links:

Medicare Reform Position Statement

Principles of Health Care Reform and Specialty Care