Healthcare delivery is changing faster than a Los Angeles Lakers fast break. Insurance premiums are rising to the breaking point. Multiple plans have been proposed in Congress and are currently being hotly debated. One thing is clear: the status quo is not going to be “status quo” much longer. Change is in the air.

One of the issues being discussed is the creation of a “public option.” This government-sponsored entity would serve as an alternative to those who have trouble getting, keeping, and, most of all, paying for insurance. More importantly, it would act as a competitive “check” on traditional private insurers to keep premiums reasonable and promote value.

Let me make myself perfectly clear: I support this “public option” as a clear path to help reform malpractice insurance.

A government-based option would have many benefits. Not only could there be a national standard for benefits (limits to pain/suffering, limits on attorney contingency fees), but in exchange for taking advantage of the “public option,” surgeons would agree to participate in the Medicare/Medicaid program to promote national access to excellent orthopaedic care. The adoption of standard benefits (the California Medical Injury Compensation Reform Act might serve as a template) would go a long way toward solving tort reform. The ability to tie participation in the “public option” with Medicare/Medicaid should convince Washington that this is a serious plan with great upside for all Americans who utilize public health insurance.

It is the right thing to do for all of us. I really do not foresee any town hall meeting battles over this simple plan.

Thomas J. Grogan, MD
Santa Monica, Calif.

While we all owe a debt of gratitude to Dr. Zuckerman for correcting President Obama’s recent hyperbole comparing surgical and primary care reimbursement for diabetic lower extremity problems, we should also avail ourselves of this opportunity to consider our compensation compared to that available for primary care doctors and the underlying importance of this issue in the healthcare reform debate.

As physicians, we all know the foundational importance of our nation’s primary healthcare physicians to our patients’ health; however, we currently have a shortage of pediatricians, family physicians, and general internists, and this shortage will be exacerbated by any reform that increases the number of insured patients in the United States. An overwhelming 78 percent of American physicians believe that our country needs more primary care doctors.

Furthermore, researchers in 2007 found that an increased supply of primary care physicians is correlated with lower mortality from cancer, heart disease, and stroke; it also lessened the infant mortality rate, increased life expectancy, and increased the self-reported health of individuals. The effect of the available primary care supply on health is so marked that the addition of just one primary care doctor per 10,000 people across the country would have resulted in the prevention of 127,000 premature deaths.

A separate recent study examining primary care supply and Medicare costs found that all of this improvement in health would have come with a savings to Medicare of $684 per year per beneficiary! Therefore, increasing the number of primary care doctors would seem to be part of the magic elixir for lowering costs while raising quality of care that our country has been desperately seeking.

Unfortunately, as reported in the Journal of the American Medical Association, low reimbursement negatively affects residency fill rates in primary care specialties, and this phenomenon is likely to continue for as long as reimbursement rates are skewed toward procedural specialties. As specialists at the very top of the reimbursement system with incomes nearly two and a half times the salary of the average primary care physician, we should be quite proud of the enormous contributions that we make to the health of our patients (I certainly am), but we cannot claim that our therapies are more important than preventing a patient’s stroke by managing his or her hypertension or optimizing a patient’s heart function to prevent his or her premature death.

In today’s financial climate, with Medicare already facing bankruptcy from runaway costs, we should recognize that primary care reimbursement can only go up if our and other procedural specialists’ reimbursements are correspondingly reduced. While none of us wishes for lower compensation, the health of our collective patients is more important than our salaries, and we should advocate for reimbursement rates that adequately reward primary care professionals, even if this comes at some cost to us.

James B. Rickert, MD
Bloomington, Ind.

If you want to set AAOS Now straight, send your letters to the Editor, AAOS Now, 6300 N. River Rd., Rosemont, IL 60018; fax them to (847) 823-8033; or e-mail them to aaoscomm@aaos.org